Mental health and justice beyond borders: Global crises, sociopolitical determinants, and contemporary practices in forensic psychiatry

Abstract

In an era marked by escalating international crises, environmental shifts, and sociopolitical volatilities, global mental health is facing profound challenges. With its distinctive position at the intersection between clinical and judicial domains, forensic psychiatry can be predisposed to the consequences of adverse external determinants and events. At present, geopolitical conflicts, rising insecurities, climate change, forced and voluntary migration, and regressive sociopolitical ideologies are all compounding role responsibilities, care models, and ethical expectations across forensic-psychiatric practice; in short, complex distal factors are increasingly informing domestic considerations. These far-reaching concerns indicate a need for adaptive and proactive responses, underpinned by cultural sensitivity, social justice, and respect for human rights. Through illustrative examples from different regions, this perspective paper calls for a greater recognition of the transnational dynamics that are affecting local contexts of practice. Equally, it outlines the importance of advocacy, interdisciplinary collaborations, and potential evolutions in training and ethical frameworks to address contemporary issues. By adopting these approaches, forensic psychiatrists can promote more just systems and equitable mental healthcare for patients amidst the uncertainties of an interconnected and rapidly transforming world.

Keywords:

• Forensic psychiatry
• global mental health
• geopsychiatry
• political determinants
• climate change
• war
• migration

1. Introduction

Spanning mental health services and legal settings, forensic psychiatry encompasses the evaluation and treatment of individuals with psychiatric disorders involved in civil or criminal proceedings (Arboleda-Flórez, 2006; America Academy of Psychiatry and the Law, 2005). The clinical-judicial scope of this subspeciality thereby incorporates medicolegal issues, such as criminal responsibility, competency to stand trial, medical malpractice, and risk prognosis, alongside the provision of care in correctional systems (Arboleda-Flórez, 2006; America Academy of Psychiatry and the Law, 2005). Throughout judicial domains, forensic-psychiatric expertise recurrently converges with legal directives, international guidelines, and cultural norms (Arboleda-Flórez, 2006). Cross-jurisdictionally, this can entail heterogeneous role expectations and dual agency biases (Robertson & Walter, 2008; Salize et al., 2023). Consequently, ethical dilemmas may transpire around core principles of beneficence and non-maleficence when duties mandated by third-parties could potentially jeopardise patient wellbeing (America Academy of Psychiatry and the Law, 2005; Robertson & Walter, 2008). For instance, legal reporting typically necessitates the disclosure of confidential information, creating conceivable risks to vulnerable groups (e.g Gulrajani & Prabhu, 2018; Tullio et al., 2023).

Given their distinctive responsibilities and skills, forensic psychiatrists are well-positioned to advocate for policy amendments when judicial procedures, care models, and legislative agendas are insufficient (or even counter-intuitive) for serving patients and societies (Chaimowitz & Simpson, 2021; Cid, 2010; Grounds, 2004; Gulrajani & Realmuto, 2018; Kapoor, 2014; Liebrenz, 2024; Martinez & Candilis, 2020; Ochoa, 2023). Hence, recently, across the forensic subdiscipline, there have been burgeoning exchanges about social justice and criminal justice reforms (e.g Chaimowitz & Simpson, 2021; Martinez & Candilis, 2020; Ochoa, 2023). Yet, in the authors’ opinion, it may follow that forensic-psychiatric expertise currently remains underrepresented (and perhaps underleveraged) within larger interdisciplinary movements to address systemic issues. Relatedly, the interconnections between global mental health, adverse sociopolitical dynamics, and forensic psychiatry have not been extensively documented, representing a significant knowledge gap. This could stem from inconsistencies in the standardisation and classification of forensic psychiatry as a subspeciality, though cohesive protocols are developing (e.g Beis et al., 2022; Ogloff et al., 2000).

Nevertheless, such considerations are becoming ever-more pertinent in a globalised and interconnected world experiencing multifaceted challenges, including geopolitical instabilities, armed conflicts, climate change, natural disasters, structural inequalities, migration, forced displacement, and authoritarian tendencies, amongst others (Liebrenz, 2024). These transnational complexities are impinging upon the contours of forensic psychiatry and the needs of justice-involved populations (Liebrenz, 2024).

