Forensic Evidence in Criminal Trials I
Take it from an Expert: Authority and Hearsay in Psychiatric and Psychological Evidence
Tony Ward, University of Hull
The reluctance of English judges to admit psychological evidence about ‘normal’ people reflects an anxiety that
experts will assume undue authority and usurp the role of the jury. Such concerns are largely misplaced. Unlike
many other kinds of expert witnesses, psychologists often draw inferences which juries can evaluate for themselves,
or bring to the jury’s attention points which they may wish to consider in drawing their own inferences from the
evidence of other witnesses. There is, typically, relatively little need for the jury to accept their evidence merely on
the basis of authority: i.e. to assume that the inferences the expert draws are sound even though the jury cannot
evaluate the reasons for them. Judges themselves usurp the role of the jury when they appeal to ‘common sense’ to
exclude evidence that juries might reasonably find helpful.
However, the very fact that juries can draw their own inferences from the factual evidence relied on by
psychologists or psychiatrists raises serious concerns about the quality of that evidence, particularly when it
comprises hearsay evidence which may have been selectively gathered or relayed by the expert. Under the Criminal
Justice Act 2003, hearsay evidence about the facts of the case, as opposed to evidence of general knowledge in the
expert’s field, should (unless all parties agree to admit it) be evaluated according to the same criteria as other forms
of hearsay evidence. These criteria provide a basis for addressing with the legitimate concerns raised by the
evidence adduced in some of the leading English cases.
A.Ward@hull.ac.uk
Judicial Decision Making About Mental Health Evidence: Current Knowledge and Implications for
Forensic Practice
Richard E. Redding, Villanova University
The presentation will provide an overview of the current state of research and knowledge on the psychology of
judicial decision making with respect to the admissibility, relevance, and dispositive weight of psychological and
psychiatric evidence introduced in trial and appellate cases in American jurisprudence. Empirical and theoretical
research will be reviewed and future directions identified for research and practice with respect to: How Judges
Make Decisions, Biases in Judicial Decision Making, Psychology in the U.S. Supreme Court, Admissibility
Decisions Under Daubert and Kuhmo Tire, Judicial Decision Making on Criminal Forensic Issues, and Judicial
Decision Making on Civil Forensic Issues. For example, research indicates that, in trial court cases, judges favor
evidence about clinical diagnosis and ultimate issue testimony but view research data or statistically based
(actuarial) evidence as less helpful. Thus, it is important to explicate the usefulness of scientific evidence as applied
to the particular case. Research also shows that, at both the trial and appellate court levels, judges frequently fail to
correctly apply (or to apply at all) the Daubert criteria for the admissibility of scientific evidence. Thus, the litigants
themselves must effectively educate -- through their advocacy -- judges on how to apply Daubert to the particular
case. The focus throughout will be on these and other practical implications for how mental health professionals can
best present evidence to the courts and best influence legal decisions at both the trial and appellate court levels.
redding@law.villanova.edu
Assessing the Impact of Eyewitness Guessing and Lineup Bias on Eyewitness Performance
Steven Penrod, John Jay College of Criminal Justice
Lisette Garcia, John Jay College of Criminal Justice
Rommel Robertson, City University of New York
A recently published study (Behrman & Davey, 2001) of actual police records relating to 58 attempted lineup
identifications—reveals that 50% of witnesses chose the suspect, and that many witnesses (24%) erroneously
selected lineup foils. Similar data from studies of British witnesses confirms that about one-third of lineup
selections made by witnesses are innocent foils—these choices can be characterized as (bad) guesses. Of course, if
many choosers are erroneously guessing innocent foils, it is logical that some witnesses are guessing the suspect—
who may or may not be guilty. Researchers, who (unlike the police) know whether a choice is correct or not,
typically (but perhaps erroneously) regard any choice of a perpetrator as a correct identification—even though the
identification may be a guess.
Other research raises significant questions about the frequency with which suspects may be selected through
guessing. In a perfectly fair six-person lineup (where, for example, the 24% foil guesses noted above, are
distributed across five foils—an average of nearly 5% each) we would expect 5% of witnesses to guess the suspect
by chance alone. However, other research (e.g. Brigham, et al., 1999; Py, et al., 2003; Steblay, et al., 2001,
Valentine & Heaton, 1999) indicates that arrays are typically strongly biased against suspects such that suspects may
be selected two to five times more often than one would expect by chance.
This presentation will discuss: 1. the intersecting implications for the diagnosticity of witness identifications of
lineup bias in target-present and target-absent arrays, witness guessing, and the mixture of target-present and targetabsent lineups presented to witnesses, 2. the implications of ignoring guessing in experimental research, 3. a model
of witness choosing that takes into account witness guessing to provide a more complete picture of witness
performance in lineup situations, and 4. implications for police and judicial practice.
spenrod@jjay.cuny.edu
ligarcia@jjay.cuny.edu
RRobertson@gc.cuny.edu
Empirical Observations of the Formation of False Memories
Lena Hellblom Sjogren, Psychological Consultant, Fagersta, Sweden
False memories formated in the process to help children and adults to tell and to remember about abuse are focused
with examples taken from criminal and custody cases investigated by me. An eagerness to help can explain why
investigating policement and other professionals develop tunnel viewing and put suggestive questions resulting in
confirmation bias, though not often identified as sources of error with serious consequences for the alleged victims
of abuse. The difficulties to erase false memories are discussed in connection with the concept of deprogramming as
a way to help a child who has developed a Parental Alienation Syndrome, partly because of false memories.
mail@testimonia.se
Forensic Evidence in Criminal Trials II
Expert Psychological Evidence in English Criminal Courts: An Under-used Resource?
James McGuire, University of Liverpool
The admissibility of expert psychological evidence in court has been a topic of extensive interest amongst both
lawyers and psychologists in several countries. In numerous studies and commentaries, authors have delineated
several key elements of this, focusing on a wide range of issues including evaluation of witness accuracy,
assessments of mental state, judgments of criminal responsibility, and violence risk assessment. Much of the
resultant debate has been focused on careful scrutiny and analysis of some key landmark cases. Unfortunately in the
United Kingdom comparatively little attention has been paid to these questions. The greatest headway in
establishing the value of psychologists’ evidence has been made with respect to false confessions and miscarriages
of justice, and in assessment of vulnerable witnesses. A search of legal databases yielded very few cases that showed
psychologists providing evidence beyond their traditionally perceived role in ‘mental testing’. In the present paper,
this state of affairs will be examined. Discussion will focus on the extent to which it is attributable to the pervasive
effects of the Turner Rule in English courts. The paper will consider whether, on the basis of recent scientific
advances, an increased use of psychological evidence could be advantageous in making legal decisions.
merc@liv.ac.uk
A Critical Examination of the Court of Appeal’s Decision in R v Gilfoyle [2001] 2 Cr.App.R.57
Faye Boland, University of Liverpool
Traditionally, admissibility decisions in the United Kingdom have required scant attention to the reliability of
evidence tendered in criminal trials. Rather, decisions on the admissibility of evidence have focused on the expert’s
qualifications or experience (R v Robb (1991) 93 Cr.App.R.161) and on whether the proffered evidence is likely to
be outside the experience and knowledge of a judge or jury (R v Turner [1975] QB 834). However, Davie v
Edinburgh Magistrates 1953 S.C.34 provided that expert witnesses must furnish the court “with the necessary
scientific criteria for testing the accuracy of their conclusions, so as to enable the judge or jury to form their own
independent judgment by the application of these criteria to the facts proved in evidence.”
In R v Gilfoyle [2001] 2 Cr.App.R.5 the Court of Appeal declined to receive evidence of a psychological autopsy
offered by a distinguished psychologist. The basis of its decision was the absence of any literature or body of
knowledge or experiments by reference to which the Court could test the methodology or the expert’s particular
application of it. The Court of Appeal held that psychological autopsies were not recognised as having any real
scientific basis and so should not form the subject of expert evidence, citing the Texas Court of Appeal decision in
Thompson v Mayes 707 S.W.2nd 951 (1986). Furthermore, the Court placed some reliance on the decision of the U.S.
Supreme Court in Frye v U.S. (1923) 293 F 1013 which held that “the thing from which the deduction is made must
be sufficiently established to have gained general acceptance in the particular field in which it belongs”.
This paper will examine the extent to which Gilfoyle represents a change to the law relating to the admissibility of
psychiatric evidence in the United Kingdom and in particular, in will focus on whether the criteria set out in Gilfoyle
will involve an increased focus on reliability. When questioning if the Court of Appeal’s approach is an
improvement on the former approach of the English courts towards the admissibility of psychiatric evidence,
particular regard will be paid to the controversial operation of the Frye general acceptance test in the United States.
This paper will address the English courts’ somewhat stricter approach to psychological than psychiatric evidence
and in this light will question the generalizability of the Frye test in the United Kingdom after Gilfoyle. This
approach will involve examining whether the general acceptance test is likely to be confined to the particular type of
evidence offered in Gilfoyle (novel psychological evidence) or whether it is likely to apply more generally to novel
scientific evidence.
fblaw@liverpool.ac.uk
The Brave New World of Expert Evidence in the Adversary System – Part I
Elizebeth Brimer, Barrister, Melbourne
There are a number of successful steps and procedures developed to improve the compilation and presentation of
expert evidence. They include exchange of reports, joint conferences between experts, joint expert reports
identifying points of agreement and issues in dispute and the “Hot Tub” procedure in the Federal Court of Australia
designed to identify and isolate issues. There are also education programs for experts and a greater focus by
professional bodies on ethical standards.
Although these new practices still have some problems which need to be resolved, they appear to be achieving the
right balance between maintaining the right of the parties to use expert evidence and a more efficient and focussed
system of using expert evidence without destroying the fundamentals of the adversary system.
The Brave New World of Expert Evidence in the Adversary System – Part II
George Hampel, Monash University Law School
The use of Court appointed experts and single experts are developments which are bound to produce more problems
then they are intended to solve. The test of these developments should be by reference to the difficult not the easy
cases. In a difficult case, where there is genuine dispute between experts, who will be the single expert? Will a
party against whose interest an expert opinion is expressed by a single and/or court appointed expert be entitled to
call its own experts? If so, what is being saved? If not, is it unjust? Who will choose the single expert? Will the
Court be prepared to reject the evidence of experts it has appointed? What sort of experts will be on the Court
panels? Will there be a need for “shadow experts”?
Not only are these real problems, but the whole approach so undermines the good qualities of the adversary system
that it tends to have the potential of producing unjust results.
George.Hampel@law.monash.edu.au
Advocacy I
Mental Health Law, Information and Advocacy Services in Northern Ireland
Jim Campbell, Queens University at Belfast
This paper describes a triangulated study into legal and information services for people with mental health problems
in Northern Ireland. It explored both advice and information services for people living in the community as well as
legal and other forms of advocacy for individuals detained against their wishes in hospital and appearing before
mental review tribunals. The views of three constituents were sought using a variety of approaches - five focus
groups with service users and carers (n=43), interviews with key informants who were expert in the field of legal
and advocacy services (n=8) and a questionnaire survey of 300 solicitors who claimed to be providing advocacy for
clients who attended mental health review tribunals.
The study revealed a growth in legal and information services available to people with mental health problems living
in the community, but that this tended to be piecemeal and unstructured. Views on the operation of the mental health
review tribunal tended to be mixed, ranging from an appreciation of the sensitive and principled management of the
legal process to criticisms about advocates being under resourced and lacking in key knowledge and skills. The
paper concludes by arguing for a more robust system of information and advocacy in such a key area of human
rights and at a time when the current mental health law is being reviewed.
Jim.campbell@qub.ac.uk
Lessons Learned: The First Year of Mental Health Services in a Student Community Legal Clinic
Lora M. Patton, Osgoode Hall Law School of York University
As Ontario’s mental health system transitions from a centralized, institutional-based structure to one more focused
on increasing independence and home-care, persons defined as being seriously mentally ill are being treated more
often within their own communities. With the change, persons previously living in hospital gain new independence
but also must deal with new realities, often without the promised community support: a lack of safe, affordable
housing, significant deficiencies in the social assistance programs, criminalization of behaviours related to their
illnesses and discrimination in every form. As such, they are interacting with the law in an entirely new way, an
interaction in which lawyers dealing with committal, capacity and treatment are unprepared to manage.
Community lawyers could hold the key to redressing some of the inequities facing this client group but as a
profession, we remain largely unprepared to meet this challenge. Typical legal training, clinical training in
particular, does not provide the knowledge of mental health systems nor the skills necessary to work with clients
with mental health needs. In order for the profession to respond effectively, legal education, both formal and
clinical must adapt.
In response to the recognized needs of the community and the educational needs of students, Community and Legal
Aid Services Programme (CLASP), a student clinic with a dual purpose of serving the community while providing
legal education to the student body, has created a priority program for persons with mental health needs. The initial
goals of the program were threefold:
 to increase awareness of mental health issues among law students thus increasing the number of lawyers
interested in the practice area
 to increase mental health law knowledge and develop skills necessary to effectively work with persons with
mental health needs among all law students in the program
 to increase access to justice for persons with mental health needs by prioritizing such matters within the
clinic
In addition to describing the historical background and the broader context of the programme, the paper will discuss
the challenges of developing the mental health priority within the clinic: getting staff and student “buy-in”,
identifying and meeting educational needs, addressing stigma/ discrimination, conducting community outreach and
building and stakeholder support. It will note the lessons learned over the first year and will help to identify the first
steps in building a foundation for clinical or skills development programs trying to integrate mental health into the
broader education structure.
lpatton@osgoode.yorku.ca
Engaging Law Students in Mental Health Issues: The Development of a Hospital-Based Legal Aid
Clinic for Mental Health Patients
Evelyn Vingilis, University of Western Ontario
Brenda Fuhrman, University of Western Ontario
The University of Western Ontario (UWO) Community Legal Services is a student legal aid clinic situated at the
law school. However, persons with serious mental illness are unlikely to attend this clinic, despite the fact that many
have legal issues that need counsel. Moreover, law students have little contact with persons with serious mental
illness in their education and practice, and a limited understanding of the issues and challenges facing persons with
mental illness as they try to navigate through the justice system. This presentation will describe a two-year
evaluation of the program logic model for developing a hospital-based legal aid clinic for mental health patients and
the implementation of the service. The purpose of the clinic is to provide a comprehensive mental health law
program that includes service provision to hospitalized persons with serious mental illness and an effective
education plan for both law students and health care students and professionals. The specific activities of the clinic
include: 1) patient access point to law students and UWO community legal services; 2) supervision of law students
at the tertiary care hospital; 3) intake and access to other services (e.g. marital problems) and 4) teaching and
additional training of law students and physicians. The paper will outline the short, intermediate, and longer term
objectives from the logic model and identify the indicators by which to determine whether or not program objectives
are being met. Additionally, the process evaluation will present data on program implementation, successes, issues
and challenges.
evingili@uwo.ca
Strengthening the Patients’ Position: Patients’ Advocacy in Austrian Psychiatries
Jutta Knoerzer, Association for Guardianship and Patients`Advocacy, Austria
In 1991 a new commitment law in Austria established a new profession: the Austrian patients` advocacy. This
branch of the “Association for Guardianship and Patients` Advocacy” has two main tasks: to represent all committed
psychiatric indoor patients at court and to support them in their communication with the hospital staff members. The
patients` advocacy is subsidized by the ministry of justice and is independent of the psychiatric hospitals and wards.
After a short survey of the Austrian psychiatric landscape information will be given regarding the patients` rights
and the legal frame of the commitment law with the patients´ advocates function.
The 40 patients` advocates in Austria can refer to an experience of yearly about 12.000 interviews with psychiatric
patients within the first days of commitment (“first interviews”) and 12.000 court hearings a year. Focus will be laid
on commitment, further coercive measures and medical treatment.
The patients´ advocacy does networking aiming to bring forward the exchange of the different points of views of
judges, psychiatrists and other experts. On the other hand the networking helps patients and their relatives to express
their points of view to the experts. It deepens transparency in psychiatry and has an increasing impact through
professional handling of complaints, for example against disregard and incursions.
The Austrian patients` advocacy works at the interface of law and mental health and tries to reduce the gap between
these two necessary, old and powerful social systems on behalf of psychiatric patients and their next of kin.
A Madness for Identity: Psychiatric Labels, Consumer Autonomy, and the Perils of the Internet
Louis C. Charland, University of Western Ontario
Psychiatric labelling has been the subject of considerable ethical debate. Much of it has centered on issues
associated with the application of psychiatric labels. In comparison, far less attention has been paid to issues
associated with the removal of psychiatric labels. Ethical problems of this last sort tend to revolve around identity.
Many sufferers are reticent to relinquish their iatrogenic identity in the face of official label change. Some actively
resist it. New forms of this resistance are taking place in the private chat rooms and virtual communities of the
internet; a domain where consumer autonomy reigns supreme. Medical sociology, psychiatry, and bioethics have
paid little attention to these developments. Yet these new consumer-driven initiatives actually pose considerable
risks to consumers. They also present complex ethical challenges for researchers. Clinically, there is even sufficient
evidence to wonder whether the internet may be the nesting ground for a new kind of identity disturbance. The
purpose of the present discussion is to survey these developments and identify potential issues and problems for
future research. Taken as a whole, the entire episode suggests that we may have reached a turning point in the
history of psychiatry where consumer autonomy and the internet are now powerful new forces in the ‘manufacture
of madness’.
charland@uwo.ca
Alterity – Our Relationship with the Other
The Recovery Model: Discourse Ethics and the Retrieval of the Self
Joseph Fardella, Providence Continuing Care Centre, Kingston, Canada
The Recovery Model, as applied in mental health, is significant because it intends to foster a critical retrieval by the
subject of herself as a self-determining agent of change. As such, the Recovery Model recognizes the influence of
internal and external circumstances toward a healthy retrieval of the self. The internal conditions include the
individual’s ability to reflect on personal ideas, values, attitudes which may inhibit or promote transformative
change. The external conditions include policies, professional practices, systems, etc., which may enhance or
impede the clients possibilities for self-expression or growth. Consequently, the client is engaged in an ongoing
conversation with herself, and with others, concerning those individual and social conditions most conducive to her
ongoing recovery and care of the self. As such, the client must be mindful of the ways in which she may have
internalized concepts or expectations which impede her possibilities for positive growth. At the same time,
professionals who support the Recovery Model, must continue to ask themselves (and their clients) whether their
approach invites clients to greater freedom, or masks a misuse of power. Consequently, the paper will argue that the
discourse ethics of Jurgen Habermas provide moral and cognitive categories which assist both clients and
professionals as they critically assess the extent to which agreed-upon interventions promote non-coercive forms of
recovery. It will also argue that this “dialogical” approach to decision making is intrinsic to a healthy retrieval of
self.
joseph.fardella@sympatico.ca
Towards an Understanding of the Interfacing between Sociological and Psychological Alterity in the
Case of Baudelaire
Judith Spencer, University of Alberta
The concept of alterity as it relates to Baudelaire has, to date, been explored from a psychoanalytical standpoint. The
will-to-failure on the part of the poet, whose permanent moral distress is now legendary, is not new to critical
scholarship: the syndrome d’échec postulated by Laforgue in 1930, and reiterated by Sartre in his celebrated essay
on the poet dating from 1946, resurfaces in Pichois and Ziegler’s more recent biography of the poet which focuses,
amongst other things, on the manner in which Baudelaire deliberately brought upon himself the cataclysmic events
which shaped his life, namely the conseil judiciaire and the condemnation of Les Fleurs du mal by the court in 1857
on the grounds of immorality. The latter notwithstanding, it is not without significance to underscore the fact that the
fundamental alterity grounding the poet’s being arguably finds its place in the context of the problematics of the
romantic poet striving towards the Infinite in a finite world, that permanent striving making of him the eternal
outsider. Our understanding of the concept of alterity from a psychoanalytical perspective, however, can in no way
be dissociated from the problematics of existential alterity as manifest in the social pariahdom of the post-maecenic
writer on the post-revolutionary stage of History. The aforementioned problematics has been analyzed both by
Sartre and by Benjamin who goes so far as to consider the lyric poet living in the era of high capitalism as outcast
and whore by virtue of the fact that he is obliged to make of his œuvre an economic commodity to be sold in the
literary forum. This paper will examine the manner in which the dysfunctional relationship of the poet to his
environment is exacerbated by the pathological social context facing the post-maecenic writer, the impetus towards
self-destruction ingrained in the poet’s modus vivendi ultimately finding allegorical expression in the pathological
functioning of the self-consuming romantic aesthetic artefact.
spencerj@augustana.ca
Moral Communities and Moral Universalism
Donald Ipperciel, University of Alberta
Since Kant’s formulation of the universal moral law, morality has been defined in terms of universality. Today, the
“moral point of view,” understood as a principle of impartiality, reflects the Kantian concern for universalism. At
the level of justification of norms, moral universalism is quite compelling. But at the level of application of norms, it
seems to come short of being truly useful or practical.
Moral universalism seems to negate the true experience of the other by bringing every human being to an equal
status of dignity. In so doing, it defines a “we,” a sameness or an identity lumping together all of humanity, leaving
no space for otherness with a human face. “Other” applies then only to non-human entities.
Evidently, I will not be trying to do away with equal dignity, which is a fundamental tenet of Western morality. But
on the other hand, morality has to be made relevant for our daily lives. It has to be practical and reflect our daily
experiences, especially our experiences of otherness. Moral arguments that eliminate otherness may simplify moral
problems, but at the cost of making itself irrelevant to practical use.
By introducing the notion of “moral community,” I will try to maintain the validity of moral universalism while
finding a legitimate space for otherness in the sphere of morality. The goal will be to preserve the complexity of
concrete moral problems – in order to make moral reasoning relevant to the lived situations – while respecting
universal principles – thereby affirming the “moral point of view.”
More specifically, this paper will try to propose answers to questions such as: “What is the medical practitioner’s
responsibility towards Third World populations?”; “Is there an order of priority regarding the services and help
rendered to patients?”; “While delivering care services, is it morally right to favour one person or one group over
another?” etc.
donald.ipperciel@ualberta.ca
The Influence of Contemporary Media on the “Otherness” of the Mentally Ill
Cheryl Webster, Capital Health, Edmonton, Canada
Contemporary media has a profound impact on the development of public opinion and public attitudes towards
people with disabilities. These attitudes impact the lives of people with mental illness. Mental illness is relatively
common. Approximately 20 percent of the population in Alberta, Canada were treated for mental health problems
in 2002-2003. Despite the banality of mental illness, media representations of people with mental illness are so
powerful that they override the public’s personal experiences in relation to how they view mental illness. Inaccurate
portrayals influence the generation of public opinion regarding how a person with this disability should be treated
and views of how this disability should be managed. As consumers of contemporary media we must think about the
messages contained within this genre and recognize oppressive, prejudicial, and discriminatory content that
perpetuates stereotypes of people with mental illness. It is these stereotypes that typically result in power-over
versus power-with dynamics forming between people with mental illness and those without. The main consequence
of this dynamic is the de-humanization of the Other. From a relational ethic perspective a relationship is unable to
form when one of the participants is de-humanized. As a result there is not the capacity to make ethical decisions
and for those stigmatized they are often treated in an unjust and unfair manner resulting in biased decisions being
made related to healthcare treatment, resource allocation, employment opportunities, and available social supports.
clw2@ualberta.ca
Moral Distress and Moral Action: A Participatory Research Project to Enhance the Moral Climate for
Nursing and Interdisciplinary Practice
Patricia Rodney, University of Victoria
As a result of more than a decade of fiscal restraint by governments, nurses and other health care providers
throughout Western health care--especially in North America--are confronting serious limitations in the structural
and interpersonal resources available for their practice. At the same time, changes in biomedicine (e.g. an expanded
repertoire of life-prolonging treatments), demographics (e.g. an aging population), and social supports (e.g. the
expanding impact of poverty) mean that nurses and other health care providers are also dealing with increasing
acuity and distress of patients/clients, families, and communities. Such difficulties raise significant values-based
questions about the quality of treatment and care received by patients/clients, families, and communities. They also
raise significant values-based questions about the moral well-being of nurses and other health care providers, as well
as the moral well-being of managers/administrators. There has been erosion in the moral climate for nursing and
interdisciplinary practice. And when nurses and other health care providers are unable to practice according to their
ethical standards, they experience moral distress. Moral distress is associated with feelings of anger, frustration,
guilt, and powerlessness, and is an important component of what we have been calling "burnout".
In this paper, the author will describe the design and findings to date from a Canadian participatory action research
study that is aimed at improving the moral climate for nursing and interdisciplinary practice (Ethics in Action:
Strengthening Nurses' Enactment of Their Moral Agency Within the Cultural Context of Health Care Delivery). This
is a three year study funded by the Social Sciences and Health Research Council of Canada, and is taking place in an
acute medical/oncology unit and a busy suburban emergency department. The author and the team of investigators,
graduate students, and clinical researchers she is working with will be completing the third year of the study at the
time of this presentation.
During her presentation, the author will explain the research team's methodology, including the specific methods the
research team has used. She will also outline the research team's major insights and achievements. This will include
highlighting the policy implications of the research findings. Audience members will have the opportunity to engage
in discussion about the implications of the research.
prodney@direct.ca
Workplace Empowerment as a Predictor of Nurse Burnout and Mental Health in Canadian Health
Care Settings
Heather K. Spence Laschinger, University of Western Ontario
Joan Finegan, University of Western Ontario
Judity Shamian, University of Western Ontario
Piotr Wilk, University of Western Ontario
Nurses have been hit hard by health care restructuring initiatives in Canada. There is evidence to suggest that rather
than increase productivity, these changes have resulted in increased work stress among nurses, greater risk for
medical error, patient dissatisfaction and possibly litigation. It is critical to find ways to help nurses do their work
more effectively to avoid endangering patient care. Employee empowerment has been suggested as a strategy to
foster improved performance and lower job stress. Kanter’s (1993) Theory of Organizational Empowerment
provides a framework for investigating the role of empowering work conditions on nurses’ mental health. This study
tested a model linking the effects of empowerment at one point in time to nurses’ reports of burnout and mental
health three years later.
A longitudinal design was used to test the model in a random sample of 192 Canadian staff nurses. Measures of
structural and psychological empowerment and mental health and burnout were mailed to a random sample of
registered nurses (Conditions of Work Effectiveness Questionnaire-II: Psychological Empowerment Scale, and the
Maslach Burnout Inventory-General Survey.
Nurses in this study (44%) reported high levels of emotional exhaustion according Maslach’s norms, suggesting
they were at risk for severe burnout. Structural equation modelling analyses revealed a good fit of the data to the
hypothesized model (Chi-square=198.68, df=85, IFI=.90, CFI=.90, RMSEA=.08). Perceptions of structural
empowerment had a significant direct effect on psychological empowerment at Time 1 (.435), which in turn, had a
significant effect (-.283) on perceptions of emotional exhaustion at Time 2 (3 years later).
Nurses’ perceived access to workplace empowerment structures resulted in increased psychological
empowerment at Time 1 and these feelings of empowerment were predictive of lower burnout levels at
Time 2. These results strengthen those of previous cross-sectional research linking empowerment to
burnout among nurses and suggest that fostering environments that enhance perceptions of empowerment
can be an effective way of preventing burnout and improve mental health among nurses. The results
provide insight for managers, nurses and policy makers regarding the applicability of Kanter’s work
empowerment theory in creating work environments that reduce the likelihood of job stress and poor
mental health among nurses.
hkl@uwo.ca
Substance Abuse I: Amphetamines, Mental Health and Law
Clinical and Sub-Clinical Symptoms of Psychosis in a Sample of Young, Injecting Amphetamine Users
Sharon Dawe, Griffith University
David Kavanagh, University of Queensland
Ross Young, Queensland University of Technology
John Saunders, University of Queensland
Amphetamine use has emerged as a major drug problem in Australia and especially in SE Qld where its use far
exceeds that of heroin. Among amphetamine users there appears to be a substantial but poorly described experience
of mental disorders that range from frank psychoses to subclinical symptoms that include abusive and aggressive
behaviors, suspiciousness and impulsivity.
In order to define the extent and nature of mental health problems and to gauge what treatment responses are
appropriate for the health care system, we conducted a systematic examination of these symptoms in a cohort study
of 232 amphetamine users presenting at a Needle Syringe Exchange Program. Measures included the Brief
Psychiatric Rating Scale (BPRS) and the Psychosis Screening (PS) measure (Degenhardt & Hall, 2001) and detailed
drug and psychiatric history.
The mean number of days amphetamine use in the last 30 days was 10.4 (+ 8.7), 28% had used daily. 19% reported
that they had been admitted to a psychiatric hospital for psychosis, mean age of first episode was 20.8 (+6.2) years
and 21% scored > 3 on the PS. The relationship between positive symptoms and recent amphetamine use was
investigated using hierarchical multiple regression. After controlling for previous hospital admissions for psychosis,
and other drug use (cannabis and alcohol), recent amphetamine use was significantly predictive of current positive
symptoms.
These data raise important clinical questions on how best to approach the treatment of amphetamine both
pharmacologically and psychologically, given the high rate of comorbid psychotic illness.
S.Dawe@griffith.edu.au
Dynamic Pupillometry and its Use in the Prognosis of Relapse in Alcohol Dependent Patients
Alexander Dvorak, Medical University Vienna
I. Hertling, Medical University Vienna
K. Ramskogler, Medical University Vienna
G. Böck, Medical University Vienna
L. Linzmayer, Medical University Vienna
J. Grünberger, Medical University Vienna
H. Walter, Medical University Vienna
O.M. Lesch, Anton Proksch Institute
The chronic intake of alcohol in harmful amounts leads to a shift in the balance of all neurotransmission systems in
the central nerve system. For instance an overexprimation of acetylcholinesterasis sensitive muscarinergic receptors
leads to an increase of apoptosis in the cholinergic basal frontal lobe. After the ingestion of psychotropic substances
cholinergic receptors induce a miosis of the pupil, whereas sympathic receptors lead to a dilatation (mydriasis) of
the pupil.
The Receptortest used in pupillometry is a noninvasiv method to evaluate an occurring deficit of
acetylcholinesterasis and the resulting cognitive impairment of the patient assessed.
During this examination drops of tropicamide (a potent anticholinergic and mydriatic substance) are applied to one
of the eyes of the patient leading to maximal pupil dilatation after approximately 40 min. The pupil’s diameter is
now recorded during the following hour. The last value is then compared to the first result and the difference stands
in direct correlation to any decrease in cholinergic receptors, whereas a deviation of over 20% can be seen as
pathologic.
Earlier studies showed, that alcohol-dependent patients usually show a greater dilatation compared to baseline as can
be found in control-groups. These aberrations are never as high as seen in patients suffering from Alzheimer’s
disease.
In our trial we performed the receptor-test on 52 alcohol dependent patients between the 2nd and 4th day of
withdrawal. Additionally biological parameters and the Typology of Lesch were performed.
As the quantity of cognitive impairment in alcohol-dependents stands in direct correlation to their risk to suffer a
relapse, this examination method can be used to better assess the probability of an upcoming relapse and also the
further course of the individual patients dependence.
In combination with the Typology of Lesch, this test can be of great value for the prognosis of alcohol relapses in
forensic alcohol dependent patients.
alexander.dvorak@meduniwien.ac.at
The Course of Psychotic Symptoms in Young Amphetamine Users Admitted with Early Psychosis
Leanne Geppert, Griffith University
Sharon Dawe, Griffith University
William Kingswell, The Park Centre for Mental Health, Queensland, Australia
The symptom profile of amphetamine induced psychosis is usually considered to mimic that seen in other non-drug
induced psychoses, especially paranoid psychosis. However, few systematic investigations have been conducted and
none that control for stage of illness (early stage vs. chronic) and assess substance use in detail. In this study young
people with early psychosis (less than 3 previous episodes) underwent detailed assessment of historical factors
implicated in the development of psychosis, recent substance use and current symptoms. Further, the course of their
illness was monitored.
63 inpatients were assessed at day 1-2, day 4, day 7 and then weekly until discharge. The Brief Psychiatric Rating
Scale and the Disturbed Behaviour Rating Scale were administered at each time point. Demographics, drug and
alcohol use and history were also collected.
The mean age of the sample was 26.5 years (SD=7.3) and 71% were male. Drug use was common with just under
half of the sample smoking cannabis (30% smoked > 20 days) in the last month. Amphetamine use was reported by
40% of the sample with 15% using > 20 days in the last month. Preliminary analyses have been conducted to
determine the relationship between amphetamine use and symptoms at admission. There is a significant r between
manic excitement and amphetamine use and a significant negative correlation between negative symptoms and
amphetamine use at baseline. Further analyses are planned.
There were high rates of substance use. Symptoms profiles between those with amphetamine use and those without
had some similarities; e.g., positive symptoms. However, days of amphetamine use was related to the severity of
symptoms rated as manic excitement (hostility, grandiosity, distractibility, excitement, elevated mood and motor
hyperactivity). Further, there are fewer negative symptoms in those with greater number of days of amphetamine
use.
leanne.geppert@griffith.edu.au
Amphetamines, Psychosis, and the Insanity Defence
William John Kingswell, The Park Centre for Mental Health, Queensland, Australia
Amphetamine use is a significant public health problem in Australia generally and in Queensland particularly.
Amphetamine is the second most popular illicit drug (after cannabis) and the most commonly injected drug in
Australia. Markedly abnormal mental states occur following the use of amphetamines and amphetamines can induce
an acute or chronic psychotic state. These mental states often result in hospital admission and place a significant
burden on health services. One large metropolitan hospital in Brisbane has reported 2.5 admissions per day to the
mental health unit for the management of amphetamine related psychiatric disorder. The distinction between
“intoxication”, transient or chronic “psychotic states” and the legal definition of “mental disease” causes some
confusion for psychiatrists and lawyers. Amphetamine related disorders have formed the basis for an insanity
acquittal in a number of Australian Jurisdictions.
This paper briefly:
1. reviews the public health implications, particularly mental health implications of current patterns of
amphetamine usage in Australia and within Queensland,
2. discusses the literature in relation to psychiatric sequelae of amphetamine abuse,
3. reviews Australian case law contributing to the legal definition mental disease,
4. reviews a number of determinations of Australian courts dealing with amphetamine abuse, psychosis and
the insanity defence,
5. outlines the unique function of the Queensland’s Mental Health Court and reviews a number of cases
decided in that division of Queensland’s Supreme Court.
And finally suggests some guidelines for practitioners involved in assisting courts determine insanity provisions
when amphetamine abuse is a complicating issue.
Bill_Kingswell@health.qld.gov.au
Epidemiology of Drug Abuse
W. Compton, National Institute on Drug Abuse, USA
The past 30 years of research in the United States on the epidemiology of drug use, drug use disorders and related
health conditions such as HIV has provided major insight into these conditions. Drug use peaked in the late 1970’s
decreased across the 1980’s, increased in the 1990’s and has remained generally stable during the past few years.
Within this broad pattern, specific epidemics of crack cocaine, amphetamines, club drugs (such as 3,4methylenedioxymethamphetamine), heroin and prescription opioids as well as associated epidemics of HIV and
other infectious diseases have been identified and tracked. In addition to major accomplishments in surveillance,
drug abuse epidemiology has traditionally focused on identifying risk factors at the individual (e.g. genetic factors,
high risk behaviors), family (e.g. child abuse), neighborhood (e.g. high availability of drugs) and social (e.g. policies
and laws) levels. Studies include both careful cross-sectional and longitudinal observational studies as well as
clinical epidemiology experiments in which prevention interventions serve as tests of specific etiological theories.
Now, the field needs to focus on linking basic science with epidemiology in order to make progress in understanding
these complex health conditions.
wcompton@nida.nih.gov
Addiction and developmental disability: research and treatment
Morwenna Nieuwold, Hoeve Boschoord, Boschoord, The Netherlands
Maria Trentelman, Hoeve Boschoord, Boschoord, The Netherlands
Hoeve Boschoord is an institute in the North of Holland where people with a developmental disability and problem
behaviour are treated. The majority of the population have been sent there by the court, some are there voluntarily.
Research and treatment are subdivided into four specialisms: aggressive behaviour, sexual deviations, autism and
substance abuse. Research and treatment are geared for each other.
Little is known about the combination of developmental disability and substance abuse. In the research department
of Hoeve Boschoord an examination of the literature on this specific combination has been conducted and results are
shown. Furthermore implications of these findings for treatment are discussed.
Treatment in Hoeve Boschoord is based on a behavioural approach. The development of a treatment programme
aimed at substance use disorder and developmental disability will be presented. A picture of the current state of
affairs is painted on the basis of real-life cases and practical experience of patients and field workers. Difficulties in
the treatment of this population are discussed, such as required treatment and the implications of cognitive deficits.
M.nieuwold@hoeveboschoord.dji.minjus.nl
M.Trentelman@hoeveboschoord.dji.minjus.nl
Assessment and Treatment of Sex Offenders in Switzerland
Present and Past Practices of the Biological Treatment of Sex Offenders in Switzerland: A. Review
Andreas Frei, Psychiatrische Klinik, Lucerne, Switzerland
The biological or pharmacological treatment of sexual offenders in Switzerland has - in spite of unquestionable
success concerning recidivism - been challenged in the last decades and was hardly ever applied; mostly due to an
uncritical application of this treatment charged with heavy side-effects. Since the conceptualisation of some of the
paraphilias as disorders of the OTC-spectrum, the application of SSRI's has been recommended. Since some years,
anti-testosterone treatment with so-called LDHD-Agonists is said to be both successful and better tolerated than the
one with Androcur® (Cyproterone-Acetat), a perpherically acting substance. Due to some very encouraging studies,
the application of drug-treatment for dangerous and/or reoffending perpetrators in Switzerland should be
reconsidered.
andreas.frei@ksl.ch
Release from preventive criminal detention of high-risk offenders. Methodical considerations based
upon a catamnestic study about the results of a swiss expert commission
Marc Graf, Universitäre Psychiatrische Kliniken, Basel, Switzerland
N. Händel, Universitäre Psychiatrische Kliniken, Basel, Switzerland
Volker Dittmann, Universitäre Psychiatrische Kliniken, Basel, Switzerland
In switzerland every year about 15 high risk offenders are sentenced to preventive detention whereas one offender
per year is released. Since the introduction of the interprofessional expert commission in the canton of berne in
1995, none of the 18 released cases led to relevant relapse. The expert commissions duty is to perform risk
assessment and to advice the responsible authorities .We will present the data of our catamnestic study on the release
of these high risk offenders, outline the method used for risk assessment, discuss methodical problems and consider
the actual legislative development in this field.
marc.graf@upkbs.ch
Criminal career and relapse of sex offenders – results from a swiss cohort study on forensic-psychiatric
risk assessment
K.D. Römer, Universitäre Psychiatrische Kliniken, Basel, Switzerland
Marc Graf, Universitäre Psychiatrische Kliniken, Basel, Switzerland
C. Kiss, Universitäre Psychiatrische Kliniken, Basel, Switzerland
Volker Dittmann, Universitäre Psychiatrische Kliniken, Basel, Switzerland
As part of the Basel cohort study on forensic-psychiatric risk assessment, we examined the sub-population of 63 sex
offenders. Mean observation time was 90 months and the group consisted of an almost equal number of child
molesters and offenders against adult victims. We raised data on previous convictions, forensic assessment, courts
decisions, the process of sentences or court ordered treatments and, of course, recidivism. 16 subjects reoffended,
half of them again with sex offences.
We will provide data on criminal careers of different subtypes of offenders and a differentiated evaluation of risk
prognosis. The latter beeing accomplished by means of a structured criteria based method, better known lately as
„structured professional judgement“.
Konstanze.roemer@upkbs.ch
Is there a difference between consumers of child pornography and child molesters?
Marc Graf, Universitäre Psychiatrische Kliniken, Basel, Switzerland
Volker Dittmann, Universitäre Psychiatrische Kliniken, Basel, Switzerland
Pedophile paraphilia is considered to be a strong predictor for child abuse. At a first glance, the large number of
persons convicted lately for consuming pedophile internet pornography and the data on prevalence of pedophile sex
interest in the general population raise questions, wheter this thesis can be held. On the other hand, this might
explain the high prevalence of child abuse. The above mentioned question becomes crucial, when it comes decide,
for example, wheter a school teacher, convicted for the consumption of pedophile internet pornography, is at risk to
committ sex offences against children and therefore to disqualify for his profession.
The forensic psychiatric department at the univeristy of basel, switzerland, is therefore running a comparative study
with different group therapies for consumers of pedophile pornography and child molesters. Both, methods and
results of psychiatric, forensic and biological assessment will be presented and considerations for therapy and risk
assessment will be outlined
Marc.graf@upkbs.ch
Capacity and Consent I
Review of the Office of the Protective Commissioner in New South Wales
Andrew Constance, Parliament of New South Wales
The New South Wales Parliamentary Public Bodies Review Committee is currently reviewing the New South Wales
Office of the Public Trustee. The Office acts as an independent and impartial administrator and trustee for the
people of New South Wales. It has four core functions: will making; estate administration; trusts; and power of
attorney services. The Public Trustee is currently a financially self supporting government trading enterprise with a
revenue stream derived from both commissions and fees levied against individual estates, trusts and agency matters.
The Office only makes wills for people who appoint the Public Trustee as Executor, Co-executor or Substitute
Executor. Will making is free and thus a loss leader for the Office. The Public Trustee also acts as trustee, manager
or receiver of funds for infants or those unable to manage their own funds. Key issues the Committee is examining
are: fee structures; delays in estate and trust handling; existing powers of attorney; competency issues; and the
financial future of the Office. Recent radical reforms to tort law in New South Wales have seen a significant drop in
the amount of compensation payouts being awarded for injuries and thus subsequent trusts being handled by the
Office.
catherine.watson@parliament.nsw.gov.au
Communicating with Carers; A Key to Consent, Care and Treatment
Pauline Gill, Central Mental Hospital, Dundrum, Ireland
Working with carers is more than adhering to a political correct philosophy. In 2003 a programme of positive
engagement with carers was established within the National Forensic Mental Health Service. A central principle of
the programme was to improve the standard of care for the patient. The aim of the programme was to develop a
partnership with carers and empower them to participate and contribute to the treatment and care plan of their
relative. It was also to recognise the positive contribution that carers make to assessment, treatment and compliance
with treatment and care plans
From the questionnaire carers identified the main issues as:
 Recognition that carers have an expertise that when accessed, enables professionals to formulate accurate
assessment and treatment plans
 Carers’ ability to support their relatives within the service in decision making regarding their treatment and
care
 The more informed carers are the greater their ability to provide accurate information and engage in
discussion with their relatives (informed consent)
 The ability of carers to become powerful advocates on behalf of the service. communicating the needs of
the service in a unique way
 Recognition of the protective factors that family support provides for patients on discharge from hospital
 The need to feel valued and supported as carers
 A lack of easily accessible information regarding mental illness and current treatment.
 Difficulties in understanding the complex legislative framework governing the mentally ill, particularly in
regard to their detention in a Forensic Mental Health Centre
 The difficulties and stigma related to people with mental illness especially people who may have offended
This presentation reviews the outcomes the carers program within a National Forensic Mental Health Service.
Pauline.gill@ecahb.ie
Are Measures of Psychopathology Reflective of Functional Mental Capacity?
Emer Rutledge, Glenroyd Day Hospital, Nenagh, Ireland
Helen O’Neill, Central Mental Hospital, Dundrum, Ireland
Harry Kennedy, Central Medical Hospital, Dublin, Ireland
We hypothesized that in schizophrenia and schizophreniform psychoses (1) tests of functional mental capacity
should be independent of general measures of mental state if these capacities can really be preserved in the presence
of psychosis (2) tests of functional mental capacity should be independent of each other if they are truly functionspecific (3) tests of functional mental capacity should differentiate patients according to independent criteria.
