How does Court Attendance impact the Mental Health of Patients with Psychiatric Disorders? A Literature Review
N Bhagrath 
R Evans 
Cite as: Bhagrath N. & Evans R., "How does Court Attendance impact the Mental Health of Patients with Psychiatric Disorders? A Literature Review", (2015) 21(2) EJoCLI.
The idea for this exploratory qualitative research developed from anecdotal evidence gathered from discussions with clinical colleagues about the impact attending Court seems to have for patients with mental health disorders. A literature search was performed using the clinical databases Psychinfo, CINAHL, Medline, Embase and HMIC. Other sources such as NHS evidence, Health Business Elite and general web searches were carried out. Due to the limited papers located the search was opened to international papers, though in English language. Search terms such as "Court appearance" and "going to Court" were used which were merged with "mentally ill persons." Different combinations of search terms were inputted, but ultimately 15 research articles were found. The available literature on this topic is scarce, with many identifying the need for further research. 
It is accepted that the prevalence of psychiatrically disordered individuals within the Court population is significant, and some have required referral to psychiatric teams within the Court diversion programmes.  These difficulties may go beyond the practical limitations of transporting patients to the Court which requires the presence of escorting mental health professionals, usually nursing staff, to be absent from the clinical duties within the psychiatric ward. Attending Court can clearly be stress-inducing for professionals involved as suggested by Robertson et al in their phenomenological study of the effects of clinical negligence litigation on midwives.  They also found that being a witness in Court provoked "significant stress," and that this could present as physical or mentally ill health. However, the impact on defendants having to attend Court, though hypothetically likely to be stressful, has not been robustly considered to date. The impact could be worse than transient affective symptoms given the accepted vulnerability of people with mental disorders. A paper by Snow, which retrospectively reviewed defendants after attempted self- injury or attempted suicide cited "concerns about forthcoming Court appearances" as a motivational factor. 
The issue of the impact of attending Court is becoming increasingly topical, though this has predominantly regarded those that have given evidence about sexual abuse that occurred as a child. Lord Judge, the most senior criminal judge in England and Wales stated that, "research should be carried out into the long-term affects on those who give evidence about sexual abuse when they were a child. The aim of this would be to "improve the way that young people are treated by the justice system."  The article, written in The Guardian, identified a mismatch between lawyers that might focus on the Court process itself, and mental health professionals who may be more concerned about the welfare of the individual primarily.
Lord Judge also identified the lack of research into the impact on child witnesses after making their Court appearances. This impact of attending Court for defendants could be viewed separately; initially viewing the potentially transient, short term effects that may occur before, during or after attendance in Court and then the longer term effects on the individual. Quas et al. investigated "the role of children's emotional reactions in Court in predicting their later mental health attitudes."  They noted the emotional reactions of children in Court and the level of emotional distress whilst they waited to give oral evidence or "take the stand." There has been some research in adults with developmental disabilities and Court proceedings. Ericson et al. suggested in the research into the knowledge of legal terminology and Court proceedings in adults with developmental disabilities (DD), that there was "need for education of DD individuals and legal professionals to support participation and fair treatment of DD individuals in legal situations." 
There is little research to support the positive effects of attending Court to date, although Awad et al. suggested that the process could "act as a catalyst" within the treatment process.  There have also been suggestions that great inter-disciplinary collaboration should occur between legal and mental health professionals which could ultimately "impact on the quality of defendants' lives."  It has also been noted that some mentally-ill defendants were not dealt with appropriately in Court proceedings. It is also unclear as to whether defendants should be routinely required to attend Court other than due to it being accepted practice; especially given their contribution at times is minimal.
3. Conclusion & Recommendations
Having considered the limited research available, we propose further research aimed at reviewing the impact of the Court proceedings upon defendants with mental disorders. This could incorporate individual patient feedback via questionnaires or even focus-groups. We would suggest that Courts are unable to meet the needs of mentally disordered patients because they were never developed with the foresight to be able to attend to the needs of mentally disordered individuals. There are fundamental difficulties such as delays, which can result in patients having to be managed within unfamiliar and potentially unsafe settings such as cells or within secure transport, for longer than anticipated periods. The proposed research will provide evidence that the decision to request defendants with mental disorders to attend all Court proceedings in person is complex, as it can have significant impact on the mental health and wellbeing of defendants. We would suggest that this impact should be given greater consideration with advice sought from mental health professionals involved in the provision of care for these individuals. After the impact of the Court attendance on patients has been established, this will allow a greater flexibility for the Court and treating clinicians to carefully consider the impact of attending Court. Ultimately, if the personal cost of Court attendance outweighs the sometimes, arbitrary demand for their required attendance, then excusal from attendance should be considered be considered with greater utilisation of technology such as video conferencing.
 University of Birmingham, Specialist Registrar in Forensic Psychiatry
 Emeritus Professor of Socio-Legal Studies, School of Law, Liverpool John Moores University.
 This review was completed with the support and guidance of staff within South Staffordshire and Shropshire Healthcare NHS Foundation Trust.
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