Therefore, using illustrative examples, this perspective paper calls for wider recognition about how ongoing crises and macro trends are affecting modern forensic psychiatry, proposing potential responses to evolving contexts of practice. Underpinned by advances in geopsychiatry, an emerging area examining the interactions between distal determinants and proximal outcomes, these dynamics highlight the importance of promoting mental health, human rights, and social justice as mutual objectives (Castaldelli-Maia & Bhugra, 2022; Liebrenz, 2024; Smith et al., 2023).

2. The influence of sociopolitical and societal dynamics in forensic psychiatry

Due to its intersections between medicine and the law, forensic psychiatry can be susceptible to governmental, sociolegal, and sociopolitical agendas (Grounds, 2004; Liebrenz, 2024; Mitchell, XXXX). Ultimately, through its health and judicial authorities, the state maintains a substantial influence on the definitions of mental illnesses and the legal mechanisms for managing patients and offenders with psychiatric disorders in a given jurisdiction, including involuntary detention measures (Mitchell, XXXX). Moreover, cultural beliefs often determine societal perceptions about normality and deviance, thereby informing how psychiatric issues are understood within different legal frameworks (Kirmayer et al., 2007). Importantly, prevailing ideologies about criminal justice may engender a dissonance between retributive and rehabilitative approaches, or between notions of medicalism and legalism in mental health legislation (Brown, 2016; Tyler et al., 2011).

These juxtapositions can raise ethical dilemmas for forensic specialists during interactions with legal systems, accentuating the importance of practices and policies that better support patients and society. Despite this, several commentators have previously identified somewhat insular traditions across forensic psychiatry, with limited cross-jurisdictional standardisation (e.g Beis et al., 2022; Ogloff et al., 2000). Yet, as has been repeatedly demonstrated, global sociopolitical shifts and domestic priorities have frequently shaped forensic-psychiatric procedures, care models, and specialist role responsibilities.

In this regard, political and legislative actions have facilitated progressive modifications in forensic services (Beis et al., 2022). This was illustrated when Italy became the first country to definitively close forensic-psychiatric hospitals in 2017 (Beis et al., 2022; Di Lorito et al., 2017). Driven by sociocultural, legal, and governmental factors, these measures enhanced holistic treatment but simultaneously attracted criticism for the consequential imprisonment of offenders with psychiatric disorders and associated socioeconomic challenges (Beis et al., 2022; Di Lorito et al., 2017). Elsewhere, as endorsed by forensic psychiatrists and policymakers, multimodal therapeutic strategies, such as community-based and integrative interventions, have yielded positive recidivist outcomes for distinct target populations (e.g Goulet et al., 2022; New Zealand Government, 2021). Likewise, in different jurisdictions, interdisciplinary campaigns have stimulated sociopolitical impetus towards humane treatment and solitary confinement restrictions within correctional settings (Kapoor, 2014; Tadros et al., 2023).

Conversely, regressive ideologies have hindered the design and efficiency of clinical care provisions. In South Africa, outdated principles from the colonial and apartheid eras are still undermining extant service capacity and forensic-psychiatric facilities (Pillay et al., 2023). Exacerbated by financial barriers and flawed legislation, South African forensic services remain impaired by cultural insensitivities and inequalities, disadvantaging marginalised groups (Pillay et al., 2023). Similarly, austerity measures in Greece after the 2008 global financial crisis worsened service pressures and hampered progress in state psychiatric reforms, affecting specialised domains like forensic psychiatry (Giannakopoulos & Anagnostopoulos, 2016). More generally, sociopolitical patterns and punitive attitudes towards criminality can dictate resourcing priorities, possibly resulting in deficiencies across forensic care structures (Gunn, 2000).

Societal exigencies and sociopolitical circumstances can change and expand the remit of forensic psychiatrists, necessitating diverse obligations, particularly during complex national or supranational litigation. For example, forensic-psychiatric expertise was integrated into genocide cases at the Extraordinary Chambers in the Courts of Cambodia and war crimes trials at the International Criminal Tribunal for the former Yugoslavia (Chhim, 2013; Soyka, 2002). Beyond conventional civil and criminal contexts, the psychopathological and culturally-specific impacts of mass violence played a significant role in these proceedings, informed by larger objectives of peace, justice, and reconciliation (Chhim, 2013; Soyka, 2002). Analogously, in post-war Kosovo, the establishment of forensic-psychiatric services entailed multidisciplinary roles for specialists in capacity-building, legislative development, and international cooperation (Salize et al., 2014).