For legal purposes, functional capacities are held to be specific to the task in hand, and it is assumed that some
functional capacities can be intact even while others are impaired. The most extensively researched instruments for
the measurement of functional capacities, e.g. the capacity to stand trial, to consent to treatment, to make a will;
emphasize the capacities to understand relevant information, to reason about the task in hand, and to appreciate the
relevance of the information and reasoning to one’s self.
A sample of 67 forensic inpatients with schizophrenia or a schizophreniform disorder, were interviewed. The
instruments used for rating functional mental capacity were: The MacArthur Competence Assessment Tool – Fitness
to plead (MacCAT-FP) and the MacArthur Competence Assessment Tool – Treatment (MacCAT-T). We used the
Positive and Negative Syndrome Scale (PANSS) and the Global Assessment of Functioning scale (GAF). We used 2
criterion tests: 1. Clinician’s rating of fitness to plead using Prichards’ criteria. 2. The capacity to express a treatment
choice.
Tests of functional capacity are correlated with measures of general psychopathology, but the correlation only
accounts for 30% to 40% of the variance. The elements of functional capacity correlate with each other and are not
function-specific. Using the criteria of fitness to plead and the capacity to make a treatment choice the MacCAT-FP
performs better than the MacCAT-T in differentiating between those who can make valid treatment choices and
those who cannot. The PANSS-positive, PANSS-total and GAF also differentiate between these groups.
Measures of mental state and functional capacity are only partly independent. 64% of the variance in functional
capacity measures is not accounted for by variation in mental state as measured by the PANSS.
erutledge@oceanfree.net
Understanding and Appreciation: Physiology or Philosophy?
Miriam Kennedy, Central Mental Hospital, Dundrum, Ireland
A person is deemed to be competent to consent to treatment and the burden of proving otherwise resides in the
person who would seek to overturn the person’s decision. This is seen as a means of protecting some of the most
important values of our society. The historical development of what constitutes informed consent drives the legal,
political and clinical research interest in capacity to consent and its assessment. Many of the premises on which
research is based derive from philosophical constructs of reality itself, how we ‘know’ and ‘understand’, how we
can ‘appreciate’ or connect that understanding with our own individual experience. Modern European Philosophy
from Descartes onward has sought out a rationalist ethic seeking a basis for reality and behaviour. He was the first
philosopher to formulate a “critique” in the sense of looking at previous discoveries in a critical manner. Everything
can be doubted. This supremacy of thinking (‘Cogito ergo sum’) was the notion that led philosophy along a
subjectivist line. Within the scepticism regarding knowledge that ensued, Kant sought to see science as being much
surer and apply the criterion of Newtonian physics to philosophy. The mind works on subjective ‘categories’ which
have no objective content – this is provided by the information which comes in from the senses. In this paper the
main tenets of these philosophies will be outlined and compared and contrasted with the clinical cases where lack of
capacity is judged to be present. While the Enlightenment drove the emphasis on individual choice in western
society, the clinician is faced with the reality of how to restore the capacity for individual choice where it is absent
or seriously impaired. The balance of autonomy and protection (from harm) is constantly being weighed. From a
physiological point of view, cognitive deficits have direct bearing on decision making capacities. A person who is
suffering from a psychotic delusion most likely will fail to accept the relevance of treatment for their own
circumstances because they think that what they are told is not true for them. In appreciation we want to know
whether the patient comprehends the information but also whether they actually ‘believe’ it. It is not a matter of
questioning the patients’ choices but of questioning the quality of beliefs or premises on which these choices are
based (these beliefs must be relevant to the treatment decision)
The appropriateness of our attempts to quantify or categorise functional capacities will be discussed.
Findings to date on functional capacity on acute admissions to a national forensic service and six weeks
post treatment will be presented.
miriamkennedy@eircom.net
The Model of Human Occupation as a Guiding Theory in Forensic Occupational Therapy Service
Provision
Leighton Thomas, Central Mental Hospital, Dundrum, Ireland
Clinical work in a secure mental health service carries with it certain ethical and cultural difficulties. These are most
apparent when Occupational Therapy is introduced for the first time in a long established service. Cultural change
can be very difficult. Successful modernisation requires a clear message about the benefits to patients and how care
workers can achieve them. We introduced Occupational Therapy as part of a modernisation program for the
introduction of Multi-disciplinary team working in a 150 year old Forensic Psychiatric Hospital.
The Model of Human Occupation (MOHO) is a widely used and accepted structural and conceptual framework for
Occupational Therapy service provision. It has the advantages that it is easy to communicate to other disciplines;
and other disciplines can be easily involved in the process. It is also flexible enough to be applied to high security
and community based settings. There is evidence that it is effective in delivering therapeutic gains to patients.
Obstacles were identified to the introduction of an Occupational Therapy service. The reluctance to change the tried
and tested traditions within the hospital; fears from established staff that their role might be diminished, or that they
could be relegated to less interesting work. We found that by applying the MOHO framework in secure wards and
open settings new ways of working including community workshops were developed. Existing staff were consulted
and involved in the treatment planning process.
Ethically, we were concerned that patient involvement should reflect at every step with proper respect for their
consent. Often this meant testing their capacities for the tasks and programs we wished to engage them in.
Communicating matters of consent can often be accomplished better in non-verbal work.
Leighton.thomas@ecahb.ie
The Silence Behind the Walls: How the Forensic In-Reach Nurse Can Assist in Ensuring an Informed
and Meaningful Decision making Process
David Timmins, Central Mental Hospital, Dundrum, Ireland
Forensic services are provided by a national tertiary service based at the Central Mental Hospital (high and medium
secure beds) to a population of approximately 4 million, inclusive of a prison population of 3200. The guiding
principle of the service is that the mentally disordered patient should have the equivalence of care provided to the
rest of the population, whether in hospital or in prison.
Community forensic mental health nursing was first established in Ireland in 2002. The role was devised with two
main components in mind, namely to provide assertive out-reach into the community and assertive in-reach into the
prisons. The model for the latter is to provide community forensic mental health nurse services in prisons to see
inmates identified at reception as high risk or mentally disordered.
The competence of patients to make decisions about their own care is a fundamental issue in health care and as a
general principle the ability of patients to consent and/or refuse treatment should be respected. However, mentally ill
patients find themselves in the position where they can have treatment forced or coerced upon them. Such treatment
decisions are not taken lightly and should be considered with the patients best interests in mind, following full and
informed discussion with the patient, and in light of the respective legislation.
Nurses share a responsibility for ensuring that patients are informed about and understand their rights with regard to
the issue of consent and specific treatments. The prison in-reach nurse is ideally placed to play a key role in
ensuring that the elements of informed consent are met, providing a longitudinal nursing assessment on the issue of
capacity and advocating the patient’s views to the team.
This session will explore how the forensic community mental health nurse can play an integral role in ensuring an
informed and meaningful decision making process within a prison environment.
timmonsdavid@hotmail.com
Capacity and Consent II
Contrasting Contractual with Testamentary Capacity
Lawrence A. Frolik, University of Pittsburgh School of Law
Anglo-American law has long of enforced a higher level of mental capacity for an individual to enter into a valid
contract than to execute a valid will, the latter being known as testamentary capacity. There are several reasons for
the differing standards of mental capacity.
The difference arose in part because the law of contracts developed in English courts of law while the law of wills
was created by the English courts of equity. The courts of law were enforced the principal of contract law that
mandated a “meeting of the minds” before there could be a valid contract. If, because of a lack of mental capacity,
either party to the contract could not understand the essence of the agreement, no contract could result. The result of
judicial invalidation of a contract placed the parties back in the position that they occupied prior to the aborted
attempt to enter into a contract.
In contrast, when asked to admit a will to probate, courts only required a relatively low level of mental capacity
because they had a strong bias towards validating wills and avoiding having the estate of the decedent pass by
intestacy.
Because the validity of a will is not determined until the individual who executed the document is deceased, a
finding that the will is invalid cannot be rectified. Consequently, courts adopted a very low standard of testamentary
capacity in order to ensure that they could validate wills even if executed by decedents who had a very low level of
mental capacity at the time that they executed the will.
A comparison of the level of mental capacity required for a valid contract or will reveals that it is defined by its
context. Legal mental capacity is a creation of the Anglo- American common law tradition that permits judges to
create law and legal standards that respond to social and economic realities. Consequently, the determination of
legal mental capacity is best understood not as a fixed standard, but as an adaptive, flexible response to larger
societal concerns.
frolik@law.pitt.edu
Determination of Capacity and Judicial Commitment to Safety and Order in Will Contests and
Guardianship
Alison Barnes, Marquette University Law School
Legal mental capacity proves to be an elusive standard to define for all cases. The capacity for testamentary
decision, while one of the lowest requirements for capacity, is sharply criticized for contradictions in similar cases.
Once removed from the objective and professional realm of decision making, it is apparent that people capable of
making decisions are not necessarily recognized as such. Indeed, the psychological evaluation and judicial
commentary, of persons alleged to have mental disabilities-- particularly those related primarily to age or chronic
physical disability-- tends to show that a conclusion of incapacity is related as much to the abilities and efforts of
family and professionals providing care as to the actual capability of an individual in making decisions.
If such decisions regarding capacity are prevalent during a lifetime, it is most likely that decedents with similar
disabilities are sometimes deprived of their testamentary freedom in the context of a will contest by means of
judgments of incapacity. This presentation discusses the connection between the elusive standards for determination
of incapacity in life and in will contest decisions.
alison.barnes@marquette.edu
Testamentary Capacity
Mary F. Radford, Georgia State University
Under state law in the United States, an individual cannot execute a valid will unless the individual has
“testamentary capacity.” Testamentary capacity is the legal level of competence required to make a disposition of
one’s property at death. The court will not enforce the provisions of a will if the testator lacked that capacity.
When a testator’s will is submitted for probate, those submitting it must prove that the testator did in fact have
testamentary capacity at the time the will was signed. The law favors a testator's right to dispose of his or her
property at death, and, consequently, the required level of capacity for doing so has historically been quite low.
Generally, a testator must have only a basic comprehension of the extent of her estate and the general nature of the
disposition she is making. These two components of the test for testamentary capacity resemble somewhat the test
used to determine whether an individual needs a guardian of her property. However, in most states, an individual
can be adjudicated to be “incapacitated” for purposes of having a guardian of the property appointed and yet still be
found to have had testamentary capacity. This session will explore how these two definitions of capacity differ and
yet mutually co-exist. An additional element of testamentary capacity that will be discussed is the requirement that
a testator recognize those persons whom the law deems to be the “natural objects of her bounty.” The law considers
a testator’s immediate family to be the “natural objects of her bounty.” Sometimes testators make dispositions that
are considered "unnatural" in that the testator gives the property to people other than family members or leaves it in
trust for purposes that are eccentric or unusual. While the “unnatural” disposition of a testator's property is not
sufficient to show the testator lacked capacity, this often becomes the focus of will contests. This session will
explore traditional definitions of testamentary capacity as well as cases in which decision-makers confuse the
question by infusing their own values into the determination of whether a testator had the requisite capacity.
mradford@gsu.edu
Assessment of mental capacity in medical and psychiatric in-patients
Matthew Hotopf, Institute of Psychiatry, Weston Education Centre, London, England
In England and Wales, two draft bills - the Mental Capacity Bill and the Mental Health Bill - will have a
considerable impact on how mentally incapacitated adults are treated. There have been calls for the Mental Health
Bill to be based on a test of mental capacity, rather than the current and proposed “status” approach, in which the
presence of a mental disorder determines the use of the Act, rather than the patient’s ability to make a specific
treatment decision. There has also been concern over the potential gaps in legislation between the two Bills.
In this presentation, I will describe three studies supported by the Wellcome Trust. First, I will present data which
suggest that mental capacity can be assessed with excellent inter-rater reliability when using the MacArthur
Competence Assessment Tool – Treatment (MacCAT-T). Second, I will describe our general hospital study in
which 159 consecutive patients admitted to medical wards were interviewed, using MacCAT-T. 31% of the
interviewed sample lacked capacity; this figure rose when taking into account non-participants who did not complete
the interview because of severe cognitive impairment or unconsciousness. Mental incapacity was strongly
associated with cognitive impairment and advancing age, but not with ethnic group, education or social class. Third,
I will describe a similar study involving 112 psychiatric inpatients interviewed within one week of admission. In
this sample, 43% lacked mental capacity; incapacity in this group was strongly associated with psychotic illness and
with country of birth - those born outside the UK were more likely to be rated as lacking capacity. Of the 63
patients who were judge to have mental capacity, 10% had been admitted under the Mental Health Act; this group
perceived their treatment to be more coercive than the remainder of the sample. Of the 49 patients who were judged
to lack mental capacity, 39% were not admitted under the Mental Health Act, and would therefore fall in the
“Bournewood gap”. This “gap” refers to incapacitated patients who are treated informally – that is, without being
sectioned under the Mental Health Act, because they accept hospitalisation and treatment "compliantly". The
European Court has ruled that such patients should be treated formally, which has major implications for services,
patients and carers. Finally, I will discuss the implications and potential impacts of these findings in terms of
proposed legislation.
m.hotopf@iop.kcl.ac.uk
An Instrument for Assessing Informed Consent in Inpatient Populations with Psychosis
Geoffrey Rees, Coronation Place Specialist Centre, Brisbane, Australia
It is widely assumed that long-term inpatients with chronic psychosis often have impaired ability to give informed
consent. In many individuals where inpatient hospitalization and treatment are mandated by law, treatment may be
given irrespective of the presence of informed consent and often against their wishes.
We have devised an instrument in the form of a 10 minute questionnaire that is easily administered to inpatients with
chronic psychosis.
Its aim is to measure and improve levels of informed consent in all patients considering treatment, with particular
use in those with psychosis.
Issues covered include patients’ experiences of ill-health / health on current, alternative and previous medication and
contrast this with past experience of mental status when medication free (including periods of non compliance or
voluntary abstention).
Assessment of any acknowledgement of risk to self / others when taking or ceasing treatment is attempted. We will
also assess patient preparedness and understanding of known risks should they cease treatment.
A simple risk/benefit analysis enquiry is undertaken. Responses are adjudged on bases including:
 Coherence and consistency
 Awareness of relevant issues
 Consideration of other people
 Preparedness for any known risks
Results of a comparative application of this instrument with 2 populations will be presented--1. Inpatients with a diagnosis of Chronic Schizophrenia
2. Outpatients with non-psychotic Axis 1 (DSM – IV) disorders
catherine@impressionbay.com.au
Children and Sexual Abuse
Determining the verite of childhood sexual abuse: the problems for courts, clinicians and law
enforcement
Mark J. Mills, Columbia University
As allegations of child sexual abuse/exploitation have become more frequent (and to some extent more credible), it
has become necessary for the law to develop acceptable methods to investigate such abuse. Interviews by clinicians
and/or law-enforcement officials can easily distort childhood memories of what occurred and my complicate
psychological recovery. This presentation examines a variety of troublesome issues involving abused/exploited
children from the perspectives of clinicians, attorneys and courts. Clinicians are typically most interested in helping
the victim work through the experience and less interested in the verity of what occurred. Law enforcement
typically takes the opposite tact: most interested in what actually occurred to bring perpetrators to justice and less
interested in the clinical impact of what is assumed to be reasonable inquiry. Courts try to balance these two
interests--bringing abusers/exploiters to justice while wanting to ensure that child testimony, if it occurs, is brief and
not harmful to the child. In the “real world,” of course, the lines blur. What is difficult in the U.S. judicial system is
that the accused has the right to confront the accuser--a principle that makes sense for two adults, but may be very
difficult when the victim is a child and even gentle cross examination may compound the psychological sequelae of
the original event. These issues are made more complex by parents who overreact to routine physical and sex play
between children. More difficult still are thde differences in international law that attempt to regulate such matters
across international borders. These matters and more will be discussed by the panel and the audience.
mjmills@forensicsciences.com
Borders, Boundaries, & Barriers: Cross-Cultural Legal Issues in International Cases of Child Sexual
Abuse
Delissa A. Ridgway, U.S. Court of International Trade, New York, USA
Cases of child sexual abuse/exploitation have always implicated physical and psychological boundaries. But,
increasingly, they cross geographic boundaries as well. In today’s globalized society, clinicians, courts and legal
counsel around the world are beginning to grapple with the unique challenges of investigating and prosecuting cases
that span more than one country. This presentation will survey some of the complex cross-cultural issues that may
be raised in such cases – ranging from linguistic barriers and differing psycho-social mores and taboos, to wide
variations in legal standards and procedures on matters such as the rights of all interested parties, proper
investigative and interrogation techniques, the requisite burden and quantum of proof, admissibility of testimony and
other evidence, the role of mental health professionals, statutes of limitations, and disparate approaches to
punishment and/or treatment of offenders, as well as issues of international judicial cooperation.
delissa_ridgway@cit.uscourts.gov
Assessing children’s allegations of sexual abuse - Discussant
Leonard D.Goodstein, Forensic Sciences Medical Group, Inc., Washington, USA
LenDG@AOL.com
Evaluation of Sexual Abuse
Roy Lubit, Mount Sinai School of Medicine
The evaluation of alleged sexual abuse is difficult and complex. Both children and adults frequently deny that they
had been sexually abused when they had been. Others assert that they have been sexually abused when they had
not. To assess whether sexual abuse had, in fact, occurred it is necessary to understand children’s memory and
children’s response to pressure. The propagation and use of appropriate interviewing techniques of allegedly
sexually abused individuals is crucial since once someone has been subject to problematic questioning techniques
their future reports may be forever contaminated. Appropriate techniques and the results of inappropriate techniques
will be discussed in this section.
Roylubit@rcn.com
Assessment of Post-Traumatic Stress Disorder in Children and Adolescents: Methods and Pittfalls
Wilfred G. van Gorp, Columbia University College of Physicians and Surgeons
Children who are the victims of child sexual abuse often experience, or are thought to experience, post-traumatic
stress reactions secondary to the abuse. Additionally, questions of credibility of the child’s report often come into
question. This presentation will focus upon assessment of validity of self-report, as well as assessment of signs and
symptoms of post-traumatic stress disorder (PTSD) in children and adolescents. Assessment of post-traumatic stress
disorder in children and adolescents poses special challenges. Assessment can be based upon structured interview,
indirect methods (e.g. play, projective tests), observation, and objective questionnaires. This presentation will review
the current, state of the art methods to assess for PTSD in children and adolescents, with a critique of the most
commonly used methods. Issues in deciding which, if any, of these formal instruments to use will be discussed with
the audience. Also, we will review the differences between standard clinical measures and newer research-based
instruments, with a review of pro’s and con’s between these two approaches for use in the non-research setting. We
will end with audience discussion of the utility of these various methods of assessment for the child who is
suspected of being the victim of sexual abuse.
wvangorp@aol.com
Children and Trauma I: Assessment and Intervention
Conducting Forensic Interviews with Traumatized Children
Kathryn Kuehnle, University of South Florida
Childhood trauma is frequently associated with a child’s maltreatment (i.e., sexual abuse, physical abuse, neglect)
and/or exposure to his or her parent’s abuse (i.e., domestic violence). When the traumatic events are of human
design, such as the various forms of family violence, the effects on the child may be especially severe. Furthermore,
co-occurring exposure to multiple forms of family violence, compared to single form exposure, is associated with
heightened trauma for the child. Studies on the psychobiological consequences of family violence and longitudinal
studies of abused children’s functioning indicate that family violence is associated with cognitive (e.g., impaired
memory, dissociative reactions), emotional (e.g., dysregulation), and social (e.g., aggression) impairments. Because
the traumatized child may persistently avoid stimuli associated with the trauma and make deliberate efforts to avoid
thoughts or conversations about the traumatic event or people who arouse recollections of it, the child’s effective
provision of a trauma narrative during investigative interviews may not be obtainable.
By training forensic interviewers to conduct non-leading and open-ended interviews so that children do not provide
false information or become cognitively contaminated, only one element of the disclosure dilemma has been
resolved. The part that has not been resolved is how to identify the chronically abused and traumatized children
who make deliberate efforts to avoid thoughts or conversations about their traumatic experiences or who disclose
bizarre, improbable, or seemingly impossible statements during the forensic interview. This presentation will
explore how trauma may impact the child’s perceptions, memory, and/or disclosure of family violence. A decision
tree will be offered to assist in the identification of these chronically abused and traumatized children.
kkuehnle@aol.com
Nature vs. Nurture: Are They More Than Complementary?
George B. Palermo, Medical College of Wisconsin and Marquette University
Present-day genetic and biological research seems to be complementary to the long-standing observations of
behavioural psychology. Traumatic experiences in childhood and adolescence and their behavioural consequences,
at times antisocial, have been well-documented by Sigmund Freud and Anna Freud and by numerous criminologists
thereafter. The consequences of abuse may be explained not only on the basis of an interactional relationship
between the offender and his or her usually young victims, but also on the poor myelinization of neurons in the
young person’s brain; a dysfunctional interplay of neurotramsmitters, such as serotonin and dopamine; and a
disruption of the victim’s hormonal balance, including that of CRF (corticotrophin releasing factor), ACTH
(adrenocorticotropic hormone) and cortisol. There is, obviously, an interplay between the mind and the brain, and
better knowledge of it will allow in the future a more thorough therapeutic approach to the victims of abuse and of
their later antisocial behaviors when present. Indeed, it is common knowledge that not all victims of abuse become
abusers. That has been a puzzling observation for socio-behavioral psychologists and criminologists. Recent new
genetic research may shed light on the observation that some abused children go through periods of physical and
sexual maltreatment without showing later the antisocial behavioural consequences seen in other persons who had
been abused as children. This recent research may further contribute to overcoming the perennial dichotomy of
nature vs. nurture.
Palermogb@juno.com
Innovative Mental health Programs for Treatment of Trauma With Incarcerated Juvenile Habitual
Serious Offenders and Juvenile Sex Offenders
Roy W. Persons, Beaumont Correctional Facility, Beaumont, Canada
Natasha Persons, Bon Air Juvenile Correctional Center, Richmond, Canada
This presentation will review innovative treatment programs used at our facilities that are designed to avoid the
typical defense mechanisms and resistences that serious habitual and sexual offenders utilize to avoid psychological
engagement in the treatment process. A specific focus of the use of these procedures with trauma cases in juvenile
offenders is presented. Art therapy, journaling, bibliotherapy, and gestalt therapy are combined with cognitivebehavioral therapy into a uniquely integrated approach. The program combines individual psychotherapy, organic
group therapy, and milieu programs with the above listed approaches.A slide presentation of the art work of the
trauma cases will be presented to illustrate the dynamics and the therapeutic process. Participants will be able to
chart and follow the method and process of the treatment procedures. Both qualitative and quantitative research will
be presented. The presentation will end with a voluntary experiential procedure that is utilized in our treatment
program with juveniles with trauma. Research and treatment method papers will be distributed.
personrw@djj.state.va.us
discoveryroy.@aol.com
The Biology of Childhood Trauma: Is it time to Rethink Our Concepts of Accountability and Justice?
Kathleen M. Heide, University of South Florida
Eldra P. Solomon, Center for Mental Health Education, Tampa, USA
This paper will review recent findings in the developmental neurophysiology of children subjected to Type III
(extreme, multiple event) trauma. Studies link psychological trauma with long term changes in the brain and
endocrine system that affect development and lead to problems in cognitive, affective, social, and physiological
function. These children have difficulty regulating affect and, without intervention, may not develop empathy. When
confronted with stressful situations, survivors of extreme childhood neglect or abuse have difficulty accessing higher
cortical centers, the areas of the brain essential for formulating socially appropriate decisions. Instead, they are
driven by limbic system activity leading to emotionally driven responses.
The authors discuss the implications of these findings for forensic evaluations, including competency
evaluations, mental status at the time of the offense, and factors in mitigation. Knowing that childhood
maltreatment compromises brain development and affects future ability to make decisions, the authors ask
whether it is just and fair to hold Type III trauma survivors to the same standards of accountability as
others who do not have the same history and risk factors? Based on new understanding of the effects of
child maltreatment, the authors invite law and mental health professionals to rethink their notions of
justice and offender accountability.
kheide@cas.usf.edu
epbsolomon@aol.com
Psychological Impact on Children of the Death of a Parent or Close Relative by the Police
John Burris, Attorney-at-law, Oakland, USA
In police abuse cases involving the death of a parent or loved one at the hands of the police, children are often the
neglected victim(s). It is well established that children suffer terribly when they are the victims of direct physical
and psychological abuse whatever the source. This presentation will focus on the children of the victims of police
abuse in death cases where the child has lost a parent or a close relative. In a death case much attention is given to
the adult members of the families particularly the spouse and the victim’s parent. But often the child of the decedent
suffers terribly and little if any attention is given to his/her emotional and psychological needs. Many children
suffer long-term effects of Post Traumatic Stress Disorders and other debilitating disorders but rarely do they
receive immediate and timely intervention.
I will draw upon my experience with many families where the police caused a death of their loved one. I will
discuss the short and long terms affects of the death on the children, and what efforts if any were made to meet their
needs. Also I will explore what effects this type of death had upon the child’s development from childhood through
adolescence and in some cases adulthood (school, social behavior, relationships with families, friends and the
police). As a reference, we will use my cases accumulated through 25 years of practice working with families
suffering the shock, despair and frustration of losing a loved one at the hands of the police causing the children as
innocent by standers suffering in silence. I will also explore the available options for these child victims.
I will also look at other cases in the United States and Western Europe to compare and contrast whether victims of
police abuse manifest similar mental health distress when confronted with outrageous police abuse such as that
reflected in the case study. Also, I will examine mental health treatment options available for these types of child
victims in other countries.
Burris@lmi.net
burris@pacbell.net
Children and Mental Health Treatment
The Precautionary Principle: A Guiding Standard for the Administration of Psychiatric Medication in
Children
Michael Fakhri, Barrister and Solicitor, Toronto, Canada
Mercedes Perez, Barrister and Solicitor, Toronto, Canada
In Canada, certain psychiatric medications, including selective serotonin reuptake inhibitors (SSRIs), are routinely
prescribed and administered to children. Some of these drugs have been approved for use in children by Health
Canada, the national drug regulator, even though their safety and efficacy in children has yet to be established.
Furthermore, we now have published scientific evidence confirming the potential adverse effects of some
psychiatric medications such as SSRIs and/or their lack of effectiveness in children. Documented adverse effects of
SSRIs in children include suicidality, aggressiveness, violence and mania. Health Canada recently retracted its
approval for some SSRIs, yet most of these drugs can still be legally prescribed by doctors “off-label”.
The pediatric use of drugs “off-label” is particularly worrisome given enduring allegations that drug manufacturers
tend to cloak the results of clinical trials in ways that are biased towards their own products. Recently, for example,
the State Attorney of New York launched a lawsuit against leading pharmaceutical company GlaxoSmithKline
(GSK) for engaging in “repeated and persistent fraud by misrepresenting, concealing and otherwise failing to
disclose to physicians information in its control concerning the safety and effectiveness of its antidepressant
medication paroxetine” in treating children diagnosed with Major Depressive Disorder. GSK settled out of court,
agreeing to release negative data. Nevertheless, the case highlights the dangers of “off-label” use of psychiatric
medications in children. The exercise of professional discretion required for such use is often distorted by lack of
information, or even by misinformation.
This paper will argue that the precautionary principle should guide the administration of psychiatric medications to
children in Canada. The precautionary principle has already been accepted as a guiding principle by the Supreme
Court of Canada in the context of environmental law. In the case of mental health law and children, Canada would
not need to take dramatic measures to apply the same precautionary approach. Several European countries, for
example, have already banned outright the use of certain SSRIs such as Paxil, Effexor and Seroxat in children.
Where there is reason to believe that the pediatric use of such medications is likely to cause serious harm, precaution
should be exercised, even in the absence of scientific certainty respecting causation. A precautionary approach
would place the onus on the pharmaceutical industry to first provide clinical proof that medications to be marketed
for use in children will provide benefits that clearly outweigh any risks.
mfakhri@swadron.com
mperez@swadron.com
Have We Gone too Far in Labelling Children ADD/ADHD?
David R. Friedman, Attorney-at-law, Madison, USA
A federal law known as the Individuals with Disabilities Education Act (IDEA) mandates that schools, upon proper
notice, evaluate students to determine if that student has a disability. The purpose of the law is to ensure that
children receive a free appropriate education (FAPE) in the least restrictive environment (LRE).
If it is determined that a child is in need of services, a plan known as an Individualized Education Plan (IEP) is
devised. This plan indicates the level of special education services to be provided, the location of these services and
the amount a time a student will be placed in either a special education program or educated with the student’s nondisabled peers. This plan cannot be changed except by reworking the IEP.
Certain disciplinary suspensions and expulsions based upon a student’s behavior cannot take place where the
student’s behavior is a manifestation of the disability. When discipline is going to be imposed, parents and students
who were not previously classified as disabled, often seek to have the student classified as disabled to avoid the
disciplinary action.
The most common disability associated with behavioral problems is either ADD or ADHD. Many of the disease’s
symptoms are the same as those associated with bad or inappropriate behavior.
There is a myriad of sources of information on ADD and ADHD. Books have been written on the subject, Internet
cites abound, and ad as even placed in newspapers that list common childhood behavior such as losing things,
interrupting others, talking excessively and having trouble waiting for his or her turn as possible symptoms of
ADHD.
In the course of representing school district in there efforts to discipline students, I have become concerned that
there is a drive by parents to label their child ADD or ADHD as a means of avoiding school imposed disciplinary
actions. Social and emotional factors as well as neurological factors can contribute to this disease. It is my
contention the parents are pressuring doctors to assist in this endeavor just as patients pressure doctors to prescribed
the latest medicines advertised on television.
I have heard comments from school board members and administrator indicating a belief that parents and students
are using this diagnosis as a means to avoid being disciplined. This belief is due in part to the awareness of school
officials to the potential for over diagnosis. This perception hurts the students the law was designed to protect.
Over diagnosis of the disease for those who are not ADD or ADHD, devalues the disease for those who truly need
the diagnosis. This over diagnosis also causes those who have to make decisions to view students using their
disability as a means to scam or play the system. This view also leads to the perception, which does have some
validity, that there are two discipline systems - - one for disabled students and one for non-disabled students.
Another concern is that over diagnosis causes a misapplication of scare resource.
The law was intended to make sure that children with a disability receive an appropriate education. The unintended
consequence of over diagnosis creates the perception that the disease is not real but merely a means by which
students and parents can avoid the consequence of the student’s actions.
friedlaw@chorus.net
Is it Time to Develop Protocols for Non-drug Treatment of ADD/ADHD in Schools?
Debra K. Friedman, Bioenergy Clinic Inc., Madison, USA
There are questions and concerns about prolonged use of Ritalin in ADD/ADHD children such as physiological
damage and addiction. What alternative non-drug approaches have been tried and what is their success rate?
Schools have developed protocols for administering drugs. Do schools have or need to develop protocols for nondrug therapies? Discussion will follow of the costs and feasibility of non-drug treatments.
info@bioenergyclinic.com
The Right To Mental Health Rehabilitation Under Article 39 The Convention On The Rights Of The
Child : The Case of Palestinian Children
Reem Bahdi, University of Windsor
This paper will examine Palestinian children’s rights to mental health rehabilitation under article 39 of the
Convention on the Rights of the Child.
Article 39 requires States Parties to take all appropriate measures to promote the psychological recovery and social
reintegration of a child victim of armed conflicts. Both Israel and the Palestinian Authority owe a duty to promote
the mental health rehabilitation of Palestinian children and both have breached that duty.
The paper will be divided into five parts. Part I will examine the experiences of Palestinian children to determine
how armed conflict and occupation has affected their mental health. The analysis will start with the first Intifada
which began in December 1987 and extend to the present crisis in the both the Gaza Strip and West Bank. Part II
will explore the extent to which the Children’s Convention binds Israel, as an Occupying Power, and the Palestinian
Authority, as a non-state actor, in relation to Palestinian children. It will critically examine the claim that
international human rights treaties do not apply to Israeli actions in the occupied Palestinian territories while also
defining how the Palestinian Authority, as a non-state actor, may be held accountable under the Convention. Part III
will offer an interpretation of article 39 for the purposes of determining to what extent Israel and the Palestinian
Authority owe a duty under international law to promote the psychological recovery and social reintegration of
Palestinian children. Finally, Part V will explain why it is important to turn to international law in general and the
Convention on the Rights of the Child in particular to measure the conduct of Israel and the Palestinian Authority at
this critical juncture of the Israeli-Palestinian conflict and in light of the difficult history of negotiations between the
parties.
If there is sufficient time, the paper will also identify and assess the mechanisms available under international law to
secure compliance with the obligations recognized under article 39 of the Convention.
rbahdi@uwindsor.ca
Children and Mental Health: The Elusive ‘Best Interests’ Principle?
The Best Interest of the Child
Barbara Willenbacher, University of Hannover
Nearly all western countries instituted joint custody in the recent decades. The aim of the legislation was to
influence the behaviour of parents. Parental responsibility rests automatically on both parents; it is an enduring
status that is not lost on separation or divorce. The legislation aims to reduce legal involvement in parents’ care of
their children past separation. Many statutes established a preference for joint custody over sole custody. They have
established presumptions that shared parenting is in the best interest of the child not limiting the application to cases
where parents are in agreement. In deciding any question relating to the upbringing of the children the court has to
make the welfare of the child its paramount consideration. Court substantiates the best interest of the child in the
following arenas:
1. Custody Orders
Courts have the option to make joint awards despite a parent’s objections.
2. Residence, Specific Issues and Prohibiting Step Orders
Courts have to adjudicate when parents disagree in relevant joint parental decisions. In some aspects residence,
specific issue and prohibiting step orders replace custody orders.
They are designed to restore concrete, practical issues relating to the care and upbringing of children. The court must
choose the most appropriate order in the particular case and can specify where the child will live, disallow certain
aspects of parental responsibility or suggest how specific areas of parental responsibility should be carried out.
3. Contact Orders
The strong presumption in favour of contact between the child and the non-resident parent in consequence of the UN
Convention on the Rights of the Child everybody shall respect the right of the child who is separated from one or
both parents to maintain personal relations and direct contact with both parents on a regular basis. Cases involving
violence are not treated as a separate category in Germany and England/Wales, although violence may well be a
circumstance justifying the denial of contact. But contact is very rarely denied altogether.
My material is based on an analysis of published German jurisdiction 1998-2004. My aim is to discern some of the
principles that underlie decisions of the court and to deduct a welfare checklist of various factors, which determine
what outcome, is in the child’s best interest.
Willenbacher@rsoz.uni-hannover.de
The Best Interest of the Child from the Perspective of Democratic Poland
Alicja Czerederecka, Institute of Forensic Research, Krakow, Poland
Jozef K. Gierowski, Institute of Forensic Research, Krakow, Poland
The paper presents the consequences of the changes in the legal situation of a child in Poland in the years: 19892003 r. Most of the reforms are ratification of European conventions and international pacts, focused on the best
interest of a child: on convention on children’s rights, on adoption of children, on the legal status of children outside
marriage and on protection of a child. Regulations of the act on legal proceeding with juvenile as well as the new
article in the code of penal proceedings, which protects a child as a witness, play an important role, too. A lot of
organisations and associations serving to protect and help abused and neglected children have arisen and developed
in democratic Poland. Also media currently pay plenty attention to protection of children’s rights. The paper
discusses the consequences of the changes that include both: advantages and disadvantages to the children. Taking
into account the subjectivity, the dignity of a child and willingness to listen to the child are the main positive
changes in the adults’ attitude. Also children are, more and more frequently, prone looking for help when their
personal rights have been disturbed. On the other hand it sometimes happens that parents manipulate their children’s
feelings by preparing false accusations against their partners in marital conflicts accusing them of emotional,
physical or even sexual violence towards their children.
aczere@ies.krakow.pl
kgierowski@poczta.onet.pl
The Best Interest of the Child: The Russian View
Elena G. Dozortseva, Serbsky National Center for Social and Forensic Psychiatry, Moscow, Russia
Demographic problems, decrease of population and therefore problems of family and children have become an issue
of national security in the recent past in Russia. Every year about 470 000 children are left with one parent as a
result of divorce.
The Russian Family Code adopted in 1995 regulates issues of children’s rights, parents’ rights and duties, custody in
case of divorce, depriving of and limiting parental rights, adoption etc. The central notion of this regulation is that
of the best interests of the child. According to the law “Interests of the child must be the essential subject of parental
care” (Art. 65, 1). Whereas the Code defines the child’s rights, there is no clear legislative definition of the category
“interests of the child”. However some articles characterize the idea of best interest of the child including education
and care for health, physical, psychic, spiritual and moral development” (Art. 63, 1).
In cases of divorce, in principle, parents have equal rights for custody of the child, and the conflict issues in the
court are usually discussed in terms of the place of the child’s living and exertion of parental rights by the parent
who lives separately from the child. By deciding the first question the court takes into consideration “the child’s
attachment to each of the parents and to the siblings, the child’s age, moral and other personal quality of the parents,
the relationships between each of the parents and the child, conditions for the child’s education and development…”
(Art. 65, 3). The right of the separately living parent on raising and educating the child can be contested by the
former spouse when contacts with the parent damage the child’s “physical and psychical health and moral
development” (Art. 66, 1). The court can demand expert opinion in both cases considering the best interest of the
child.
The development of expert assessment in the framework of Family Law in Russia is now in its initial stage
demanding a clearer definition of the best interest of the child.
edozortseva@mail.ru
edozortseva@rambler.ru
Investigative Methods and Standards for Psychological Expertise Concerning the Best Interest of the
Child
Marianne Kalinowsky-Czech, Practicing Psychologist, Buchholz/Nordheide, Germany
After 1998 when the Child Reform Act came into effect in Germany joint custody is obligatory, but in contested
cases parents can ask for awarding sole custody. That means for psychological experts to answer the question for the
best interest of the child. This paper will demonstrate by a concrete case the plan of the investigation, the hypothesis,
and the guideline for the explorations with the parents, the child and other related persons.
The position of the law court depends on stereotypes of the judges e.g. preferring a rapid decision, to award custody
for the benefit of the mother (where in most cases the child lives), expecting damages or disadvantages of the best
interest of the child practicing joint custody, or ask for the communication and co-operation between the parents as a
base for the decision. Important points to explore are the educational positions and opinions of the parents
concerning physical custody, every day life problems and important concerns like school choice or change, religious
denomination, or basic conception about medical treatments.
Psychological expert experience shows that most parents agree about the important concerns for the children, if they
are both asked in a concrete and understandable way. The expertise must be carried out carefully to avoid a too
quick decision for sole custody. In these cases one parent loses responsibility and contact to the child with the
consequences of more disadvantages for the well-being and best interest of the child. Psychological expertises can
improve better legal decisions and enforce the best interest of the child.
M.Kalinowsky@t-online.de
Joint Custody – Psychological Aspects of the Best Interest of the Child
Adelheid Kühne, Univeristy of Hannover
Family law in Continental Europe and also in Germany prefer joint custody for children of married and unmarried
parents. In Germany the Child Reform Act came into force in July 1, 1998. Since that time unmarried parents can
agree to the joint custody and now they have equal rights like married parents.
This means for parents to continue the practice of joint custody after divorce and separation. The capital motive of
the legislator is to maintain the best interest of the child independent of the question whether the child is living either
with both parents or with a single educating parent. Parents can not give up the claim of responsibility.
Best interest of the child comprises to care for all issues of life like everyday maintenance, health care, pedagogical
decisions of school development and job education. Only a judge’s decision can change the joint custody and award
custody only to one parent after request. In those cases the judge asks for psychological expertise.
One of the main topics of the report is the redefinition of the parental custody under the new Child Reform Act.
Forensic research points out the necessity of new abilities of the parents like consensus and compromise, tolerance
of attachment and the readiness for continuity concerning emotional, social and environmental relations. These facts
are more and more important for an undisturbed future development of the child. The protection of children against
maltreatment and abuse remains a topic of the family law; psychological expertises have to deal with these severe
problems.
Kuehne@erz.uni-hannover.de
Best interest of the child: the interface of family law and mental illness
Jennifer Boland, Family Court of Australia (Appeal Division), Sydney, Australia
The Family Court of Australia regularly deals with applications by parents of both nuptial and ex nuptial children
about where they should live, and the contact they should have with their non residential parent. In many cases one
or both parties are or have been affected by psychiatric conditions, often drug associated. This paper examines how
the Court in Australia is dealing with these cases, including the use of expert evidence, appointment of a
representative for the child, supervised contact orders and imposing conditions including treatment for a parent as a
condition of an order. Also examined are difficulties in conducting such hearings particularly when parties are self
represented, require the appointment of a “next friend” or guardian for the litigation, and repeat litigation. It also
looks at the Court’s recent pilot of dealing with all children’s cases in a less adversarial manner to achieve best
outcomes for children before the Court.
justice.boland@familycourt.gov.au
Children and Trauma II: Acute and Situational Risks
Traumatic Presentations and Behaviors in Youth Exposed to Family Member Homicide
Paul T. Clements, University of New Mexico
Homicide of a family member leaves more than just bodies behind and leaves survivors to struggle and cope with
sudden and violent loss of life, crossing all cultures, races, and both genders. For youth, homicide of a family
member may result in more negative post-trauma reactions than loss to natural causes since deaths by homicide are
typically sudden and often entail human malintent directed at the deceased. Interviews conducted with children ages
8-17 years during the initial 18 months following family member homicide provided insight into themes of
bereavement and traumatic stress. A major finding in the studies was that the witnessing or hearing the news of a
family member homicide was a powerful associative factor for childhood posttraumatic stress disorder and for
complicated bereavement. Many issues for bereaved youth after family member homicide are unique in scope.
Serious consequences can occur surrounding a youth’s evolving moral reasoning, understanding of the
consequences of a person’s actions, and the significant need for family permanence. Family member homicide can
confound all of these developmental tasks simultaneously. A primary issue is the helplessness of youth at having to
watch or listen to the sights and sounds surrounding a violent act and being unprotected from the full emotional
impact of the violence.
pclements@salud.unm.edu
Effects of Abusive Intimate relationships on mental health status of portuguese young adults
Carla Alexandra Paiva, University of Minho
Doutora Bárbara Figueiredo, University of Minho
Introduction: Quality of intimate relationships has a major role on mental health. However, when abuse is a part of
the relationship, negative consequences in health can emerge, attending to the type and severity of abusive
behaviour. Aims: To determine the prevalence and severity of abuse, and its implications on mental health status of
Portuguese young adults.
Methods - Sample: 500 university students, 64.6% females, mean age 23 years old, 84.8% in a dating relationship,
61.5% for a period of time longer than 1 month. Instruments: Revised Conflict Tactics Scales (Straus, Hamby,
Boney-McCoy, & Sugarman, 1996, Paiva & Figueiredo, 2001); Brief Symptom Inventory (Derogatis, 1993,
Canavarro, 1999). Statistics: descriptive and inferential; independent samples t test, variance and linear regression
analysis (stepwise).
Results: Twenty five percent of the sample reported clinical index of psychopathology. The best predictor of
psychopathological symptoms is the victimization of assault and, both the perpetration and the victimization of
psychological aggression (F(3,320)=9.24,p=.001) predict 59.3% of the variance.
Abuse prevalence rates, respectively in terms of perpetration and victimization are: psychological aggression (53.250%), sexual coercion (25-24.8%), assault (18.8-15.5%) and injury (4.6-4.3%). Compared with non abused
individuals, the victims of assault (t(388)=3.0, p=.003) and the perpetrators of psychological aggression (t(302)=
2.4, p=.016) reported significantly more psychological symptoms.
