No change of attitude toward forensic psychiatry: 5 years after the Medical Treatment and Supervision Act in Japan

Objective: The forensic 
mental health system in Japan changed dramatically with the enforcement of 
the “Act on Medical Care and Treatment for the Persons Who Had Caused Serious 
Cases under the Condition of Insanity” or MTS Act, in 2005. The aim of this 
study is to evaluate the changes in attitude and behavior of general 
psychiatrists, towards forensic psychiatry. Methods: We conducted a 
questionnaire survey in 2010 on forensic psychiatry for Japanese psychiatrists, 
mirroring a previous study from 2007. Results: Comparing the results from both 
questionnaires, it is not evident that awareness of forensic mental health 
has improved among psychiatrists in the intervening three years. Conclusion: 
Further education about forensic mental health needs to be considered inJapan.


INTRODUCTION
The need to establish a sophisticated forensic mental health system has increased, as a result of the global trend toward deinstitutionalizing patients with mental disorders [1].For many years, Japan had no specific legal provisions for offenders with mental disorders [2].In 2005, Japan enforced a new law entitled the "Act on Medical Care and Treatment for Persons Who Have Caused Serious Cases under the Condition of Insanity", shortened to the Medical Treatment and Supervision (MTS) Act.This Act provides a hybrid solution that straddles the judicial and medical systems, with the District Court serving as a judgment panel.This panel consists of a judge and a mental health reviewer ("seishinhoken-shinpan-in"), with the latter being selected from a group of psychiatrists who hold a Judgment Physician license ("seishin-hoken-hantei-I", a national license for forensic mental health specialists).
A comprehensive forensic mental health system was subsequently established in Japan as a result of the MTS Act.However, the number of specialists dedicated to this system remained low [3].
We conducted a questionnaire survey in 2007, to examine the attitude of general psychiatrists in Japan toward this field, in order to develop measures for dealing with this issue.This survey revealed that, while general psychiatrists were interested in forensic mental health issues, they had little knowledge about forensic psychiatry and were reluctant to work in the forensic mental health field [4].
Recently several programs of professional education about forensic psychiatry were performed in Japan [5].We have conducted a resurvey using our original questionnaire, to evaluate changes in attitude and behavior of general psychiatrists, towards forensic psychiatry.

METHODS
The paper questionnaire contained 22 questions and was mailed to 3334 Japanese psychiatric facilities, including all mental hospitals, mental clinics, and mental health and welfare centers that we could identify those addresses.The respondents were general psychiatrists practicing in Japan.
The questionnaire followed the same format as that used in the original study, covering areas including, experience with criminal responsibility evaluation, knowl-edge of involvement with the MTS Act and general perspectives on forensic psychiatry.Statistical analyses were performed using PASW Statistics 18 (SPSS Inc., Chicago, IL, USA).Values of P < 0.05 were considered significant.

RESULTS
The questionnaires were sent in January 2010 and were returned and analyzed, in April 2010.The total number of respondents analyzed in this study (n = 1617) accounted for 11.4% of all registered psychiatrists in Japan (n = 14201) [6].Of these, 23.6% (n = 382) reported that they were qualified as Judgment Physicians of the MTS Act, accounting for 42.2% of all Judgment Physicians in Japan (n = 905) [7].This result is almost same as the past study in the attribute of the respondents.
Over 60% of respondents were inexperienced in all types of forensic evaluations.One-third of respondents felt that they were "definitely familiar" with the content of the Act.Of the total respondents, 64.5% were interested in forensic psychiatry to some extent, but only 29.6% were willing to work within the field.For increasing professional awareness, 57.9% of respondents were interested in participating in a seminar on forensic evaluation.A higher percentage of respondents selected workshops and case conferences, over videos and textbooks, as the preferred educational tools.
As part of this study, we compared all responses from this questionnaire with those given in 2007.An example of the comparative analysis is shown in Figure 1.Question: "Do you want to do the work related to the forensic psychiatry?" (Figure 1).
No statistically significant differences were found in responses to the same questions between the two surveys.Therefore, we could find no evidence of increased awareness of forensic psychiatry among general psychiatrists over the past 3 years.

DISCUSSION
We conducted a national survey in 2010 and compared the results to an identical survey from 2007.This survey could not detect any significant shifts in attitudes, in the three years period since the original survey.
Following enforcement of the MTS Act, several workshops and conferences were held all over Japan, to inform psychiatrists about the new clinical and legal requirements.Our results may suggest that a lot of psychiatrists have not changed their working practices to embrace forensic psychiatry, a surprising and even disappointing fact for experts in the field.
A possible explanation for the lack of change could be linked to the small number of patients for whom this act is applicable.In Japan, there are over 3 million patients with mental disorders [8], however the number of pa- tients who commit serious crimes and who would therefore require evaluation under the MTS act, is as few as 2 thousand [7].In the course of their daily work, general psychiatrists would seldom be presented with an applicable patient, and therefore be less motivated to learn about the MTS act.
It is also possible that 3 years are too short to change the mind of general psychiatrists even after the new legislation started.Periodic surveys may be needed in future to evaluate the matter precisely.
There is the third hypothetical explanation.In Japan, clinical psychiatry evolved without a formal forensic mental health system [2], leaving psychiatrists to develop their own evaluations and assessments of forensic psychiatric needs, as a natural part of everyday clinical practice.So, to varying degrees, forensic psychiatry is commonly practiced in Japan, but outside of the national formal framework.Indeed, some key opinion leaders of general psychiatrists insist that it would be impossible for psychiatrists not to utilize forensic mental health principles within their routine clinical practice, albeit at a subconscious level [9].For psychiatrists who are selftaught through routine clinical practice, patients who present with a medical history that warrants forensic intervention are currently deemed "hard to deal with".
If the current situation is allowed to persist, forensic psychiatry in Japan runs the risk of becoming a niche field, further widening the gap between clinical practitioners and specialists.It would be best, for the proficiency of psychiatrists and ultimately patient care, if elements of the forensic mental health system, such as risk assessment, restraints and ethical considerations, were regarded as an integral part of clinical practice, and not a mere subspecialty.Great efforts need to be placed on devising more effective national educational programs to make this a reality.
The limitation of this study is that self-selection bias is not avoidable for questionnaire survey.Psychiatrists with higher interest for forensic psychiatry may tend to answer the questionnaire more than in others.Indeed 23.6% of respondents are JPs, compared with 6.4% (905 JPs/14201 psychiatrists) in Japan.If general psychiatrists in Japan are less interested in forensic psychiatry, then the importance of this issue is more severe.

CONCLUSION
We conducted a questionnaire survey in 2010 on forensic psychiatry for Japanese psychiatrists, mirroring a previous study from 2007.Although several educational programs were performed, it is not evident that awareness of forensic mental health has improved among psychiatrists in these 3 years.We need a stronger strategy to enhance the interest toward forensic psychiatry of general psychiatrists in Japan.

Figure 1 .
Figure 1.Percentages of each answer for the question "Do you want to do the work related to the forensic psychiatry?" are shown.Chi-square test did not suggest statistical significance.