Historically, state institutions have regulated the interpretation of forensic-psychiatric concepts (Mitchell, XXXX), like psychiatric evaluations and judicial decisions about ‘dangerousness’. As a culturally-contingent construct, theoretical classifications and ensuing medicolegal responses for ‘dangerousness’ can be conditioned by broader agendas, leaving forensic-psychiatric opinions subject to non-psychiatric interpretation (Petrunik, 1982). These tendencies have contributed to abuses in authoritarian domains, such as the so-called ‘sluggish schizophrenia’ diagnoses in the Soviet Union (Keith & Regier, 1989). Typified by purportedly ‘subversive’ behaviours, these enabled Soviet regimes to repress opposition by exploiting egregious notions of ‘dangerousness’ (Fulford et al., 1993). Further psychiatric abuses have transpired in other jurisdictions and states (e.g. in Maoist China and Nazi Germany), as have ideologically-informed definitions of ‘dangerousness’, again epitomising the intricate connections between forensic-psychiatric practices and sociopolitical determinants (Mitchell, XXXX; Munro, 2002).

3. The effects of contemporary international crises and sociopolitical factors

Reflecting similar patterns, contemporaneous transnational developments are posing multifaceted dilemmas for global mental health, with intersectoral consequences for forensic psychiatry (Liebrenz, 2024; Smith et al., 2023). This includes geopolitical conflicts, climate change, forced and voluntary migration, and regressive sociopolitical trends. Although such distal concerns may seem far removed from local clinical or judicial work, they are increasingly impinging upon societal and legal frameworks. Below, we outline several illustrative examples of current global issues and their implications for modern forensic psychiatry.

3.1. Geopolitical conflicts, ethical dimensions, and professional obligations

The years 2022 and 2023 have witnessed the most conflicts since the end of World War Two, with two billion people across the globe living in places marked by war; in 2024, hostilities are escalating in Ukraine, parts of Africa, the Middle East, and beyond, threatening to engulf neighbouring regions (United Nations, XXXX). Ongoing conflicts have carried a significant human toll, worsening psychiatric symptoms and mental health services already pressured by resource constraints and the COVID-19 pandemic. For example, in the Russo-Ukrainian War, an elevated prevalence of psychiatric disorders is evident amongst civilians, accompanied by extant care shortages (Seleznova et al., 2023). Comparably, a high mental health burden has been identified in warzones in Sudan and the Middle East (Mohammed Bilal et al., 2024; Chatterjee, 2023).

Within certain jurisdictions, geopolitical conflicts are complicating professional and ethical duties, as was the case in previous scenarios (Chhim, 2013; Soyka, 2002). In wartime situations, human rights can be politicised or neglected by belligerent states (Cioffi & Cecannecchia, 2023; Sriram et al., 2018), with stark repercussions for at-risk and justice-involved communities. In modern settings, the conscription of incarcerated offenders and attacks on psychiatric in-patient facilities in the Russo-Ukrainian War exemplify inherent difficulties in upholding moral standards amidst wartime excesses (Liebrenz et al., 2023). As an adjunct to global conflicts, terrorism and radicalisation present additional challenges for forensic evaluations and risk prognosis in balancing individual rights and immediate security considerations, particularly given the possible psychopathological components of extremism (Arboleda-Flórez, 2007; Smith et al., 2022).

As per past hostilities, forensic specialists can be mandated to evaluate mental illnesses and the sequelae arising from conflict-specific circumstances (Chhim, 2013; Soyka, 2002). With contemporary reports of human rights violations and war-induced displacement, forensic-psychiatric expertise could conceivably be sought in supranational or domestic war crimes cases and other composite proceedings (Chhim, 2013; Smith et al., 2022). This was recently demonstrated in the indictment of a former Ugandan militant by the International Criminal Court for crimes against humanity, who unsuccessfully adopted a mental illness defence (Hiromoto & Sparr, 2023).