Conclusion: The experience of abuse in early adulthood in close premarital relationships is frequent and is
considered a major determinant factor for psychological distress. This study strengthens the importance of
significant relationships, and warns the negative effects of violence regarding mental health status. Social, legal and
mental health strategic politics in premarital relationships and early adulthood are needed to be implemented, as a
way to prevent violence, promote the quality of close relationships, and have an impact on the reduction of later
dysfunctional marital relationships (e,g., divorce, domestic violence, mental and physical illness).
cpaiva@iep.uminho.pt
Psychiatric nursing staff’s views of aggression management in the treatment of minor patients with
aggression and impulse control problems
Johanna Berg, University of Tampere, Tampere, Finland
A qualitative study on nurses’ understanding and beliefs of and attitudes to adolescent aggressive behaviour in
psychiatric inpatient units specialising in treatment of adolescents with forensic background and / or violent and
noncompliant behaviour is presented. Nursing staff are interviewed with help of a semi-structured theme interview
about their views on reasons of adolescent aggression, optimal ways of managing aggressive behaviour in safe way,
and preferences for improving aggression management in psychiatric care. The presented analysis is a part of a
cross-cultural comparative study to be carried out in five adolescent forensic units in four European countries. The
first part, carried out in Finland, will serve as reference for the cross-cultural analyses. In the pilot interviews,
nursing staff members in one Finnish and one Dutch unit emphasized, for example, the importance of being able to
trust the team as an essential part of aggression management.
johanna.berg@turkuamk.fi
Clinical Criminology in the Italian Context I
Preliminary Study Carried out in J.P.H. (Judicial Psychiatric Hospital) on 20 Cases of Filicide
Mother-Standardization of the Operating Criteria and Premature Location of Risk Factors
(« Paleopatterns ») in The Primary Prevention of Familiar Murders
Vincenzo Mastronardi, University of Rome, Italy
Matteo Villanova, University of Rome, Italy
Alberto Mendini, Medico Sezione Femminile Ospedale Psichiatrico Giudiziario Castiglione delle
Stiviere, Italy
In terms of predictivity of intra-familiar murders of the minor as Victim in an optics of ethological-comparative
understanding of mankind (Mastronardi V., Villanova M., 2003, by Miller 1987, Genta M. L. e Tartabini A., 1991;
Eibl-Eibesfeldt, 1998; Dennett, 1997), specific structured protocols have been prepared (items A, B, C, D, E) for the
analysis of Personality of 20 cases of filicide mothers. The methodology of data collection comprises the direct
observation of the Perpetrator of crime in intra-building condition (Judicial Psychiatric Hospital of Castiglione of
Stiviere - Mantua) and through clinical-anamnestetic dossier, diaries and judicial procedures. Therefore, statistic
analysis and correlation/comparison with confrontation groups. Items: A) Dossier; B) “Predisposing” factors
(specific patterns such as behaviour/symptom) e.g.: Separation immediately after the birth from the biological
mother, Extended institutionalization (first year of life), Continuous physical ill-treatment of the adoptive mother,
Educational incongruous and alternate strategies, Lack of caressing communication of parents, Social semi-isolation
until the sixth year and removal form coetaneous, Isolation and refusal in the group of coetaneous, Incongruous
punishments, Sexual abuse of the boarding-school educator, Continuous sadistic punishments, with ferocious
treatment, Lack of positive adult figures, To had been present to stigmatising scenes or violent tales; C)
“Precipitating” factors (“quid novi, quid plus” in determining the event/crime) e.g.: Unexpected affective and sexual
uncertainties in the familiar context, Serious situations of indigence and emotional uneasiness, Occurrences of
bereavement and narcissistic hurts of the mother and/or the father, Relational limitation resulting from the attending
to the children, Imitative vulnerability to the mass- media’s imaginary; D) Systematic destruction of the Himself of
the adult on the child at the future risk of infanticide when adult; E) Sacrifice of children for the maintenance of
psychic homeostasis of the parent.
iissrcm@uniroma1.it
Aggressiveness: Pointers of Risk, Paleopatterns and Primary Prophylaxis
Matteo Villanova, University of Rome, Italy
Antonino Calogero, Ospedale Psichiatrico Giudiziario di Castiglione delle Stiviere, Italy
The “Primary prophylaxis”, even in the operating need to contain social coasts, is aimed at those strategic operations
before the disturbing behavioural symptomatology is no more latent. By the way, the importance of the continuous
demand for constant advise made on the territory is known and comprehensible to everybody. In line with the
philosophy of intervention already adopted by culturally advanced Countries, and in agreement with the necessary
politics of observation, control, prevention, deal of phenomena joined in social aggressiveness, and above all by the
possibilities of massive retrenchment of Judicial System, the permanent formation of future Operators and of those
already present on the territory should tend towards the maturation of contents relating to the connection between
the clinical reality and possibility of evolution of the uneasiness towards situations that progonostically interest the
judicial and the medical-legal field through the ability to acknowledge and to isolate of predictive factors (paleopatterns) with individualization of elements considered “quid-novi” or “quid pluris” thus incident on the sociorelational continuum of a context in observation, and also of emergent "patterns" of relative and absolute risk as
predisposing factors which after will bring to the individualization of the same one, or of other Operators, of a
“behaviour-symptom” becoming “running wild-factors” of a possible “event-crime”, future bearer of an enormous
judicial cost. At the moment results de facto unsatisfied the continuous proved request of institution of an active
services for demand of territorial preventive-treatment intervention in situations of social alarm and territorial
defense (aggressiveness and sexual abuse, murders and serial killers syndromes, psychosis of post-pregnancy and
infanticide, family mass murders etc.). Some studies conducted on 1.500 students of middle school of the roman
district and on 20 cases of homicide mothers are related too.
matteo.villanova@uniroma3.it
European Data Base on Serial Killers Updated to 2004
Ruben De Luca, University of Rome, Italy
Vincenzo Mastronardi, University of Rome, Italy
The survey about well- known and less- known Serial Killers in the European – Italian framework, has been updated
to 2004 and its Data Base provides:
-nationality
-date of birth
-date of death
-towns where murders have been perpetrated
-typologies of victims
-presumed period of time in which murders have been perpetrated.
For each serial killer, the Data Base provides all available information about biography, personality, sexual
behaviour, modus operandi and the murders committed by the offender.The survey begins with the English serial
killer Margaret Davey (1542). The research has been made in order to spread technical – investigative supports
highly needed for future researches on criminological profiling.
ruby007@vodafone.it
Post Critical Incident Seminar
Barbara Nardi, Ministry of the Interior, Rome, Italy
Emanuela Tizzani, Scientific Committee, SMART, Rome, Italy
Aim of this article is to describe a workshop that the South Carolina Law Enforcement Assistance Programme
yearly organises in order to reduce the impact of Critical incident stress amongst policemen. The workshop, called
Post Critical Incident Seminar (PCIS) last three days and involves many therapeutic elements that perhaps interact to
achieve a decrease in traumatic stress: peer debriefing exercises, educational portion of the workshop while
information on coping are provided, addition of EMDR. The three day format allows time for the participants to
open up to their experience and process it. Being in a group with others who have experienced similar traumatic
incidents facilitates sharing of one's experience, normalization, and validation of experience. Research shows that
the addition of EMDR appears to have resulted in significantly lower levels of distress. It is important that the
workshop process be professionally guided and adequately staffed to deal appropriately with emotional material that
may surface.
barbara._nardi@libero.it
Post Critical Incident Seminar
Barbara Nardi, Ministry of the Interior, Rome, Italy
Emanuela Tizzani, Scientific Committee, SMART, Rome, Italy
Being involved in a violent crime, as a victim or as a witness, means often being exposed to a traumatic event.
Right after the event itself victims or witnesses has to face the consequences of this exposure, but at the same time
they have to present themselves in front of police officers to give statements and evidences. This statement is often
crucial in order to allow police forces to reach success in the investigation, but at the same time telling the story
again is an “at risk” situation for being secondary traumatized. Besides, the evidence itself can be influenced by the
peculiar characteristics of traumatic memories. During a critical event subjects can have perceptive distortions and,
after the event, traumatic memories are often disconnected from other memories, rich in sensory details and poor in
language, at least in the beginning, and might not integrate in the spatial and temporal context. Right after the
exposure to a traumatic event the subject is shocked, can be dissociated, and is very weak and fragile. The recall of
trauma can bring him back to the same emotional feelings experienced during the event and he can feel like being
there again. In order to prevent secondary traumatization during the statements and to obtain the better evidence as
closer as possible to “what really happened”, a structure is needed. Concrete procedures, created according to what
scientific community discovered about trauma and memory, can be very helpful in this direction. The aim of this
presentation is to describe how trauma can impact memory and recall and to give practical recommendations for
preparing traumatized subjects to the statement and for conducting the interview.
barbara._nardi@libero.it
Clinical Criminology in the Italian Context II
Psychological Profiles and Forensic Animation Through PC Graphic Reconstruction
Vincenzo Mastronardi, University of Rome, Italy
Antonella Conticelli, Rome, Italy
Mariano Fischetti, Rome, Italy
In this study which leads us to a thesis on the above topic directed by Prof. V. Mastronardi at the Forcom University
of Rome on termination of a Master in Clinical Criminology and Forensic Psycopathology, the authors, after a brief
analysis of judicial issues on the theme of Forensic Animation in these last years, inspect certain classical typologies
that emerge in the modality of behaviour profiles, as those deduced from the scene of the crime. Therefore, various
graphical riconstructions have been carried out through computer animations, for example: scene of the crime and
drug addiction, scene of the crime and satanic rituals, scene of the crime and rape, and so on.
iissrcm@uniroma1.it
Guidelines for the Reduction of Illegal Behaviours and the Relapse through the Integration of Several
Operators of the Social Security on the Territory
Michele Di Nunzio, University of Rome, Italy
Matteo Villanova, University of Rome, Italy
In relation to the popular perception of psychiatric patient dangerousness, guidelines to follow are proposed for
preventive-treatment interventions achievable in a Diurnal Centre for Psychosocial Rehabilitation. Such institutional
interventions can accomplish both to the cure of sick person, and to the citizenship protection. In an examination of
10 years integration data relating to the 5 main activated sectors have been studied: Artisanship, Artistic
expressiveness, Professional pre-Formation, Tourism and Culture, Sport. The wide alternative of activities allow, for
each patient, a Personalized Therapeutic-Rehabilitative Project (P. T. -R. P.) ensuring personalized
psychoeducational courses. The neighbourhood citizens involvement improved the therapeutic interventions quality,
favouring a different and better perception of the psychiatric patient. The citizenship has been involved in literary
and popular-scientific events (books presentation, documentary, etc.), ludic-recreational events (parties, dances,
etc.), and also meetings for subscription (exposures, open-air markets, etc.). Often, some citizens, after that patients
have been well known, proposed themselves as volunteers in order to collaborate. The study, even though aimed to
the tertiary prevention (damage consequences reduction), confirmed that the insertion of the patient in cure plans
which involve him in everyday life, detracting him from social alienation, reduces the motivation or the possibility
to make illegal acts, with noticeable advantages even on the primary prevention (risk reduction) and the secondary
one (damage reduction), and on the expenses of the future judiciary intervention.
matteo.villanova@uniroma3.it
Guidelines Aimed at the Monitoring and the Forecast of Typologies of Crime, Perpetrator of Crime,
Victim and Preventive Intervention in the E.U. States
Marica Villanova, University of Rome, Italy
Matteo Villanova, University of Rome, Italy
Emerging typologies of crime, perpetrator of crime, of possible victim are analysed starting from a historical-legal
examination and an inquiry of demands developed from the prevention system and the Social Defense control
(Treaty of European Communities of 1957 in Rome, Schengen in 1985, Maastricht in 1993, Amsterdam in 1999,
Tampere in 1999, Brussels in 2001, Frame-Decision of the European Council of the 13\07\02 and finally the Treaty
for the European Constitution in order to make Europe a space of “Freedom – Security – Justice”), offering
subsequently an operative profiling of identification for the use of the Territorial Operators. Moreover, protocols
aimed at various typologies of intervention are proposed, providing execution guidelines according to standardized
moments going from the primary prevention (risk reduction) to the secondary (damage reduction) and then to the
tertiary (damage consequences reduction) with possibility of monitoring, filing and comparation of data to share for
an Homogenization of intervention of Operators from different countries of the U. E. From the projection and
extrapolation of the data derived from a statistic analysis, the crime typologies mostly predictable are fraud,
conspiracy, robbery and extortion, recycling and receiving of stolen goods, corruption, theft, human trade for the
purpose of adoption or traffic of organs or forced prostitution, new crimes related to informatics against the
property, counterfeiting and piracy against the property, traffic of drugs and production of new psychotropic
substances, abetting of illegal immigration, kidnapping of person for sexual or extorsive purposes, terroristc
organisation with the “honour killing”, new sexual crimes joined to minors and new pervertions or emerging
paraphilium of destructivity nature, included snuff sex and perpetrate rape by both the sexes. Emerging typologies of
perpetrator of crime coincide with the following profiling: subject of upper-middle culture with strong
entrepreneurial incentive and insufficient formation, subject of lower-middle culture who lives of expedient often
with mental troubles, subjects in second generation of permanence in a Country coming from a Country with a poor
economy, subjects affected with serious mental troubles. Emerging typologies of crime victims are: subject of
upper-middle social-economic level (freelance, manager, entrepreneur); subject of low social-economic level
(labourer and irregular worker); subject of the lowest social-economic level (unemployed, tramp included). The
intervention typologies aimed to create a “space of Freedom, Security and Justice”, according to the Treaty of
European Constitution, applying the Institute of European Arrest Order and the European Constitution in The U. E.
States, are: Europol; Eurojust; S.I.S.; Quadro-Decision of 13 July 2002; Green Book of the European Commission
(on the procedural guarantees); European judicial net; European Anti-Fraud Office (O.L.A.F.); Green book on the
protection of the financial and communitarian interests and the creation of an European Procurator, forecasting the
institution of the European Power of attorney; the common investigative Teams; the Principle of subsidiariness in
case of terroristic attacks; the Quadro-Decision relating to the fight against the human trade, the sexual abuse of
children and the infantile pornography, and against the corruption in the private sector. The great investment of the
next years concern the permanent formation of various Operator figures and the facilitating action of the connecting
capacities intra- and inter- territorial in order to operate an effective control regarding the Social Defence on the
Territory.
matteo.villanova@uniroma3.it
International Outline of Most Wanted Terrorists in the World
Silvia Leo, Milano, Italy
Vincenzo Mastronardi, University of Rome, Italy
The research, already published in a monographic study with the Newton & Compton (2005), signed by Mastronardi
V. – Leo S., starts from the definition of terrorism to deal with the whole international outline of most wanted
terrorists in the world. It takes into account the Basque terror, the IRA’s terrorists and the italian Red Brigades
(Brigate Rosse), displaying of these latter the different sub or related groups, such as:
BR-PCC = Brigate Rosse – Partito Comunista combattente (Red Brigades – Communist Fighting Party)
CARC = Comitati di Appoggio Resistenza per il Comunismo (Supporting and Resistance Commitee for
Communism)
SI = Solidarietà Internazionale (International Solidarity)
NTA = Nuclei territoriali Antimperialisti (Territorial Anti-imperialist Nuclei)
NTPR = Nucleo di Iniziativa Proletaria Rivoluzionaria (Nucleus of Proletarian Revolutionary Initiative)
NPC = Nuclei Proletari per il Comunismo (Proletarian Nuclei for Communism)
Together with a list of fugitive terrorists abroad and an outline of the BR-PCC organization structure, the research
quotes passages of “The handbook of perfect Brigade member”.
Wide space has also been dedicated to:
The Turkish terrorists;
The PKK;
Bosnia and Kosovo,
Cecenia’s terrorists
Moreover, considering the topical relevance of Islamic terrorism, a particular attention has been devoted to the
Middle East question and the International Jihad, reporting on terrorist groups of islamic matrix, training camps in
Afghanistan and Pakistan, the Organization flow-chart of Al Qaeda, the 11th September 2001 attacks and the
relevant planned strategies. After the illustration of the flow-chart of Bin Laden’s dinasty, the research focused on
the recruitment and training modes of jihadists, the seven specialization courses and advanced Masters of 15-45 and
60 days, as well as a summary of the Handbook of training theory, organized in 11 Volumes and CD, which sets
also the 11 qualifications required to be an Allah Agent.
The work closes with a description of the tools and strategies used in the armed and IT activities, the Cyberterrorism
included, and gives information about the financing of activities too.
slsawuk@infinito.it
Hypnosis and Brainwashing Strategies Used in Terrorist Training
Ermanno Gioacchini, Rome, Italy
Vincenzo Mastronardi, University of Rome, Italy
Antonella Pomilla, Palermo, Italy
Methods of persuasion used in mass suicides and mechanisms of moral disengagement employed in changes of faith
and religion, from Christianity to Satanism, the Stockholm Syndrome and techniques of psychological manipulation
used by several religious sects physiologically resemble the construction of brainwashing strategies used in the
psychodynamics of terrorist training as mentioned by Bandura and re-elaborated in its 12 fundamental steps by
Mastronardi (2005). The report aims to use the latest research to review, in light of the most recent developments in
international terrorism, the most peculiar aspects that are also mentioned in the book “Manuale del perfetto
terrorista” [The Perfect Terrorist Manual].
ermanno.gioacchini@fastwebnet.it
Competency Issues in Law and Psychiatry
The Continuing Conundrums of Competency
John A. Devereux, University of Queensland
Competency operates as a “gatekeeper”. Those patients who are competent must have their wishes as to consent or
refusal of treatment respected. Those who are not competent may have their treatment decisions overruled. (Faden
and Beauchamp 1986). Competency functions both as a legal construct and as an acknowledgement that patients
who are able to exercise autonomy ought have their autonomy respected. Attempts to universally define
competency have foundered on the basis of an inability to reach a sufficiently precise test. Early attempts preferred
to outline differing possible tests of competency (Roth, Meisel and Lidz 1977, President’s Commission for the Study
of Ethical Problems in Medicine and Biomedical and Behavioural Research 1982).
This paper will argue that the continuing conundrums of consent are sourced not so much in differing views of what
amounts to competency, but rather in a failure to correctly interpret key legal terms such as “understand” and
“nature of treatment, which are sub-sets of defining competency. There is a tendency in the legal literature to use the
terms “inform” and “understand” interchangeably. Schwartz and Roth argue convincingly that there are three kinds
of “understanding”. These three meanings are explored in the paper. Obscuring which type of understanding is
referred to in any particular competency determination leads to unclear outcomes. The term “nature of the
treatment” is also not clearly understood. Exploring what is encompassed by the term “nature of treatments” will be
outlined in the paper.
The advent of guardianship legislation in Australia has permitted a re-thinking of competency issues. Much of the
recent literature, however, suggests the concept of competency continues to be a difficult one which needs further
thought and definition. (Stewart 2004, Parker 2004).
j.devereux@law.uq.edu.au
Fitness to be sentenced: An Historical, Comparative and Practical Review
Allan Manson, Queen's University
A Canadian, in a decision called R. v. Balliram recently held that a person convicted of a criminal offence who
suffered a substantial deterioration in mental condition since the trial could be found unfit to be sentenced. The
court based its conclusion on both historical arguments and the Canadian Charter of Rights and Freedoms. While
the reasons themselves may be open to question, there are compelling justifications for recognizing this concept.
The paper examines the Balliram decision and then looks at the history of fitness and how the sentencing phase
became disconnected from claims of unfitness in the late 19 th century. It then considers theoretical justifications
based on fairness and the need for sentencing to be a moral discourse before looking closely at a variety of issues
arising from the Canadian Charter of Rights and Freedoms. Recognizing the number of practical questions that need
to be addressed before implementing a concept of unfitness at the sentencing stage, the paper looks at some common
law jurisdictions for guidance: Australia, New Zealand, and the American states of New York, Illinois, Connecticut,
and Ohio. From these comparisons comes the idea of a “provisional cap”. That is, the recognition of unfitness at
the sentencing stage should be followed by a form of sentencing that takes into account the gravity of the offence,
the prosecutor’s position, any relevant aggravating or mitigating factors that can be adduced, and then results in a
“provisional” sentence, whether custodial or community-based, which stays in effect until the offender becomes fit.
The paper ends with a model that incorporates this approach while providing both that offenders will be confined, if
necessary, in hospitals and not prisons, and also that the dispositions will be reviewed annually to ensure that the
least restrictive and least onerous sanctions are imposed.
mansona@post.queensu.ca
The Rating of Psychiatric Impairment for Legal Purposes: Issues Of Validity And Reliability
George Mendelson, Monash University
Workers’ compensation jurisdictions utilise medical ratings of permanent impairment to determine the quantum of
compensation payable to injured workers. In Australia, similar provisions have been enacted in statutes that
provide compensation or common law damages to those injured in motor vehicle accidents. More recently, as part
of tort law reform, ratings of permanent impairment have been introduced as a “threshold” to be met before an
injured person is allowed to commence an action for damages.
Although the American Medical Association’s Guides to the Rating of Permanent Impairment are frequently
prescribed by legislation as the method for the medical assessment of impairment, the recent editions of the Guides
do not provide for the percentage rating of psychiatric impairment. The rating method for psychiatric impairment in
the 4th and 5th editions of the Guides deals with the assessment of disability rather than impairment, and for these
two reasons the legislature in Victoria, Australia, considered it unsuitable for use within the relevant statutory
schemes in that State.
The Clinical Guidelines to the Rating of Psychiatric Impairment have been developed, based on six aspects of
mental functioning that are assessed during a psychiatric interview as part of the mental state examination.
Descriptors indicative of the severity of impairment have been provided for each of the six categories, and the
median method is utilised to determine the whole person psychiatric impairment.
george.mendelson@med.monash.edu.au
Supreme Court of Canada on Consent to Treatment: Findings and Fallout
John E.Gray and Richard L. O'Reilly, University of Western Ontario
Few mental health cases reach the Supreme Court of Canada. There was therefore considerable interest when the
case of an involuntary patient, described as "Canada's beautiful mind," who had been found to be capable of refusing
treatment by lower Ontario courts, was appealed to the Supreme Court of Canada. This decision was of considerable
interest because in addition to guidance on how judgements of incapability in Ontario should be made by physicians,
review tribunals and courts it appeared to some to address the issue of the right of an involuntary patient to refuse
the treatment required to become well enough to be released from detention.
This paper will briefly describe the Ontario law concerning capability and substitute decision maker rules and the
facts of the case. This will include the intellectual abilities of the patient Scott Starson, who was a brilliant amateur
physicist with 17 previous psychiatric admissions and an active delusional system.. The differences between the
minority on the Supreme Court of Canada, which included the chief justice, and the majority will be identified.
Implications for Ontario and provincial mental health acts that do not allow refusal of the treatment required to
enable the person to be discharged will be addressed. Finally, the effects of the Court decision on Scott Starson, who
has now spent 6 years hospitalized without treatment, and his family and those in similar situations will be
discussed.
jegray@shaw.ca
Voluntary Intoxication and Guilt in Criminal Cases: A Comparative Perspective
Steve Thaman, Saint Louis University
The Criminal Law has struggled with how to take account of voluntary intoxication when assessing a perpetrator’s
mental state and criminal responsibility for an act which would otherwise be clearly unlawful. The Common Law
originally treated evidence of voluntary intoxication as being inadmissible to disprove guilty mens rea in criminal
cases. In the 19th Century, however, most U.S. jurisdictions began to admit evidence of voluntary intoxication to
negate guilty mental states, and a specific doctrine developed, that of general and specific intents, to deal with the
complexities of evidence of intoxication. As the trends in accepting insanity and diminished mental capacity
became more liberal, so did those relating to intoxication evidence, and, thus implicitly recognized the fact that
intoxication has the capacity to substantially alter mental capacity in ways relevant to the assessment of criminal
responsibility.
European influences, especially from Germany, certainly had an impact on the development of the American
Common Law in this area in the 19th Century and my paper will compare the current US approaches with the
contemporary approaches to this issue in major European countries, such as Germany, France, Spain, Italy, Russia
and the U.K. Some countries, such as Germany, provided for a substantive offense of “complete intoxication” under
which a drunk person may be condemned, even if the elements of the crime originally charged cannot be proved due
to the defendant’s intoxication. At least 10 American jurisdictions have returned to the original Common Law
approach and made evidence of intoxication inadmissible, thereby raising serious doubts as to whether a defendant
in such cases can receive due process and a fair trial. The paper will try to place this issue in its social, criminal and
mental health context as well.
thamansc@slu.edu
At the Fringe of the Law: Interpretive Oscillations in Assessing Fitness to Stand Trial
Michael Feindel, Ministry of the Attorney General (Ontario), Toronto, Canada
This paper closely examines the test employed by Canadian courts, psychiatrists and Review Boards in determining
whether an accused is unfit to stand trial. The case of R. v. Taylor decided by the Court of Appeal in Ontario (1992)
adopted what the court referred to as the “limited cognitive capacity” test for fitness: if an accused person suffering
from a mental disorder demonstrates a rudimentary understanding of the legal process and has the capacity to
communicate with counsel, she is “fit to stand trial.” The fact that the accused was not capable of making rational
decisions beneficial to her did not merit a finding of unfitness. Such is the basic law for Canada. The low threshold
of the test has attracted some criticism over the years. The test has also been the source of inconsistent application,
where the same evidence has given rise to different assessments, as happened in the recent case of R. v. Balliram—a
case primarily noteworthy for having extended the relevance of fitness to the sentencing stage of a criminal trial.
The paper discusses the elements of the fitness test that are notoriously subject to interpretive oscillations
particularly in cases involving accuseds embracing delusions or suffering delusional disorders. Should the accused
demonstrate a personal understanding of the trial process or is it sufficient that he have a hypothetical appreciation
of what a trial involves? What constitutes a sufficient capacity to instruct counsel? What merits “an instruction”?
These and other questions are no less troubling for the forensic psychiatrist expected to give expert evidence on
fitness. Other jurisdictions are examined for applying an explicitly higher standard of cognitive capacity in
determining fitness.
Finally, the paper examines the consequences of a “higher” or “lower” threshold being applied to determine this
question. Each, it is argued, has “complex” (i.e. positive and negative) consequences for the accused person.
Resolution of this dilemma requires a careful examination of both the ethical basis for the concept “unfit to stand
trial” and the practical consequences for the overall criminal proceeding, for the safety of the public and for the
liberty interests of the accused.
Michael.Feindel@jus.gov.on.ca
Contemporary Challenges in Law and Psychiatry
Killing for the State: The Darkest Side of American Nursing
Dave Holmes, University of Ottawa
The aim of this presentation is to bring to the attention of the international nursing community the discrepancy
between a pervasive ‘caring’ nursing discourse and a most unethical nursing practice in the United States. In this
presentation, the author will present a duality: the conflict in American prisons between nursing ethics and the
killing machinery. The US penal system is a setting in which trained healthcare personnel practice the extermination
of life. The author looks upon the sanitization of deathwork as an application of healthcare professionals’ skills and
knowledge and their appropriation by the state to serve its ends. A review of the states’ death penalty statutes shows
that healthcare workers are involved in the capital punishment process and shielded by American laws (and to a
certain extent by professional boards through their inaction). In considering the important role healthcare providers,
namely nurses and physicians, play in administering death to the condemned, the author asserts that nurses and
physicians are part of the states’ penal machinery in America. Nurses and physicians (as carriers of scientific
knowledge, and also as agents of care) are intrinsic to the American killing enterprise. Healthcare professionals who
take part in execution protocols are state functionaries who approach the condemned body as angels of death: they
constitute an extension of the state which exercises its sovereign power over captive prisoners.
dholmes@uottawa.ca
On The Road Again: Insights into Predators on the Information Superhighway
Eileen M. Alexy, The College of New Jersey
While the Internet opens a vast array of communication, entertainment, and educational resources for children and
adolescents, it also opens a gateway to home and school for predators. The anecdotal terms used by law enforcement
to describe Internet predators are “traders” and “travelers.” This descriptive study introduces the phenomenon of
Internet predators and provides illustrative examples of “traders” and “travelers.” Additionally, a third type of
Internet predator is described, that of the “combination trader/traveler.” To date, few studies in the psychiatric,
criminology, and sociological literature have examined cases of Internet predators. This investigation points toward
understanding and identifying assessment and prevention strategies for predators and suggests future areas of
research surrounding this phenomenon.
emalexy@nursing.upenn.edu
Polygraphy as a Treatment Strategy for Sex Offenders: Policy Development, Process & Outcomes
Rochelle A. Scheela, Bemidji State University
This research study explored the outcomes of instituting polygraphy as a treatment strategy in an outpatient sex
offender treatment program. Data collection involved polygraphy, focus group interviews of sex offenders and
treatment providers, direct observations during group treatment, a survey of offenders, a survey of therapists and
probation agents, and record analysis. The subjects were 189 adult male sexual offenders currently in a rural
community sexual abuse treatment program, and the therapists and probation agents working with the offenders.
Descriptive and inferential statistics were utilized to analyze the data.
The findings indicated an exponential increase in disclosures, a clearer picture of offender abuse patterns, visual and
graphic documentation of offender deception, increased complexity of treatment, and increased costs.
In this presentation, the treatment program will be explained and the process of instituting polygraphy will be
discussed including the use of a community collaborative representing treatment providers, law enforcement
officers, corrections agents, defense and prosecuting attorneys, a judge, a polygrapher, clergy, social service
providers, and victim advocates. The outcomes will be addressed, as well as future research and practice
implications and recommendations
rscheela@bemidjistate.edu
Assisting Families of Sudden Traumatic Death after Interpersonal Violence and Crime: An Evolving
Role for Forensic Nursing
Joseph T DeRanieri, Thomas Jefferson University
This presentation will explore the role of forensic nursing management, in the Emergency Department/Urgent Care
Environment (ED), in assisting the family members with death resulting from interpersonal violence and crime.
The sudden and violent nature of murder can leave surviving family members with an immense burden of
unresolved issues. Understanding the unique facets of medico-legal procedures in the ED can provide a platform for
ED nurses to educate surviving family members and promote the important beginning stages of adaptive grief and
bereavement in the chaotic trauma of murder.
When a death occurs in the ED due to injuries sustained from an act of violence, it raises special considerations for
the ED nurse. It automatically triggers a medico-legal investigation. In such investigation, the body, clothing and
personal effects are all considered evidence. This presentation will discuss the role that the nurse plays in preserving
evidence on the body and clothing, preserving physical evidence removed from the body, and preserving personal
effects, while working with the family who may be asking for the personal effects.
In addition, this presentation will discuss methods to promote the beginning stages of adaptive grief and
bereavement when faced with murder, how to prepare the family for viewing the decedent and how to approach the
family while providing a supportive environment for family to allow the grieving process to begin.
Given the complexity of murder and the impact it has on families, complicating factors, typical and atypical
responses will also be discussed, ending with a listing of basic interventions nurses can perform in this setting.
The presentation is drawn from clinical and research experiences from a large urban area.
drjoed2@comcast.net
Dating Violence: Comparing Victims Who Are Also Perpetrators with Victims Who Are Not
Angela Frederick Amar, Georgetown University
In adolescent populations, dating violence is regarded as bi-directional. While many researchers have studied the
associated effects of victimization and perpetration, limited research has explored differences in victims who are
both victims and perpetrators and victims who do not report perpetration of violence. The purpose of this study was
to compare injury and mental health symptoms of victims who reported perpetration with victims who did not.
A sample of 411 young women was recruited from a historically black college in the south and a private college in
the Mid-Atlantic. Participants completed the Abuse Assessment Screen and the Symptom Checklist-90-Revised.
While all of the participants reported dating violence victimization, 35% (n=144) of the women also reported
perpetration of dating violence. As compared to non-perpetrating victims, victims who reported perpetration were
more likely to report injury, had significantly higher scores on depression, hostility, and general psychological
distress, and were at greater risk of psychiatric diagnosis.
Findings suggest the importance of further research on the effects of perpetration. Clinical implications include the
importance of assessing all young women for victimization and perpetration of violence and the inclusion of
perpetration in health teaching.
acf25@georgetown.edu
Culture and Context I: Culture and Context in Programme Design
Providing Culturally Competent Mental Health Services to America’s Under-represented
Racial/Cultural Populations
Harvette Grey, DePaul University
This paper will focus on indicators of institutional racism within organizational structures and systems with
suggested clinical intervention methods for the 'diverse' populations who are often the victims. Such treatment
aspects will include those methods that are recommended by representatives from the specific groups. The audience
will gain information pertaining to how these barriers to effective communication operate within the system and
how they effect those 'diverse' populations who are employed in those systems. For the sake of this discussion, the
groups emphasized for discussion are: African American, Asian, American Indian and Latino/a, the four largest
groups within the United States.
According to cultural expert Derald Wing Sue, individual and institutional racism continue to affect the quality of
life for America's 'minority' populations. This is often reflected in the stressors that lead to emotional problems such
as anxiety and depression and physical health problems. Because of racism or white supremacy, the health status for
many 'minority' populations reveals disturbing disparities related to life span, death rates and susceptibility to illness.
Traditional mental health care is often inappropriate and antagonistic to the cultural values and life experiences to
this population. Clients, after being 'abused' in organizational settings can easily feel that they have also been
invalidated, abused, misunderstood and oppressed by those mental health providers.
This paper will explore those indicators of institutional racism and discuss those culture-specific mental health
treatments consistent with the cultural values and life experiences of particular groups.
hgrey@depaul.edu
The Procedure for Referring a Psychiatric Patient to Hospital in China
Hu Jinian, Beijing AnKang Hospital, China
Mental health services are provided in China in a very different way from that of the West. The present paper gives
an introduction to the structure of China’s mental health service system today, and the procedure for referring a
psychiatric patient to hospital in China. This procedure varies greatly with different types of psychiatric hospitals
and with different kinds of patients. Some related problems, such as mental health legislations, are also introduced.
hujinian@yahoo.com
Organizing for Beauty: A Model of Appreciating and Leveraging Difference to Promote
Organizational Excellence
William Marty Martin, DePaul University
This paper will provide the participants with a historical analysis of the application of beauty to the design of
organizational structures, processes, systems, and culture interlaced with the growing reality of diverse employees
working in organizations and serving diverse customer bases. Furthermore, this paper will highlight specific
strategies in which organizations must move beyond legal/regulatory requirements in order to not only comply with
legal/regulatory requirements but to fully embrace the rich talents of a diverse workforce to achieve and sustain
organizational excellence. One of the critical measures of organizational excellence is a healthy work environment
because of the generally recognized principle that a healthy work environment results in higher productivity which
results in a more financially viable organization.
The focus of this paper will be three-fold:

To explore the application of Appreciative Inquiry, Art, and Building on Strengths in the design and
management of organizations.
 To identify the potential of diverse human resources in a fashion that leader and organizations design work
processes to “bring out the best” in all workers.
 To describe a framework for leading and designing an organization that values diversity, uplifting
experiences and beauty.
A case study will be presented which will illustrate the core tenets of this presentation. The case study will describe
the leadership and operations of the Mayo Clinic and how diversity is managed for the sake of creating wonderful
experiences for the patients, their families, their loved ones, the employees, and the students as well as a model of
care [Planetree] that emphasize the beauty of physical spaces that result in higher productivity, higher satisfaction,
and greater smiles among diverse stakeholders.
martym@depaul.edu
Dimensions of Diversity and the Phenomena of Diverse Groups within Dominate Culture
Organizations
Elizabeth Ortiz, DePaul University
Organizations recognize the significance of diversity as a strategic factor contributing to organizational
performance. However current practices and strategic planning revolves around the organization. This paper
however will focus on the individual’s experience verses the business enterprise. It will explore the dimensions of
diversity with an emphasis of the behavior of diverse groups and their subsequent coping mechanisms within
dominate culture organizations. Discussion will include the feelings of isolation and alienation as well as other
issues that arise when one experiences “being the other” within a dominant cultures’ organizational structures,
processes, and systems. This session will focus on the individual’s experience and their process of navigating and
surviving the sometimes chilly and hostile organizational climate. Issues of assimilation, acculturation and strategies
for success will be highlighted. This paper will also discuss the importance of effective approaches toward diversity
in business organizations. Related aspects involve effective communications, employee relations, training and
development, recruitment of talent, customer service, and the redirection of potential workplace conflict toward
positive organizational outcomes. Furthermore, this paper will detail how organizations can assist in this transition
in order to maximize the benefits of diversity and the contributions that a diverse workforce brings to an
organization.
Eortiz4@depaul.edu
Race Matters: Leadership Contentment and Discontentment at DePaul University
Marco Tavanti, DePaul University
DePaul University is the largest Catholic university in the United States of America and the largest private
university in Chicago. In a survey of thousands of students across the country, The Princeton Review found
DePaul's students to be the happiest in the nation. DePaul is also ranked 18th for "Diverse Student Population,"
making it the only Illinois university ranked in the top 20. Such diversity is increasingly better represented within
University leadership for administrators, faculty and staff. However, Latino, Black and Asian leaders at DePaul
show both satisfaction and frustration with the institution and its primary mission of teaching and service. Since
2002, the Hay Leadership Project and DePaul’s Office of Mission and Values have collected both quantitative and
qualitative data from more than 300 people who have taken specifically designed assessment instruments, the
Vincentian Leadership Assessments (VLA-Self and VLA-Observed) and the Mission Values Instrument (MVI), and
have participated in focus groups and in-depth interviews. Quantitative data of leadership practices collected through
the Vincentian Leadership Assessments are compared and contrasted with values and mission perceptions collected
by the Mission Values Instrument and another instrument, the DePaul Value Instrument, coordinated by Dr. Joseph
Ferrari, Ph.D. from DePaul University’s Psychology Department. Statistical significance for the independent
variable Race is explained though additional findings in in-depth interviews conducted by the Hay Leadership
Project and confidential focus groups sponsored by the Office of Mission and Values. This paper shows how “race
matters” more in actual leadership practices than in perceptions. Generally, faculty, staff, administrators and
students view DePaul’s organizational culture as “clearly oriented by its mission and values.” Minority faculty, staff,
administrators and students perceive that “DePaul’s leadership needs to make sure their practices and policies align
with the organization’s mission and values.” The outcomes of this study are relevant to the ongoing debate of value
based practices and to the effectiveness of racial and ethnic minority leadership participation in higher education.
mtavanti@depaul.edu
Care of the Mentally Ill in Ghana: Different Methods, Same Worrying Issues
Sam Ohene, University of Ghana Medical School
Persons with major mental health or substance abuse disorders in Ghana have 3 main modes of treatment open to
them. Cultural beliefs and limited access to formal psychiatric services dictate that all 3 systems are used jointly or
severally by most affected persons.
A Mental Health Law enacted in 1972 [currently under review], a Traditional Healers Act, the Criminal Code [1962]
and the 4th Republic Constitution of Ghana are all relevant to the practice of psychiatry and treatment of mentally ill
persons. Despite the relatively strong human rights provisions of the laws, many people believed to suffer from
mental disorders are often subjected to custodial care against their expressed wishes. Legal requirements are
frequently circumvented by proxy consents in “voluntary” admissions.
Conditions in most custodial care facilities and treatment methods are fraught with abuse and contravene the letter
and spirit of the regulatory laws.
sam_ohene@yahoo.com
Culture and Legal Insanity I
Legal Insanity and the Work of Culture
Micah Parzen, Attorney-at-law, San Diego, USA
According to DSM-IV-TR, culture-bound syndromes (“CBS”) are “localized, folk diagnostic categories that form
coherent meanings for certain repetitive, patterned, and troubling sets of experiences and observations . . . [that are]
generally limited to specific societies or culture areas[.]” As thorns in the side of the biomedical model that
dominates contemporary Western psychiatry, CBSs pose a direct challenge to the universalizability of
psychopathological processes and categories and force us to reexamine the extent to which all mental disorders are
culturally constituted. At the same time, these patterns of psychosocial distress that emerge only within particular
cultures or cultural contexts also present a valuable opportunity to rethink how we assign criminal blame with
respect to immigrant and minority offenders. Indeed, the introduction of CBSs into the courtroom raises a wide
variety of epistemological issues ranging from the relationship between culture and legal insanity to the
admissibility of culturally-based evidence regarding mental disorder. Using CBSs as a springboard for examining
some of these issues, this paper characterizes the assignment of blame as a cultural task that suffers from a
particularly myopic understanding of the ways in which human emotion and consciousness drive behaviour.
mparzen@luce.com
Provocation, Insanity, and Culture: The Problem with “Non-Volitional” Extreme Emotional
Disturbance Defences in the Criminal Law
James J. Sing, Attorney-at-law, New York, USA
In my previous work, I have argued that in criminal cases involving a non-volitional culture-based defence, courts
have been largely mistaken in analyzing these defences as akin to Not Guilty By Reason of Insanity (“NGRI”)
claims, and furthermore that the adequate provocation defence provides a more appropriate doctrinal analogue. This
paper examines more closely the ways in which adequate provocation straddles the line between defences based on
lack of criminal capacity (like NGRI) and defences bases on justification (like self-defence), and in so doing,
implicate a deeply-nested paradox that courts must overlook (or ignore) each time a defendant raises a so-called
“heat of passion” provocation defence—including one that links non-volitional criminal behaviour with cultural
background.
The first step toward exposing the aforementioned paradox is an examination of those instances in which the
propagation of cultural norms through the application of the criminal law appears in tension with the goal of meting
out individualized justice. Can it be, as previous commentators have suggested, that the notion of a non-volitional
provoked response is a legal myth whose existence perseveres for reasons of either convenience or affirmation of the
dominant normative landscape? How far do the linkages between cultural background and emotional behaviour
extend, and what can we assume about a defendant’s capacity for reason—as opposed to his or her capacity for hotheaded behaviour, when culture is added to the balancing scales from which we aim to derive and mete out
individualized justice? The answers to these questions, or the extent to which some are indeterminate, not only
have implications for the relatively small body of cultural defence jurisprudence, but may also militate in favour of
re-conceptualizing the cultural defence’s doctrinal parent: adequate provocation.
jjsing_2k@yahoo.com
A Consideration of the Validity of the "Witchcraft" Defence
Alison Dundes Renteln, University of Southern California
Modern legal systems differ from customary law systems in the extent to which arguments concerning the
supernatural influence legal proceedings. This paper considers a set of cases in which defendants, who kill
individuals accused of harming others through the use of “witchcraft”, raise a cultural defence during their trials.
The nature of the argument varies, sometimes appearing to be a form of the insanity defence, sometimes a mistake
of fact defence, and other times a provocation defence. Of particular interest for this analysis is the manner in which
courts ascertain the validity of these “witchcraft” defences in cases taken from different countries. Ultimately the
question is whether the “witchcraft” defence is a legitimate use of the cultural defence.
arenteln@usc.edu
The Insanity Defence in England: A Five-year Study Cases from 1997-2001
Ronald Mackay, De Montfort University
In 1991 Parliament enacted the Criminal Procedure (Insanity and Unfitness to Plead) Act. This statute, which came
into operation on 1st January 1992, resulted from major dissatisfaction with the way in which those found unfit to
plead or not guilty by reason of insanity were dealt with under the Criminal Procedure (Insanity) Act 1964. In
particular, under the 1964 legislation there was only one form of disposal in respect of such cases which was the
equivalent of indefinite and indeterminate hospitalisation. Although the 1991 Act did not change the legal test for
insanity, which remains governed by the M’Naghten rules, it did introduce much needed flexibility of disposal. This
meant that in addition to the indefinite hospitalisation under the 1964 Act, the court was given the discretion (except
where the charge is murder) to order admission to hospital without the equivalent of restrictions; or the make a
guardianship order under the Mental Health Act 1983, or a supervision and treatment order, or an order for an
absolute discharge of the accused. An earlier study of the first five years (1992-1996) of the operation of the 1991
Act showed that with this new disposal flexibility the number of insanity verdicts had slowly begun to rise, although
not as rapidly as might have been anticipated. This second empirical study of the insanity defence during the next
five years (1997-2001), shows how often and in what types of cases the M’Naghten Rules have continued to operate
in England. It will examine the role of psychiatric reports and their impact on the use of the insanity plea and will
answer the question: How have the new disposal powers continued to impact on the number of insanity verdicts and
with what effect?
rd@mackayr.freeserve.co.uk
Reshaping the Boundary between Insanity and Provocation in Ireland
J Paul McCutcheon, School of Law, University of Limerick
In Ireland the defence of insanity and the partial defence of provocation have been developed by the courts in recent
decades. Irish judges have departed from the strictures imposed by the M’Naghten Rules and the law accommodates
a version insanity known as “volitional insanity” or what was previously referred to as “irresistible impulse”. On the
other hand the Supreme Court has declined to recognise the partial defence of diminished responsibility in the
absence of legislation to that effect. At the same time the courts have fashioned a purely subjective version of
provocation under which the elements of that plea are evaluated exclusively in terms of the personal characteristics
of the accused. In this regard the courts, unlike their counterparts in England and elsewhere, have not been required
directly to consider the effect of mental disorder on the plea of provocation: consistent with the subjective stance
that is adopted the accused’s mental condition is simply one of the personal characteristics to be taken into account
in determining the application of that defence. These developments in the law governing insanity and provocation
can be traced to judicial dissatisfaction with the prevailing law but the unsystematic way in which the courts
engineered legal reform has resulted in confusion where mentally disordered defendants are concerned. There is a
strong suspicion that the defence of provocation is being employed as a surrogate for diminished responsibility: a
mentally disordered defendant cannot currently avail of the latter defence and is typically unwilling to rely on the
defence of insanity. However, it is suggested that it is a distortion of the plea to use provocation to solve problems
posed by mental disorder.