Likewise, practitioners may have crucial functions in risk assessment, capacity-building, and initiatives aimed at reintegrating and rehabilitating justice-involved or vulnerable populations exposed to war (e.g. veterans and internally displaced refugees), (e.g Liebrenz et al., 2023; Rosenthal & Finlay, 2022; Smith et al., 2022). Similarly, forensic psychiatrists can be engaged by military entities, who typically maintain their own healthcare and legal systems (Turner & Neal, 2003). This can result in professional and moral complexities around beneficence and non-maleficence, especially when military agencies are transgressing human rights laws through conflict-related actions (Mitchell, XXXX).

3.2. Climate-related challenges and patient care

Driven by a reliance on non-renewables and insufficient policy progress, climate change is harming the psychological wellbeing of communities, particularly in the Global South, contributing to distinctive stressors (Cianconi et al., 2020; Walinski et al., 2023). Resultantly, new psychopathological classifications around climate-specific phenomenology have been proposed (i.e. solastalgia, eco-grief, and eco-anxiety) (Cianconi et al., 2020). At the time of writing, these emerging symptom profiles are not incorporated in standardised diagnostic manuals and to the authors’ knowledge, have not yet been cited in forensic-psychiatric expertise during litigation to-date. That said, climate-specific determinants can influence individual behavioural changes and this may have implications for forensic psychiatry and sociolegal outcomes. High temperatures have been linked to elevated aggression and extremely high temperatures, which have become increasingly frequent in parts of the world, have associations with an increased incidence of aggressive offences (Cianconi et al., 2020).

Equally, climate change is presenting immediate consequences for justice-involved patients in detention, who already exhibit elevated psychiatric morbidities and lack access to mental health care (Fazel et al., 2016; Smith et al., 2022). Internationally, infrastructural deficiencies, insufficient natural disaster preparedness, and intramural overcrowding are being worsened by punitive criminal justice procedures and legislation, which in turn can be shaped by social disparities (Maner et al., 2022; Smith et al., 2022). For example, flooding and acute temperatures have adversely affected correctional environments in the United States that house 25% of the total incarcerated population worldwide with an overrepresentation of minority groups (Maner et al., 2022). Analogous patterns have been observed in carceral settings elsewhere, including throughout Africa and the Asia Pacific region (Van Hout et al., 2023; International Committee of the Red Cross, 2023).

Correctional systems and mass incarceration can create a vicious cycle of carbon emissions and concomitant climate-related challenges (McGee et al., 2021). Additionally, the detrimental environmental impact of forensic-psychiatric in-patient facilities has also been highlighted (Tomlin, 2021). This has prompted arguments for reforming custodial sentencing and forensic care models, with an emphasis on sustainable development plans, ecologically responsible policies, and community-based schemes (Cowan et al., 2022; Tomlin, 2021). As the climate crisis deepens, these multimodal considerations will require diligence from forensic practitioners, who must engage with policymakers and legal stakeholders to safeguard the wellbeing and human rights of patients and justice-involved groups in any proposed contingencies (Tomlin, 2021).

3.3. Migration, displacement, and forensic-psychiatric assessments

Internationally, geopolitical conflicts, climate change, and social disparities are accelerating forced and voluntary migration. According to figures from the United Nations, there were 281 million migrants in 2020 (accounting for 3.6% of the global population), which is over two times higher than 1990 (United Nations Institute of Migration, XXXX). Of these, refugee numbers increased from 27.1 million in 2021 to 35.3 million in 2022 (United Nations Human Rights Council, 2023). Migrants and refugees exhibit a high prevalence of mental health symptoms and risk factors, including psychosocial stressors associated with migratory journeys, acculturation, and discrimination (Bhugra et al., 2011). Driven by geopolitical determinants, burgeoning migratory trends will likely necessitate significant adjustments to clinical services tailored to diversifying patient populations (Khan & Simpson, 2022).