For a number of reasons it has become clear that the current state of the law is unsatisfactory and legislative reform
is in the offing. The Criminal Law (Insanity) Bill 2002 is progressing through the Oireachtas (the National
Parliament). That measure proposes to introduce a partial defence of diminished responsibility, to refashion the law
on fitness to plead, to overhaul the dispositional arrangements and to introduce a system of periodic review of
detention by a Mental Health Review Board. However, the defence of insanity would remain unchanged. In 2003
the Law Reform Commission published a Consultation Paper on provocation in which it suggested a retreat from the
current subjective approach to one closer in form to that which is adopted in Canada, Australia and New Zealand.
These proposals prompt the question as to how the law might properly deal with disordered offenders: in particular
which defence might appropriately be adopted and how the boundary between insanity, diminished responsibility
and provocation might be redefined.
paul.mccutcheon@ul.ie
Culture and Legal Insanity II
Civil Commitment and the Criminal NGRI in Israeli Law: A Comparison
Assaf Toib, University of Virginia
The presentation will focus on a comparison in the Israeli legal system between the rate of civil commitment of
patients suspected to present danger to society and the rate of commitment in criminal proceedings based on the
plea of “not guilty by reason of insanity” (NGRI). The underlying presumption in this comparison is that there is no
fundamental difference between the mentally ill civil patients who present danger to society and the legal suspects
eligible to use the NGRI plea. They both suffer from a mental illness, both are presented as a danger to society and
the danger is assumed to stem from their illness. However, despite this lack of difference, the rate of compulsory
admissions to hospitals of mentally ill people who are suspected to be dangerous to society is much higher than the
rate of successful NGRI pleas in the courts. Data collected in Israel about civil commitment of people who present
danger to society and of NGRI pleas will be presented and these rates will be compared to rates in the USA. In the
final part of the presentation an explanation for the observed differences between the civil and the criminal fields
will be offered.
atoib@mscc.huji.ac.il
Forcing Shock: Legal and Cultural Dimensions of Involuntary Electroconvulsive Therapy
Jonathan Sadowsky, Case Western Reserve University
In the United States, most law recognizes a right to refuse medical treatment, but does not consider that right to be
absolute. A major limitation of that right often involves emergency situations created by psychiatric illness. But
while the interest of the state to administer psychiatric drugs in certain circumstances occasions only modest
controversy, the situation is more complicated when the clinicians believe the appropriate treatment is
electroconvulsive treatment (ECT).
The American Psychiatric Association made informed consent a typical requirement for administering
Electroconvulsive Therapy [ECT] in 1979. Involuntary ECT, however, is still administered, with court approval, in
cases where the patients are deemed incompetent to assess their need for the treatment. ECT is a highly
controversial procedure in the United States, with some opponents calling for banning it outright, some proponents
considering it a safe and badly under-utilized therapy, and a spectrum of beliefs in-between. Although there are
exceptions, much of this controversy is due to a gap in perception between lay and clinical perceptions. There is
perhaps no other medical treatment is this gap so wide. This controversy, inherent to the treatment, inevitably
inflects skirmishes over involuntary administration.
American Jurisprudence (Rochester: Lawyers Cooperative Publishing, 1996) notes that “The provision of
electroshock treatment to persons with mental impairments has received heightened court scrutiny, since it is seen as
a highly invasive treatment.” This statement is true, but the use of the passive voice in the sentence is instructive,
since it does not indicate by whom the procedure is considered invasive. Some recent clinical textbooks on ECT
portray the treatment as an inconvenience, no more “invasive” than a typical trip to the dentist. Indeed, while ECT’s
“invasiveness” is a key feature of most legal writing on the subject, little of it specifies what the criteria for
invasiveness are.
This paper argues that the legal history of involuntary ECT can be fruitfully understood by viewing the legal arena
as a frontier where lay and clinical perceptions of ECT clash—but in a clash where tacit understandings of key
words such as “invasive” carry implicit residues from the cultural history of ECT.
Jonathan.sadowsky@case.edu
‘Manifest Madness’: Change and Continuity in the Insanity Defence
Arlie Loughnan, London School of Economics
This paper examines the development, construction and operation of the insanity defence in England and Wales. The
paper focuses on the history of the insanity defence in attempting to understand the role of the contemporary
insanity defence in the criminal law more generally. The insanity defence is usually understood as the uneasy result
of tensions between law and medicine, legal and medical professionals, voluntariness and determinism and
punishment and treatment. These binaries obscure the blending process through which the criminal law plots its
boundaries and maintains a coherent conception of responsibility. Contrary to dominant understandings of the
insanity defence, I argue that it has been ‘formalised’ rather than ‘medicalised’. I argue that the key to understanding
the development of the insanity defence lies not in theoretical binaries but in lay understandings of mental illness.
This often neglected aspect of the insanity defence goes some way toward explaining change and continuity in this
area of the law.
a.e.loughnan@lse.ac.uk
Constituting the “Insane” in Supermax Confinement
Lorna A. Rhodes, University of Washington
In the United States supermax confinement is increasingly used as a routine management tool; while prison growth
has slowed slightly, new supermax facilities continue to be built. Much of the debate about these prisons centers on
their effects on mentally ill inmates. While the Boscobel decision (Jones ‘El v. Berg) was an important step toward
acknowledging the harm to these inmates, in most states mentally ill prisoners remain in supermax facilities; even
when transferred out, they may be held under similar conditions. Drawing on research from Washington State, I will
describe the supermax population as a whole and will then present an ethnographic case study of a “borderline”
prisoner held alternatively under both supermax and psychiatric forms of “lockdown” and restraint. This case raises
questions about the relationship between these forms of confinement. First, how do mentally ill prisoners come to
be confined, sometimes for long periods, in supermax facilities? I will show how mental illness becomes an
ambiguous category within the prison and how the diagnostic system and managerial decisions combine to produce
this result. Second, what are the consequences of this ambiguity for prisoners? I will show how they occur within
the terms of an institutional environment in which psychiatric treatment itself resembles the conditions of supermax.
Finally, I will consider the situation of those not recognized as mentally ill and raise concerns about how supermax
confinement can be approached in terms of its general, as well as specific, harm to prisoners and about how this
harm might be framed in public discourse.
lrhodes@u.washington.edu
Death Penalty: Historical and Theoretical Perspectives
Adaptation: Employing Narrative Persuasion and Psychological Theory in Advocacy on Behalf of
Condemned Inmates
Philip N. Meyer, Vermont Law School
This presentation develops materials from two chapters of a book-in-progress, Retelling the Story: A Guide to
Narrative for Attorneys Representing Condemned Inmates (Amsterdam & Meyer). The book reconceptualizes the
representation of condemned inmates as a narrative practice, and systematically analyzes techniques of narrative
persuasion to assist attorneys and other professionals serving as advocates representing condemned inmates.
Simply put, it is the quality and power of narratives (legal and factual), and the persuasiveness of these stories, that
determine outcomes in death penalty practice. Yet, the vocabulary and theory of storytelling has never been
systematically developed or applied to this discrete area of practice. This book seeks to do that. The goal of
Retelling is to transform narrative theory (and some psychological theory) into pragmatic tools that postconviction
litigators and other professionals can employ to better understand and reconceptualize the fundamental nature of
their practice.
Sample materials from two chapters are presented – Plotting and Style. Plotting presents an overview of
components of narrative structure, and applies this theory to analyses of examples from popular culture, literature,
and legal texts including legal briefs and petitions for the writ of certiorari. Style includes analysis of such diverse
topics as: perspective and point of view, “voice,” rhythm and tempo, use of details and images, and developing
scenes. Again, the relevance of these topics in legal argumentation is developed through analysis of literary and
popular cultural stories, and legal texts.
The presentation emphasizes the primacy of narrative as tool for persuasion, and also attempts to identify several
effective storytelling practices that will be relevant for mental health professionals testifying in death penalty cases.
PMeyer6104@aol.com
Psychiatric Ethics in Death Penalty Cases
Jagannathan Srinivasaraghavan, Southern Illinois University
Although death penalty is abolished in most western countries, United States of America remains an exception. The
ethical issues involving death penalty arise from one’s personal viewpoints and professional standpoint. Both
American Psychiatric Association (APA) and American Academy of Psychiatry and the Law (AAPL) prohibit
participation in legally authorised execution such as administration or supervision of administration of lethal
injection, pronouncing death and witnessing execution unless specifically requested by the prisoner. Ethical issues
arise in testifying as to aggravating factors in order for the prosecution to get death penalty verdict, performing an
examination for competence to be executed and treating a prisoner to restore competency to be executed. There will
be discussion of “Dr. Death” who invariably testified in the sentencing phase of death penalty cases to stress the
ongoing danger to society of the defendant. The presentation will deal with varying viewpoints that can only be
realised in a country allowing death penalty posing special challenges for the forensic psychiatrists.
jvan@dhs.state.il.us
The Origin of Death Penalty Reform in Illinois
Daniel W. Hardy, Loyola University
In September, 1988, Anthony Porter was on death row two days away from execution by lethal injection for a
double murder committed in 1982 when the Supreme Court of the State of Illinois granted a stay of execution to
allow Dr. Daniel Hardy to evaluate Mr. Porter for his competency to be executed.
Two days before Dr. Hardy was scheduled to testify regarding his opinion that Mr. Porter, whose I.Q. was 51 and
who appeared to have suffered a psychotic decompensation, was not competent to be executed, another person, in a
nationally televised interview with a private investigator working with a team of journalism students from
Northwestern University, admitted that he had committed the murders for which Mr. Porter had been convicted. Mr.
Porter was shortly thereafter completely exonerated of any wrongdoing and released after 16 years of incarceration.
These circumstances led to the creation of a special commission to review the death penalty process and procedure
in the State of Illinois, and ultimately resulted in the one-time commutation to life imprisonment of all death row
prisoners in the state.
Dr. Hardy will discuss various aspects of the Porter case as well as the findings and recommendation of the review
commission.
DHSC5919@dhs.state.il.us
The Death Penalty in the United States: A Historical Perspective
Claudia Kachigian, Southern Illinois University
Even as the international community continues to recognize the death penalty as a form of human indignation and a
desecration of the right to life, the number of executions in the United States continues to increase. The Eighth
Amendment of the Constitution of the United States bans “cruel and unusual punishments”. Despite this ban, the
death penalty has persisted as a legally sanctioned form of punishment in the United States. The framers of the
constitution when referring to “cruel and unusual” punishment, never considered death itself as befitting of that
description, but only the manner in which it was carried out. For example, burning at the stake or drawing and
quartering may have been considered cruel and unusual, but death by shooting was not. Subsequent case law
continued to focus on the manner of death or the impetus for reaching the death penalty, accepting that death in and
of itself is a viable punitive option. In the 1972 case of Furman v. Georgia, the Supreme Court of the United States
articulated that the death penalty was being arbitrarily applied, and statutes would undergo strict scrutiny to assure
that they could be equally and fairly applied. This effectively abolished the death penalty at the time, until states
began to re-frame their capital sentencing statutes to conform to the requirements set forth by the Supreme Court in
a series of death penalty cases, starting with Furman. The focus of this presentation will be on the history of the
death penalty, focusing on the United States, with some review of arguments for and against capital punishment.
dhsmhtb@dhs.state.il.us
Death Penalty II: Practical Concerns
Death Penalty in Juveniles: What did U.S. Supreme Court say?
Gagan Dhaliwal, University of South Alabama
Juvenile death penalty has been a subject of extensive debate and discussion both in United States and other
countries. The United States of America is one of a few countries in the world that until recently executed juvenile
offenders. Since the death penalty was reinstated in 1976, twenty-three juveniles have been executed. However,
Texas, Oklahoma, and Virginia remain the only states to have executed a juvenile offender since 1999. There is a
worldwide opposition to the juvenile death penalty outside the United States. United States Supreme Court recently
decided ROPER v. SIMMONS. This case dealt with subjecting a juvenile to death penalty. The Supreme Court
resolved this contentious issue in the wake of ATKINS v. VIRGINIA, which made it unconstitutional to execute
mentally retarded offenders. The court decided that it is against the concept of "the evolving standards of decency in
a civilized society," to use death penalty in the juveniles. The driving force behind such a progressive legal
transformation was growing evidence that the physiological and emotional state of the adolescent brain makes
juveniles in the sixteen and seventeen age range less culpable than adults who commit the same crime. The decision
of finding that death penalty in juveniles is unconstitutional is a great step forward in United States death penalty
jurisprudence. It not only reflects the national consensus against juvenile execution, but it also has brought this
country into line with the rest of the world. Finally, juvenile death penalty does not exist in United States anymore.
The evolving standards of decency concept was first introduced in Weems v. United States. Weems involved a
public official who was sentenced to twelve years of enchained "hard and painful labor" and deprived of various
civil rights on charges of falsifying documents that resulted in defrauding the United States government of the
Philippines Islands of some 616 pesos. The Supreme Court found the sentence cruel and unusual punishment
because the sentence should be proportioned to the crime. Supreme Court justices have two opposing positions in
defining evolving standards of decency in juvenile death penalty cases. One position allows their own personal
judgments to enter into the analysis through subjective factors. The second position promotes disconnecting the
personal beliefs of members of the Court from the analysis, and focusing on objective analysis of numbers based on
legislative enactments and jury findings. Despite the two opposing positions, the Court agreed that the cruel and
unusual punishment clause is not fastened to the obsolete and is a “progressive” concept that may acquire meaning
as public opinion changes with time and therefore must be reinterpreted based on current societal standards. In other
words, the standards of justice and punishment should grow, develop, and evolve with successive generations. The
members of the Supreme Court have differed in context of the relevance of international law in interpreting the
United States Constitution in Juvenile death penalty cases. ROPER v. SIMMONS also raised issues about
international perspectives on how various societies deal with crime, culpability and punishment of juveniles. The
paper will delineate criminal and judicial aspects of the case and how it was decided at various levels of legal system
until it reached the United States Supreme Court. Cognitive immaturity and diminished culpability in some juveniles
in context of death penalty’s role in establishing deterrence and retribution will be specifically discussed. I also
intend to discuss the influence of increased scientific knowledge in the field of adolescent development and
positions taken by various professional associations, which probably played some role in the final decision.
gagandhaliwal@yahoo.com
The Death Penalty in Children and Adolescents
Stephen M. Soltys, Southern Illinois University
Many trace the origins of child psychiatry to the pioneering work of William Healy, who in 1909 became to be
involved with delinquent children who were appearing before the Cook County Court in Chicago, Illinois. Ten
years earlier the Cook County Court was the first to establish a juvenile court. Prior to this time children over the
age of 7 years were generally treated as adults. Children as young as 8 years old were executed for crimes as minor
as theft in the 19th century. Healy established the Juvenile Psychopathic Institute, which later evolved into the
Institute for Juvenile Research. This began a trend of taking a more benevolent attitude towards American offenders
where by the juvenile courts attempted to focus on meeting the mental and physical health care needs of the child
coupled with social interventions with the goal of promoting rehabilitation. Unfortunately treatment resources and
funding for the volume of cases has never been adequate, resulting in many interventions failing to have any effect
on hard-core delinquents. With increases in juvenile violence, public opinion is moving again towards removing
juvenile court protections and treating juveniles committing serious crimes more like adults.
This presentation will focus on the speaker’s experience as director of the South Carolina Department of Mental
Health, when he was mandated to put together a violent sexual predator program that required the screening of all
juvenile sexual offenders as well as adults. Some individuals admitted to the program had been sexually abused as
children, sexually acted out as early adolescents and then were committed to sexual predator programs for as long as
they were perceived to be a risk (perhaps for life). Given the lower threshold of evidence for being adjudicated a
delinquent in juvenile court, youth with minor sexual offenses could be at risk for shunted into this adult oriented
system. The speaker will reflect on the attitudes that resulted in this system being created and the potential
implications that these attitudes can have for youthful offenders who have committed murder.
ssoltys@siumed.edu
Death Penalty in the Mentally Ill and Mentally Retarded
Angeline Stanislaus, Southern Illinois University
Death penalty is the most controversial punishment in the world. In the United States, several aggravating factors
and mitigating factors are considered by the court, prior to death penalty sentencing. Mental health professionals
provide expert testimony in the determination of these factors. Presence of mental illness can either be a mitigating
factor or an aggravating factor. This depends on whether the presence of mental illness is seen by the court as
reducing the culpability of the crime or increasing the propensity for future violence. In the United States there are
several seriously mentally ill convicts awaiting the death penalty. While awaiting to be executed in the prison, if
these convicts exhibit very acute psychotic symptoms, an evaluation to determine their competency to be executed
may be ordered by the court. These issues will be discussed in depth. Another controversial issue in the United
States is the execution of defendants with mental retardation. Recently, several states have banned the execution of
the mentally retarded. But there are difficulties in legally defining mental retardation. This is debated in several legal
cases. This presentation will provide a good review of the legal and clinical issues involved in the execution of the
mentally ill and mentally retarded.
astanislaus@hotmail.com
Mental Illness/Brain Impairment as a Bar to the Death Penalty in the United States
Mark E. Olive, Attorney-at-law, Tallahassee, USA
The death penalty in the United States is regulated primarily through the Eighth Amendment to the United States
Constitution which prohibits punishments that are cruel and unusual. One of the tests for whether a punishment
violates the Eighth Amendment is whether it violates the “evolved standards of decency in a civilized society.”
Because this test is dynamic and not static, a punishment that has been accepted may become unacceptable as
standards of decency evolve. For example, in 1989, the United States Supreme Court held that it did not violate the
Eighth Amendment to execute persons who suffer from mental retardation. In 2002, the Court found that standards
of decency had evolved and that such executions violated the current standards of decency. The Court determined
that “because of their disabilities in areas of reasoning, judgment, and control of their impulses, persons suffering
from mental retardation do not act with the level of moral culpability that characterizes the most serious adult
criminal conduct. Moreover, their impairments can jeopardize the reliability and fairness of capital proceedings
against them.”
Does it violate the Eighth Amendment to execute persons who suffer from mental illness or brain damage? Many of
the considerations that led the Court to ban the execution of the mentally retarded also apply to the execution of
persons who suffer from other mental diseases and defects. A successful challenge to the execution of the mentally
ill or neurologically impaired would require, among other things: (1) a definition of impairments that are
sufficiently narrow (i.e. restricted to persons who dissociate or become psychotic); (2) a widely shared, nationally
and internationally, public understanding of and sympathy for the severe limitations and disadvantages shared by
sufferers of mental illness and brain impairments; and (3) a recognition by juries, state legislators, and persons who
make charging decisions that the mentally ill and impaired should not face the ultimate punishment. This
presentation will invite the international mental health community to engage in a dialogue regarding how to: (1)
develop categories of mental impairments that would justify exclusion from the death penalty based upon the
considerations that led the United States Supreme Court to bar execution of the mentally retarded; (2) increase
public understanding of the debilitating effects of mental illnesses and defects; and (3) convince policy and decisionmakers to support protecting the mentally ill.
meolive@aol.com
Prosecutorial Misconduct in Capital Cases
James R. Merikangas, The George Washington University School of Medicine
“The duty of a prosecutor is to seek justice, not merely to convict.”
The Prosecution Function, Standard 3-1(c)
This presentation will discuss the varieties of prosecutorial misconduct, using case material including Gall v. Parker
U.S. Court of Appeals, 6th Circuit,) ct. 30, 2000, Brady v. Maryland 373 U.S. at 87, 83 S.CT, 1194, Berger v.
United States, 295 U.S. 78, 88 (1935), and The People of the State of Illinois, Appellee v. Murray Blue, Appellant,
No. 84046 Supreme Court of Illinois, Jan. 27, 2000.
The Constitution of the United States serves to protect citizens from the unbridled power of the State, and nowhere
is this more important than in the area of criminal justice. Psychiatric testimony has been ridiculed and disparaged
by judges and prosecutors, resulting in injustice. The case of Gall illustrates the contempt in which psychiatric
testimony is held, not only by the court, but also by the general public. A judge in Pittsburgh referred to psychiatric
testimony as “MUMBO JUMBO”. When a prosecutor tells the jury not to be “HOODWINKED INO THE
DEFENSE OF INSANITY”, that is reversible error. Prosecutors engage in misconduct when they mischaracterize
crucial evidence and testimony pertaining to a murder defendant’s showing of extreme emotional disturbance and
insanity, including key expert testimony.
Misconduct occurs when prosecutors seek victory, not justice; when they try to “send a message”; attack “straw
men”: let ego rule reason; are politically motivated: and suffer from HUBRIS.
Neuropsych2001@hotmail.com
Death Penalty III
Incestuous Rape and the Death Penalty in the Philippines
Seema Kandelia, University of Westminster
The majority of those on death row in the Philippines have been convicted of rape (including rape of a minor, rape
of a family member and other aggravated forms of rape). Looking at incestuous rape in particular, this presentation
will examine some the problems associated with imposing the death penalty for such a crime. It will focus on the
effects the administration of the death penalty has on the victim and the victim’s family. Some of the legal,
evidential and procedural problems associated with rape cases in the Philippines in general will also be highlighted.
Despite the existence of the death penalty for incestuous rape, the number of cases has not diminished. Recognising
this, local women’s groups in the Philippines have called for root causes of incest and other forms of violence
against women to be addressed rather than imposing the death penalty for rape. This response will also be
considered within the broader context of Filipino gender relations.
S.Kandelia@wmin.ac.uk
Gender and the Death Penalty Under Nigerian Sharia Law
Nicola Browne, University of Westminster
Since the first sharia death sentences were imposed in Nigeria in 2001, the state has been roundly condemned by
NGOs, governments, the United Nations and the European Commission to name but a few. Even those familiar with
the frequent executions carried out in certain states of the USA witnessed a level of censure that American
executions rarely inflame. This paper aims to look at the imposition of death sentences under sharia law in Nigeria.
It will examine the reasons behind the outrage expressed by many in the international community particularly in the
wake of the death sentences passed on Amina Lawal and Safiya Husseini. The paper will consider the role Lawal
and Husseini’s gender played in attracting such a level of censure across the world stage. Was the wider world’s
view of the disproportionality of the punishment of stoning for the crime of adultery under sharia legislation in
Northern Nigeria the reason for the wave of condemnation? How does this sit in regard to the marked contrast in the
level of international support attracted by Lawal and Husseini’s cases in comparison to the muted reaction received
by several cases involving Nigerian males accused of child sex abuse and given stoning sentences. What can we
learn about the role gender and crime play in the politics of death penalty abolition?
brownen@wmin.ac.uk
The Impact on Families of Homicide Victims of Replacing the Death Penalty with Alternative
Punishments
Peter Hodgkinson, University of Westminster
In countries retaining the death penalty, the latter punishment is often offered as the primary vehicle for justice and
coping with the aftermath of bereavement for the family members of victims of homicide, whilst in reality it is little
more than a political tool whereby politicians are perceived to be cracking down on violent crime. Both advocates
and opponents of the death penalty often refer to the needs and rights of these “secondary” victims as part of their
rhetoric and yet they rarely, if ever, offer any practical support to help victims cope with the aftermath of the loss of
a loved one. One aim of this presentation is to highlight some of the issues arising for victims from the use of
different punishments as a response to murder. These range from the harshest punishments of the death penalty and
life imprisonment without the possibility of parole, to other terms of life imprisonment and the relatively new
restorative justice programmes such as Victim Offender Mediation / Dialogue, where the victim and offender can
choose to meet as a way of understanding the crime and helping the process of accepting the loss of the family
member. The presentation will thus compare and contrast some of the varying effects these punishments have on
the bereavement process for victims, and attempt to reach some conclusions as to their relative value for families of
homicide victims.
hodgkip@wmin.ac.uk
Good Women and Bad Mothers: Capital Punishment, Motherhood and Infanticide
Rupa Reddy, University of Westminster
The response of criminal justice systems to crimes of infanticide committed by women has over the course of time
varied between punishment, treatment, or a combination of both. Women who kill their children are seen to have
committed one of the most heinous crimes that a woman could commit, and to have gone 'against nature' in killing
their own child. Societal constructs of women who commit heinous crimes have contributed towards their unequal
treatment within the law, and in cases of infanticide this gender bias has combined with perceptions of motherhood.
The historical entrenchment of these ideas is well documented, and the execution of women accused of infanticide
in witchcraft trials is one interesting example of this. In the last century the approach to infanticide became more
clinical, and in many circumstances it may now be viewed not only as a criminal justice matter, but also as a social
and mental health issue. This presentation will attempt to demonstrate that despite this, the earlier focus on
infanticide as a crime against women’s natures which should be punished severely is still present today, albeit in a
less open form. This issue will be examined with reference to the recent cases in Texas of Andrea Yates and Deanna
Laney, mothers who killed their infants in similar circumstances but received differing sentences within the same
capital punishment system. This will help to highlight the role societal perceptions of womanhood and motherhood
continue to play in cases of women who kill their children, specifically in the context of capital punishment.
R.S.Reddy@wmin.ac.uk
Human Rights Implications of Recent U.S. Exonerations
Russell Stetler, Capital Defender Office, New York
Over the past decade and a half, two sets of wrongful convictions have attracted great interest in the United States:
exonerations based on hard scientific evidence, chiefly DNA evidence and mainly in rape and homicide cases, and
death row exonerations based on intense postconviction scrutiny of the most serious murder cases. Both sets of
exonerations now number well over a hundred. The rate of exonerations has increased dramatically. According to
one recent study, exonerations averaged about a dozen per year in the early 1990s, compared to 43 per year after
2000. These exonerations have prompted both governmental inquiries (such as the governors’ commissions in
Illinois in 2000 and Massachusetts in 2003-4) to propose legislation to reduce risks of wrongful conviction, as well
as academic studies and bar association interest in the implications for the American criminal justice system. But
placed in a global context, the lessons of these cases have even larger implications to the extent that they illuminate
the practical common-sense underpinnings of our core values in human rights.
In two training programs organized by international human rights organizations I have used the U.S.
exonerations as a means of addressing these issues. At a court training program in Cambodia in 1995 and in a
public defender training program in the People’s Republic of China in 2003, the lessons of the U.S. wrongful
convictions were used to demonstrate the societal effects of false confessions, eyewitness errors, informant perjury,
and the malfeasance of police and prosecutorial agencies. Core protections of individual rights were underscored as
vital to a fair and just polity. Finally, the demonstrated high risk of wrongful execution has altered the public
discourse on capital punishment itself in the United States.
rstetler@nycdo.org
Culture and Context ll: Definitional Issues on Mental Health and Treatment
In psychiatric medicine it is often observed that the definitions and accepted treatments of illness are liable to
change under the influence of shifting cultural and economic forces. The historical analysis of such change in the
past can be a powerful tool for illuminating how forces are similarly working change today in the field of mental
health. In this session we examine the origins and changing status of five different psychiatric illnesses in cultural
context: addiction, anhedonic depression, bipolar disorder, chronic fatigue, and paranoia. The historians of
psychiatric medicine shall explore how political and economic forces impressed themselves upon the definitions of
all five conditions, and point to lessons for mental health today.
Charting Influences on Punitive vs. Medical Responses to Illicit Drug Use in the United States
Caroline Acker, Carnegie Mellon University
Addiction’s ambiguous status as criminalized disease in the U.S.A. has resulted in a framework in which policy was
adjusted in more or less punitive directions in response to changing conditions over the course of the twentieth
century. Changes in class profiles of illicit drug use have played particularly important roles in shaping American
drug policy. This paper will examine four episodes in the twentieth century: first, the U.S. Public Health Service
Narcotic Hospitals functioned from the 1930s to the 1970s as prison hospitals; second, methadone maintenance,
introduced in the 1960s, and the most highly regulated form of American medical practice; third, the rise of white,
middle class demand for drug treatment at the same time that American hospitals faced serious fiscal pressures in
the 1970s and 1980s , and the emergence of private sector “chemical dependency” units in hospitals, independent of
the criminal justice system; and fourth, the recent introduction of buprenorphine as a treatment for opiate addiction
that can be administered in the privacy of a physician’s office and its place in the two-tier where class and race
remain powerful determinants of who receives punishment for drug use, and who receives medical treatment
without criminal sanctions.
acker@andrew.cmu.edu
Medicalisation and De-medicalisation: Cross-national Reflections on Recent Re-Makings of Chronic
Fatigue Syndrome
Rachel A. Ankeny, University of Sydney
Chronic Fatigue Syndrome (CFS) remains a controversial disease category, and debates continue about how to best
to diagnose and treat individuals with this and related conditions. This paper is based on a study of the relatively
recent development of practice guidelines for CFS in Australia as compared to previously existing guidelines in the
US, UK, and Canada. These guidelines and the process by which they were produced will be explored with
particular attention to debates about medicalisation and how this concept has been used by both professionals and
lay groups to support divergent positions. As recent historiographic literature has indicated, deeper attention must
be paid to the tensions inherent in the very concept of medicalisation in order to provide a richer basis for historical
work on concepts of disease.
rankeny@science.usyd.edu.au
Delusional Diagnosis? The History of Paranoia as a Disease Concept in the Modern Era
Ian R. Dowbiggin, University of Prince Edward Island
The history of paranoia (or delusional disorder as it is now called) has had a roller-coaster history as a disease
concept in the modern era. In all likelihood over-diagnosed in the late nineteenth century, it was reduced to a
residual diagnosis for much of the twentieth century, what patients received when it was determined they did not
have neurosyphilis, schizophrenia, or bipolar disorder. In the last thirty years paranoia experienced a brief
resurgence in clinical popularity, but several factors, including inter-professional competition, health consumer
demand, the changing modalities of medical reimbursement, and the introduction of drugs such as Prozac
(fluoxetine) are threatening to reduce it to what it was for much of the twentieth century: extremely rare or simply a
sub-type of larger disease classes.
idowbiggin@upei.ca
From Folie Ciculaire to Bipolar Illness
David Healy, Cardiff University
While madmen have been described as having mania since the time of Hippocrates, modern notions of manicdepressive illness stem from the description of Folie Circulaire in Paris in the 1850s, which was transformed by
Emil Kraepelin into Manic Depression in 1896. In clinical practice however mania continued to be used as a
generic term for madness until approximately 1914, when patients with what would now be called a mood disorder
began to be regularly distinguished from other cases of madness. In 1966, shortly after the introduction of lithium,
the notion of a bipolar illness was put forward to distinguish manic-depressive disorders from recurrent unipolar
mood disorders. Bipolar disorders remained comparatively unrecognised however until the late 1990s, when
following the marketing of "mood stabilizers," bipolar disorder emerged as the currently most fashionable disorder
in psychiatry.
healy_hergest@compuserve.com
Inventing the 'Antidepressant': Medical Science, the Drug Industry, and Anhedonia in Amphetamine’s
Introduction to psychiatry, 1935 – 1950
Nicolas Rasmussen, University of New South Wales
Long before the tricyclics, MAOIs, and SSRIs, amphetamine was introduced as the first 'anti-depressant' -- a term
invented during the 1940s to describe Smith, Kline and French's Benzedrine (racemic amphetamine), as part of the
firm's marketing of this new product. Here I explore changes in the definition of neurotic depression that
accompanied the construction of this novel drug category around amphetamine, and the marketing of both drug and
drug category in psychiatric medicine from the late 1930s through the 1950s. A key part of this marketing involved
redefinition of depression, generally understood at the outset in terms of neurasthenia or nervous exhaustion. The
campaign for Benzedrine Sulfate instead promoted a then-marginal theory of 'mild depression' that characterized the
condition as a failure of the mechanisms driving purposeful activity and reward, and thus promoted apathy and
anhedonia as the fundamental symptoms rather than exhaustion and weakness. Measured by levels of interest in
activities and by pleasurable activity itself, amphetamine indeed represented an effective antidepressant. This
episode shows that redefinition of psychiatric disorders around drugs -- at least partly through the actions of drug
companies -- is not so recent a phenomenon as is widely supposed. Furthermore, it raises questions about the extent
to which anhedonia’s continuing ascendance in psychiatric thinking about depression ever since the Second World
War has depended on amphetamine’s original construction as an antidepressant, and on the subsequent introduction
of later antidepressants with similar (even if superior) clinical profiles.
Nicolas.Rasmussen@unsw.edu.au
Cultural Safety and International Human Rights
Vicky Smye, University of Victoria
This paper explores the exportability of the concept of “cultural safety” from its use in a Canadian context as a lens
for examining policy affecting Aboriginal peoples to an International Human Rights context. Irihapiti Ramsden, a
Maori nurse leader in New Zealand, developed the concept of cultural safety within a nursing education context in
response to colonizing processes in Aotearoa/ New Zealand and the consequent inequities in health status and
opportunity for the Maori people. Cultural safety is derived from the idea of “safety” as a standard that must be met,
akin to an ethical standard – it involves the recognition of the social, economic, and political position of certain
groups within society that create disadvantage, such as the Maori people in New Zealand or Aboriginal people in
Canada. Importantly, it reminds us to consider the historical context of peoples’ lives that shape those positions. I do
not use cultural safety as a fact or entity, something to look at, but rather I use it as something to look through, as an
interpretive lens. It prompts the asking of a series of moral questions to unmask the ways current policies, research,
and practices may perpetuate inequities in mental health care for Indigenous peoples. Here, “cultural safety” will be
set within the context of eating disorders as a mental health issue.
smye@interchange.ubc.ca
Depressive Disorders: Trends and challenges
Challenging Normative Orthodoxies in Depression: Huxley’s Utopia or Dante’s Inferno?
John R. Cutcliffe, University of Northern British Columbia
Compelling evidence provided by the World Health Organisation indicates that the global rate of depression
continues to rise, affecting approximately 121 million people worldwide. It is within this epidemiological context
that the contemporary position regarding depression has emerged. Riding squarely ‘on the back’ of the Hollywood
perpetuated myth is the normative orthodoxy that if a person is suffering from depression, then he/she needs
‘fixing.’ That if one is not skipping joyfully every moment of every day, then there is something wrong with you.
Inevitably, in these days of an immense political lobby wielded by the pharmacological industry, such ‘fixing’
inescapably means drug treatment. The highly addictive nature and questionable efficacy of some of these drugs
notwithstanding, the entire treatment paradigm ignores or dismisses an essential axiom.
Depression is an essential piece, if not maybe even a necessary component, of the human experience. We can no
more deny this existential state of being than we can any other – including joy. Furthermore, the pivotal
developmental task and immense experiential value of accepting the limitations of life and learning that life can
never be perfect, is inextricably bound up with the experience of being depressed. Maltsberger (2004) makes this
point most poignantly when he states, “successful adulthood demands that one must passively endure
disappointment over and over again….Maturity demands that one must accept passive suffering without
flying into rages against life or against one’s body”.
Consequently, in the search for a world where the automatic response to depression is a pharmacological
intervention that inhibits the person’s chance to explore the meaning of their experience, we are preventing people
from individual growth and personal development. Interestingly, in worlds analogous to this pharmacologically
induced depression free state, such as Utopia’s like Huxley’s Brave New World, no ‘properly conditioned citizen’ is
depressed or suicidal. Yet in the same Brave New World no one is free to suffer, to be different or crucially, to be
independent (Maris, 2004).
Dr.johnr@shaw.ca
cutclifj@unbc.ca
Rurality and Depression: A Three-country Perspective of the Issues and Challenges of Providing
Mental Healthcare for Rural Populations
Ian Blue, University of Northern British Columbia
Henry Harder, University of Northern British Columbia
In this presentation we will focus on the issues and challenges faced by rural communities in three countries,
Australia, Canada and the United Kingdom, with respect to accessing and receiving adequate mental health care.
Particular attention will be paid to the problems associated with depression’ and suicide. Drawing on the empirical
evidence from each country, such as it is, we will demonstrate how the epidemiological figures for depression are
more concerning for populations who live in the rural and northern areas. In British Columbia, Canada, for
example, when compared to their urban counterparts who live in the south of the Province, health outcomes,
including those associated with depression and mood disorders are markedly worse.
Further, this presentation will illustrate that despite the huge geographical differences between the countries and the
cultural idiosyncrasies, there are significant areas of commonality and overlap in the issues and challenges they each
face. Additionally, to date the majority of research on rural mental health has been from the perspective of providers
not consumers, as a result, there is a great deal we do not know about why depression is common amongst these
populations, why these populations do not seek formal healthcare input, why the stigma associated with mental
health problems appears to be a larger concern in these communities and what may be different in the experience of
being depressed in rural communities. Accordingly, the presentation concludes by highlighting the value in
‘pooling’ the epistemological resources, engaging in international collaborative studies of depression in rural
populations where there is obvious synergy and commonality, and by illustrating the direction of future research in
this area.
blue@unbc.ca
harderh@unbc.ca
Co-Occurring Depression and Problem Substance Use in Women: Psychosocial Factors and
Treatment Considerations
Corinne Koehn, University of Northern British Columbia
Depression and problem substance use are relatively common co-occurring conditions in women. Each disorder has
the potential to affect the onset, course, and treatment of the other. For example, substance use may increase the risk
of an individual becoming depressed, exacerbate depressive symptoms, or interfere with the treatment of depression.
Alternately, depression may predispose an individual to using substances, contribute to more frequent relapses, and
interfere with substance use treatment.
Depression and problem substance use both occur as a result of the interplay of various biological, psychological,
and social factors. The first part of this presentation will focus on the social and psychological factors associated
with depression in women. Poverty, gender socialization, negative life events, cognitive distortions, and particular
coping styles may increase women’s vulnerability for depression. The multiple pathways in which these factors may
link depression and problem substance use will be explored.
The second part of the presentation will examine ways in which co-occurring depression and problem substance use
may lead to specific challenges in treatment. These challenges can be grouped into those that pertain to how the
client experiences herself, how she functions within the therapeutic process, and how she performs in activities
intended for completion outside of the therapy session. Health providers need to recognize that women with cooccurring depression and problem substance use may require interventions that are designed to take into
consideration the nature of both conditions.
koehn@unbc.ca
Psychological Recovery and Personal Responsibility in Depression
Chris Stevenson, University of Teesside
Sue Jackson, University of Teesside
Jim Campbell, University of Teesside
Existing methods for treating depression are firmly anchored in a biomedical model of mental health, reinforced by
the might of the pharmaceutical industry. In the UK anti-depressant prescribing by general practitioners in the UK
has doubled in the last 10 years. Yet, there is a growing recognition that depression might be thought of as part of
the whole life experience. Indeed, this is difficult to deny as 121 million people are affected worldwide (World
Health Organisation). 1 in 5 people will experience depression during their lifetime.
The psychological recovery research group, at Teesside Centre for Rehabilitation Sciences (TCRS), in collaboration
with the Institute for Mental Health Recovery, Ireland, have developed an approach to recovery as a multidimensional process, named ‘PROSPECT’ to indicate a positive outlook for people who experience psychiatric
distress. PROSPECT does not pathologise the person, as some models do by predicting relapse (Copeland’s 1997).
Nor does PROSPECT involve stripping the individual of freedom, choice and responsibility, socially, morally and
legally.
The PROSPECT approach incorporates the view that we are all always recovering our lives to a lesser or greater
degree. It synthesises existing best practice (e.g., the principles and practice of Barker’s (2000) Tidal Model) and
insights from the TCRS programme of psychological recovery research that has focused upon: how professionals
can meaningfully respond to people in distress; models of empowerment/service user involvement; and critical
review of evidence and practice. PROSPECT encourages professionals to help the person make sense of their
distress in relation to past, present and future lives. In so doing, it places the person as a central, responsible agent
who in engaged in a partnership with the professional, rather than being the passive recipient of care.
C.Stevenson@tees.ac.uk
sp.jackson@tiscali.co.uk
Jim.Campbell@tees.ac.uk
Three Generations at High Risk for Depression
Myrna M. Weissman, Columbia University
The familial nature of major depression (MDD) is well documented with about a three fold increased risk in the first
degree relative of probands with MDD. None of the published studies have gone beyond two generations or have
followed the families over many years. We report results of a high risk, longitudinal study of three generation at
high and low risk for MDD.
Methods: 161 grandchildren their parents and grandparents were systematically assessed blind to previous
generations and previous interview on their psychiatric status and functioning. The first two generations were
assessed over 20 years.
They were high rates of anxiety disorders in the grandchildren (mean age 12 years) with two generation of MDD.
Grandchildren with both a depressed parent and grandparent as compared with those where the parent was not
depressed had over a four fold increased risk of anxiety and over two fold increased rise of mood disorders.
Anxiety disorders are the early signs of psychopathology in young grandchildren at high risk for MDD.
Grandchildren from two generations have the highest rates of anxiety and depression. Families with three
generations affected with MDD or anxiety could be the target for neuroimaging, genetic and other biological studies.
mmw3@columbia.edu
Diagnosis and Treatment of Mentally Ill Offenders I
Deficient error-monitoring in violent psychopathic offenders: a research proposal
Jacques van Lankveld, Pompe Mental Hospital, Nijmegen, the Netherlands
A substantial proportion of violent sexual offenders and other violent offenders are diagnosed with psychopathic
disorder, characterized by a failure to accept responsibility, lack of empathy and compassion with the victim,
shallow affect, a manipulative style, pathological lying, and lack of remorse or guilt and impulsive, antisocial
behavior. Underlying to psychopathy, and more specifically to psychopathic individuals with a history of violent
offences, may be abnormalities in the response monitoring process during conscious or unconscious and during
willed or unwilled error making. Executive control systems regulate important global aspects of human behavior,
such as decision making, and planning, specifically in the context of difficult and novel tasks. Errors during the
execution of tasks are accompanied by the so called error-related negativity (ERN) in the electrocortical waveform
at approximately 80 ms after onset over frontal-central regions of the skull, with maximum amplitude in a region
over the supplementary motor area. The onset of the ERN coincides with response initiation, with the onset of
response conflict, with the onset of the delivery of error feedback without the concomitant emission of motor
responses, and in general, with response evaluation. Researchers largely consent to the view that the ERN is
generated by a high-level, generic, error-monitoring system, highly flexible and capable of dealing with errors in
widely varying. The function of the ERN is hypothesized to adjust the goal-directed behavior. Neuro-anatomically,
the ERN is associated with the anterior cingulate cortex. The current state of evidence on this subject will be
summarized and a proposal for new research will be presented. The new research aims to elucidate the cognitive
processes during error making of violent offenders employing the error-related electrocortical negativity (ERN) as a
psychophysiological marker. This will be investigated in both sexual and nonsexual contexts to investigate the
contribution of sexual arousal. The modulating effect of psychotropic drugs on the response monitoring process
during error-making will be investigated.
j.v.lankveld@pompestichting.nl
Do Remand Prisoners With and Without ADHD Differ in Their Patterns of Offending?
Marijke Drost, IJsselmeer Hospital, Lelystad, The Netherlands
The persistence of Attention Deficit Hyperactivity Disorder (ADHD) in adulthood increases the risk of developing
other psychiatric disorders, addiction, social personality disorder and an increased contact with the law. Does this
mean that prison inmates with ADHD are different from inmates without ADHD regarding the age of onset of
delinquent behaviour and type of offending? This paper discusses a study among 75 male remand prisoners aged
18-35 years in the Netherlands. The present subject is part of a larger design to determine the prevalence of ADHD
in this population and the reliability of several ADHD questionnaires.
The diagnosis of ADHD was made by semi-structured interview. Information about the respondent´s age of first
contact with police, first arrest dates and types of offending were obtained from the interview and Diagnostic
Interview Schedule (DIS). In 44 cases objective information was obtained from the penitentiary registration system.
The study was conducted in two remand prisons. Subjects were approached in a non-select order by the prison
psychologists. They were then interviewed and the DIS was used by the interviewer.
Figures about age of onset and offence from the ADHD vs. non-ADHD subjects were compared with Fisher´s exact
test.
The range of offence-types was too wide to allow for further analysis in this small population. When they were
regrouped into violent and non-violent offences for the ADHD and non-ADHD groups, no significant difference
could be found. Age of onset and committing more than three offences also did no show significant differences
between the two groups.
These findings are based on incomplete objective data (44 of 75 subjects) and selfreport. They can only be
considered as an estimate. From the selfreport it became apparent that in both the ADHD and non-ADHD groups
very severe offences occurred in both groups, but the numbers were too small to allow for further analysis.
M.Drost@IJsselmeerziekenhuizen.nl
About the European ADHD Network: Differences between the Countries and Implications for
Forensic Psychiatry
Karen Foeken, Psychiatrist, La Gaude, France
The subject of ADHD in adults is of great clinical and forensic interest. Internationally there is a search for reliable
diagnostic instruments and the standards of treatment are being developed. The European ADHD network is an
initiative of Dr.S.Kooij, a Dutch psychiatrist and specialized in ADHD in adults. Actually about 17 countries are
represented. The purpose of this network is to come to consensus about the diagnosis and treatment of ADHD in
adults. Also we would like to coordinate research done in this field.
ADHD is a well known as a diagnosis in children and about one third of these children will still have the disorder in
adulthood. The estimated prevalence of ADHD in adults is between 1-5 %. Although both DSM IV and ICD 10
criteria recognise that symptoms of ADHD persist beyond childhood into adulthood neither gives fixed thresholds
for the number of symptoms required to make a diagnosis in adults. There is a growing awereness nowadays that
one seems to outgrow to criteria rather than the disorder. A lot of research still needs to be done to adjust the criteria
to diagnose ADHD in adults. There are some promising results about a scale that consists of six questions and has
been translated into several languages.
ADHD can be a life time condition and because of some invalidating aspects of the illness it is important that the
illness should be diagnosed properly and treated properly. In some countries it is still not well known that ADHD
can persist into adult life.
Treatment varies in Europe.Stimulants are considered first choice, but the way they are prescribed differs from
country to country. This also has implications for forensic psychiatry and forensic reports. People, in this case
mainly males, with ADHD may, because of their symptoms, come into contact with the police at a very early stage
of life. This can lead to a long criminal record . The prevalence of ADHD in adult males with a criminal record is
estimated around 16%. It is important to be able to recognize the illness in an early stage, to be able to start a proper
treatment in order to prevent relapse.
A case of a forensic report will be presented.
k.foeken@wanadoo.fr
Psychiatric Characteristics and Service Use in Psychotic and Personality Disordered Offenders
Kris R. Goethals, Pompe Mental Hospital, Nijmegen, The Netherlands
Hjalmar van Marle, Erasmus University Medical Centre, Rotterdam, The Netherlands
In a recent study (Nolan & Volavka, 2003) the impact of positive symptoms of the psychosis on aggressive behavior
was studied. In a prospective investigation of patients in community treatment (Hodgins et al., 2003), the presence
of severe psychotic symptoms and the development of TCO symptoms were antecedents of aggressive behavior.
The temporal relationship between schizophrenia and crime was studied by Munkner et al. (2003). The following
hypotheses are formulated: 1. In psychotic TBS-patients, positive symptoms of the psychosis and psychomotor
poverty are more frequently seen than in general psychiatry psychotic patients. Especially paranoid delusions are
important in violence; 2. a) Psychotic TBS-patients used less psychiatric services and took less medication before
the index offence, compared to general psychiatry psychotic patients; b) Psychotic TBS-patients with a personality
had earlier and more contact with psychiatric services, compared to psychotic TBS-patients without a personality
disorder, probably due to early behavioral problems or/and substance misuse; 3. In psychotic TBS-patients with a
personality disorder and in personality disordered TBS-patients, more often a positive familiar anamnesis of
substance misuse is seen, compared to psychotic TBS-patients without a personality disorder; 4. More placements in
institutions and in child psychiatry and more pervasive developmental disorders are seen in psychotic TBS-patients
with a personality disorder and in personality disordered TBS-patients, compared to psychotic patients without a
personality disorder. Four groups of patients are rectruited from forensic hospitals (TBS-hospitals) and one general
psychiatry hospital (total number of patients = 147). All patients were matched to sex, age and etnicity. Only
severe violent offences are included, no sex offences. The design is retrospective, all information is taken from
existing files. Beside a list of socio-demographical, psychiatric and criminological variables, the following
instruments are used: axis IV and V of the DSM-IV, the HCR-20 H-items and the PCL-SV. A SPSS statistical
package was used to analyse the data. Preliminary results are presented and recommendations are made for future
research.
k.goethals@pompestichting.nl
Therapeutic Relationships : The Perspective of Patients Enrolled in a Aggressive Behaviour Control
Program
Ms. Penny Schafer, Correctional Service Canada, Saskatoon, Canada
When the treatment setting is a correctional facility and the patient is incarcerated the clinical challenges associated
with the development of therapeutic relationships are amplified. Setting limits and maintaining a safe distance are
often over-emphasized and under-involvement becomes the accepted practice. Yet, the development of therapeutic
relationships is central to maximizing treatment outcomes and providing care. Understanding the development of
therapeutic relationships from the perspective of incarcerated patients can guide treatment staff in responding to
clinical challenges and establishing therapeutic relationships with this group. This presentation will highlight the
constructed reality of therapeutic relationships for twelve patients participating in a treatment program for violent
offenders. Participants identified contextual factors of significance in the treatment environment, engaged in
processes to evaluate the treatment staff, and had experiences that hindered and promoted the development of
therapeutic relationships. In the end, they discovered a way of being with the treatment team member assigned as
their primary therapist. Recommendations for mental health professionals caring for incarcerated patients conclude
this presentation.
schaferpe@csc-scc.gc.ca
Diagnosis and Treatment of Mentally Ill Offenders II
Crisis Intervention Team Programs for Law Enforcement: More Than Just Training!
Michael S. Woody, Ohio State Crisis Intervention Team, Uniontown, USA
Law Enforcement has very little training in dealing with persons that are mentally ill. Yet, 10% of police calls for
service involve persons with this illness. The results are sometimes catastrophic for both parties. Ohio borrowed
from Memphis, Tennessee a 40-hour intensive training program that challenges exceptional officers to deal more
appropriately with this special population. Four years later, Ohio has every major city active with Crisis Intervention
Team programs or planning them. This was accomplished through the building of long-lasting relationships between
law enforcement agencies, mental health providers, and other interested parties such as the National Alliance for the
Mentally Ill and the Ohio Supreme Court. Administrators are taught officer safety, proper conduct and liability
issues. Ohio has more Crisis Intervention Team (CIT) law enforcement agencies than any other state or country in
the world. This paper will describe the Crisis Intervention Teams and explain the training courses.
michael.s.woody@earthlink.net
Subjective and Objective Short-Term Outcome of Inpatient Psychiatric Care: Impact of Coercion and
Content of Care
Tuula Wallsten, University of Uppsala
Lars Kjellin, Psychiatric Research Centre, Örebro, Sweden
In mental health care policies, treatment and care in the community is emphasized. The number of psychiatric beds
for in-patient treatment has been reduced over the last decades and the average length of stay has been shortened.
Often after a short episode of voluntary or involuntary in-patient treatment, severely mentally ill patients are
discharged to the community and offered outpatient contacts. Thus, the immediate outcome of acute, short-term
psychiatric in-patient care is of major interest.
The aim of this study was to explore the outcome at discharge from such care in relation to coercion at admission,
coercive treatment and characteristics of the patients and of the care they received.
At four Swedish psychiatric departments, 233 legally involuntarily and voluntarily admitted patients were
interviewed, using the Nordic Admission Interview within five days from admission and a semi-structured interview
at discharge or after three weeks of care. Additional data were collected from the case records. Outcome was
measured in two different ways: subjectively reported by patients as improved or not improved, and change in level
of functioning according to the Global Assessment of Functioning Scale (GAF). An increase in GAF scores of 10 or
more was regarded as an improvement.
Two thirds of the patients were subjectively improved and 58% were improved according to GAF. Forty percent
were improved according to both measures. Legal status at admission, perceived coercion at admission or perceived
coercion during care were not associated to outcome. The strongest predictors for a positive subjective outcome
were if the patient reported that they had been well treated by the staff and that they had one or more contact persons
at the ward. The most significant predictor for a GAF improvement was a low GAF score at admission and having a
mood disorder diagnosis.
Subjectively reported outcome and outcome measured by assessing change in level of functioning seem to be
different phenomena. The degree of coercion was not related to the result of the treatment during the hospitalisation
period. The way the patient perceived they had been treated by the staff was strongly related to subjective outcome.
tuula.wallsten@ltvastmanland.se
Longstay-units in Germany
Uwe Dönisch-Seidel, Düsseldorf, Germany
Until the end of the last decade, “long stay” was practically no topic of the rule execution in Germany. Apart from a
few exceptions, long-term patients were “treated” integratedly; specific conceptions did not exist. Activated by the
Dutch developments and also due to the distinct increase in the number of long-term patients with or without little
dismissal prospects, we have, in the meantime, more and more seen the demand also in Germany to establish
specialized wards for these patients. In the federal state of North Rhine-Westphalia, we are aiming at an
implementation and a scientific evaluation of long stay departments together with Dutch institutions in order to
discuss open questions with regard to the arrangement, conception and necessary number of personnel.
Long stay wards should:
 use the latest developments in research as a guide
 satisfy constitutional requirements
 take the patients’ interests into account
 manage with as little public money as possible
The arrangement of long stay wards requires special attention concerning the following aspects:
 spacious design of the premises (one- or two-bed rooms, freedom of movement within the highly secure
institution)
 work facilities (instead of work therapy)
 leisure time facilities (instead of social / milieu therapy)
 self-sufficiency (instead of supply by the clinic).
Uwe.doenisch-seidel@lbmrv.nrw.de
The Effect of Treatment on Quality of Life of Forensic Psychiatric Outpatients
Yvonne H.A.Bouman, Pompe Mental Hospital, Nijmegen, The Netherlands
In general health one of the most important outcome measures of treatment is Quality of Life. The primary aim in
forensic psychiatry is protection of the society which is done by improving those facets of a patient, and of a
patient's life which are considered to have a negative influence on the behaviour of the patient. The general
hypothesis of this study is that if a patient's quality of life improves the need for criminal behaviour diminishes. To
study a part of this hypothesis the influence of treatment on quality of life needs to be established. In a multisite
study app. 100 patients in a community based setting are followed over a period of six months. The study population
comprises of male patients diagnosed with an Axis 2 disorder or Axis 2 traits (DSM-IV, 1994), both with or without
a criminal background. Using the Lancashire Quality of Life Profile (Oliver et al, 1996) these forensic psychiatric
outpatients' life satisfaction on various life-domains is measured with an interval of six months.
The number and kind of treatmentsessions will be linked to the outcome measures. The number of no-shows,
sessions a patient skipped, and also if treatment stopped during the six-month's period is included. The influence of
life events (VRMG, Willige, G. van de, et al, 1985) and self report criminal behaviour (ZRCG, van Dam et al,
1999) during that period will be taken into account. Treatment implications of the results will be discussed.
y.bouman@pompestichting.nl
Exposing Myths Surrounding Preventive Outpatient Cimmitment for Individuals with Chronic Mental
Illness
Raymond M. Deeney, Seton Hall University School of Law
Using New York’s “Kendra’s Law” as an illustrative vehicle, this article addresses the principal criticisms lodged by
opponents of preventive outpatient commitment. The authors argue that preventive outpatient commitment is a useful
adjunct to conditional release or placement in the least restrictive alternative that has neither produced revolutionary
change in psychiatric commitment standards nor will be used inappropriately to assert governmental control over
mentally ill citizens. The authors contend additionally that preventive outpatient commitment does not violate federal
constitutional norms or represent bad policy making. The authors acknowledge, however, that the coercion inherent in
outpatient commitment schemes may produce certain undesirable side effects. Thus, they explore an alternative
approach currently in development in Australia that promotes community based treatment for chronically mentally ill
persons without judicial intervention.
raydeeney@comcast.net
Diversion of the Mentally Ill from the Criminal Justice System
Results of an International Web-based Survey of Pre-arrest Diversion, Court Diversion and Mental
Health Courts
Kathleen Hartford, University of Western Ontario
To develop evidence-based, best practices we conducted an extensive literature review and an international webbased survey of police pre-arrest diversion, court diversion and mental health courts in Canada, the US, the UK,
Australia and New Zealand during six months of 2004. Identifying individual email addresses for the web-based
survey involved a multi-stage effort and a convenience sample of 850 persons/organizations was assembled. Three
surveys were developed with commonalities among the questionnaires: (a) mental health court survey with 60
questions, (b) court diversion survey with 41 questions and, (c) police pre-arrest diversion survey with 38 questions.
The surveys were pre-tested with police and community mental health agencies and converted into a web-based
format. Additionally Word, Wordperfect and PDF documents were attached providing respondents with a range of
response options. Four waves of surveys were sent with an overall response rate of 47%. Identifying incorrect
addresses by phoning the organization left 266 usable addresses. The distribution of responses by country, type of
survey and type of format will be presented. Although the response rate is typical for Web-based surveys, when
Dillman was conducting his research in the late 1990s the volume of email that employees received was lower.
Increased volume and the problems associated with spam make it easier for respondents to delete unexpected email
and for individual and corporate spam filters to eliminate unexpected email. Findings from the web-based survey
supplemented the literature review and themes from the court diversion survey will be presented and include: (a)
training needs, (b) outcomes and monitoring, (c) inter-agency need for memorandum of understanding, (d) treatment
options and, (e) costs and cost-effectiveness.
Kathleen.Hartford@lhsc.on.ca
How Will Ye Knoweth that Your Pre-arrest Diversion Program Maketh a Difference? Tracking Trends
in Police Contacts with People with Mental Illness
Lisa Heslop, London Police Service, London, Canada
Kathleen Hartford, University of Western Ontario
Larry Stitt, University of Western Ontario
The London Ontario Police maintain a database to track events and information related to their involvement with the
public. An algorithm, previously reported on, was developed to identify contacts of persons with mental illness
(PMI) and police. Individuals were classified as definite, probable or possible MI based on these variables. This
paper reports on trends from 1998-2003 in contacts of Definite-PMI compared to the general population in the
police database. Charge and disposition data were extracted through a manual search of the database. In 2003,
London Police Service signed a service agreement with the London Mental Health Crisis Service whereby a mental
health worker would attend police calls involving PMI to ensure a more appropriate, seamless response to PMI. This
data will allow us to monitor the following annual outcomes of this pre-arrest diversion program: (a) contacts of
PMI with police; (b) number of frequent contacts; (c) arrests, and (d) dispositions.
lheslop@police.london.ca
Evaluation of a Mental Health Court: Offense Recividism Outcomes of Matched Samples
Virginia Aldige’ Hiday, North Carolina State University
Marlee Gurrera, North Carolina State University
This paper describes the operation of one mental health court for persons with mental illness who are charged with
misdemeanors and/or felonies, including violent offenses; and it evaluates the impact of the court on reducing
criminal recividism. Mental health court participants are matched with traditional criminal court defendants from
the same jurisdiction in the year before establishment of the mental health court on criminal history, race, and
gender then compared with traditional criminal court defendants on their number of arrests and their severity of
arrests in the year before and the year after their participation in their respective courts. Mental health court
participants are also divided by whether they completed or failed to complete their agreed period of cooperation with
the court; and both groups are compared with traditional court defendants on arrests and severity. Using paired T
tests of matched samples, we find that mental health court participants had no significant decline in arrests or in
severity of arrests from the year before entering mental health court to the year following; but that traditional court
defendants had significant increases in both their average number of arrests and in the severity of arrests. There were
no significant changes in number or severity of arrests when mental health court participants were grouped by
completers and noncompleters; however, there was a nonsignificant trend for the completers to show a decline in
both arrests and severity while the noncompleters showed a nonsignificant increase.
Ginny_Hiday@NCSU.edu
Diversion Systems in the UK: A Curiosity Whose Time Has Passed?
David James, North London Forensic Service, London, England
This presentation will consider the state of court diversion in the United Kingdom, some fifteen years after its
inception. It will provide a commentary on the development of services, and on the factors that have facilitated and
impeded their growth. A tour through all the published UK literature on the subject will be given, including the
major outcome study that we ourselves conducted for the UK interior ministry (Home Office). A sober assessment
will be presented of the future of such services, and indeed on the issue of whether they should have a future.
david.james5@ntlworld.com
The Emergence of Therapeutic Courts: Research and Implications
John Petrila, University of South Florida
One of the most important jurisprudential developments in the last decade has been the emergence of therapeutic
courts in a number of countries. These courts most importantly include drug courts and mental health courts. Such
courts are based on the principle of therapeutic jurisprudence and attempt to achieve non-traditional aims, e.g.,
access to mental health treatment, for criminal defendants. This presentation will describe briefly the origins and
characteristics of such courts; describe the implications of these courts for the traditional role of judges and lawyers;
describe briefly the research on outcomes done to date; and suggest new directions for research into the operation
and impact of therapeutic courts.
petrila@fmhi.usf.edu
Domestic Violence I
Waitakere New Zealand – Family Violence Court: A Model Based on Logic, Common Sense and
Fairness but One not Speedily Adopted or Followed by Other Courts. Why?
Philip James Recordon, District Court, Auckland, New Zealand
As in most parts of the world, Family [Domestic] violence is an ongoing, repetitive problem - linked frequently with
anger, alcohol and drugs. As many as 80% of our reported cases were, prior to the commencement of our Pilot
scheme, falling over before reaching defended hearings for the reasons common world wide - the victim's injuries
heal and their need for the perpetrator, financial and other need, increases.
To assist these families in the longer term and to ensure as far as possible that victims will not be dissuaded from
involving the police and Courts where there are future problems we [Judges], as quickly as we can, ask the
perpetrator to accept responsibility for the offending on the basis that if there are anger etc issues he[or she] will
address those issues over a period of time [with recognized community agencies] with a carrot at the end of some
sort - may be a community based sentence or a discharge with no conviction - aim to have the same judge and
prosecutor involved throughout - bail and progress with "issues” monitored on 6 or so week basis.
We have a protocol - difficulties often with visiting Judges and "traditional" methods of judging. Difficulties also in
acceptance at the highest level of the Pilot - lack of funding for evaluation - lack of encouragement generally - a
sense of being involved in a renegade Court!! - a good but at times difficult feeling.
Our primary objective is to focus on all those affected by the violence - to look to the present and the future - to
strengthen and stabilize and reduce risk.
Judge.Recordon@justice.govt.nz
Motiveless Paternal Infanticide during Partial Limbic Seizures of Beloved Children: "Limbic
Psychotic Trigger Reaction" (?): Two Cases with Certain Organic Features
Anneliese A. Pontius, Harvard Medical School
Paternal infanticide is rare compared to maternal infanticide. Two infanticidal fathers (in their late 20's under
discussion had however identified themselves with the maternal role to an unusual degree, as epitomized by Mr.
A.’s statement: "Maria is not the mother of Jesus, God (father) is Jesus' mother". The two men's motiveless
unplanned infanticide implicates a proposed kindled partial seizure, "Limbic Psychotic Trigger Reaction” (LPTR),
with the symptoms of a brief fronto-limbic imbalance. So far 23 cases of LPTR have met l6 inclusion and l3
exclusion criteria. There is a primate model of seizure kindling, and its 12 symptoms and signs include a fleeting de
novo psychosis, and retained memory of the out-of-character acts afterwards with deep puzzlement and remorse,
typically surrendering voluntarily to the police, asking to be punished. LPTR implicates a partial limbic seizure,
apparently elicited by a chance encounter with an individualized trigger stimulus reviving past repeated hurts. The
two men under discussion were overly worried about their infants' well-being, and when they encountered an actual
trigger stimulus which revived previously repetitive moderate stresses, Mr. A. killed by slapping on the back
(helpful in the infant's previous choking attack and Mr. B. killed by suffocating his two infants (with plastic covers
within eyesight). During his (ictal?) acts, Mr. A. whose mother had just died a few days before suddenly harbored
grandiose delusions about his mother's wealth and his inheritance from her of huge tracks of lands along a major
highway system. This delusion seemed again to enhance a powerful maternal status. Mr. B. experienced various
visual hallucinations.
From an organic viewpoint it is of note that both fathers had suffered closed head injuries (as had half of the 23
LPTR cases). Further, both men had actual or borderline brain dysfunctioning, respectively: Mr. A had a
"porencephalic cyst involving the motor and limbic systems. He had a history of left-sided "Jacksonian seizures”
and "absences" and had been on anticonvulsants but hat skipped them on the day of the infanticide. Mr. B." scalpEEG and CT showed borderline abnormalities in his temporo-occipital brain region, right more than left. It might
be telling that he suffered six types of psychotic visual distortions for the first time ever during the infanticidal acts
of both is daughter (age l) and his son (age 3). The visual distortions appeared as macroscopia, tunnel vision, seeing
his infants' faces without any facial features, and visual intensification: "the ear ring was extremely bright like a
source of supernatural energy".
anneliese_pontius@hms.harvard.edu
Alcohol, Anger, Attachment and Domestic Violence: How Can Research Data Inform Interventions?
Elizabeth Gilchrist, Coventry University
Survey data suggest that, similar to many other country, domestic violence is not at all uncommon in the UK.
Indeed, domestic violence constitutes the largest single type of violence against women and accounts for 25% of all
violent crime in the UK (Home Office, 2002). This paper considers data from a national study (funded by the Home
Office) to explore the characteristics and needs of domestic violence offenders being referred for community-based
interventions.
Much of what we currently know about DV offenders has come from influential studies conducted in North America
where suggestions of sub-groups of offender have been enjoying some discussion, including a recognition that
different groups of offender may evidence different need and require different interventions additional to those
traditionally offered.
This study supported much of the North American findings, for example indicating that general criminogenic need
was evidenced across the sample (e.g. personality dysfunction, history of antisocial behaviour, negative early
experiences, low levels of education, high levels of unemployment, alcohol dependence). Also, there was support
from the offender and victim data for two sub-types of DV offender (Borderline/Emotionally Volatile and
Antisocial/Narcissistic offenders) with reduced or elevated need in certain areas (e.g. Borderline/Emotionally
Volatile offenders have the highest anger levels and so it is suggested that this type of offender might particularly
benefit from treatment focussing on anger management).
This paper will use data from the file and psychometric assessments from round 300 offenders to explore
issues related to alcohol, anger and attachment and discuss implications for interventions, particularly
those managed via the Criminal Justice system.
E.Gilchrist@coventry.ac.uk
Staying the Domestic Violence (Dis)Course: (E)racing the Battered Woman, Battering the Raced
Woman
Adele M. Morrison, Northern Illinois University College of Law
This work explores the “battered woman” as a necessary and therefore privileged identity which has become a
fundamental object of domestic violence discourse. This identity is necessary because it is part of an “empowerment
continuum,” that moves those who have been abused along a path from victim to survivor. The author asserts that
the battered woman identity and supporting discourse speaks of multi-racial inclusivity but is actually single race
focused; that single race being white. Women of color are erased from domestic violence discourse and are left to
stay in the cycle of abuse. The mental and physical impacts of victimization continue while women of color remain
unable to access the very identity necessary for the transformation from victim to survivor. The author then
proposes a course to discursive racially inclusivity that should produce more positive outcomes for women of color.
That course begins by reconstructing the battered woman with women of color located at its center and as the core
of domestic violence legal and service providing discourse. With women of color as the central subject, the ones
whose interests are most significant, the discourse shifts course and the battered woman victim moves through the
empowerment continuum to become a multi-racial survivor.
amorrison@niu.edu
Domestic Violence and Mental Diseases
Vivian Peres Day,
Recent studies concerning domestic violence show that most of that violence takes place at home. The place where
people seek protection turns out to be a threatening and terrify place due to violent behavior in the family. The
author discusses the different determinants through a multidisciplinary perspective of the problem.
vivianday@brturbo.com
Domestic Violence II: Domestic Violence and the Psychological Impact of the
Justice System
Understanding the Psychological Impact of Domestic Violence on the Victim and the Perpetrator in
the Justice System: The Response to Perpetrators
Joani M. Moore, Ohio Department of Alcohol and Drug Addiction Services, Columbus, USA
Domestic violence is the single greatest cause of avoidable injury to women in the United States and strains the time
and efforts of law enforcement, judicial and correctional personnel. Communities that have come to understand the
theoretical basis for this phenomenon and have developed system approaches have been more effective in the
management of domestic violence perpetrators.
This presentation will provide a historical perspective on domestic violence. It will compare and contrast the
different types of batterers and the challenges presented to law enforcement, court personnel, probation officers,
drug and alcohol treatment providers, domestic violence clinicians and jail personnel. Special attention will be
given to how perpetrators may manipulate the justice system to further victimize their partners. The presenter will
also discuss the skills and training that are necessary for probation officers to effectively manage batterers in a
community setting and offer specific supervision techniques. In addition, the correlation between battering and
chemical dependency will be discussed and how substance abuse compounds the management and treatment of the
offender.
The presenter will discuss appropriate treatment for perpetrators of domestic violence based on standards developed
by the Ohio Domestic Violence Network. The presentation will focus on delivering services to domestic violence
perpetrators which enhance victim safety while maintaining perpetrator accountability.
Moore@ada.state.oh.us
Joani@stereolimited.com
Understanding the Psychological Impact of Domestic Violence on the Victim and the Perpetrator in
the Justice Systems and Appropriate Community Response: The Response to Victims
Tuesday A. Ryan Hart, Ohio Domestic Violence Network, Columbus, USA
Victims of domestic violence appear in both criminal and civil court rooms daily across the United States, and yet
court officials are unprepared to deal with the complexity of this type of victimization. The experience of domestic
violence can result in a range of mental health issues including post-traumatic stress disorder, anxiety disorders,
depression, and substance abuse.
This presentation will focus on acquainting the audience with common traumatic responses that survivors of
domestic violence experience. Most psychological literature deals with trauma as a discreet, acute episode or event,
with fairly straight forward symptomatology. The presenter will discuss the difference between this type of
traumatic experience and the chronic experience of trauma that characterizes domestic violence.
Common traumatic symptoms will be discussed, with particular attention being given to how these symptoms may
be evidenced during civil and criminal court processes. The presenter will specifically discuss those trauma
responses which may not be readily apparent or understood in the context of court proceedings but which can affect
those proceedings and outcomes.
The presenter will discuss how the very nature of court processes may be revictimizing for survivors of domestic
violence and exacerbate their current trauma symptoms. The session will end with a discussion of the coping
strategies commonly used by victims of domestic violence which may help or hinder court proceedings as well as a
discussion of appropriate mental health treatment for victims.
tuesdayrh@odvn.org
Understanding the Psychological Impact of Domestic Violence on the Victim and the Perpetrator in
the Justice System: The Legal Response
Alexandria M. Ruden, Legal Aid Society of Cleveland, USA
A victim’s behavior in court is consistent with being traumatized by violence and with being battered by a partner.
Often, how the victim acts in court is a direct response to what the perpetrator did prior to the court appearance or is
doing during the court proceeding. Some victims of domestic violence may minimize or deny the violence or
rationalize it by blaming themselves for making the perpetrator angry. Sometimes victims may tell only parts of the
violent episode in court. Sometimes they lie in court because of a fear of retaliation by the perpetrator. Seemingly
crazy behavior is often a normal reaction to a crazy situation.
However, even a victim who is reluctant to testify against the perpetrator has the same goal as the court: to make the
violence stop. When the violence does not immediately cease, the victim re-engages in prior survival strategies of
complying with the perpetrator during the court process because it appears that the perpetrator is in more control that
the court.
While protection orders should provide victims with protection throughout the duration of the criminal justice
process, many judges avoid these legal remedies in an effort to prevent further violence. This only serves to further
escalate the violence by reinforcing both the perpetrator’s and victim’s beliefs that no negative consequences will
result from the violence.
This presentation will focus on the impact of domestic violence on the victim and perpetrator in the courtroom and
appropriate and effective response by court personnel including judges, prosecutors, attorneys, and probation. The
presentation will also examine the use of court orders as legal remedies and how the dynamics of domestic violence
affect child custody and divorce proceedings.
amruden@lasclev.org
Understanding the Psychological Impact of Domestic Violence on the Victim and Perpetrator in the
Justice System and Appropriate Community Responses: The Community Response
Nancy Neylon, Ohio Domestic Violence Network, Columbus, USA
Domestic violence and in particular intimate partner violence has been identified as a widespread problem in the
United States and across the world. The Council of Europe has stated that domestic violence is the major cause of
death and disability for women ages 16 to 44. The justice system processes domestic violence as an isolated incident
of physical assault while the relationship between the parties is very complex and dynamic. In all instances of
criminal behaviour the justice system seeks to apprehend and sanction the offender. In domestic violence cases the
justice system must also prevent future abuse and trauma to the victim and connect them with mental health and
community resources that will enhance safety and address the trauma experienced. The victim of domestic violence
frequently suffers from post traumatic stress disorder and the perpetrator may experience a range of mental health
problems. The individual mental health of both parties impacts the processes of the justice system and requires new
approaches to successfully intervene in these cases. These new approaches require a high level of co-ordination and
co-operation among the court, law enforcement, prosecution, probation, victim advocacy services and mental health
treatment providers. The most effective way to ensure this collaboration is to establish a forum at which all of the
appropriate personnel meet on a regular basis to develop policies and procedures that promote effective intervention
strategies and meaningful sanctions.
This presentation will discuss this co-ordinated community response in detail. The co-ordinated community
response is critical in facilitating change within a community. It can improve the justice systems and mental health
systems response to domestic violence, thereby reducing and ultimately preventing domestic violence. The
presentation will discuss initial planning necessary for this endeavour, including membership, needs assessment,
data collection, policy development, organisational structure and evaluation. The critical components of a successful
co-ordinated community response to domestic violence include the quality of the infrastructure, the quality of
internal working climate, the breath and nature of the activities and the short-term outcomes of the group.
nancyn@odvn.org
A Study of Uxoricides (Men who kill their wives)
Michael H Stone, Columbia University
Men who kill their wives (uxoricides) constitute an important subgroup of persons committing murder. The present
study is based on the full length biographies of 97men who have killed their wives. These must be considered “highprofile” cases, since we know, epidemiologically, that only a small proportion of uxoricides become the subject of
extensive biographical reporting.
There are several remarkable features noticeable in this group. Confession, for example, is rare. Among the 97, 2
resisted arrest and were killed by the police, one committed suicide, 2 made partial confessions, and one made a
deathbed confession. Of the remaining 91, 71 never confessed (78%), even in the face of incontrovertible evidence
(the cases of OJ Simpson & Scott Peterson are exemplary).in 30% of cases there was “staging”; i.e., an effort made
to obscure the evidence of a murder – by various means (such as drowning a wife in a bathtub or pushing her off a
cliff to make the death appear accidental). In 15 cases other persons were hired to kill the wife, while the husband
was far from the scene. Three of the men disposed of their wives in the ocean, such that their bodies were never
found. The average age of the wives was 35 (the median, 34). There was no significant difference in the underlying
motives (jealousy, greed, wish to be with another woman, etc.) either in cases where the wives were younger than 30
or older than 38 – except that there was a trend toward jealousy being the motive in the murders of the younger
wives. Psychopathy was common in the husbands (63/97); others often showed prominent narcissistic traits (26/97).
Shame at acknowledging the killing of one’s wife was an important factor in the need of these men to hide the
nature of their crime and to refuse to confess their guilt, no matter the circumstances.
mstonemd@aol.com
Dutch Court Orders and Ambulatory Treatment Facilities
Symbiotic Mother-Son Attachment as Marker for Perversion and Sexual Assaults
Karola M.Lehnecke, Tilburg University
Karel Oei ,Tilburg University
The symbiotic mother-son attachment and the resulting erotic parentification could have a significant stifling impact
on the psychological and object relational development of a young boy. The authors base their contention on an indepth study of 30 sexual delinquents who had very close symbiotic ties with their mothers, excluding the fathers
from their primary caretaker- rolls. Moreover, we found that in the fundamental family units, most of the fathers
were prominently physically absent or emotionally detached. During the spare moments that these fathers were
present in the home, 73% of the fathers tended to be physically and/or sexually abusive, and caused feelings of
persecution and traumatization in the child. The authors found in one ‘TBS’ group (an acronym for Forensic Mental
Health Patient), that all of the sexual perpetrators had been severely bullied, being chronically outcast from peer
group activities during their latency and adolescence. Most men in this group tended to skip classes/school resulting
in lower socioeconomic employment chances. As to this life event, concerning their elementary and high school
periods, all of these TBS men reported to have felt extremely emotionally isolated because of their outcast positions.
In our sample, very few (TBS) men were able to maintain a partner relationship. Some men were never able to
commit themselves to an enduring relationship with a member of the opposite sex; some could only develop an
erotic preference for (small) children; others did not know how else to gain access to women than to rape them. The
authors will compare two groups of sexual perpetrators and present data to support their findings.
lehnecke@planet.nl
Forensic Psychiatric and Psychotherapeutic Outpatient and Day Clinic ‘The Tender’
Geert Schuthof, The Tender Psychiatric Clinic, Deventer, The Netherlands
Karel Oei, Tilburg University
The Tender, started one decade ago, is an ambulatory forensic psychiatric clinic. This place was originally
meant for justitiables in preventive detention under the Dutch mental health act by rehabilitation and
reintegration programs. Very soon there seemed to be a need for treatment of offenders under other
judicial titles of imposed treatment. Patients who conducted criminal acts influenced by any psychiatric
illness, or who are prone to do so, are sent by probation officers or by health care workers for proper
diagnoses and treatment. The ‘core- business’ of our institute is to reduce risk of criminal offence.
Treatment can consist of individual or group psychotherapy, psychopharmacological interventions or
assistance in social embedment. For sex offenders the institute designed a total package of therapies in a
day clinic setting. This review presents so far the treatment program, risk assessment, numbers of patients
treated, and also some results, the position of the outpatient clinic in the field of forensic psychiatry and
regular psychiatric healthcare system. Some of the judicial aspects of the treatment imposed on patients
by law are discussed as well.
schut657@wxs.nl
Partial Day Treatment and Prevention of Offences
Ameon Struijk, The Tender Psychiatric Clinic, Deventer, The Netherlands
Karel Oei, Tilburg University
The judge can apply a partial treatment sentence if the defendant is willing to do so. The probation officer is
participating in the execution of such sentence in the course of time, especially in cases of sexual assaults. The
motivation for treatment is dependent on such agreement between court and defendant. In some cases, defendants
are getting group therapy in our policlinic ‘de Tender’. Beside programs of offence prevention, active techniques
like screening therapy procedures are used as well. By confrontation are different treatment facilities intensified.
Preliminary results of the follow-up will be discussed.
schut657@wxs.nl
Psychopathy Revisited
Max Westerborg, Forensic Psychiatrist Services, Almere, The Netherlands
Karel Oei ,Tilburg University
Psychopathic development belonged to the exceptional diagnoses within the realm of the neuroses
(psychoanalysis/Freud). The diagnosis was considered when the patient had considerable flaws in the superego
structure, called lacunas. Emotional shortcomings, possibly caused by amydala dysfunction, excessive selfcenteredness, not caring for other people and having instrumental relations, only to fulfil their own needs. It was
then believed that psychopathic development was the tragic result of severe shortcomings of affection in childhood
combined with bad environmental circumstances (poor upbringing and/or education). It was thus considered a
severe developmental disorder, with a poor prognosis if not treated right! At that time the diagnosis was not limited
to criminals or criminal behaviour, although psychiatrists considered the diagnosis as a severe risk for social
maladjustment and criminal behaviour. What happened to the diagnosis since then? Is the diagnosis still valid or do
we have to revisit the diagnosis psychopathic personality. The vicissitudes of this diagnosis, the way it disappeared
from our diagnostic horizon (DSM - narcissistic and antisocial personality disorders) and the way it returned, but
now in criminal law and mental health (the PCL-R). The outline will be shown of the similarities and differences in
the diagnosis now and then, and the consequences for the prognosis.
R.I. Simon, Bad Men do what Good Men dream, Washington: American Psychiatric Press, Inc. 1996. J. Monahan et
al. Rethinking Risk Assessment. The MacArthur Study of Mental Disorder and Violence. Oxford University Press
2001. K. Schneider, Klinische Psychopathologie. Stuttgart: Georg Thieme Verlag, Neunte, unveränderte Auflage
1971.
ambermax@wxs.nl
Dutch Forensic System: Evaluation, Services, and Process
Psychiatric Screening as a Service for Forensic Evaluations
Theo Bakkum, Ministry of Justice, Rotterdam, The Netherlands
In the city of Rotterdam there are many requests from the court for forensic evaluations. The crime rate is fairly high
and psychiatric and psychological problems seem to cluster in the city, which is overall poorer and socially less
developed than most of Holland. The forensic psychiatric service as the institution that trains and checks on the
psychologists and psychiatrists, who make the forensic evaluations, states that in every request from the court a
psychiatrist from the forensic psychiatric service (experienced and with an overview of both prison- and hospitalfacilities) sees the suspect for a psychiatric screening and can give the court advice onwhich type of forensic
evaluation should be done (or not be done) and give a first impression of the person and possible mental disorders.
Because of the shortage of psychiatrists (especially child- and adolescent-psychiatrists) the system isin practice not
feasible. Therefore some criteria were developed to identify cases in which a psychiatric screening is necessary
before further forensic evaluation takes place. Other criteria have been developed to identify cases in which
psychiatric screening is advisable. These criteria can be extracted from the dossier, but in some cases the psychiatric
screening may prove to be in retrospect superfluous, where in other cases the forensic evaluation would have been of
better quality if a psychiatric screening had been done. The criteria and the method of working is being discussed by
the court as well as the forensic psychiatric service but seems to be at this moment a workable option.
This paper outlines the criteria for psychiatric screening how they can be used by the court. For each criterion a
case-description will serve as an illustration. Some general information about forensic evaluations (methods,
locations) as performed in Rotterdam will be given but with emphasis on the psychiatric screening early in the
process, as well for youth as for adults.
T.Bakkum@fpd.dji.minjus.nl
Care Consultancy by Forensic Psychiatrists in Dutch Penitentiary Facilities
Paul Frodl, Ministry of Justice, Rotterdam, The Netherlands
Karel Oei, Tilburg University
Together with the courts, the Netherlands has 19 different justice districts. In each of them, like the Hague,
Rotterdam, Amsterdam, and other cities, there is an FPD office: Forensic Psychiatric Service.
The psychiatrists involved are judicial forensic psychiatrists, who fall under the Ministry of Justice.
One of their core working fields is the care consultancy in prisons for mentally
disturbed/psychiatric inmates. Patients with emergency psychic stress like suicidal behaviour can be the object of
psychiatric consultancy as well.
Our work is primarily multidisciplinary. There is a panel consisting of the prison doctor, nurses (medical service),
psychologists, and the psychiatrist. This panel discusses the patients’ psychological problems before seeing them
and, after having seen the inmate/patient; the results are presented and evaluated. This panel is the so-called PMO:
psychic medical communication. Generally the psychiatrist goes to the same prison twice a week. He/she sees
inmates from different units. In nearly each prison, there is a specialized care unit smaller than the standard units
with more qualified personal called BZA.It is, in fact, possible to see the inmate/ patient twice a week. The
consultancy is not only done verbally in the PMO but also by means of a medical letter for the medical service in the
prison, the psychologist, and the medical dossier/status. It is important that the psychiatrist sees his patient as often
as necessary in order to control the expected treatment effect. If the patient's condition worsens in his psychiatric
illness, there are possibilities to transfer him to a psychiatric hospital outside the prison walls, but preferably they
can be transferred to the FOBA: Forensic Observation and Treatment Unit within the Prison system, which is like a
psychiatric clinical prison unit.
P.Frodl@fpd.dji.minjus.nl
Dutch Forensic Mental Health Aspects of Unfitness to Stand Trial
Frans Koenraadt, Utrecht University
In this presentation we will discuss from the mental health point of view what it means to be fit to stand trial in the
Netherlands and which (psychical, physical an/or intellectual) disturbances can reduce this competence. This will be
illustrated with a few cases.
With respect to the issue of fitness to stand trial criminal law requires the forensic mental health expert to make a
distinction between a mental disorder that originated after having committed the offence and a mental disorder that
existed at the time of committing the offence. The implications of this distinction will be shown.
Attention will be paid to two particular, completely different variants in mental health of the unfitness doctrine,
namely war criminals and former dictators, and mentally disordered persons who commit crimes while being
detained in a psychiatric hospital.
f.koenraadt@law.uu.nl
The Criminal Non-Punitive Order as Seen From an Economic Standpoint
Karel Oei, Tilburg University
In the second half of the 19th century, there was an increasing need in society for an alternative to punishment as
retribution and general prevention, all the more because the courts were only able to sentence mentally disturbed
people based on the principle that they were either insane or not. In the event of insanity, the court could only
sentence a defendant to mandatory commitment to a psychiatric hospital, but it was not clear whether such a person
would actually be less likely to commit repeat offences after the end of the treatment.
As soon as the physician in charge was of the opinion that the insanity was over, the legal ground for further
treatment under the old Lunacy Act (Krankzinnigenwet) disappeared, and, pursuant to (old) Section 28, the
administration of the institution had to release the patient. However, such a person often proved not to be free of
psychic disorders, and was therefore still a danger to society.
This paper deals with the role of the criminal non-punitive order in giving legal subjects the treatment that helps to
improve their behaviour, as well as the issue of whether the supply of non-punitive orders may possibly be
exceeding the demand as their effectiveness proves inadequate.
t.i.oei@uvt.nl
Are changes of memories of certain offenders comparable with for the amnesia, victims of psycho
trauma ?
Ruth van der Pol, Ministry of Justice, Rotterdam, The Netherlands
In the course of time, memory changes. Parts disappear, parts become distorted, the sequence changes, or parts are
replaced by other memories. Most likely these changes take place in the first weeks after the event. Changes in
memory are often seen in suspects. Also in those who have confessed. Psychologists and psychiatrists mention
lying, suppression and other mental processes as a cause of the partial amnesia and distortion of memory in suspects.
The question is: are there significant differences in memory change in the course of time between suspects and
normal people? For research purposes the circumstances during the offense and, for the control group of “normals”
during the event should be comparable. Certain perpetrators accidentally find themselves in a situation that has all
the aspects of psycho trauma. Comparative research of the process of memory should be possible between these
accidental perpetrators and victims of psycho trauma. This presentation describes briefly the different memory
processes during and after the events and tries to answer the question whether research may be possible. Description
of one case and some literature are discussed.
R.vanderPol@fpd.dji.minjus.nl
Responsibility and the Relation between Disorder and Offence, An Empirical Study
Titus van Os, Ministry of Justice, Rotterdam, The Netherlands
In the Netherlands the court can have offenders assessed by behavioral experts (psychiatrists, psychologists, or
social workers) on how far they can be held responsible for their acts, based on the presence of any mental disorder.