This is especially pertinent in forensic-psychiatric services and criminal justice systems, where migrants and refugees are often overrepresented, as shown in various jurisdictions (e.g (Cohn et al., 2024)). These individuals may have limited comprehension about the legal specificities in the host country, which can be compounded by psychopathological vulnerabilities and structural inequalities, conceivably contributing to disproportionate detention rates. Notably, justice-involved migrants frequently encounter communication barriers and cross-cultural challenges (Khan & Simpson, 2022). In this regard, actuarial risk prognosis instruments encompass culturally-contingent components that could potentially affect their impartiality in these communities (Shepherd & Lewis-Fernandez, 2016). For example, the nature of familial relationships in migrant communities can differ from hegemonic Western cultures, and factors such as socioeconomic and employment status can be framed in ways that disadvantage minority groups (Sreenivasan et al., 2022). Researchers have also identified cultural biases with certain items in individualised structured professional judgement evaluations (Sreenivasan et al., 2022).

During legal proceedings involving migrants, forensic psychiatrists fulfil diverse medicolegal roles. Alongside assessing mental state and reaching a diagnosis, their expertise can condition immigration status and the right to remain in a host country, raising concerns about patient welfare, human rights, and dual agency biases (Disla de Jesus & Appel, 2022; Gulrajani & Prabhu, 2018; Prabhu & Baranoski, 2012; Tullio et al., 2023). Presently, encouraged by certain political actors, immigration controls and nativist rhetoric are proliferating across higher-income nations, particularly in the Global North (e.g Vohra, 2023). In countries with restrictive migration policies, even legitimate asylum claims on psychiatric grounds may be prejudicially scrutinised or dismissed, contingent on sociopolitical or sociolegal trends.

These ideologies could elicit biases in forensic assessments, underlining the necessity of rigorous ethical and professional standards, irrespective of politicised pressures. Specifically, the United Kingdom’s provisional plans to transfer migrants to Rwanda have engendered moral injury risks amongst practitioners and may violate supranational human rights legislation (Sen et al., 2022). Despite this, other states are contemplating similar approaches (Smith et al., 2023). Under these proposals, the medicolegal opinions of forensic psychiatrists could have severe implications, potentially informing whether migrants are deported to a country with an inconsistent human rights record where they lack sociocultural or familial ties (Sen et al., 2022; Smith et al., 2023).

3.4. Authoritarian policies and legislative determinants

The expansion of authoritarian and populist ideologies internationally has coincided with an upsurge in punitive measures and attitudes in public and governmental domains, provoking discrepancies between rehabilitation and retribution. These situations can compound care provisions and ethical principles in forensic psychiatry. Lately, this has been illustrated by authoritarian drug policies in Southeast Asia and beyond, as enacted through robust law enforcement and repressive procedures (Alibudbud, 2023). For example, in the Philippines, the so-called war on drugs has entailed state-sanctioned violence towards individuals with substance use disorders and extrajudicial killings, particularly affecting socioeconomically disadvantaged communities (Simbulan et al., 2019).

Equally, the treatment of justice-involved groups and people with mental illnesses in certain political frameworks reveals gaps between regressive policy agendas, medicolegal standards, and social justice. In El Salvador, gang violence has led to repressive law enforcement, widespread human rights violations, and mass incarceration (including of people with psychiatric disorders) (Human Rights Watch, 2022). Correspondingly, capital punishment still endures in numerous countries, where individuals with severe mental illnesses continue to be executed (Gulrajani & Realmuto, 2018; Kapoor, 2014; Salzer, 2020). In some jurisdictions, including liberal democracies, validated psychiatric systems may be neglected owing to sociolegal and sociopolitical paradigms, as was recently shown by the discontinuation of the mandatory use of standardised diagnostic manuals under Swiss law (Schleifer et al., 2022). These developments reflect concerning trends of political and legal systems enforcing inequitable or even discriminatory policies towards marginalised groups and individuals with mental illness.

4. Evolutions in modern forensic psychiatry to mitigate global crises and sociopolitical challenges

Contemporary forensic psychiatry is being shaped by external dynamics and macro-level factors, affecting care delivery, professional duties, and ethical values. In the authors’ opinion, this warrants a reconsideration of existing practices adapted to specific cultural and societal needs, incorporating targeted advocacy, sustained engagement with national and international policymakers, and pragmatic evolutions to educational and ethical guidelines.

In a changing world, the moral obligation of forensic psychiatrists to champion legislative and criminal justice reforms that better protect at-risk patients and serve civil society must be reiterated. Recently, researchers have foregrounded this duty for various proximal and systemic issues, such as insecure housing, migratory patterns, racial disparities, discrimination, and structural disadvantages (Chaimowitz & Simpson, 2021; Gulrajani & Realmuto, 2018; Martinez & Candilis, 2020; Ochoa, 2023; Sreenivasan et al., 2022). With current global events and sociopolitical determinants disproportionately impacting vulnerable groups in criminal justice systems and beyond, there is a need for advocacy and progressive schemes to be widely adopted across forensic psychiatry; these should aim to address immediate concerns, whilst developing more equitable policies and forward-looking care systems.

To maximise their efficacy, relevant initiatives could be integrated with existing objectives in global mental health, complimented by empirical research and international partnerships. Interprofessional and interdisciplinary collaborations will be critical for supporting cohesive actions, as underlined by prior policy alterations in forensic psychiatry (Brown, 2016; Kapoor, 2014; Di Lorito et al., 2017; Goulet et al., 2022; Gulrajani & Realmuto, 2018; New Zealand Government, 2021; Tadros et al., 2023), involving diverse fields like law, human rights, political sciences, and others. These cooperative approaches can bolster ongoing work in geopsychiatry and the United Nations’ Sustainable Development Goals (SDGs), which explicitly contain targets related to mental health (SDG: 3), inequalities (SDG: 10), and justice and strong institutions (SDG: 16) (Smith et al., 2023).

Based on precedents in various jurisdictions (e.g Di Lorito et al., 2017; Gulrajani & Realmuto, 2018; Salize et al., 2014; Tadros et al., 2023), meaningful change can be achieved through capacity-building and leveraging sociopolitical impetus. To that end, forensic practitioners must be encouraged to liaise with state bodies, juridical actors, and international organisations, illustrating how geopolitical and legislative issues affect justice-involved and marginalised individuals. This should include exchanges on optimal care models, policy design, and how to protect marginalised communities amidst shifting contexts of practice. In this regard, the climate crisis and migratory movements are increasingly demanding more culturally-sensitive services and sustainable care provisions (Khan & Simpson, 2022; Tomlin, 2021).

Nonetheless, in certain settings, there may be governmental resistance to reforms, or barriers to advocacy for practitioners, such as threats to personal safety or vocational hazards (The Lancet, 1979). Accordingly, professional organisations and supranational agencies can use their platform to support cross-jurisdictional and cross-cultural discussions to pioneer best practices and innovative solutions to ongoing crises (Grounds, 2004).

Contingent on cultural specificities and domestic legal frameworks, modifications to ethical guidelines may be necessary to respond to the evolving nature of modern challenges in forensic psychiatry (Candilis & Martinez, 2021; Chaimowitz & Simpson, 2021; Martinez & Candilis, 2020), together with emerging care structures and specialist duties. This extends to training and educational programmes, which should be expanded to encompass aspects of global mental health, sociopolitical factors, cultural competency, and principles of social justice. As an example, training about asylum evaluations should be mandatory, reflecting legal and humanitarian considerations in contemporary settings (Disla de Jesus & Appel, 2022). Likewise, advocacy needs to be accentuated as a key professional role, empowering forensic practitioners to inform policy agendas and act as positive agents of change in the crucial interphase between mental health services and justice sectors (Gulrajani & Realmuto, 2018; Piel, 2018). This echoes arguments in general psychiatric education, which have proposed curricula expansions to foreground advocacy and transnational determinants (e.g Bhugra et al., 2023).

5. Conclusion

Due to its clinical-judicial interfaces, forensic psychiatry has consistently been shaped by legislative and sociopolitical directives. In modern practice, escalating international crises and adverse distal determinants are translating into composite local issues, with implications for the profession in terms of justice-involved populations, care models, and ethical obligations.

Given these challenges, it is expected that the subdiscipline needs to adapt to confront the multifaceted transnational and domestic concerns. The medicolegal responsibilities of forensic psychiatrists offer distinctive opportunities to drive reforms to safeguard the rights and needs of vulnerable patients and attend to shifting societal exigencies in a rapidly changing world.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

No funding was received.