Five levels of responsibility are distinguished, ranging from fully responsible to not responsible. The greater the
influence of the disorder on the offence, the lower the responsibility. In this presentation we will study a sample
(300) of expert examinations for the level of responsibility assessed in relationship to the type of offence committed,
and the mental disorder diagnosed.
t.w.d.p.van.os@acggn.a.nl
The Dutch Way of Deinstitutionalization I
Organisation of Mental Health Services: Epidemiology
Ellen van Hummel, Psycho-Mmedisch Centrum, The Hague, The Netherlands
The Hague has 450.000 inhabitants and is the third largest city of the Netherlands. As in many big cities The Hague
has a population of severe mentally ill. In this paper we will explain how the care and the financing of the care for
this group of patients is organised. We will present some epidemiological data including data about compulsory
admissions, financial data and global information about the mental health care system in the Netherlands.
hummee@parnassia.nl
Care for Schizophrenic Patients in a Transmural View
Fred J. van Essen, Psycho-Mmedisch Centrum, The Hague, The Netherlands
In The Netherlands, a country with a long cultural tradition in seeking consensus, the process of ‘deinstitutionalisation’ of mental health services was of relatively late onset and gradual without abrupt changes in the
institutions.
The psychiatric hospitals remained largely unchanged into the early 1990’s, despite the formation of community
mental health services in the 1980’s. By the late 1990s the institutions had been integrated into one comprehensive
mental health system. The incorporation of the community mental health centres by the psychiatric hospitals had
ultimately as effect that the focus of services shifted from the clinic to the community.
Not surprisingly, the development of comprehensive services for psychotic patients fulfilled a leading role in the
‘transmuralisation’. Several multi-disciplinary teams, modelled according to the Assertive Community Treatment
principles, offer approximately 2500 psychotic patients integrated and comprehensive care over their lifetime. This
continuity of care provides a diverse range of services, which will be presented.
Though the amount of support is dependent on the needs of the patient, an assertive engagement when necessary
cannot be avoided, also to the point of compulsory admission of treatment (involuntary commitment).
essenf@parnassia.nl
Team for Public Mental Health Service (Team Oggz Parnassia)
Jorijn M. Deenen, Psycho-Mmedisch Centrum, The Hague, The Netherlands
In this presentation we explain how we recently reorganized the care for the homeless who are mentally ill or have
severe addictions. The majority of patients have a combination of mental illness and addiction. We offer an
integrated treatment based on the Assertive Community Treatment model. Through good collaboration with all
partner institutions that in some way are connected with our target group, we are able to reach most of the homeless.
The integrated treatment is quite unique in the Netherlands.
deenej@parnassia.nl
Normal Housing in Parnassia
Hans Oolders, Psycho-Mmedisch Centrum, The Hague, The Netherlands
Sometimes a major psychiatric disorder is constantly out of balance, like trying to balance a broomstick on your
finger. You always have to adjust your hand to keep the stick upright. If this is the case a patient with a major
psychiatric disorder cannot leave the hospital if there is exacerbation of the symptoms within days or weeks. To give
these residents more independence or even a life of there own, with psychiatric guidance nearby, Parnassia has
formed a place where this is possible. In this presentation will be given a detailed overview of how life is in
Parnassia for those residents and in what way we try to make this bearable or even a nice place to be. In the process
of normalization there are intentions for housing severe mental ill patients in the city offering them treatment and
daily life support.
ooldej@parnassia.nl
The Dutch Way of Deinstitutionalization II
Suicide in Parnassia
Ruud H.P. van Beest, Psycho-Mmedisch Centrum, The Hague, The Netherlands
Parnassia covers the major part of psychiatric and addiction care in the city of The Hague; beside psychiatrist in
private practice, youth facilities and nursing homes.
Handling patients with suicidal ideations is a difficult task. It is possible to determine whether the individual belongs
to the risk group however a prediction for one person is difficult. Besides it is not to prove that an intervention is
successful. Sometimes suicidal ideation is not reported by the patient even when asked for.
Common sense in clinical practice: When there is a great psychic dysfunction and in any case when the patient is
non competent protection is necessary. When the patient suffers form a personality disorder protection may have
adverse side effects.
Figures will be presented about the suicide of patients of Parnassia during 2000-2004. (20-25 p.a.). Looking over a
longer period: Though the number of suicides has remained relatively stable, there has been a pronounced shift from
inpatient to outpatients.
A comparison will be made with the city registration of suicide. Around half the persons that committed suicide
were (recently) in treatment at Parnassia.
Prevention of suicide is still an important aim. When the person is in treatment there is an opportunity to share the
responsibility of the prevention of accidents. General prevention is complicated and some ideas will be discussed.
r.van.beest@parnassia.nl
Rehabilitation/Probation and Integrated Mental Health
Chris van der Meer, Psycho-Mmedisch Centrum, The Hague, The Netherlands
Besides its mental health and addiction services Parnassia has a rehabilitation / probation department (RPD) of 60
persons, financed by the Justice department. It is embedded in the Forensic and Intensive Department, which offers
specialised treatment and care for patients (severe psychiatric and/or addicted) who are treatment resistant or
forensic. The RPD is functioning as an intermediate service between the judicial system (general prosecutor office,
police, prison service) and the treatment facilities of Parnassia. It is trying to play a major role in reducing criminal
behaviour of repeat offenders, especially those who are suffering from mental and/ or drugs-related problems (about
80% of this group).
A number of projects will be presented with their (preliminary) results. Examples are:
 The Signalling and Control system which is specially developed in the Hague. Repeat offenders from the
city top 500 list, who are on probation, are in an intensive case management and control system, mostly in
combination with a care or cure trajectory.
 The Co morbidity project is a pre-treatment project for severely disturbed detainees in the special care
department of The Hague House of Detention. In the project psychiatrically trained rehabilitation officers
give individual and group training to the detainees and prepare the referral to Parnassia or another facility.
Since the start of this project (2003) the number of forensic patient who were successfully referred to
Parnassia psychiatric and addiction programmes has risen dramatically.
 The programme for criminal addicts Triple-Ex. This is a modified therapeutic community with much
emphasis on vocational training and social reintegration of long term drug abusers, mostly from ethnic
minorities. Programme evaluation showed promising results, both for abstinence rates and for social
integration indicators including criminal recidivism. The Justice department has given the programme a
provisional accreditation.
meerc@parnassia.nl
Ambivalence in legislation : outpatient commitment in the Netherlands
J. (Remmers) van Veldhuizen, GGZ North Holland North, Heiloo, The Netherlands
In 1994 a new Dutch mental health act (BOPZ) started. Autonomy of the patient was the central issue. The law
regulates forced admission and ‘protects’ the patient against too intrusive treatment. Involuntary treatment is only
possible in case of ‘danger’ at the ward.
The law didn’t regulate community orders. After 1994 we saw an informal process in which conditional leave was
used more and more with short periods of hospitalization and (sometimes involuntary) treatment. This procedure
was called an “umbrella procedure”. Recently the government decided that this was no longer appropriate. A new
legislation on outpatient commitment was introduced.
The new procedure asks the formal consent of the patient with the ‘forced’ treatment plan. If the patient doesn’t
cooperate with his treatment plan, involuntary treatment is not possible. If the patient continues to refuse treatment,
the next step is forced admission, only possible after some formal steps (including a second opinion by an other
psychiatrist). Compared with the community treatment orders in other countries, this legislation works time
consuming and insufficient: it has no teeth and it leads to more admissions.
This legislation reflects the ambivalence of the legislator. Mental health care services are urged to give assertive
outreach (or –forced- admission) to disturbing patients. But on the other hand the government hesitates to diminish
the autonomy of the patient .
The parliament starts to recognise this problem and is beginning to ask for other legislation. The Dutch discussion
regarding ‘danger’ and ‘autonomy’ needs to be broadened with the aspect of ‘treatment’. The recommendation Rec
(2004)10 of the committee of Ministers of the Council of Europe concerning the protection of human rights and
dignity of persons with mental disorder will play an important role in this process.
remmersvv@hotmail.com
r.vanveldhuizen@ggz-nhn.nl
Assertive Community Treatment (ACT) in the Netherlands
Bert-Jan Roosenschoon, Rotterdam, The Netherlands
Assertive Community Treatment (ACT) is one of the evidence-based practices in the USA. It is the only type of
case-management that is proven to be effective. In the USA ACT is implemented on a broad scale. In the UK the
National Health Service ordered to implement ACT nation-wide. They call it Assertive Outreach. In the Netherlands
we try to implement ACT and do research to investigate whether the implementation shows fidelity, that is to say
according to the American ACT-model.
We translated the DACTS (the Dartmouth Assertive Community Treatment Scale) in Dutch and applied it to our
ACT-teams. The fidelity of the implementation in the Netherlands proved to be moderate. A lot of items of the
DACTS scored high, but the integration of some services in the ACT-team was low., e.g. Crisis-intervention,
Double-Diagnosis Treatment and parts of the medical treatment. According to the ACT-model all services should be
given by the ACT-team itself. Also the contactfrequency and integration of consumer-helpers in the teams was low.
Some people in the Netherlands would like to adopt a Dutch version of ACT, because the Dutch health care
situation is so different from the situation in the USA. That would be a Type of ACT with lower fidelity to the
American model. The problem with that is that this Dutch-version would not be evidence-based anymore.
So we would like to adopt as many items of the American model as possible. Especially for urban areas we think
that would be wise. There is discussion going on however whether high-fidelity is always possible/ necessary,
especially in rural areas. In our presentation we show some results of our research on the high and low scoring ACTitems and the possibilities and willingness to adopt the different parts of ACT-fidelity in the Netherlands.
B.Roosenschoon@BavoRNOGroep.org
The Duty to Warn, Confidentiality and Patient Protection
The Development of European Guidelines for Confidentiality in Healthcare
Roy McClelland, Queen’s University at Belfast
The Information Society and the technology upon which it is founded render obsolete the traditional notions of
confidentiality between doctor and patient. In the modern context the concept of one-to-one privacy has been
reinterpreted as patients’ rights to maintain control over information flow and to know how their personal data are
used and processed.
The need to safeguard the confidentiality of information that patients share with clinicians is from a clinical
perspective as fundamental as the principle of consent. This issue has come to the fore in the context of the rapid
developments and applications of information and communication technologies within society in general and within
the health sector in particular.
In addition to the impact of new technologies consideration also needs to be given to the impact of changes in health
care organisation and practice, for example multi-disciplinary and multi-agency working. Mental health services are
in many respects at the vanguard of these changes where the ideals of community care, shared care and seamless
care depend fundamentally on good communication and information sharing.
There is a tension between the needs for patient information to optimise the quality of care and the expectation of
patients that information about them will be kept confidential.
Confidentiality and privacy are also legal concepts and the relationship between healthcare professionals and their
patients carries with it legal obligations of confidence as well as moral ones. In addition, doctors have a professional
duty for maintaining confidence and the misuse of confidential medical information is likely to be regarded as
serious professional misconduct.
This European project consists of a detailed consideration of the ethical issues in confidentiality in healthcare with
specific attention to issues of concern for vulnerable groups; a review and analysis of existing laws, policies and
guidelines on confidentiality in Europe; preparation and distribution of confidentiality guidelines for healthcare
practice.
r.j.mcclelland@qub.ac.uk
Psychiatrist-Patient Confidentiality
Karen De Freitas, McMaster University
Physician-patient confidentiality is one of the cornerstones of medical practice. It is especially important in
psychiatric practice where patients often reveal intensely personal information. However, there are several
commonly accepted exceptions to the rule of confidentiality. These exceptions are usually justified on the basis that
the benefit to a third party of having the information exceeds the harm to the patient of revealing the information.
Examples include the duty to warn third parties of threats made against them, and the obligation to inform child
protection agencies of suspected child abuse. This presentation will review some of the more commonly
encountered exceptions to physician-patient confidentiality, especially as it applies to psychiatric practice.
It will also explore the issue of role conflict, which can occur when a single clinician must assume the dual roles of
both caregiver and evaluator. An example of this is the case in which a treating psychiatrist must report on a
patient’s condition to an insurance company in order to aid in the processing of a disability claim. Finally, this
presentation will explore some of the potentially detrimental effects that the existence of exceptions to
confidentiality can have on the psychiatrist-patient relationship.
kdefreit@cogeco.ca
The Development of the Tarasoff Principle and its Application in Europe
Colin Gavaghan, University of Glasgow
It is well established in U.K. law that, in certain circumstances, a medical professional is permitted to depart from
his or her duty of confidentiality, to issue warnings about a patient who is believed to present a real and serious
threat to other parties (W v. Edgell, R. v. Crozier). However, what was less certain was whether a medical
professional could ever be duty-bound to give such a warning. The approach adopted throughout much of the
U.S.A., and famously expounded in the Tarasoff judgment does in fact impose such a positive duty on a medical
professional to take steps to safeguard other parties from dangerous patients, but no such rule has ever been
acknowledged in a U.K. court.
However, the European Court of Human Rights’ ruling in U.K. v. Osman seems set to introduce the Tarasoff
approach into the U.K., and indeed throughout Europe. The case concerned an alleged failure by the police to
prevent a schoolteacher from attacking and seriously injuring a pupil with whom he had become obsessed, and
killing the pupil’s father. The Court recognized that article 2 of the Convention imposes a duty on employees of
signatory states to take positive steps to safeguard the lives of all citizens of that state. I will suggest that this
decision could apply equally to those working in medicine and psychiatry (at least those employed in the state
sector), requiring them to breach patient confidentiality in some circumstances and notify identifiable endangered
parties of the risk posed by “dangerous” patients.
c.gavaghan@law.gla.ac.uk
The Duty To Warn In A Prison: Should the Tarasoff Principle Apply?
John L. Hill, Barrister and Solicitor, Toronto, Canada
Prisons, by their very nature, contain dangerous people that are constantly at risk of doing harm to staff and other
inmates. How far should prison authorities go to ensure that persons inside a penitentiary should be protected from
harm? Could adoption of the Tarasoff principle make our prisons safer?
An examination of several Canadian cases suggests that the Tarasoff principle in Canadian prisons has been turned
on its head: Prison authorities who have access to confidential prisoner information have been shielded from liability
when assaults upon unsuspecting inmates have occurred. It has come to be accepted that no liability attaches unless
the inmate victim has first informed the Correctional Service of the likelihood of harm.
It will be argued that by ignoring the Tarasoff principle to avoid civil liability, there is an inducement for the
Correctional Service of Canada to turn a blind eye to suspected trouble. Thus we have a situation that arose in a
2004 decision of the Supreme Court of Canada, R. v. Kerr, where an inmate was acquitted of possessing a knife in a
penitentiary and subsequently killing another inmate because no other protection was available.
conlaw@pathcom.com
The Duty to Warn and the Duty to Protect
John Wilton, Anglican Archdiocese of Toronto, Canada
The duty to warn is not limited to doctors and lawyers. Increasingly we are learning that in virtually all
organizations there are expectations that the organizations will not put persons who deal with it in harm's way. This
is especially true for churches. Like other faith communities, the Anglican Church of Canada has emerged from a
period where sexual abuse by clergy and parishioners that has been highly publicized. It is time for reconciliation
between the abusers and the abused.
However, how this reconciliation can proceed raises serious issues needing to be explored. How does the church
respect its obligation for confidentiality in dealing with its members and yet ensure that members are safe from
exploitation from others in their midst? Should the church seek out information on the private lives of its members
in order to inform itself of potential risk? How far should it go in this regard? What special precautions should be
taken to ensure that past incidences of abuse do not reoccur? How can the values of forgiveness be balanced with the
need to ensure the safety of all members of the faith community?
The Diocese of Toronto has taken a proactive step to try to balance these seemingly irreconcilable values. In part,
these initiatives are in response to addressing the damage done in historical sexual abuse claims. However, there is a
new realization that protection of the public from potential future harm is required. This presentation will focus on
the initiatives taken within the church and suggest that the experience within the church can be a model for other
secular organizations wanting to be proactive in avoiding future problems.
jwilton@stgeorgestoronto.ca
Dynamics of Societal Re-entry for Offenders with Mental Illness
Criminal Justice and Mental Health Systems Collaborations for Prisoner Re-entry: Boundary
Spanning or Picking Up the Ball?
Jeffrey Draine, University of Pennsylvania
Amy Blank, University of Pennsylvania
Prisoner re-entry efforts have gained great policy interest with the increase in prison releases that follows the
incarceration increase of the 70s to 90s. We conducted a national assessment of the structure and practices of reentry programs for people with mental illness. The goal was to develop a classification of service strategies based on
an understanding of operating programs rather than relying on a priori classification schemes.
A national survey was conducted to identify the spectrum of service strategies being used by mental health programs
to bridge the transition from incarceration to the community for mentally ill offenders. A total of sixty-one re-entry
programs were identified. Fifty-two are included in this analysis. When ever possible telephone interviews with key
program staff were used as the primary source for program information. Interview probes were used to elicit
information about the programs’ structure, target population, location, staffing, and service strategies with special
emphasis on strategies of engagement and retention. Interview notes were transcribed immediately after each
interview. Other sources of program information included conference presentations, program brochures, published
articles, and internet websites. A constant comparison of information gathered from programs was used to develop
variables that operationalized important program characteristics. These characteristics were used to develop a
typology of re-entry programs for mentally ill offenders.
Re-entry programs vary based on their location relative to the criminal justice and mental health systems, types of
professionals staffing the treatment programs, and degree of collaboration between the two service systems. The
findings of this survey supported the use of a 2 by 2, four group typology of initiatives, with one factor being which
system initiated the program (criminal justice or mental health); and the other factor being whether or not there is
significant collaboration between the mental health and criminal justice systems. Of the 52 mental health treatment
services included in this analysis 37 were classified as being located within the criminal justice system, while only
13 were located within the mental health system.
Differing approaches to prisoner re-entry have implications for organization cultures of agencies/programs as well
as how program effectiveness may be measured. If the funding trend identified in this survey continues, the criminal
justice system will quickly become the primary funder to treatment services for mentally ill offenders returning to
the community. What are the ways in which the shift in funding will affect the provision of mental health services?
Jdraine@ssw.upenn.edu
Ablank@ssw.upenn.edu
Understanding how Operationalization Affects Implementation: The Case of Selection and Linkage
Wendy Pogorzelski, Rutgers University
Amy Blank, University of Pennsylvania
Connecting persons with mental illnesses (PMIs) to needed services is integral to successful offender reintegration.
Research on specialized programs for PMIs primarily focuses on client outcomes (such as adherence to treatment
and recidivism) yet we know very little about the process of identifying clients for program participation (selection)
and how PMIs are connected to the services (linkage). This analysis draws on data collected during an evaluation of
three jail-based re-entry programs for persons with mental illnesses. This presentation will focus on three crucial
points in service delivery: identification of clients’ eligible for the program; selection of service recipients; and the
process of linking clients to community services. Identification and selection of clients depends on the quality of the
institutionalized and informal relationships between the service provider and the jail, whether the service provider is
jail-based or community-based, and the point at which the service provider has contact with the client within the jail.
Linkage is heavily influenced by the goodness of fit between the client’s treatment needs and the service system’s
capacity to meet them. This includes issues such as the menu of services available in a specific service system,
accessibility of these services, and the ability of the service system to provide clinically meaningful treatment that
meets the specific needs of this client population. In addition we will examine how the concepts of selection and
linkage are operationalized in daily practice and how contextual dynamics, such as agency collaboration and access
to relevant institutional resources, facilitate and inhibit the delivery of services and program operation. The paper
will conclude by assessing how program implementation differed from the proposed intervention due to the way
selection and linkages were operationalized in practice.
wpogorzelski@ifh.rutgers.edu
Ablank@ssw.upenn.edu
In Search of Employment: Community Reintegration for Incarcerated Women with Mental Health
Problems
Cynthia L. Blitz, Rutgers University
Kris Paap, Rutgers University
Increases in women’s incarceration in the United States have led to an increasing number of women who must
struggle through the processes of reintegration into their families, into educational and social institutions, and into
the paid workforce after their release from prison. These already difficult transitions are further complicated by the
fact that women in prison are more likely than men to be diagnosed as mentally ill and to have a minimal or
negligible work history.
As part of a larger project on formerly incarcerated women and work, the entire population of a women’s prison in a
northeastern U.S. state was surveyed about the women’s individual employment-related strengths and deficits. The
survey included questions about the women’s work skills and experience, their educational history, their perceptions
about their upcoming return to life and work outside of prison, and their previous experiences with mental illness
and/or mental health services. The women’s occupational skills and histories were then compared to the jobs
available in the areas where women from this institution are most likely to settle after their release, thus providing
supply and demand-side comparisons. Results suggest not only that mental health continues to be a viable factor in
post-release vocational planning, but also that demand-side planning must be at the fore of intervention designs. We
conclude with suggestions for practice and policy.
cblitz@ifh.rutgers.edu
paap@rci.rutgers.edu
Social Capital and Re-entry: The Case of La Bodega de la Familia
Nancy Wolff, Rutgers University
Jane Siegel, Rutgers University
Most people returning to the community from prison rely to some extent on their families and communities for
assistance. Resource exchange through family, friends, or professional affiliations is known as social capital. The
ways through which social capital translates into reduced recidivism and desistance from crime among returning
prisoners is unknown. This study identifies and measures the value of resources exchanged through the social
networks of people who, because of their criminal behaviors, are involved as clients of La Bodega de la Familia, a
family system approach to re-entry. The unit of analysis is the family. There are three informants: the identified
substance user (ISU), an adult family member, and one of the ISU's children. The ISU, family member, and youth
are interviewed, using a structured interview protocol, at baseline, 3, 6, 9 and 12 months (5 interviews per person).
Thirty family units will be enrolled in the study. In this presentation, we will provide information on the first 15
family units enrolled in the study. Evidence will be provided on the ways resources within the family and
community are exchanged and are affected by the return of the ISU. Findings from this study would inform policy
by providing a more accurate representation of the way in which families and communities contribute to the welfare
of those who are leaving prison and jails and help to reduce recidivism and foster community reintegration and
recovery post release.
nwolff@ifh.rutgers.edu
jasiegel@camden.rutgers.edu
Providing Mental Health Care at the Prison’s Back Door: Re-linking Mentally Ill Offenders to
Community Treatment
Kathryn A. Burns, Case Western Reserve University
All offenders returning to civilian life after a period of prolonged prison incarceration have a difficult time adjusting
to non-inmate life. The situation is particularly difficult for offenders with serious mental illnesses: securing
community treatment without lapses in medication from supplies provided at the time of prison release, delays in
processing of disability benefits for basic necessities, medical care and prescription coverage; problems in securing
safe, affordable housing that will accept convicted felons, and exacerbation of psychiatric symptoms during periods
of high stress all contribute to the problems experienced by offenders with serious mental illnesses upon prison
release. A program of Assertive Community Treatment (ACT) for mentally ill offenders returning to an urban area
after being paroled from prison has been developed in Cleveland, Ohio to address these problems. The specialized
ACT team developed represents a unique collaboration between the state prison system and a county mental health
treatment provider. The staffing composition, frequency of contact with parolees, housing options, treatment
protocols, and other operating procedures, including selection criteria for participation in the program will be
presented. Parolee sociodemographic and psychiatric diagnostic characteristics will be presented. Finally, ACT
program outcomes, including psychiatric stability attained, housing stability and criminal recidivism will be
discussed and compared to a sample of similar released offenders receiving non-specialized mental health care.
burns@cccmhb.org
burnshill@wideopenwest.com
Elder Law I
When Abusers Seek Guardianship: How Adult Protective Services and Guardianship Courts Can
Work Together to Protect the Elderly
Marguerite Angelari, Loyola University Chicago
Adult guardianship is a court process through which an individual loses virtually all of his rights and a
substitute decision maker is put in place to make all major decisions. The aging of our population has led
to a dramatic increase in the need for court ordered guardianships, which is severely straining court
systems in the United States. As a result, despite the magnitude of the decisions they are called upon to
make, guardianship judges are limited in the amount of attention that they can devote to individual cases.
Under such circumstances, it is not difficult for an abuser to become his victim’s court appointed guardian
and thereby obtain full legal control over his life. Elder abuse investigators can offer critical information
on whether proposed guardians may be exploiting their wards. Unfortunately, in Illinois, and throughout
the United States, adult protection services agencies and guardianship courts operate independently of one
another. Therefore, a judge conducting a guardianship proceeding and an investigator in an elder abuse
case are unlikely to be aware that the two proceedings are occurring simultaneously. Furthermore, elder
abuse investigators report that even when they become aware of the guardianship proceeding and appear
in court, they are often unable to present evidence of abuse at the guardianship hearing. As a result, they
have stood by while alleged abusers have been appointed guardian. This paper presents the findings of a
research project on the interaction between elder abuse investigations and guardianship cases. The study
included face-to-face interviews with elder abuse investigators about particular investigations followed by
a review of corresponding guardianship court files. This paper documents the need for greater interaction
between guardianship courts and adult protective services and offers recommendations for reform.
MANGELA@luc.edu
Elders and Models of Testamentary Undue Influence in the United States, United Kingdom, Australia
and Canada
Fiona Burns, University of Sydney
Since the 19th century common law jurisdictions, unlike their civil law counterparts, have espoused and applied the
principle of freedom testation (subject to modifications such as the statutory or forced share in the United States or
family provision legislation in the United Kingdom). A will is subject to scrutiny where there are allegations that the
principle of freedom of testation has been compromised: for example, where there are allegations that the testator
was subject to undue influence at the time that the will was made. This paper will examine the doctrine of
testamentary undue influence with special attention to the wills of elderly testators where the elderly testator
exhibited some mental impairment or physical illness at the time the will was made; or lived in a situation where he
or she was dependent upon the assistance of others for daily care. Elderly people in such circumstances are
particularly vulnerable to undue influence. Such elders ought to be protected not only from whatever form the undue
influence takes, but also from the impact upon their right to exercise testamentary freedom. It will be contended that
there are, broadly speaking, two very different doctrinal versions of testamentary undue influence in common law
jurisdictions – the United States model and the United Kingdom model. The former addresses the abuse of a
relationship of special trust and confidence; while the latter focuses on coercive action which has overcome the
testator’s will and autonomy. The paper will: Compare and contrast both undue testamentary influence models.
Evaluate to what extent courts in both jurisdictions rely on undue influence and how this may affect the outcome of
individual cases. Consider the impact that each model has on the goal of preserving the testamentary autonomy of
elders and suggest which approach is more desirable. Determine which model (if any) has been applied in two other
common law jurisdictions, namely Australia and Canada; and examine how effectively testamentary undue
influence has been applied in elder cases in these jurisdictions.
fionab@law.usyd.edu.au
Older Adults, Competency and Mental Health: Implications for Healthcare Professionals
Cynthia Zubritsky, University of Pennsylvania
As populations age around the world, the numbers of older adults with mental disorders increases proportionately; in
the U.S., approximately 236 elderly people per 100,000 suffer from mental illnesses, severe cognitive impairment,
and dementias, including Alzheimer’s disease (American Association for Geriatric Psychiatry, 2001). Technology
and medical advances have significantly increased the life span, resulting in ever growing numbers of older patients
suffering from dementias and mental illnesses. Loss of competency or decision making capacity, characterized by
confusion, memory loss, and disorientation, is often a result of mental disorders and dementias, complicated by
advancing age. As the capacities for memory, judgment, reasoning and planning erode, patients with cognitive
disorders lose decision-making capacity in every sphere of life, such as the capacity to drive, to manage finances, to
make medial decisions, to live independently and to manage personal affairs (American Medical Association, 1995).
Healthcare professionals, including primary care physicians, have traditionally turned to psychiatrists for guidance
and assistance in making a determination of competency (Farnsworth, 1982); however, interdisciplinary teams
should be trained in the process of determining competency. Healthcare and support systems must, therefore,
develop standardized methods for assessment of competency that are transferable across professional fields. Clear
standards should be established for a continuum of competency and benchmarks established to identify legal rights
within and across the continuum. The loss of competency has significant legal, ethical, and medical consequences
for patients, families, caregivers, health care professionals and society at large.
cdz@mail.med.upenn.edu
Responding to the Financial Abuse of Older People with Impaired Capacity: the challenges for
Guardianship and Administration Tribunals
Cheryl Tilse, University of Queensland
Financial abuse of older people is an area of increasing concern as a result of the extent and nature of older people’s
assets and increasing longevity which brings with it a higher risk of impairment in cognitive capacity. Evidence
from research and practice suggests that financial abuse is under reported as a result of attitudes towards the use of
older people’s assets, older people’s unwillingness to disrupt family relationships and practitioners’ concerns that
interventions may not be in the best interests of the older person. Legal provision in Australia to protect older people
with impaired decision making capacity from such abuse includes enduring power of attorney legislation,
guardianship/administration legislation and guardianship and administration tribunals. There is no provision for
mandatory reporting of elder abuse. In such conditions, it is particularly important to understand who reports
financial abuse of older people with impaired capacity to appropriate tribunals, the circumstances under which abuse
is reported and the interventions that result. This paper reports on a research program exploring the management of
older people’s assets. It focuses on a systematic analysis of cases coming to the attention of a State Guardianship
and Administration Tribunal in 2002-2003 to explore how and why cases of financial abuse come to the attention of
legal institutions and what decisions are made as a result. It concludes that legal frameworks and institutions have an
important but limited role in protecting older people with impaired decision making capacity in the area of financial
abuse.
C.Tilse@social.uq.edu.au
Grappling with the Gray Zone: Creative Legal Tools for Partial Incapacity
Kate Mewhinney, Wake Forest University
This presentation will assess the legal tools being developed in different countries to address partial mental
incapacity among the elderly. How can laws best provide for mildly impaired elders to select someone to help with
financial decisions?
Using a comparative law approach, we will focus on concerns such as supervision of surrogates, options for the
mildly impaired older person, and simplicity of court procedures. For example, the U.S. model provides for a
“power of attorney.” Generally, this person acts without supervision. Would this approach be improved by the
requirement of a monitor or by registration with a court? Will impaired elders take advantage of court procedures,
if they are given a more active role in financial decisions? Japan, with exploding numbers of elderly, offers a
partnership model, in its recent reforms of its guardianship laws. Italy – another country with very high percentages
of elderly – has modified its guardianship laws to offer more options for the mildly impaired person.
The session will cover:
 The representation agreement developed in British Columbia, Canada, in 2000;
 England’s court process for supervision of enduring powers of attorney;
 Italy's less invasive form of guardianship, adopted in 2004 ("l'amministratore di sostegno"); and
 Japan's "voluntary guardianships" and "advisorships" which went into effect in 2000.
These user-friendly tools may have such advantages as being lower cost than previous legal options. They also help
to keep the impaired person involved in decision-making, while still protecting the person from exploitation. In
addition, they are easier for courts and litigants to handle.
mewhinka@law.wfu.edu
Elder Law: II
Principle Without Elder Policy: Are Lower Courts in Australia Taking the Aged Seriously?
Fiona Burns, University of Sydney
The centrality of free, open and voluntary transactions in common law jurisdictions has been an overarching
principle which has underpinned the judicial consideration of contracts, sales and gifts made by competent adults. In
Australia, appellate courts have recognised that although an adult may exhibit sufficient competence to enter into a
transaction, his or her freedom of action may be severely compromised by a variety of external pressures such as:
coercion, manipulation, duress, undue influence, misrepresentation and unconscientious advantage-taking.
Accordingly, a number of legal principles have been adopted from the English common law and refined by the
Australian High Court to address such inappropriate conduct. Nevertheless, this paper challenges the assumption
that there has been a consistent and systematic approach to protecting vulnerable persons, such as elders, who enter
into a contract or make a gift. From the perspective of the elderly claimant, there are two significant problems with
the present regulatory framework which will be explored in this paper in the context of unconscionable dealing and
undue influence: Such principles have been framed to address a particular kind of conduct generally, rather than to
protect vulnerable elders specifically. Therefore, the law has not conferred upon elders a special status at either the
pre-transactional or enforcement stages. The lower courts, in which most claims are made, have remained reluctant
to set aside such transactions; and have applied principles in a rigid and mechanical fashion. Reasons for this trend
include: the over-emphasis on the apparent intention of the elder to enter into the transaction; a lack of appreciation
of the effects of aging, the circumstances in which the aged find themselves and the potential of financial
exploitation; and the focus on the process of transacting rather than the ultimate outcome Therefore in this paper it
will be contended that there is an urgent need to unite legal principle and elder policy to protect vulnerable elders.
Suggestions on how the legal needs of elders could be addressed will be posited.
fionab@law.usyd.edu au
Guardianship Laws for the Elderly in Japan
Fusako Seki, Yokohama National University
Japan has only recently managed to establish Guardianship Laws for the elderly. The so-called “Adult Guardianship
Law (AGL)” was legislated with the revision of Civil Code and enactment of other laws in 1999. AGL updated the
old guardianship laws; in particular it adjusted the laws concerning cases where elderly people have lost mental
capacity.
AGL was instituted in accordance with the enactment of Long-term Care Insurance Law, whose system was based
on the elderly contracting with care associated companies and institutions. In order to make a contract, the elderly
have to be either mentally capable or supported by a guardian. Thus the legislation sought to solve many hurdles
concerning different mental capacities among the elderly. Moreover, AGL was established after studying many
other countries’ guardianship laws. Thus the law was supposedly well thought out, examining other countries
experiences and problems. However, its enforcement is facing many obstacles. For example, an elderly person
losing mental capacity needs help in health care decision-making. In such cases, an attorney alone cannot supply
enough support. There remains the task of making good support-system networks between attorneys, health care
workers and others. At the same time, contracts under AGL need refining.
This presentation will first give an outline of the new Guardianship law, since Japanese AGL---which is interesting
in that it was enacted as the result of comparative studies---has not yet gained international recognition. Second, this
presentation will analyze the complicated legal dilemmas associated with elderly mental capacity that the AGL
confronts.
seki@iblaw.ynu.ac.jp
Autonomy in Preserving and Passing on Wealth: Cross-Cultural Practices in Wills and Intervivos Gifts
Nathalie Martin, University of New Mexico School of Law
Every society has its own methods of passing wealth from person to person and generation to generation. From the
Reserve Legale under French Succession law, to the extensive testamentary freedoms of the U.K. and the U.S.,
autonomy in passing on wealth appears to vary greatly from country to country. This presentation will explore these
differences in two contexts, testamentary autonomy and autonomy in making intervivos transfers.
Testamentary Freedom
Testamentary freedom can be limited by statutes, court decisions and public policy considerations. Some European
nations have forced heirship doctrines, in which a certain portion of the estate must be left to children or a spouse. In
the United States on the other hand, testamentary freedom is considered paramount. In theory, individuals have full
freedom to distribute their property as they wish. In practice, however, American courts limit testamentary freedom
more than one might think. U.S. courts do not always adhere to testamentary freedom above all other
considerations. Rather, many are more committed to ensuring that testators devise their estates in accordance with
normative views than to upholding the intent of the testator. Some courts use doctrines such as mental
incompetence, undue influence and fraud to frustrate intent. Others accept less strict compliance with will
formalities when a will conforms to the perceived moral duty of the testator, but require strict compliance when the
testator’s wishes are non-conforming. Enforcement of stated testamentary intent may be even less predictable when
the decedent is female or from a cultural minority. Thus, in contrast to some European nations that have forced
heirship rules, American law considers autonomy a high priority. However, prevailing societal norms may limit
testamentary freedom, by invalidating (or at least applying more scrutiny to) wills that don’t conform. As a result,
when those nonconforming wills are invalidated and estates are distributed according to intestacy statutes that favor
close family relationships, the effect may not be much different from those nations that have forced heirship.
Apparent Freedom in Intervivos Gifting
A person’s freedom to dispose of his or her assets as he or she wishes can also be limited by family members,
attempting to take advantage of tax and public benefit laws that favour intervivos transfers. For example, most
developed societies provide government-supported long-term care to at least some members of society. Many
countries provide this care based upon need (also called means testing), but this varies from place to place. The U.S.
and U.K. spend down rules (as compared to those in places like Germany, for example) create large incentives to
transfer assets prior to death, which can further restrict the freedom and future choices of many elderly people.
martin@law.unm.edu
When Abusers Seek Guardianship: How Adult Protective Services and Guardianship Courts Can
Work Together to Protect the Elderly
Marguerite Angelari, Loyola University Chicago
When Abusers Seek Guardianship: How Adult Protective Services and Guardianship Courts Can Work Together to
Protect the Elderly Marguerite Angelari, Loyola University Chicago Adult guardianship is a court process through
which an individual loses virtually all of his rights and a substitute decision maker is put in place to make all major
decisions. The aging of our population has led to a dramatic increase in the need for court ordered guardianships,
which is severely straining court systems in the United States. As a result, despite the magnitude of the decisions
they are called upon to make, guardianship judges are limited in the amount of attention that they can devote to
individual cases. Under such circumstances, it is not difficult for an abuser to become his victim's court appointed
guardian and thereby obtain full legal control over his life. Elder abuse investigators can offer critical information
on whether proposed guardians may be exploiting their wards. Unfortunately, in Illinois, and throughout the United
States, adult protection services agencies and guardianship courts operate independently of one another. Therefore,
a judge conducting a guardianship proceeding and an investigator in an elder abuse case are unlikely to be aware
that the two proceedings are occurring simultaneously. Furthermore, elder abuse investigators report that even when
they become aware of the guardianship proceeding and appear in court, they are often unable to present evidence of
abuse at the guardianship hearing. As a result, they have stood by while alleged abusers have been appointed
guardian. This paper presents the findings of a research project on the interaction between elder abuse
investigations and guardianship cases. The study included face-to-face interviews with elder abuse investigators
about particular investigations followed by a review of corresponding guardianship court files. This paper
documents the need for greater interaction between guardianship courts and adult protective services and offers
recommendations for reform.
mangel@luc.edu
From Elder Guardianship to Long Term Legal-Care
Israel Doron, Haifa University
Since the 1987 Associated Press report that found "[t]he nation's guardianship system, a crucial last line of
protection for the ailing elderly, is failing many of those it is designed to protect," the legal landscape in this field
the United States and many other Western countries, changed dramatically. Law reform concerning guardianship
swept these countries. Yet, despite deep and extensive reform activity, debate and disagreement continue to rule the
field of guardianship over older persons.
This paper argues that what guardianship needs today in order to break "the rock of guardianship culture" is a totally
new path. Not just another wave of reform nor further attempts to educate or train, but rather a totally new model:
the long-term legal-care model (LTLC). The key to the proposed model is understanding that the challenge for
guardianship is its transformation from a narrow substitute-decision-making mechanism into an integral part of
community-based long-term care program.
idoron@univ.haifa.ac.il
Self-Neglecting Elders: Is intervention by Protective Services for Adults an Ethical Dilemma or Legal
Obligation?
Susan B. Somers, International Network for the Prevention of Elder Abuse, Nassau, USA
Self-Neglect occurs when older people refuse the help or care they need, for some, it is a symptom of mental heath
problems, such as depression, dementia, substance abuse or mental illness (Nerenberg, L, NCEA, 2/2002).
In 1996 2.2 million cases of elder abuse were estimated in the US, including 1.0 million cases of self-neglect
(NCEA 1997). Some 20 separate types of self-neglecting are reported in Elder Abuse Literature. Behaviors ranging
from direct suicide and covert suicide through various types of self destruction behavior to indirect life threatening
and indirect self destructive behavior (ISDB) or self injurious behavior (SIB) “ … that results in organ or tissue
damage to the individual: (Sengstock, Thibault and Zaranek, JEAN Vol. 11 No 2, 1999; Pies & Polpi, 1995, p 580)
This presentation will focus on the practical aspects and integral roles of Protective Services for Adults and the
Mental Health Professional, in investigating self-neglecting elders, and in achieving protection through the least
restrictive intervention. The factors of capacity (self-determination) and risk in determining the appropriate nature
and level of intervention for the protection of at-risk populations will be evaluated. This presentation will discuss the
guardianship process designed to protect the interests and well being of vulnerable adults.
sbsomers5@aol.com
Ethical and Psychological Reflections on Restorative Justice
Trust and Power-distance: Implications for Restorative Justice
Diane Sivasubramaniam, University of New South Wales
Youth Justice Conferencing (YJC) is a Restorative Justice (RJ) procedure, operating in the Juvenile Justice system.
Many studies examining YJC have found that conferencing increases participant satisfaction, compared to court
procedures. However, little is yet known about the mechanisms by which this occurs. There is a growing need for
experimental research regarding: why RJ achieves this objective, for whom RJ is working, and whether it is working
differently for different people (Polk, 2002). Research involving Hofstede’s (1980) power-distance variable suggests
that people who measure low on power-distance emphasise procedural justice concerns in their fairness evaluations,
whereas those who measure high on power-distance emphasise distributive justice concerns. Since power-distance
tends to vary across cultures, this represents an important consideration in the way in which participants from
different cultural backgrounds respond to mediation. This project investigates differences in the ways in which high
and low power-distance participants determine fairness in a facilitative mediation, such as YJC. Conferencing
processes in Australia can be divided into two broad categories: police-convened and other models. Perceived bias
in an evaluative mediation leads to a qualitative change in the way in which participants evaluate that procedure.
Based on evidence that young people of ethnic minorities often view the police as untrustworthy, bias in this
experiment was manipulated through the use of a police (bias) vs. civilian (no bias) convenor. Results are discussed
in terms of their implications for procedural justice theory, for debate on RJ procedure, and for culturally-relevant
police practices.
dsivasubramaniam@psy.unsw.edu.au
Making Amends for Wrongdoing
Antony Duff, The University of Stirling
Some advocates of ‘restorative justice’ focus on the need to repair the harm that is caused by crimes—though it is
often unclear just what this harm amounts to, or how it can be ‘repaired’. Others, rightly, focus on wrongs, rather
than merely on harms, as what make ‘restoration’ necessary in the aftermath of crime: what requires ‘repair’ is the
wrong that was done to the victim and, through the victim, to the wider community. This then raises the question of
what can count as ‘restoration’, or ‘repair’, in the aftermath of criminal wrongdoing.
It seems natural to say that the wrongdoer should ‘make amends’ to those whom he has wronged (to the direct
victim, if there was one; to the wider community, if the wrong was a ‘public’ wrong): but how can amends be made?
Apology is central to making amends, and I will focus on three questions about apology in the context of the kinds
of public wrong with which the criminal law is concerned—
 What does apology involve? What is it to apologise to someone I have wronged?

What are the key differences between public and private apology? What role does a requirement of
sincerity play in either context?
 Can apology be enough to make amends for a serious wrong? Or is something more required?
The last of these questions leads us towards punishment: for, I will argue, we can see certain types of punishment as
giving forceful material form to the apology that the offender owes the victim and the community.
Restorative Justice, Emotion and Therapeutic Culture
Gerry Johnstone, University of Hull
One of the most significant recent developments in the sphere of crime, criminal justice and penal policy has been
the emergence of a complex of ideas and practices known as restorative justice. The pros and cons of restorative
justice as a feasible and effective form of crime control have been much debated. This paper forms part of a broader
attempt to place the emergence of restorative justice in a broader cultural context, by looking at the cultural sources
of its ideas and examining where it is taking us culturally.
Distinctively, instead of relating restorative justice to the ‘new penology’ or the ‘new regulatory state’, as others
who have asked such questions tend to do, this paper relates the rise of restorative justice to a rather different
phenomenon: the triumph of the therapeutic.
Social theorists have long suggested that there has been a long-term shift from religion, then to law, then to therapy,
as the dominant institution of regulation and social control. Whilst such a shift has often been celebrated as
‘progress’, social theorists have been concerned to explore its darker side. Amongst the latest contributions to this
debate is Frank Furedi’s book Therapy Culture (London: Routledge 2004). Furedi claims that we now live in a
society in which the challenges and misfortunes of everyday life are regularly interpreted as threats to our emotional
well-being and hence as targets for therapeutic intervention. For Furedi, this development is highly undesirable. This
paper asks:
To what extent can the emergence of restorative justice – with its emphases on the emotional consequences of
victimisation and on the need to heal the injuries of crime - be understood as an aspect of a broader rise of
therapeutic culture?
To the extent that restorative justice incorporates the assumptions of therapeutic culture, how does this affect our
assessment of it?
J.G.Johnstone@hull.ac.uk
Doing Justice to Victims of Violence
Albin Daering, Legal Advisor, Vienna, Austria
The presentation inquires into the functions of the criminal justice system (police, the public prosecutor’s office and
courts) in the context of the recovery process of victims of violence.
1) It is suggested that the recovery process should be constructed along four stages, which are:
 Re-establishing a basic feeling of security
 Establishing concepts that allow to understand the traumatizing event/process and to construct an account
of this event/process
 Experiencing justice
 Social reintegration
2) Police and the criminal justice system have to understand -and to adapt their interventions to - these phases of the
recovery process in order to promote and not to endanger the recovery of victims of violence. This needs:
 An overall human rights-centered approach in policing and of the criminal justice system and in particular
an awareness of the human rights of victims of crime;
 Concrete policies and profound training;
 Organizational structures that open the police and the criminal justice system to the needs of victims and to
the cooperation with victim support organizations.
3) On the basis of recent Austrian reform projects related to domestic violence and trafficking of persons the
preconditions and the results of victim-centered approaches in policing and in shaping an adequate response of the
criminal justice system’s response are explored.
office@weisser-ring.at
What Can Victims Reasonably Expect of State-sponsored Restorative Justice?
Christopher Bennett, University of Sheffield
The notion of restorative justice draws intuitive power from a certain conception of restoration as it is practiced in
non-institutional or informal interpersonal relationships. However, in this paper I argue that the standards by which
institutional restorative justice (that is, within the context of the criminal justice system) is to be judged satisfactory
are not straightforwardly the same as those we would use to judge the adequacy of restoration in the noninstitutional or purely informal case. I claim that it can be the case that offenders should be regarded as restored even
if they fail to co-operate with the restorative process or do so reluctantly. But taking this line requires changing what
we expect (as opposed to hope) to come out of state-sponsored restorative justice. In particular, victims may have to
revise their expectations of offenders when engaging in such a process, and be prepared to accept results that would
be unacceptable in everyday life. This may be a difficult shift to make. But I argue that it is important to make it,
and that restorative justice so understood can still be important for victims when compared with going through the
courts.
c.bennett@shef.ac.uk
European Evaluation of Coercion in Psychiatry: Legal Dimensions
Involuntary Outpatient Treatment (IOT) of Persons with Mental Disorder – The Current Legal
Discussion across Europe
Gerhard Hegendörfer, Saxon Ministry for Social Affairs and Health, Berlin, Germany
In most mental health systems as well as in Europe there are persons with severe mental illness, mental disorder or
alcohol and drug abuse problems who are prone to relapse after repeated hospitalisations or contacts with the
criminal justice system because of their persistent risk of harm to themselves or to other people due to illness.
Another group of mentally disordered people often has the disposition to self-destructive behaviour or the incapacity
to realise the necessity of a medical intervention and therefore may also represent a significant danger for their life
or health. Such individuals habitually fail to pass a medical examination or therapeutic treatment, worsening their
condition. For both characteristics a (further) involuntary impatient commitment such as an admission or placement
to a psychiatric hospital or facility would particularly imply conflicts with the patient's right of liberty and also
question the legal principle of proportionality. So many states discuss the Involuntary Outpatient Treatment (IOT) as
an alternative to hospitalisation and intent to improve that way the effectiveness of psychiatric therapy for
involuntary patients. Simultaneously they hope to tackle the increasing costs of psychiatric impatient services by
providing a decentralised psychiatric health system composed of private doctors and therapists and adapted to
compulsory forms of treatment.
The presentation emphasises on legal questions of IOT with regard to European statutes and national regulations
across Europe. It comprises a survey of European principles and standards on this issue like the outcoming
Recommendation of the Council of Europe concerning the protection of the human rights and dignity of persons
with mental disorder (CDBI/INF 2004/5) and illustrates their impacts on national legislation. The following
questions are supposed to be pointed out in particular: How should be the legal prerequisites for IOT? How has IOT
been implemented in European states that currently use it and which difficulties do arise? How does a court order an
individual to comply with a specific outpatient treatment regimen? How will a treatment be implemented if the
patient does not co-operate and refuses it by using physical force? Who should be vested with power to order and
enforce coercive measures in those cases?
g.hegendoerfer@arcor.de
gerhard.hegendoerfer@diplo.de
Design of the EUNOMIA Project and Preliminary Cross-national Comparison of Socio-demographic
and Clinical Characteristics of Legally Involuntarily and Legally Voluntarily Admitted Patients Who
Feel Coerced to Hospital Admission
Thomas Kallert, Dresden University of Technology
Previous (mostly national) research has shown significant variation of different aspects of coercive treatment
measures. Therefore, clinical practise and outcome of these measures should be assessed at an international level
facilitating cross-national comparisons.
This is the general research objective of the EC-funded ongoing EUNOMIA-project whose naturalistic and
epidemiological study design has been implemented in 12 regions in 12 European countries. Using a standardized
battery of instruments (e.g. covering psychopathology, perceived coercion, satisfaction with treatment, quality of
life) each centre assesses two groups of patients for a three-month follow-up period (time-points of assessments:
within the first week after hospital admission, 4 weeks and 3 months after hospital admission): legally involuntarily
admitted patients (aimed at figure of complete cases in each centre: N=140) and legally voluntarily admitted patients
who – according to a screening procedure – feel coerced to admission (aimed at figure in each centre: N= 40).
This preliminary analysis will include the subgroup constituted in the first 18 months of the recruitment period (ca.
800 – 1000) patients and focus on the initial assessment of these patients (within the first week after hospital
admission) covering their socio-demographic and clinical characteristics, legal status, perceived coercion and
satisfaction with treatment.
The results will be embedded in standardized information on the organization of mental health care in the
participating catchment areas. In particular, consequences for the clinical practice of involuntary hospital admissions
across Europe will be demonstrated.
thomas.kallert@mailbox.tu-dresden.de
Legal and Cultural Aspects of Involuntary Psychiatric Treatment Regulation in Post-totalitarian
Milieu: The Bulgarian Perspective
Boris Boyadjiev, National Center for Public Health, Sofia, Bulgaria
Georgi Onchev, Sofia Medical University
The characteristics of the legal systems and social practices concerning involuntary psychiatric treatment in posttotalitarian societies are reviewed from historical perspective, with delineation made between different countries
from the post-Soviet space. Totalitarian law and its application were dominated by insensitivity to personal rights,
prejudices, and legal nihilism. Their impact on present changes in legal regulation of mental health care, and
involuntary treatment in particular, in Bulgaria, is analyzed. Cultural and legal developments are far from being
parallel, and totalitarian legacy in the area of patients’ rights and coercion in psychiatric treatment has been worked
through in a milieu with transitional rules. The basic challenging turnabouts in such context concern more cultural
issues rather than legislative ones. While legal changes nowadays could be best described as “forced normalization”
(illustrated with Bulgarian legal traditions as an example), the major cultural shift in regards to human rights and
health care impacts novel conceptual frames, e.g. autonomy vs paternalism, and high tolerance to insecurity vs
fatalism that mobilize defences and confusion. Culture, and de-culturation in times of transition for that matter, is
the limiting factor for practical implementation of law, and contributes to the demarcation between written law and
applicable law. Key issues subject to current changing legislation, such as informed consent to treatment, legal
competence, disability and guardianship, compulsory placement and treatment, as well as the promoting and are
discussed in the context of a changing culture.
georgeonchev@hotmail.com
Rules and Regulations for Involuntary Placement or Treatment of Mentally Ill Persons - Results from
a Structured Survey Instrument in 12 European Countries, and Results from a Quality Assurance
Project on Involuntary Placement/Treatment in Poland
Joanna Rymaszewska, Wroclaw Medical University
Stanisław Dąbrowski, Institute of Neurology and Psychiatry, Warsaw, Poland
The aim of the study was to gather and analyze information about differences and/or similarities of the rules,
regulations and practice for compulsory admission and involuntary treatment of mentally ill patients across the
European countries. Evaluation of implementation of the Mental Health Act provisions concerning coercion in
Poland will be also presented.
Data was collected by means of a detailed questionnaire by Salize et al. which was filled in by legal experts* of 12
European countries (Bulgaria, Czech, England, Germany, Greece, Israel, Italy, Latvia, Poland, Slovakia, Spain,
Sweden). The questionnaire addressed 4 main areas: legislation, practice, patients’ rights and epidemiology. Quality
assurance project on involuntary placement/treatment in Poland was based on analyses of the data from Polish
psychiatric hospitals: psychiatric opinions of coercive admissions and reports on physical restraint episodes.
Only half of the assessed countries have the specific mental health act. Separate mental health act concerning child
and adolescent psychiatry exists in two countries. There were essential differences in legal criteria qualifying a
person for compulsory admission as well as procedures and time frame within Europe. None of the legal acts use the
current psychiatric terminology. Only few countries have epidemiological data on coercion.
Findings reflect rather heterogeneous attitude towards coercion in psychiatry within Europe. It should lead towards
discussion and harmonization in legal and everyday practice level.
ankarym@psych.am.wroc.pl
Main Differences in Legal Control Procedures Referred to Coercive Treatment Measures in Psychiatry
– Comparing the Situation in 12 European Countries
Francisco Torres-González, University of Granada
The normative frame that regulates the use of coercive measures in psychiatry has been directly influenced by
several phenomena: a) new political configuration in countries like Germany, Slovakia, Czech Republic, and
Lithuania; b) country-specific political characteristics of the legal system (unitary, federal and regional models), and
c) the different historical development of this normative framework dealing with issues of mental health care.
According to the main international treaties on the matter, in particular the Universal Declaration of human rights,
the European Agreement of human rights and the Agreement of Oviedo, all legislations consider two main models
of involuntary hospital admission: the criminal and the civil laws.
While the criminal admission model does not vary so much, the civil one significantly differs across European
countries. The majority clearly defines the circumstances for non-voluntary admission (Belgium, Germany, Greece,
Slovakia, Poland, Sweden, Israel, Italy). This is not the case in Spain, where there is only a reference to the lack of
self-control. The procedures of involuntary ordinary admission correspond basically to the following models: a)
medical; b) administrative or judicial according to the circumstances (Germany); administrative, with a-posteriori
judicial control; c) pure judicial, this model corresponds to Spain; d) judicial with important functions attributed to
the public prosecutor (Belgium and Greece). In all cases an admission on urgency grounds exists, initially
authorized by the administrative authority or to the doctor, and followed by judicial ratification.
Not in all countries standards for the use of coercive measures have been developed. Particularly, this refers to
seclusion and mechanical restraint. Compulsory medication is usually regulated. Surprisingly enough, the
jurisprudence on the use of coercive means is scarce in all the countries and, in general terms, the lack of widespread
medical and nursing protocols is striking.
In general, the control procedures comprise three modes: a) the one assigned to the judicial authority (legality
control of the admission), b) the one assigned to the Fiscal Ministry (control of the guarantee that everybody has an
autonomy that should be protected) and c) the one executed by the Health Administration. There are countries in
which several control procedures are established although they clearly lack rigor and efficacy.
ftorres@ugr.es
Terminal Illnesses, Euthanasia and Assisted Suicide I
The Dutch Euthanasia Law: Legal, Medical and Social Developments in the Area of Voluntary Active
Euthanasia and Other End-of-life Decisions
Gerrit K.Kimsma, Free University of Amsterdam
After 25 years of building up acceptance of voluntary active euthanasia a ‘euthanasia law’ became active in the
Netherlands in April 2002. This paper will focus on the structure of the jurisprudence, the developments in medical
professional ideas/practices and present problematic issues, needing further management and choices. The ‘bottle
necks’ that are experienced by the medical profession, as outlined in June 2004 shall be compared with the positions
of the Dutch Government as outlined in a letter to the Parliament of July 2004. I shall finish my presentation with a
description of developments in the area of end-of-life interventions with Alzheimer patients.
gk.kimsma@vumc.nl
The Practices and Laws on Euthanasia and/or Physician-assisted Suicide: A Comparison of Oregon
(USA), The Netherlands and Belgium
Luc Deliens, Free University of Brussels
Els De Keyser, Free University of Brussels
Linda Ganzini, Oregon Health and Science University
Gerrit van der Wal, Free University of Amsterdam
In the Netherlands (2002), Belgium (2002) and Oregon (1994) euthanasia and/or physician – assisted suicide has
been legalised under strict due care criteria and after confirmation with a notification procedure. In the Netherlands
both medical acts, namely euthanasia and physician – assisted suicide, have been legalised. In Belgium and Oregon
(USA) only, respectively, euthanasia and physician – assisted suicide have been legalised.
Because in the Dutch society the norm setting on euthanasia and physician assisted suicide has been widely
developed through jurisprudence, the law is less extensive on the due care criteria than in Oregon and Belgium.
Furthermore, the medical associations and medical guidelines support the Dutch law, and a network of support and
consultation physicians has been implemented. Because in Belgium jurisprudence and professional guidelines are
lacking, the euthanasia law is less supported by professional caregivers than in The Netherlands. In the USA the
Oregon Death with dignity Act, the first law ever to regulate physician-assisted suicide, remains highly
controversial.
All three countries are decriminalising euthanasia and/or physician assisted suicide only when the attending
physician has respected the due care criteria. Some of these are similar, for example the patient must be well
informed about the diagnosis and prognosis; the opinion of the consulting physician must be taken in consideration,
etc. while others clearly differ.
The euthanasia and the physician assisted suicide practices and the due care criteria for these practices, as described
in the laws, will be discussed and compared across countries in this paper.
luc.deliens@vub.ac.be
Hard Cases for the Belgian Euthanasia Law
Freddy Mortier, Ghent University
The Belgian euthanasia law is in force since September 2002. It allows euthanasia, under specific conditions, in
patients suffering hopelessly and unbearably, either terminal on non-terminal. I would like to focus on the case of a
request for euthanasia recently brought before an ethics committee in a hospital. The case concerns a 34 year old
woman with a psychiatric history of severe depression and borderline personality syndrome, also suffering from
perhaps minor but persistent physical discomforts. The patient was examined by a psychiatrist independent from the
physician to whom the euthanasia request was addressed. I will analyse the (extensive) expert report submitted by
the psychiatrist and highlight the intricate problems it raises in assessing the patient’s competency, in determining
the very hopelessness of the patient’s condition, as well as in guaranteeing the general carefulness of the
consultation by the physician of colleagues. I will draw on comparable cases of requests for euthanasia or physicianassisted suicide by psychiatric patients in the Netherlands (that sometimes have been brought before the courts) and
try to answer two sets of questions: (1) what standards for good medical practice, if any, are suggested by the cases
at hand; (2) whether and how effective legal control by the federal evaluation commission of problematic cases
might be achieved, so that psychiatric patients may be sufficiently protected.
Freddy.Mortier@UGent.be
Who Should Determine Capacity When a Patient Who Cannot Speak Requests that Life-sustaining
Treatment Be Withheld? A Case Study
Colleen Cartwright, Southern Cross University
Under both common law and statute law in Queensland and other states/territories of Australia, and indeed in many
Western democratic countries, all competent adults have the right to refuse medical treatment, even life-saving
treatment. Legislation in a number of Australian states and territories also provides for competent adults to make
their wishes known for health care they would, or would not, want if at some future time they lost the capacity to
communicate. In most cases the legislation provides for completion of a written document of their wishes (in most
cases called an Advance Health Directive) and/or the appointment of a proxy decision-maker under an Enduring
Power of Attorney.
The guiding principle on which such legislation is based is “presumption of capacity”; i.e. a person is presumed to
be competence unless they are proven to be otherwise, and the onus of such proof rests with those who claim that
the patient is not competent. However, in some cases determining a patient’s competence may be difficult, e.g.
when a patient is unable to communicate verbally and/or when it is suspected that the patient’s current lifethreatening injuries have been caused by an attempted suicide.
This paper will present a case study where the above conditions prevailed. In this case, the patient was quadriplegic,
using only head movements to respond to questions and there was disagreement between consultant psychiatrists
and the treating intensive care and spinal unit specialists, as well as between members of the patient’s immediate
family, in relation to the patient’s capacity. The case was sent to the Guardianship and Administration Tribunal for
a determination. The Tribunal’s finding and the outcome of this case will be discussed.
ccartwri@scu.edu.au
Terminal Illnesses, Euthanasia and Assisted Suicide: II
Withdrawing and Withholding Treatment for Terminally Ill Infants when Parents Insist that
Treatment Must Be Continued: The Role of the Courts
Loane Skene, University of Melbourne
Sometimes parents demand that full active treatment must be given to their terminally ill child but treating doctors
and nurses, backed by the hospital’s clinical ethics committee, believe that such measures are not in the child’s best
interests; and that the child should be offered only palliative care.
Medical staff commonly believe that they should determine the appropriate treatment. If they feel compelled by the
family to continue life-sustaining measures that they do not consider in the child’s best interest, that is distressing for
them and undermines their morale. On the other hand, parents and other relatives argue that they are closer to the
child and can see developments that may be missed by health professionals. They say that the determination of what
is in the child’s best interest cannot be determined objectively from the doctor’s viewpoint. A life that is ‘not worth
living’ may be different for a fit and high achieving health professional than for person with a disability, even one
that is very severe.
This paper considers the role of a court if the hospital applies to the court for a declaration concerning the treatment
that is appropriate. What matters should the court consider? What evidence should be given? What weight should be
placed on family views? And is it ever right for a court to direct health professionals to act contrary to their clinical
judgment?
The author reviews recent case law in the UK, Australia and New Zealand and concludes that it is extremely
unlikely that a court would direct medical staff to provide treatment they do not think is clinically in a patient’s best
interests.
l.skene@unimelb.edu.au
Truth-telling in Terminal Cases: Right, Duty, or Proscription?
David Novak, University of Toronto
One of the perennial questions asked in the course of medical practice is whether a patient determined to be
terminally ill should be told of the physician’s judgment of the probability of his or her imminent death. Is what has
been called the issue of “truth-telling” a right, a duty, or a proscription? Does a patient have a right to know of his or
her terminal condition? If so, what is the source of this right? Why is its exercise justified? Does a physician have a
duty to tell a patient of his or her terminal condition? Would there be such a duty if the patient did not request to be
told the truth about his or her chances for survival? Is there a proscription of such truth-telling? Could such truthtelling, in effect, be a death sentence, indicating to the patient that his or her physician has already abandoned hope
for the patient’s recovery, however remote, while that patient is still alive? Couldn’t such truth-telling be construed
as a physician’s too easy abdication of his or her responsibility to the patient, however remote the chances of
recovery or however unpredictable the time of death probably is?
This paper will argue that the “right to be told” can be most cogently exercised by religious patients, who can be
defined as those (Jews, Christians, or Muslims) who believe that they will be judged by God at the time of death to
be worthy or unworthy of an unending world where death has finally been transcended. Such patients would surely
want to assert the right to be told of their condition so as to better resolve lingering moral and spiritual conflicts in
their life while there is still time to do so. This would better enable religious patients to prepare for the end and
depart this world in peace with God and fellow humans, thus having reason to believe themselves worthy of that
transcendent future. Many religious traditions would call this summation of one’s life “atonement” or “ultimate
reconciliation.” But religious patients must explicitly assert this right to know their true condition to their physician
in order for there be a correlative duty on the part of the physician to tell the fatal truth to them. Without such
explicit assertion in the form of a request — “please Doctor, am I going to die soon?” — There is good reason for
patient to suspect that the physician, who tells them of the imminence of their death, is engaged in premature selfexoneration from the duty to care for all his or her patients until their end.
Because of the likelihood of such a situation arising during the course of treatment for serious medical conditions, it
is reasonable for religious patients to seek out — other professional abilities being equal — a religious physician
who would better understand their right to be told the truth, and the physician’s duty to tell it to them, and to care for
them unconditionally. Such truth-telling should only be proscribed if it might lead the patient to despair of further
life in this world (however brief), which could even lead to what might be termed “pre-emptive suicide,” or if it
might lead the patient to despair of ever being worthy of the life of the world-to-come.
david.novak@utoronto.ca
Confusion between Euthanasia and other End of Life Options: Implications for Public Policy and
Practice.
Isabelle Marcoux, University of Quebec at Montreal
This paper discusses the public’s understanding of euthanasia and the implications of their conceptions of euthanasia
for public policy and decision making. The right to decide the “how” and “when” of death is becoming one of the
major ethical challenges in most industrialized countries. Public debate has been fuelled by increased media
coverage of specific cases (e.g. Diane Pretty in the UK, Vincent Humbert in France), legalization of euthanasia
and/or physician-assisted suicide in some countries (the Netherlands, Oregon, Belgium) and recent internationally
acclaimed movies (The Barbarian Invasions [Canada], Beyond the Sea [Spain].) The fact that poll results indicate
that the population is in majority in favour of euthanasia is often cited as a justification for legalizing these practices.
However, public opinion poll results concerning euthanasia may be misleading. Our study, conducted in Quebec,
revealed that people are confused about what constitutes euthanasia and that people often confuse euthanasia with
other end of life practices, such as refusing and stopping life-prolonging treatments, double effect and assisted
suicide. Furthermore, such misconceptions may influence opinions about the acceptability of euthanasia. We found
that people who thought that withholding and withdrawing treatment are euthanasia are more favourable to these
practices. Widespread confusion about the nature of euthanasia limits the validity of poll results and can influence
people’s support for public policies, as well as their decision-making concerning end of life practices.
marcoux.isabelle@uqam.ca
Psychiatry’s Normalizing Gaze at the End of Life
Malcolm Parker, University of Queensland
Psychiatry is extending its sphere of influence in numerous fields, one of which is end-of-life decision-making. The
assessment of patients’ decision-making capacity by a psychiatrist, in terminal illness situations, has been argued to
be a requirement of any acceptable program of assisted dying. For example, the Northern Territory’s Rights of the
Terminally Ill Act, which operated briefly during the mid-1990s, mandated psychiatric assessment of patients who
requested assistance to die, in order to ensure their decision-making competence.
Recently, Australian researchers have proposed that a new diagnostic category, Demoralisation Syndrome, which is
characterised by hopelessness, helplessness, loss of a sense of control and loss of purpose and meaning, should be
added to the DSM classification system as a new category of mental disorder. Proponents of the syndrome argue for
a strong link between these kinds of mental states of people with terminal illnesses, and the desire to die, which
motivates requests for assistance. The link is considered strong enough to define requests to die as always
pathological.
The principle of mandatory psychiatric assessment/review of requests for assistance to die, and the acceptance of
Demoralisation Syndrome as a psychiatric category, both raise important questions concerning the medicalisation of
existential cognitions at the end of life. In this paper I explore a number of links between psychiatry, medicine,
science and ethics, to support the claim that these recent developments in psychiatric theory and practice work to
illegitimately normalise and entrench the traditional medical opposition to active assistance in dying.
m.parker@uq.edu.au
Mental Health Community Intervention Stopos Suicide Tendency in Tabasco: Preliminary Results
Jaime Mier Y Teran Suarez, Health Secretariat, Tabasco, Mexico
Suicide tendency increase in the world in Mexico annual suicide rate was 3.34% between 1995 and 2002. In Tabasco
death by suicide is 12th cause of death, with rate 10.6 a threefold of the national level with an increasing tendency until
2002. An open transversal prospective study was conducted in order to find the effectiveness of screening by qualified
personnel in primary health care, epidemiological mental health brigades and a suicide prevention campaign in
communication media. 756 suicide risk patients were detected. 88% with depression disorders, 8.444% alcohol related
disorders and 3.4% with mixed anxiety disorders. Only one patient in the control group commited suicide. The
increasing suicide tendency was contained. Suicide risk dedection by qualified health personnel and proper care is
efficient in preventing suicide.
jmier@saludtab.gob.mx
Falum Gong
Falun Gong: The Real Story
Erping Zhang, Association for Asian Research, New York
Falun Gong has become an international phenomenon. As a traditional Chinese meditation system, it is now legally
practiced in over 60 countries around the world, except in Mainland China. Like other faith groups such as Tibetan
Buddhism and underground Christians in China, Falun Gong, rooted in Buddhist principles of “Truthfulness,
Compassion, Forbearance”, has become another victim of the atheist Communist Party since 1999 when the
campaign of persecution started. Ironically, Falun Gong was promoted by the government of China between 1992
and 1999 and was touted for its health benefits and moral contributions.
My presentation, through the visual aids of power-point slides, will help answer some of the frequently-asked
questions concerning this meditation practice: What is Falun Gong? How did it started in China? Why was it so
popular before the Communist persecution? Why did the Chinese Communist Party change its mind and is now
persecuting it? What is the current situation of Falun Gong in and out of China? And how has the international
community responded to Beijing’s campaign of persecution?
This presentation will also give a historical analysis of Chinese Communist Party’s policy toward religions and/or
spiritual disciplines since 1949.
erping_zhang@ksg05.harvard.edu
Abuse of Psychiatry, Psychological Torture, PTSD and Genocide of Falun Gong Practitioners in
China, 1999-2005
Viviana Galli, China Mental Health Watch, Hyde Park, USA
Sunny Lu, China Mental Health Watch, Hyde Park, USA
The systematic persecution launched by the former Chinese leader, Jiang Zemin, in July 1999 has used over 100
methods of torture. This persecution unlike many others in history is aimed directly and indirectly at the human
mind. It aims to extinguish belief in Falun Gong and violates the very basic human rights of freedom of thought and
belief. This not only affects Falun Gong practitioners (about 100,000,000 in China) and their families, but also
affects those who execute the orders of persecution. It includes all levels of government, public security, media, and
medical personnel, as well as all corners of society, including international communities. Over 1,000 practitioners
have already been killed, and the moral conscience of millions has also been affected.
This persecution is also causing a large number of psychiatric casualties. We have been collecting evidence through
face-to-face interviews with the victims of labor camps and brainwashing classes as well as family members who
lost their loved ones through the persecution. According to preliminary investigations, there are a large number of
Post Traumatic Stress Disorder cases. Even some left completely incapacitated, due to physical and mental torture
in labor camps and “re-education” centers. Other psychiatric sequelae such as insanity due to torture, major
depression, grief and loss, have occurred which complicates the issue of psychiatric commitment. Disrupted
families, loss of livelihood, long hours of forced labor, sleep deprivation, surveillance, and government-pressured
participation of all citizens (rewarded or punished) have contributed to a long-standing environment of mental
duress. Falun Gong practitioners, as well as the public at large, have been affected by this sustained campaign of
fear.
The persecution of mentally healthy Falun Gong practitioners in Chinese psychiatric hospitals is unprecedented in
terms of the number of victims, hospitals involved, the brutality of methods used and the severity of the
consequences. According to incomplete data, over 1,000 healthy Falun Gong practitioners have been involuntarily
admitted to mental institutions, many of whom were forcibly injected with high doses of psychotropic drugs. Some
have been subjected to electro-shock and others have been tied up and force-fed for long periods of time.
The Chinese authorities extensively use brainwashing as a form of torture. Such practices entail intimidation,
threats of terror, forced repetition of detailed information, and deprivation of sleep and food sometimes with the use
of loud high pitched sounds for long periods of time. Physical torture such as beatings, electrocution and rape are
used to facilitate “brainwashing.” These techniques create fear, hopelessness and destroy their dignity and
confidence. In the end “brainwashing” occurs in this psychological chaos and a mental breakdown soon follows.
Under these circumstances some victims then denounce Falun Gong and sign documents known as “repentance
statements” against their own will only to avoid further torture. This forced “transformation” inflicts long term
anguish, and emotional pain leaving invisible scars.
Vg10@hushmail.com
Lusy@mail.uc.edu
Social Control in the People’s Republic of China
Chu-Cheng Ming, National Taiwan University
Since the emergence of human politics, effective social control has been the central concern of governments. In the
Western tradition, the Kings relied on religion, morality, law and eventually violence to achieve the purpose. In
Imperial China, however, the emphasis was placed more upon moral education, law and violence. Religion, in
contrast to the West, played but a secondary role.
After 1949, as the Chinese Communist Party (CCP) claims to be atheistic, they completely dismiss the role of
religion, relying on the use of violence, political movements and law to maintain social order in the People’s
Republic of China (PRC). In addition, propagandarof is also heavily used as an important supplementary tool.
For people lacking the experience of living in a totalitarian society, it is very difficult to imagine, the CCP constantly
launches political movements to eliminate their political enemies and to keep the rest in line. Since 1949, they have
launched the Five Major Movements, Three Rectifications Campaign, Anti-Rightist Movement, Great Leap Forward
Movement, Four-Cleaning Movement, Cultural Revolutionary Movement, Criticism of Lin Biao and Confucianism
Movement, Revelation and Criticism of the Gang of Four Movement, etc. In these movements, harsh criticism,
organizational and group pressure, and public humiliation are commonly used methods in order to exercise
psychological control. In some movements, the CCP resort to massive physical violence, beating, physical abuses,
torture and even massive killing.
In all these movements, propaganda plays a central role. Because the propaganda tools are all monopolized in the
hand of the state, the PRC can easily denounce a single person, a group, political or non-political, a class, or any
target as anti-people or counter-revolutionary, and defame, smear and criticize as it wishes. The targets, having no
access to any channel of defense, usually fall victims in a matter of days. What comes afterwards depends totally at
the mercy of the CCP.
It is worthy noting that despite the CCP has adopted the policy of comprehensive reforms, their way to exercise
social control has not changed very much. The 1989 Tiananmen Massacre and their effort to eradicate Falun Gong
serve as two prominent examples.
The core argument of this paper is that the CCP is excessively power-sensitive. It tends to look at things, people or
other organizations through the lens of political power, and it is too suspicious of others that almost leads to the
aforementioned phenomena inevitably. Until this kind of mentality of the CCP is changed fundamentally, one can
hardly imagine the real change of the nature of the society.
jz.ming@msa.hinet.net
Justice Against Crime of Genocide
Theresa Chu, International Advocates For Justice, New York
Since Jiang Zemin, the former leader of China and the former chairman of the Chinese Communist Military
Committee, announced in public in July of 1999 that he would handle Falun Gong by “striking harshly, punishing
for control, accusing and denouncing”, he mobilized the system involving the nation’s party, politics, military,
police, special agents, and even the legal system to forcibly discredit the Falun Gong group. The annual reports from
U.S. Department of State and the international human rights organizations, including United Nation Human Rights
Commission, Human Rights Watch and Amnesty International verify that China’s rule of law has already become a
tool in Jiang’s hands to persecute the Falun Gong group and the practitioners of Falun Gong at present cannot obtain
any fair and just trial under Chinese law.
To eliminate the Falun Gong group which believes in “Truthfulness, Compassion, and Forbearance”, Jiang
exhausted huge amount of the nation’s resources and established the state-run “Leading Office Handling the Issue of
Falun Gong”, which is also known as “610 Office”. They murder, torture, brainwash, and even have the media
controlled by Jiang to frame, fabricate, defame, smear and instigate the public’s hatred against Falun Gong. What
Jiang and the Chinese government have done caused the deaths, injuries and homelessness of close to a million
Falun Gong practitioners in Mainland China. However, the international community has not really understood the
global impact of Jiang’s attempt at eliminating Falun Gong. The Falun Gong practitioners in each area, even though
many enjoy the legal protection of the democratic countries, but because of the enforcement of Jiang’s genocidal
persecution, many of them have suffered various degrees of threats and injuries to their freedom and rights.
At this time, there are more than 30 lawyers from 29 countries, including, but not limited to US, Canada, Germany,
Spain, Belgium, Greece, Austria, Russia, Portland, France, Finland, Taiwan, Korea, Australia and New Zealand,
Bolivia etc assist Falun Gong practitioners worldwide to sue Jiang Zemin, Former Beijing Mayor, Former Education
Minister, Culture Minister, Minister of Commerce Minister of Information etc for genocide, crimes against
humanity, and torture, those serious international crimes. Falun Gong’s case is known as the biggest international
legal effort in time of peace since WWII.
Taiwan Falun Gong practitioners’ experiences can be used as an example to explain a link in Jiang’s initiation of a
global persecution in the 21st century. I hope to urge, through this, that all the state signatories of the “Convention
on the Prevention and Punishment of the Crime of Genocide” (hereinafter referred to as the “Convention”), the
International Criminal Court etc--those organizations and individuals who have as their objective to promote peace
for humankind and to ensure international human rights--to reflect and consider a step further any and all provisions
regarding “Genocide” in the Convention and the Rome Statute. The international community has to face squarely
the severity of Jiang’s genocidal persecution of Falun Gong and to bring Jiang to justice internationally, so as to end
as soon as possible this largest human rights farce of the Chinese community in this early 21 st century.
Theresa.chu@4new.org
Testimonial
Chen Ying
Testimonial
Ming Zhao
Family Therapy in Assessment and Treatment
Multisystemic Treatment (MST) of Serious Behavior Problems in Youth – A Two Year Follow up
Study of Clinical Outcomes
Terje Ogden, The Norwegian Center for Studies on Conduct Problems and Innovative Practice, Oslo,
Norway
MST is an intensive home- and community-based intervention for youths with serious antisocial behaviour
including aggressive and criminal behaviour as well as drug abuse. MST has been effective at reducing out-of-home
placements and producing favourable clinical outcomes in Norway as well as in the U.S. Research results and
experiences from a Norwegian large scale implementation of MST and a multisite randomized controlled outcome
study (RCT) are presented. Participants in the RCT were 100 seriously antisocial youths in Norway who were
randomly assigned to Multisystemic Therapy (MST) or usual Child Welfare Services (CS) treatment conditions.
Data were gathered from youths, parents, and teachers before and after treatment. Pre-post results showed that MST
was more effective than CS at reducing youth internalising and externalising behaviours and out-of-home
placements, as well as increasing youth social competence and family satisfaction with treatment. Site effects were
registered and the treatment results covaried with differences in treatment adherence at the 4 sites. The sites with the
highest Treatment Adherence Measure Scores (TAMS) were also producing the best treatment results. Furthermore,
the sustainability of the clinical outcomes were documented at three out of four sites in a follow up study two years
after intake.
ogden@online.no
The Effectiveness of Functional Family Therapy with Violent and Offending Adolescents
Thomas L. Sexton, Bloomington, Indiana
Violent and behavior disordered youth are among the most prevalent in justice systems across countries and
cultures. Functional Family Therapy is among the few systematic programs designed to help these youth.
Functional Family Therapy is based on a long-term, systematic, and independently replicated series of outcome and
process research studies spanning over three decades. These results have lead the United States Center for Substance
Abuse Prevention (CSAP, 1999) the Office of Juvenile Justice and Delinquency Prevention (OJJDP), the Surgeon
General’s Report (U.S. Public Health Service, 2001) to identify FFT as a “model” program for both substance abuse
delinquency and violence prevention. The cumulative data suggests that FFT is effective on two critical fronts.
First, the results indicated that FFT was in engaging and retaining families in treatment. Engagement rates in FFT
studies range from 78% to 89.8%. This outcome is fairly dramatic given the traditionally high rates of drop-out (5075%) in most treatment programs. Second, FFT reduces recidivism between 26% and 73% with status offending,
moderate, and seriously delinquent youth as compared to both no treatment and juvenile court probation services
(Alexander, et al., 2000). These positive outcomes of FFT remain relatively stable even at follow-up times as long
as five years and the positive impact also affects siblings of the identified adolescent. In addition, it appears that
FFT not only results in significantly lower recidivism rates, but if the adolescent recidivated at all, they committed
significantly fewer severe crimes, even when pretreatment crime history was factored into the analysis.
This presentation will briefly describe the FFT model, the specific research data regarding the effectiveness
of FFT, and the application of FFT to in various cultures and populations.
thsexton@indiana.edu
Engaging with Families in the Adolescent Forensic Service. Issues Raised in the Assessment and
Treatment of Young People
Beverley Stowell, Salford & Trafford Mental Health NHS Trust, Manchester, England
Lynn Aulich, Bolton, Salford & Trafford Mental Health NHS Trust, Manchester, England
We know that young people with mental disorders and offending behaviour do not live in well functioning
supportive families. Many of the young people we assess and treat no longer live with their families and often have
infrequent sporadic contact with them. Where young people do live with or have significant contact with their
families it is often difficult to work with and engage them in the process of assessment or support of their children’s
treatment. It is even more challenging to engage parents in family work or to offer supportive interventions.
The presentation will discuss some of the psychodynamic factors at work in the relationship between the service and
the families whose children we assess and treat. The young people and their families can be equally difficult to
engage and manage. Taking these factors into account we are developing a strategy of intervention that is based on
building up trust, being non- judgemental, managing hostile and dependent feelings and fostering a sense of
confidence and capability.
The talk is based on clinical experience. From assessments we will draw on case material including kinetic family
drawings made in art therapy, information from the Bene-Anthony Test of family relations, telephone conversations
and therapeutic letter writing.
We have learned from all the difficult, awkward, needy, immature, complicated and messy fragments of families our
young patients bring with them that the established traditional methods of psychodynamic interventions in families
will not apply. We will discuss some of the cases in which we saw a chance for intervention but did not have the
means to offer one and how this has led us to think about how to extend our service to families in a form they can
use.
Bstowell@gardener.bstmht.nhs.uk
Functional Family Therapy in a day treatment protocol treating juvenile delinquents: results of a pilot
study
ReneE.Breuk, The Bascule, Amsterdam
Functional family therapy (FFT) is ‘a family-based empirically supported treatment for adolescent behaviour
problems.’ (Alexander, & Sexton, 2002; Sexton & Alexander, 2003). FFT was well founded in outcome research
with over fourteen published clinical trial studies, comparison group studies and evaluation results which suggest
that when implemented properly FFT had favourable outcomes in reducing recidivism compared to treatment as
usual (probationary services; FFT: 11%- 26%; probation: 38%-50%). At the same time it ameliorates family
functioning, communication is improved and there is less negativity between family members (Alexander et. al,
2000).
Since 2003 FFT has been implemented in the Netherlands as a central part of a day treatment program for juvenile
delinquents with psychiatric disorders.
To collect data concerning the treatment effect questionnaires were filled in by parents and children before treatment
(baseline), directly after both the engagement motivation phase, after the behaviour change phase and after finishing
functional family therapy. The diagnostic assessment consists of the Questionnaire Family Problems (Vragenlijst
Gezins Problemen) (VGP, Koot, 1997) and the Parent Child Interaction Questionnaire (Ouder Kind Interactie
Vragenlijst) (OKIV, Lange, Blonk, et al, 1997), both Dutch questionnaires based on the Family Assessment
Measure (Steinhauser). Also FFT adherence and competence measures were taken.
Results of the pilot study of 10 families are presented.
r.breuk@debascule.com
r.e.breuk@planet.nl
Applying Family Therapy to People Found Not Criminally Responsible on Account of Mental
Disorder: Rebuilding Networks to Ensure Successful Community Reintegration
Sergio Santana, University of Alberta
Family therapy is an increasingly influential therapeutic discipline. However, its application to psychiatry in general
and forensic psychiatry in particular has been fraught with difficulties. Indeed, in spite of the evidence of its
therapeutic potential and the emphasis of governments and psychiatric organizations on the cooperation of
professional and non-professional carers, family based treatments are rarely used in adult mental health.
In this presentation the difficulties faced by people who have been found not criminally responsible (NCR) on
account of mental disorder to come to terms with their crimes and successfully return to society are discussed and
how family based treatment have improved the treatment of these patients.
This NCR population committed serious crimes of a violent nature, mostly against their families and, therefore, they
found themselves in conflict with the very source of support which may have facilitated their treatment and enabled
a successful community reintegration. If left unresolved, the psychological and emotional connotations of their
crimes hindered not only the treatment of the individual patient but also the well-being of the family system as a
whole. However if the conflict and alienation caused by the perpetrators were addressed with their families, there
were significant therapeutic gains.
This type of work allowed for the rebuilding of relationships between the NCR patients and their family members,
thus rebuilding a network of support, which in turn facilitated their treatment and promoted a successful community
reintegration.
Concepts derived from the work with these families and how family therapy interventions were used to improve
both community reintegration and community tenure will be discussed.
sergio.santana@amhb.ab.ca
joseparr@shaw.ca
Female Juvenile Offenders: A Unique Challenge for Law and Mental Health
Collabortation
Female Juvenile Offenders: Gender specific patterns and challenges
Georgia B. Calhoun, University of Georgia
Research in the field of juvenile justice has only recently begun to conceptualize female delinquency independently
from male delinquency. The prevailing thought has been that similarities exist within the path and trajectory of
offending patterns for both male and female juvenile offenders. Male criminal behavior has historically been
attributed to such psychosocial factors as peer influence, sociopolitical influences, occupational and labor market
factors. In contrast, female criminal behavior has historically been attributed to personal maladjustment issues.
Programming and treatment for female juvenile offenders emanated from research that was based largely on male
samples and the results generalized to females who needed intervention. This presentation will review the current
research regarding female juvenile offenders and will provide an overview of the unique needs and challenges
associated with this population.
gcalhoun@uga.edu
Female Juvenile Offenders: Working from a University-based project
Brian A. Glaser, University of Georgia
This presentation will present and discuss the development of a model of intervention for female juvenile offenders
based on the integration of an etiological understanding, service delivery, student training and data collection and
analysis. The GIRLS project was created to study and address the psychological, emotional, and educational needs
of court-referred girls through a collaborative partnership among Juvenile court, the State Department of Juvenile
Justice, a large Research University, and the community. Using this integrated research, training, and service model,
the GIRLS Project draws together services, research and training in a collaborative and facilitative manner to meet
the needs of female juvenile offenders. The model of intervention allows emerging professionals to learn an
effective, empirically based method of serving a therapeutically challenging population while delivering quality
services to young offending females in collaboration with community agencies.
gcalhoun@uga.edu
Female Juvenile Offenders : The critical role of the probation officer
Tres Stefurak, Auburn University at Montgomery
Recent research findings suggest that relationships with significant adult figures can serve as a protective factor for
the female juvenile offender. While researchers and clinicians have frequently focused their attention on the
importance of the family, school, and personality variables of the juvenile offender, little attention has been paid to
the critical role of the probation officer. This presentation will focus on the role of the probation officer and the need
to provide these professionals with relevant training in the gender specific needs of female juvenile offenders.
gcalhoun@uga.edu
Female Juvenile Offenders : A view from the bench
James McDonald, Clarke County Juvenile Court, Athens, Georgia
This presentation will offer a perspective of female juvenile offending from the bench of a juvenile court judge. The
judge will provide an overview of gender specific issues of the youth that appear in his court. Specifically,
differences in male and female trajectories with regard to involvement in the court system will be discussed. The
judge, who has served on the bench for more than 20 years, will also discuss the challenges and concerns related to
equity and justice as specifically related to gender.
gcalhoun@uga.edu
Female Juvenile Offenders : Trends and Themes
Robin Shearer, Clarke County Juvenile Court, Athens, Georgia
Gender has traditionally been one of the strongest correlates of delinquent behavior. Whereas males still account for
the majority of crimes committed among those under the age of 17, females are now the fastest growing segment of
the juvenile justice system. Over the past two decades there has been an exponential rise in the number of girls in
detention facilities, jails and prisons. Delinquency cases involving girls increased by 83% between 1988 and 1997
and female juvenile violent offenses increased 129% between 1981 and 1995, more than doubling the increase of
male juvenile violent offenses. By 1999 girls accounted for 27% of the total juvenile arrests made that year. This
presentation by the court administrator will provide an overview of trends seen in a local juvenile court, specifically
as they relate to the rise in female juvenile delinquency.
gcalhoun@uga.edu
Children and Mental Health: Forensic Care in Youth Prisons
The Concept of Severe Mental Disorder as the Basic Commitment Criterion for Minors
Riittakerttu Kalatiaia-Heino, Tampere University Hospital, Pitkäniemi, Finland
In Finland, commitment to psychiatric care is allowed for adults in case of mental illness, and for minors in case of
severe mental disorder, when certain specific commitment criteria are fulfilled. Since the Mental Health Act
allowing for commitment in broader spectrum of diagnoses was passed in 1991, the number of involuntary
commitments of minor patients has doubled as proportion of all admissions, and increased almost fourfold in
absolute numbers. This study set out to evaluate how psychiatrists working with children and adolescents understand
the concept of "severe mental disorder". The study was requested by the Ministry of Health and Welfare that sought
to produce guidelines for interpreting the Mental Health Act in this sense. 44 psychiatrists in different positions in C
& A psychiatric services were interviewed with the help of a semi structured interview regarding their views of
problems in current mental health legislation, reasons for regional variation in commitment figures, difficulties in
interpreting the concept of severe mental disorder, and what they think should be considered as severe enough to
allow commitment of minor patients in mood disorders, anxiety disorders, eating disorders, conduct disorders,
substance use disorders, and developmental disorders. The C & A psychiatrists strongly emphasized the need to
evaluate a minor's situation beyond descriptive diagnosis. In the child and adolescent psychiatrists' opinion, severity
of a minor's disorder is bound progression / regression of childhood / adolescent development presented in
functioning in family and peer relations and ability to schoolwork / play, rather to descriptive diagnosis.
riittakerttu.kaltiala-heino@pshp.fi
A Qualitative Survey of the Views of Young People in Secure Care on Physical and Mental Health
Needs
Nathan Whittle, Salford & Trafford Mental Health NHS Trust, Bolton, England
The aim of this project was to conduct a systematic qualitative survey of the views of current service users and
providers of services of physical health, mental health and substance abuse services to adolescents in the secure
estate in England. This will focus on the continuity of care between custody and the community, the integration of
physical health and mental health care and models of best practice, including models of interagency working. A
sample of young people will be interviewed to examine their views about current services, what treatments they
have already been offered, those they thought were most appropriate and those they considered to be most effective.
Specific enquiry will be made about the continuity of care across agencies and over time. This study is currently on
going and some preliminary results will be presented. While there is growing evidence that adolescents in secure
care have a high level of physical health, mental health and substance abuse problems, they often fall through the
gaps of conventional services. There is a strong argument for the integration of these services, but before
contemplating this it is necessary to survey the views of adolescents in the secure estate. This data will contribute to
the development of a CD-ROM, which will provide information to young people in the secure estate on relevant
physical, mental and sexual health issues.
njwhittle@gardener.bstmht.nhs.uk
Developing Community Psychiatry Services for Juveniles in Detention Centers: The HomeCare
Program
Geraldine S. Pearson, University of Connecticut School of Medicine
This presentation will describe the establishment of a community psychiatry initiative developed in response to a
federal consent decree mandating psychiatry services for juveniles being discharged from detention centers. The
program, which is currently operative in five federally qualified health centers throughout Connecticut, has required
a fascinating interface between multiple systems, including detention centers, community health centers, the juvenile
justice system, and the child welfare system. The HomeCare Program has been established in federally funded
community health centers throughout the state with the goal of linking primary health care and mental health needs
of a vulnerable adolescent population. A review of the mental health/health needs of adolescents involved in
juvenile justice will be presented. The process of program development, establishing a quality assurance program,
and initiating clinical research will be discussed. All data collected to date will be summarized in the presentation.
Outcome research is ongoing. The most valuable aspect of the presentation will be the presenter’s perspective and
enthusiasm around developing a high quality clinical service within the boundaries of a department of psychiatry, a
child welfare agency, and a juvenile justice system. Future directions for research and practice will also be
discussed.
pearsong@psychiatry.uchc.edu
Policy, Rights and the Ethics of Secure Detention for Young Offenders
Inti Qurashi, Ashworth Hospital, Liverpool, England
There are an increasing number of children and adolescents in secure detention in the United Kingdom and the
debate surrounding punishment versus welfare continues. Up to one in five of these individuals will suffer from a
mental disorder and previous research shows that their needs are not being met. There are considerable challenges
facing statutory agencies and service providers in how to maintain an ethical underpinning to service delivery to
these individuals.
The aim is to describe from a United Kingdom perspective the place of children in society and present policy across
health, social care and justice as it applies to children and adolescents with mental health difficulties and
furthermore to increase the knowledge and understanding of a safe and ethical base for service delivery for children
with mental health difficulties.
A literature and policy review presenting an analysis on:
 The place of children within society in the United Kingdom.
 Review of the factors contributing to the varying age of criminal responsibility between countries in the
Council of Europe and the United Kingdom.
 The variation in legal sanctions and punishment for children between United Kingdom and European
countries.
 The balance between punishment versus welfare for children and young adults in contact with the criminal
justice. This will review overarching European legislation, United Nations Conventions and domestic
legislation and present these in the context of liberal and conservative arguments.
Children and young adults with mental health difficulties are increasingly being diverted to the criminal justice
system rather than social and healthcare pathways. There are a number of contributory factors to this including
domestic legal policy, lack of appropriate resources and service provider inexperience. The ethics of United
Kingdom policies will be discussed, both at individual and organisation levels, in the context of rights of service
users and obligations on service providers. The minimum requirements of a safe and ethical service for children with
mental health difficulties will be discussed.
intiqurashi@hotmail.com
An International Comparison of Juvenile Facilities in the Netherlands and Belgium
Robert Vermeiren, University of Leiden
The aim is to compare the judicial handling of juveniles and the population characteristics of juveniles in forensic
institutions between Belgium and the Netherlands.
Belgium and the Netherlands will be compared with respect to legislation of handling juvenile offenders and with
respect to the available facilities for forensic interventions with juveniles. Also, results from a study in juvenile
(justice) institutions by means of a self-report instrument, the SAHA (Social and Health Assessment), will be
presented.
Noteworthy differences between both countries will be reported on. The main difference is undoubtedly that
Belgium has adopted ‘protection legislation’ for juvenile delinquents (below 18), whereas the Netherlands has a
penal law system for minors between 12 and 18. Other differences that will be reported on are: the organization and
capacity of residential (judicial) institutions and the characteristics of the juveniles in those institutions. It will be
shown that differences in legislation may exert major influences on the organization of interventions for delinquents
and on the population staying in juvenile (justice) institutions.
The impact of the reported differences will be discussed, and viewed in light of the existing controversy on the
necessity of protection or punishment.
robert@vermeiren.name
Forensic Evaluation in an International Perspective
Forensic Assessment in Brazilian Institutions
Dr. Telles
A transversal and descriptive study was implemented in order to evaluate the mental desease prevalence and also to
describe sociodemographical, pathological and criminal variations of a group of defendants who were submitted to
the Penal Responsibility exam. This study was performed in a Brazilian psychiatric forensic institution. The profile
of those who were examined was: white, single men from the country side with low education level. The
most frequent criminal act was the physical one. The most prevalent diagnosis was the disturbance caused by the use
of alcohol and other substances and remarkable differences among the categories guilty, diminished responsibility
and not guilty by reason of insanity were found.
Three associations were observed through logistical regression: the probability of being considered not guilty by
reason of insanity increased 2.5 times when there was no preceding crime, having an occupation decreased the
probability of being considered not guilty by reason of insanity and the crimes against the person are more related to
not being guilty by reason of insanity than the crimes agains the property and customs.
Routine Assessment of Needs and Outcome in Forensic Psychiatric Home Treatment
Rob van den Brink, University Medical Center Groningen, the Netherlands
Alex Hooijschuur,
Markwin Jetzes,
Durk Wiersma,
Forensic Psychiatric Home Treatment (FPHT) is a relatively new form of treatment, intended for FP patients in need
of support in building up or maintaining an independent and safe existence in the community. Both patients
reintegrating into the community (from hospital or prison) and patients in need of (conditional) outpatient treatment
are targeted. Characteristic for FPHT is its focus on treatment in the patient’s home situation, in which new aspects
of the patient’s functioning may be observed. By this, FPHT offers new and challenging opportunities for risk
monitoring and management.
Routine assessment of needs and outcome is a means of monitoring the adequacy of care and its impact on patient
functioning, designed for use in routine practice. It is a widely advocated strategy in general mental health care, that
is however as yet unsupported by robust evidence of clinical or cost effectiveness (Cochrane Review; Gilbody et al.,
2005). We are currently involved in a randomized clinical trial conducted in six European countries, that evaluates
the effectiveness of routine assessment of needs and outcome in community care for patients with severe psychosis.
The FPHT study, to be presented here, is a pilot project of routine assessment of needs and outcome in outpatient
forensic mental health care. Routine measures of needs and outcome included in this study are: the Camberwell
Assessment of Need - Forensic Version (CANFOR), the Health of the Nation Outcome Scales for Mentally
Disordered Offenders (HoNOS-MDO), and the dynamic factors of the Dutch Risk Assessment Schedule (an
extended version of the HCR-20). Data will be presented on: the FPHT patient population, the needs of FPHT
patients, the care provided to them, and outcome in terms of patient functioning, assessed risk and incidents.
R.H.S.van.den.Brink@med.umcg.nl
A follow-up study on disposition of post-psychiatric assessment for 171 mentally ill offenders in
Hunan, China
Xiaoping Wang, The 2nd Xiangya Hospital of Central South University
The purpose of this study is to follow-up the disposition of mentally ill offenders after being psychiatric assessment.
240 criminal cases which were done psychiatric evaluation in our department from Jan. 2001 to Dec. 2002 are
included in this study. A self-developed questionnaire was mailed to all these patient’s family members to
investigate the disposition of these patients. The results showed that 171 letters were received and the reply rate was
71.3%. 109, 28 and 34 cases were judged not criminal responsibility, diminished responsibility and full
responsibility respectively by the forensic psychiatrists in the hospital, 110 and 61 cases were judged not guilty and
guilty respectively by the judges in court. The total consistence rate between psychiatrists’ opinion of criminal
responsibility and judges’ decision of guilty was 86.9%. Among the 110 cases had been judged not guilty, 33 of
them (30%) admitted to general psychiatric hospital for treatment, 6 of them (5.5%) admitted to forensic psychiatric
hospital for treatment, 1 of them (0.9%) received the psychiatric treatment in outpatient department. 68 of them
(61.8%) got absolute discharge to their communities without any psychiatric treatment. The authors concluded that
in most cases the judges agree with the psychiatrists’ opinion of criminal responsibility. The disposition of mentally
ill offenders is urgently needed to be improved in Hunan, China.
Xiaop6@yahoo.com.cn
xiaop@public.cs.hn.cn
Progressive Discharge: a Brasilian Experience of Freedom
Luiz Carlos Illafont Coronel, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre
The present paper reports a 35-year experience of a forensic psychiatric program called progressive discharge,
designed and developed at Instituto Psiquiátrico Forense Maurício Cardoso in Porto Alegre, Brazil. This criminal
lunatic asylum is the largest in Brazil and Latin America. It was founded 80 years ago and treats around 800
inpatients (90% male and 10% female) who have committed or attempted to commit murder (in 75% of the cases).
Until the adoption of progressive discharge, the judicial enforcement of a security measure was, in fact, translated
into a life sentence. After progressive discharge was set up, the annual rate of discharges went up from 8-9% to
25%. The number of discharges in these 35 years is reported herein and compared to variables such as relapse,
clinical diagnosis, and forensic treatment. It is concluded that the program was proven to be so successful that it has
since been recognized in other places in the country as well as by the Brazilian Penal Code.
coronel@pro.via-rs.com.br
Forensic Psychiatry and Special Needs Programmes
Mental Disorder, Substance Abuse & Crime [MSAC]: Presentation of a Follow-up Study of Mentally
Disordered Offenders with Special Focus on Interventions for Substance Abuse
Clara Gumpert, Karolinska Institute, Stockholm, Sweden
Substance abuse is common among people who commit serious crimes. In Swedish prison populations, 60% of the
inmates are reported to have substance abuse problems. A report from the Swedish National Board on Health and
Welfare concluded that a large group of mentally disordered offenders suffer from substance abuse disorders, and
that this factor has large impact on relapse into crime.
Each year, approximately 650 individuals undergo forensic psychiatric evaluation (FPE) in Sweden. Even though
only half of these are sentenced to prison (the remaining receive psychiatric care), the majority are diagnosed with
one or several psychiatric diagnoses. More than half report substance abuse problems.
This presentation will discuss the design of a Swedish follow-up study of mentally disordered offenders with
substance abuse problems. Included are Stockholm patients who have undergone FPE and who have been released
from prison or care. The focus of the study is to map care consumption in this group, both with regard to regular
after-care such as probation but with particular focus on interventions focusing substance abuse problems. The study
will use register data as well as personal follow-ups. Preliminary findings will be presented.
clara.gumpert@neeurotec.ki.se
Risk Management and Rehabilitation of Mentally Disordered Offenders
Per Lindqvist, Karolinska Institute, Stockholm, Sweden
Risk of violence among the mentally ill has been an issue of controversy in the past. However, in the 1990´s,
methodologically robust studies clearly indicated that mental illness was associated with a moderately increased risk
of violent offending. Subsequently, research on this issue, has developed in two directions, both linked to each other:
a further analysis of the exact nature of the risk factors involved (e.g. childhood characteristics, psychopathy,
antisocial personality disorder, properties of the psychotic symptoms) and risk management where the focus is set on
finding the most appropriate approaches to deal with dynamic risk factors (e.g. proper outpatient supervision,
control of substance abuse and the organisation of multiple service delivery). The outcome measures are mostly
restricted to re-offending, relapse and mortality.
We suggest that the next step in researching the risk issue among mentally disordered offenders, is to take on a
rehabilitative perspective where re-offending is just one facet of the problem. Forensic psychiatry is dealing with
people who have a number of problems, besides offending, that need and should be addressed. By doing that, the
discipline of forensic psychiatry will acknowledge its role as a patient-focused, medical activity. Such a stance will
improve the quality of life for mentally disordered offenders and, presumably, decrease the risk of re-offending.
This paper will present arguments and empirical support for shifting towards a rehabilitative perspective in forensic
psychiatry with special emphasis on the role of academy to provide the clinical world with relevant information.
per.lindqvist@neeurotec.ki.se
Methods for the Assessment and Evaluation of Inpatient Violence
Tom Palmstierna, Karolinska Institute, Stockholm, Sweden
Assaultive inpatient behaviour is a challenge for mental health service providers as it poses at threat not only for the
staff, but also to fellow-patients as well as it endangers the treatment. In recent research on inpatient violence, a
common European standard during the last decade has been to use the Staff Observation Aggression Scale in its
revised version (SOAS-R) to record violent incidents. Apart from adequate incident registration, it is imperative to
adequately predict who is going to be assaultative as well as when. During the last decade several research efforts
have been made to elucidate which patient is going to be assaultative in the psychiatric inpatient setting. Recent
research within both forensic and acute psychiatric settings has resulted in effective checklists for imminent
inpatient violence, such as the Broset Violence Checklist (BVC) and the Social Dysfunction and Aggression Scale
(SDAS). In future research, it is necessary to combine the risk assessment of actuarial variables such as age, gender,
previous violence, history of drug abuse etc with dynamic variables such as ratings on the BVC.
In this presentation, rating procedures for the adequate assessment of inpatient violence will be presented as well as
rating scales adequately predicting short-term violence within the acute or forensic psychiatric setting will be
presented. Also, the possibility to effectively analyse the combined effect of short-term predictive measures together
with actuarial predictors by modelling multivariate survival data will be presented.
Tom.palmstierna@neurotec.ki.se
Probation and Mental Health: Defining and Responding to the Challenges
Jennifer Skeem, University of California at Irvine
Each year, an increasing number of individuals with serious mental illness are placed on probation. Nevertheless,
little is known about the prevalence of mental illness in the probation population, the challenges associated with
supervising this population, or the ways in which probation agencies and probation officers are attempting to meet
these challenges. In this presentation, I will discuss a systematic line of research conducted in the U.S. that is
designed to address these issues. I will briefly review the findings of studies on (a) the prevalence of mental illness
and dual diagnosis (mental illness with co-occurring substance abuse) in the probation population, (b) perceived
sources of influence on these probationers’ adjustment and outcomes, and (c) probation agencies’ strategies for
organizing their resources to work with these probationers. This line of research suggests that “firm but fair”
relationships between probation officers and probationers with mental illness are a pivotal influence on outcomes. A
study of the nature and importance of these relationships will be emphasized.
skeem@unlv.nevada.edu
Forensic Psychiatry in Germany
Cognitive-Behavioural Therapy of Sexual Offenders in Mental Hospitals
Klaus Elsner, University of Duisburg-Essen
In Germany sexual offenders with diminished responsibility or without responsibility for their offences are
committed to a mental hospital if they are dangerous for general public in cause of a mental disorder.
In the forensic department of the “Rheinische Kliniken Langenfeld” the sexual deviant and delinquent behaviours of
the offenders are treated in groups with a cognitive-behavioural approach. The treatment focuses on the
reconstruction of the offences and the development of individual criminal history. Other aims are the change of
dysfunctional cognition, the amplification of empathic feelings towards the offenders´ victims, the explanation of
functional connections between delinquency and the individual biographic history and the elaboration of relapseprevention-strategies.
In each group there are patients with various mental disorders and different sexual offences. For the majority of
patients a Personality-disorder was diagnosed and the two major offences were sexual abuse of children and rape.
The treatment for each group requires 4 years. Altogether 18 sexual offenders finished the treatment, so far.
Besides the description of the patients’ characteristics and the contents of treatment, this paper focuses on presenting
the first results of our group treatment. For the evaluation of the therapeutic success we used psychological tests and
clinical assessment.
Klaus.Elsner@lvr.de
What Makes Drinkers Dangerous?
Norbert Schalast, Institute for Forensic Psychiatry, Essen, Germany
Considering a random sample of drinking situations, one wouldn’t come to the conclusion that alcohol and violence
are closely connected (Pernanen 1991). But in a specific subgroup of individuals, alcohol abuse goes along with a
heightened risk of violent and impulsive delinquent behaviour. Characteristics of this subgroup will be presented,
referring to data from an assessment of 150 violent alcoholics treated in German forensic psychiatric institutions (§
64 of the penal code). Three comparison groups were included in the project with 50 subjects each: prisoners,
alcoholics in deliberate addiction treatment, and non-clinical “controls”.
Among the parameters considered are age, psychological personality traits (e.g. the “Big Five”), characteristics of
the drinking behaviour and of the family background (child abuse and neglect, family violence, broken home,
parents’ substance abuse), anger, symptoms of personality disorder, and psychopathy.
The paper will discuss treatment needs in the forensic patients, rational targets of treatment, and risk factors for a
failure of therapy.
norbert.schalast@uni-essen.de
Brain Activation during Visual Sexual Stimulation in Hetero and Homosexual Child Molesters: An
FMRI Study
Boris Schiffer, University of Duisburg-Essen
Thomas Paul, University of Duisburg-Essen
Tillmann Krüger, University of Duisburg-Essen
Elke Gizewski, University of Duisburg-Essen
Manfred Schedlowski, Swiss Federal Institute of Technology, Zurich, Switzerland
Norbert Leygraf, University of Duisburg-Essen
Michael Forsting, University of Duisburg-Essen
The etiology of paraphilias, in particular the neurobiological processes of deviant sexual preferences are largely
unknown. The aim of this study was to investigate brain activation during visual sexual stimulation in sexual
offenders who were exclusively attracted to children in comparison to non-deviant healthy controls.
19 pedophile (11 attracted to males, 8 attracted to females) patients from two German forensic hospitals and 24
matched healthy control subjects (12 hetero- and 12 homosexual orientated, respectively) participated in this study.
SPM02 was used to analyze BOLD-contrasts which were measured while subjects were viewing sexually arousing
respective emotional neutral slides. In addition, appetitive and consummatory sexual behavior were assessed by
questionnaires.
As compared to viewing sexually neutral slides, slides of nude male and female adults respective children led to
some extent to similar activation of brain areas known to be involved in processing visual stimuli of emotional
content in all groups according to their sexual orientation. The sexual offenders in general did not show a pattern
very different to controls while viewing slides of the nude children of their each sexual orientation except in the
bilateral orbitofrontal cortex. This findings also remains respective became stronger when patients and controls were
compared over their specific sexual stimulation conditions.
These results demonstrate that brain response to visual sexual stimuli of both, the respective and other sexual
preferences, is to some extent similar and suggest that it partially corresponds to processing emotionally charged
stimuli in general. For the sexual arousal in pedophiles, we did not observe very different activation patterns than in
controls regardless of sexual orientation (hetero vs. homo). However, the finding of an OFC overactivation as an
area known to be involved in revaluation of emotional stimuli and sexual disinhibition may represent different
cortical networks in processing emotionally and sexually stimuli in paraphilia.
boris.schiffer@uni-essen.de
The Importance of Clinical Risk Factors in Deciding to Release Forensic Patients in Germany
Dieter Seifert, University of Duisburg-Essen
Risk assessment questionnaires of mentally ill patients are mainly based on historical items, while clinical dynamic
criteria have not been unattended but up to now insufficiently integrated. The Essener prospective prediction study
tries to offer more insight into the role that clinical items play in a multidimensional model to simplify prognostic
decisions.
Altogether 23 forensic psychiatric hospitals in Germany have been involved in the study. Since 1997 a total of 333
patients had been examined directly before their release from hospital by the treating psychiatrist or psychologist
who had to fill out the Essener prognostic questionnaire.
At present 255 patients have been released a minimum of 2 and a maximum of 6 years. During this time 22% of the
patients failed reintegration.
Essential results of the study are that clinical items are more important than historical items to predict dangerousness
(in the contrary to HCR-20, PCL-R). For example, patients, who are relatively natural in contact with women and
men, unstrained, less anxious and/or distrustful, who show a high potential of aggression, have a high position in the
patient hierarchy and seem to be less reflective are likely to fail reintegration. Furthermore it is obvious that the
quality and intensity of forensic aftercare plays a significant role in preventing relapses. In this presentation the
crucial results of the study will be introduced and discussed.
Dieter.seifert@lvr.de
The Challenge of Diagnosis and Treatment of Migrant Patients With Regard to Forensic Psychiatry
Mehmet Toker, Institute for Child and Adolescent Psychiatry, Hamm, Germany
Migration is a decisive feature of the one world that is growing together. This is also true for Germany. With regard
to forensic psychiatry, additional problems often result from linguistic and cultural problems in communication –
both in the process of examination and the development of treatment measures. In this paper the most frequent
problems in the diagnostic process will be itemized and possible solutions be discussed on the basis of case study
examples, particularly the danger of overemphasizing or denying cultural aspects. In the last section legal and
institutional conditions of the (non-) treatment of forensic patients will be subject of the discussion.
m.toker@wkp-lwl.org
Forensic Psychiatry in the Netherlands
Mean Genes and Forensic Psychiatry
Siegfried Tuinier, Vincent van Gogh Institute, Venray, Netherlands
Almost any personality trait, cognitive and behavioral, is etiologically linked to genetic endowments. This is also
true for the major psychiatric disorders. Antisocial personality, schizophrenia and bipolar disorders and many others
share a substantial genetic causation. The variance in all kinds of cognitive functions is explained by genetic factors
in about fifty to sixty percent. Recently this research, which was initially mainly based on twin studies, is augmented
by association studies of specific genes and behavior. Genes as a causative factor in a variety of disorders or
disturbed behaviors is a finding that cuts across psychiatric syndromes and behavioral dysfunction. The forensic
science is thus confronted with causation that transcends the current divisions: an illness, a personality disorder or
maladaptive behavior. These results should have an affect on the assessment that the forensic psychiatrist makes.
Diminished responsibility coupled to specific disorders is a division that is on a scientific level no more tenable. The
situation is complicated by the fact that clinical genetic examination in individual cases is at the moment not
feasible. Besides that, experts have to consider whether or not social or psychological causation are in principle of a
different nature than genetic causation. Even more complex is the fact that it is generally accepted that a complex
interaction between genes and environment is plausible. Modern genetics will ultimately lead to a disappearance of
the distinctions that are now made in court and in forensic psychiatry. This presentation will present an overview of
the available data and will focus on the applicability of modern genetics to forensic psychiatry.
stuinier@freeler.nl
Aggression Replacement Training in Forensic Clinics
Ed J.P. Brand, Flevo Future, Amsterdam, The Netherlands
In January 2004 the results were published of an Aggression Replacement Training Program in three Dutch
forensic-psychiatric clinics. An essential element of the striking successful training of in total 110 patients was to
elaborate their cognitive skills of the perception and the comprehension of bodily sensations of anger.
In Great Britain the Home Office has acknowledged the Training mentioned above as a highly effective
training program for delinquent adolescents in residential institutions. What could be a theory to explain the success
of this kind of training? One of the necessities of a possible explanation is an adequate description of the mental
process when offenders, or people more in general, if angry, succeed in controlling their negative emotions and
refrain from impulsive, violent (re)actions. To understand the psychology of staying in control of one’s behavior or,
on the contrary, of an eruption of uncontrolled violence, it is instructive to look at how young children learn to cope
with stress in unpleasant situations and the resulting, negative emotions.
In the course of their upbringing children learn to adapt to given rules; adaptation is the external condition
for socially acceptable behavior. Internally however the child has, for that cause, to live up to yet another condition:
to get sensitive to bodily cues of stress and anger and to give these bodily sensations a mental status (of an emotion).
The paper will illustrate in detail the psychological process of getting and staying in control of negative emotions
and possible violent impulses and of being able to refrain from acting out behavior.
candide.wv@move12.nl
Problems with TBS Court Order for Aliens in the Netherlands
Hannah Huizenga, Tilburg University
A.M. van Kalmthout, Tilburg University
Karel Oei, Tilburg University
There is great difficulty enforcing the TBS-measure involving aliens. At the centre of the debate is the fact that the
criminal law system clashes with the Dutch Alien Act. An alien, without a residence permit, that has been sentenced
to a TBS-measure is restricted from going on leave as this person is not allowed to be on Dutch territory. As a
consequence, the TBS-measure cannot be terminated and may therefore effectively results in a life sentence. In
some cases however, the principle of proportionality demands the TBS-measure to be terminated: the crime and the
sanction should be proportional. Such a termination of the TBS-measure however, results in the delinquent being
released without any proof that the delinquent no longer constitutes a danger to society. One of the primary goals of
the TBS-measure being a safe reintegration in society of the delinquent, both termination of TBS-measures without
leave and lifetime TBS sentences are therefore undesirable.
Thirty experts, all working in the field of criminal or alien law, have been interviewed about their experiences with
aliens sentenced to TBS-measures and the deadlock at issue. Possible solutions are often the result of great efforts on
the side of employees of TBS-clinics. The intent is to transfer the TBS-measure or the phase of resocialisation to the
country of origin of the delinquent. However, in practice this often seems impossible due to the distinctiveness of
the Dutch TBS-measure. Although not identical to the Dutch TBS-measure, many countries provide for comparable
facilities for mentally disturbed delinquents. Through ad hoc cooperation between the TBS-clinic and a facility in
the country of origin it is intended to transfer the alien delinquent to the country of origin. More and better research
in other countries with regard to this type of cooperation is required to successfully carry out more transfers. A
second problem is constituted by the Convention on the transfer of sentenced persons which requires the alien
delinquent’s consent for the transfer. Indeed, this problem remains to be solved. However, the Additional Protocol
that belongs to the Convention on the transfer of sentenced persons states that consent is not required in case the
criminal sanction also leads to a measure of administrative law resulting in the denial of right of residence in the
country where the sanction is carried out. Therefore, this AP will have to be signed by more countries in order to
prevent the alien delinquent from frustrating the transfer.
Huizenga@kabelfoon.nl
Constructing Elements for a Heuristic-Generalising Psychopathology
Marcel Tóth, Practicing Psychiatrist, Rijn, the Netherlands
Karel Oei, Tillburg University
There is a growing awareness in psychiatry nowadays that the current psychopathological conceptualisations and
nosological classification systems, such as DSM-IV and ICD-10, are seriously inadequate. This pertains to their (1)
diagnostic validity, (2) diagnostic precision and (3) very limited applicability in neurobiological research. The WPA
Congress ‘Diagnosis in Psychiatry: integrating the sciences’ (Vienna, June 2003) was partly about these issues.
Researchers in this field are becoming more convinced that the identified inadequacies are more fundamental and
may not be amenable tot solutions within the confines of the currently used psychopathological systems.
In view of these problems the Dutch psychiatrist Herman van Praag has proposed to focus diagnostic thinking in
psychiatry on the development of a more functional psychopathology. In such a diagnostic system psychiatric
afflictions are not described and conceptualised as discrete nosological entities, but as (combinations of)
dysfunctions in certain basic psychological domains, such as perception, memory and feeling.
In this contribution a specific implementation of such a functional psychopathology is proposed by introducing some
general concepts, which apply to psychopathological phenomena and can be treated to a certain extent as
quantifiable mathematical variables or vectors. Therefore this psychopathology is characterized by a heuristicgeneralizing approach.
To conclude this contribution, the potential application of this approach to forensic psychiatric diagnostic practice
will be illustrated.
martoth@xs4all.nl
Categorical Psychiatric Diagnoses and the Explanation of Crime
Siegfried Tuinier, Vincent van Gogh Institute, Venray, Netherlands
Criminal behavior is determined by a multitude of causal factors: developmental, social, genetic and psychological.
Among these factors clinical psychiatric diagnoses play a minor role unless the behavior itself is taken as a
categorical diagnosis. This was more or less a custom at the end of the 19 th century. Many so-called monomanias
were invented: kleptomania, pyromania and several others. The scientific literature of the last decennia is devoid of
substantial empirical studies on these phenomena. Nowadays other diagnoses replace these ancient ones: borderline
personality disorder, antisocial personality disorder and intermittent explosive disorder and infrequently also
psychoses. The explanation of criminal behavior by these vignettes is fruitless and should be replaced by research on
psychological dysfunctions that are as a rule not specific for any categorical diagnosis. In fact neuropsychiatric
research is severely hampered by the usual expert testimonies in court in which almost automatic links are
constructed between psychopathology and a crime. Abandoning this habit most certainly will lead to many
situations in which the psychiatrist has to declare that he is not able to give a medical explanation for the behavior
under study. In those cases he should point to epidemiological data and to scientific results that are of relevance for
the case without being able to give a full explanation. The less the psychiatrist pretends to know in court, the more
will relevant research be felt as an urgent social obligation.
stuinier@freeler.nl
Forensic Rehabilitation and Support Services
Criminality in women prison inmates before and after participation in the Reasoning and
Rehabilitation program
Anne H. Berman, Karolinska Institutet, Stockholm, Sweden
Per Konradsson, Karolinska Institutet, Stockholm, Sweden
Background: This study explores the effects of Reasoning & Rehabilitation, a cognitive-behavioral treatment
program, on 30 female prison inmates.
Method: Short-term within-group effects were measured with the Sense of Coherence-scale (SoC), the Criminal
Sentiments Scale (CSS) and the Eysenck Impulsiveness, Venturesomeness & Empathy-scales (IVE). Long-term
effects on reconviction rates were measured over a period up to five years in comparison to 99 matched controls.
Results: The strongest within-group correlation was between having committed violent crimes and low pre-program
empathy-scores. Propensity for crime (defined as number of convictions/years since first offense) and the number of
crimes committed both correlated with pre-program scores on CSS-subscales, and with post-program improvement
on said scales. A negative correlation was found between propensity for crime and the number of days to
reconviction. A negative correlation was also found between age at time of first offense and Impulsiveness, and with
anti-social scores on the CSS-subscale Attitude towards the Law. Seventeen of the 30 participants (57 %) were
reconvicted after the program. Recidivism correlated with the number of earlier offences. The recidivists were more
impulsive than those that abstained from crime. Among recidivists, improvement in the IVE- and SoC-scales
correlated with improvement in the type of crime committed after being released from prison. In a five year-follow
up, the women convicted of violent crime who had participated in the program were reconvicted to a significantly
lesser extent (46,5 %) than controls (60 %).
Conclusion: This study supports extending Reasoning & Rehabilitation to women sentenced for violent crime.
anne.h.berman@neurotec.ki.se
Love among Schizophrenic Couples
Brenda Geiger, Bar-Ilan University - Safed
Juan Bar-El, Mazrah Institution for the Mentally Ill
G. Friedman, Bar-Ilan University
H. Ordan, Bar-Ilan University
A. Lasry, Bar-Ilan University
T. Ohn, Bar-Ilan University
This qualitative study examines rehabilitative aspects of the subjective experience of love on the mental health of
couples living in secure facility and half- way house for the mentally ill. In-depth semi-structured focused
interviews were conducted with 20 heterosexual couples both diagnosed as schizophrenics and treated with
“atypical” antipsychotic drugs. Content analysis of the interviews indicated that the actions the participants in this
study engaged in to express their love were circumscribed by the rules of the institution, the participants’ ethnicity
and religion, and their level of sexual freedom. Yet, despite those constraints, the love participants experienced
meant feeling good, no longer feeling alone, giving and receiving affection, and at times, experiencing negative
feeling such as anger and jealousy. Love allowed the partners to escape social and emotional withdrawal and to
exhibit various degrees of awareness and empathy for the other’s needs and emotions. Love gave participants the
strength to escape loneliness and depression, to take care of themselves, to hope and plan for their future. No
longer in a world of their own, couples requested some privacy and physical space in which they could be intimate
in the institution or hostel. Love relationships between persons diagnosed as schizophrenics must, therefore, be
recognized and reinforced in and out the institution as one of the best indicators of recovery, and mental health and
adequate socio-emotional functioning. Legal issues of consent, right to privacy and the right to make love with
dignity are addressed; and so is the schizophrenic’s right to have children.
geigerb@netvision.net.il
Providing Recovery Services for Offenders with Co-occurring Disorders
Elizabeth Piper Deschenes, California State University
Christine B. Kleinpeter, California State University
Numerous defendants in the criminal justice system continue to re-offend due to untreated primary mental disorders
and co-occurring substance abuse. It is estimated that up to 25% of inmates in the county jails and state prisons are
mentally ill and about 80% of those defendants also have a co-occurring substance addiction problem. Providing
adequate treatment for this population is a challenge, particularly during the current budget crisis in the state of
California. The Orange County Superior Court of California has implemented a special program that targets drug
offenders who are seriously mentally ill and fail to comply with the conditions of probation under Proposition 36.
This is the first dual diagnosis court of its kind in Orange County. The Dual Diagnosis Court is designed to help
offenders through the recovery process by offering them specialized treatment and services. Similar to other
collaborative courts (such as drug courts and mental health courts), the team includes a judge, probation officer,
mental health worker, public defender, and district attorney. Offenders receive integrated treatment services
including mental health and substance abuse treatment, as well as housing, financial, and health services. Offenders
are randomly drug tested, and are monitored for treatment compliance by the court. Program compliance leads to
positive rewards whereas non-compliance leads to various types of sanctions.
This paper presents the implementation and outcomes of the Dual Diagnosis Court. Data were collected through
observation and coding information from participant records into a computerized database. The demographics,
criminal and substance use histories of this population are described in addition to measures of mental health and
quality of life at intake. The evaluation presents an overview of program participation and retention. Policy
implications regarding program design and implementation are discussed.
Libby@csulb.edu
Ckleinpe@csulb.edu
Outcomes of Forensic Rehabilitation in Auckland: Community Tenure and Reoffending Rates
Following Inpatient and Assertive Community Rehabilitation
Sandy Simpson, University of Auckland
Ceri Evans, University of Auckland
Brian McKenna, University of Auckland
Roland Jones, University of Auckland
Background All forensic patient in the northern part of New Zealand are rehabilitated through the ARFPS. The
service involves inpatient rehabilitation followed by assertive community treatment, often through supported
community accommodation. Rehabilitation includes focus on illness and non violence education, individual and
family therapy, cultural interventions, vocational integration within a legally mandated framework. Very low rates
of reoffending has been notes with this group. This paper presents a retrospective study of all patients discharged
over the last 7 years to determine patterns of successful community tenure, and reasons for relapse and readmission.
Methods
A retrospective review of case notes was undertaken to describe the patient population entering
the service in terms of demographic data, psychiatric illness, offending behaviour, history of substance misuse, and
risk profile using the HCR 20. Variables used to indicate outcome were measured including socioeconomic
variables, rates of re-offending, and readmission to hospital. Patient details were cross checked against court
appearances, imprisonment and readmission to hospital. Details of any such outcome was recorded.
Results The results of 105 patients will be described, including their clinical and risk profile. Therapeutic processes
engaged in and outcomes in terms of community function described. Implications in terms of the elements necessary
for successful rehabilitation will be considered.
Aif.Simpson@waitematadhb.govt.nz
Learning from Patients the Healing Integration
John L Young, Yale University
Criminal codes in most countries provide specific criteria for recognising that a small minority of defendants bear
significantly reduced criminal responsibility due to mental illness. They also provide procedures for these offenders
to be treated as patients rather than as inmates. With varying degrees of informed consent, these individuals then
agree to accept treatment towards the goals of recovery and freedom. Because of their criminal history, it is not
enough for them to make a conventional recovery from mental illness. These patients also have to integrate their
current self-awareness with the reality of having at least once seriously offended while under the influence of mental
illness. Achieving remorse is a major part of this challenge. Also required is a coming to terms with oneself as one
with a serious criminal history related to a mental illness. The patient must integrate this reality with all the other
facets that make up his or her personality. If this process is constructive and peaceable, its result is a healing
integration.
Unhappily, some do not succeed and remain in the hospital. Others follow a cyclical course of remission and release
followed by relapse and readmission. Most patients eventually achieve a healing integration, and thus they have the
potential to teach us much about how to help their peers. In our work over the past 15 years we have observed a
wide range of results with our patients; we are now explicitly focused on what we can learn by reflecting on them.
This presentation will utilise a series of varied case examples from our work experience in order to discern the
characteristics that distinguish the more successful patients, and to garner useful applications for the benefit of their
less successful peers.
john.young@po.state.ct.us
Gender Issues in Adolescent Psychiatry I
Girls Behaving Badly: Trauma Exposure, Post-traumatic Stress and Psychiatric Comorbidity in
Female Juvenile Offenders
Angela Dixon, University of Sydney
Pauline Howie, University of Sydney
Jean Starling, University of Sydney
This study documents the rate of posttraumatic stress disorder (PTSD) in a sample of Australian female juvenile
offenders, and its relation to trauma history, co-morbid diagnoses, attributional style and family functioning.
One hundred juvenile offenders were matched with a comparison group of 100 females on age and
socioeconomic status. Psychological profiles and trauma histories of both groups were assessed using the Schedule
for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime Version (K-SADS-PL).
Two self-report measures were used to assess family functioning and attributional style.
Rates of trauma and psychopathology were higher for offenders than controls (P < .001), with particularly
high levels of conduct disorder, substance abuse disorders, depression and PTSD. Offenders also reported high rates
of both victimization and witnessing traumatic experiences. Posttraumatic stress disorder was diagnosed in 37% of
offenders with sexual abuse the precipitant in 70% of cases. Offenders with PTSD had significantly more comorbid diagnoses than those without. The majority (73%) of co-morbid diagnoses appeared concurrent with or
following PTSD onset. Offenders with PTSD were more likely to have attempted suicide at least once. The
presence of four or more psychiatric diagnoses and a history of sexual abuse independently predicted a diagnosis of
PTSD among female juvenile offenders.
These results suggest a link between trauma, PTSD and the development of further psychopathology in
female juvenile offenders. This highlights the importance of comprehensive diagnosis and treatment of this and
other co-morbid disorders in order to ensure the effectiveness of interventions designed to treat antisocial behaviour.
angelad@psych.usyd.edu.au
Juvenile delinquency and substance use: Data from a Portuguese study
Antonio Castro Fonseca, University of Coimbra
Aims: This paper intends to assess the complex relationship between self-reported juvenile delinquency and
substance use in a large sample of Portuguese adolescents, including boys and girls.
Methodology:
Participants: The data presented here were gathered in the context of a longitudinal study initiated in 1993 and still
going on in the region of Coimbra (Portugal). More specifically, our analysis focuses on 450 boys and girls who in
1993 were 7 years old and who now are on average 19 year olds.
Instruments: Two measures were used in this study: a self-report scale of antisocial behaviour, which includes also
a sub scale of substance use, and a scale of externalizing problems.
Results: The results of several statistical analysis revealed a strong association between antisocial behaviour and
substance use both for boys and girls. However results varied somewhat in function of the measure used to assess
antisocial behaviour.
Discussion: These findings were confronted with those reported in previous studies conducted in other countries and
interpreted on the light of recent research on gender differences in the field of juvenile delinquency.
acfonseca@fpce.uc.pt
Psychopathology, Aggression, Trauma and Risk Behavior in Girls from 12 to 18 years in Youth
Custodial Facilities in the Netherlands
Sannie Hamerlynck, Free University of Amsterdam
Robert Vermeiren, Free University of Amsterdam
Theo Doreleijers, Free University of Amsterdam
Lucres Nauta-Jansen, Free University of Amsterdam
Peggy T. Cohen-Kettenis, Free University of Amsterdam
A psychiatric prevalence study has been carried out in youth custodial facilities for girls in the Netherlands. The
objective of this study was to investigate the prevalence of psychiatric pathology, aggression, trauma, and risk
behavior.
256 girls were asked to participate, 217 girls have been investigated. The diagnostic instruments included a semistructured psychiatric interview (K-SADS, items ADHD, ODD, CD, alcohol, drugs, suicidality) and self-report
questionnaires (e.g. SDQ, trauma questionnaire, CPTSD-RI, Beck Depression Inventory). Intelligence was estimated
by subtests of the WISC. In addition, a telephone interview was conducted with the parents, which included the
administration of the disruptive behavior disorder part of the K-SADS, the SDQ, the trauma questionnaire and
questions on the socioeconomic status. Teachers in the institutions were asked to report on the problem behavior by
completing the sdq questionnaire.
Preliminary analyses show that a history of trauma occurs in the absolute majority of the girls. Also, almost all girls
have a psychiatric diagnosis. Both internalizing and externalizing behaviors are frequent in this population. Sexual
risk behavior appears to be a major expression of risk behavior in this population.
Girls in youth custodial facilities suffer severe psychiatric pathology and constitute a population at risk. Therefore,
diagnostic investigation should be carried out on a regular basis in this population, and therapeutic interventions
should be available in these institutions.
s.hamerlynck@debascule.com
Forensic Treatment of a Female Pyromaniac (Fire-setter)
O. Bilke
The case of a 17 year old female patient who is being treated in a psychiatric clinic since April 2003 for fire setting
and violence against property:
Life events: The patient grew up with her two younger siblings and her mother. The unsteadiness of her mother
brought about an early undertaking of responsibility for her siblings that led to growing tensions between family
members. With her puberty the first apparent problems outside her family occurred – leading to school changes,
repetition of classes and drug abuse. She became victim to several sexual abuses by adolescents. This fact and three
suicide attempts in 2002/2003 resulted in outpatient treatment in adolescent psychiatry. The 18 assaults occurred
between September 2002 and March 2003.
Treatment: The cognitive-behavioural and problem-solving therapy is planned specific to the disorder and
pathology. When assuming a developing emotionally unstable personality disorder the main goals of treatment are
the self-perception of emotions and self-regulation as well as the interpersonal behaviour – using parts of M.
Linehans manuals. A further integral part of daily work and treatment of the patient is the experience of constant
pedagogic and therapeutic relations. The explicit therapy of the chronic post-traumatic stress disorder is not yet the
intention of the patient. Elements of trauma therapy would be possible for the future.
In regard to a pharmacological support the patient feels very ambivalent, so that the current setting includes only
sedative pharmacotherapy on demand.
Conclusion: The successful treatment of this patient necessitates a long-termed planning that has to include the
further clarification and settlement of offences. Currently no direct correlation of psychiatric disorders and offences
are being observed, so that the previous therapy strategy is unchanged.
Longitudinal Gender-specific Patterns of Psychopathology and Social Environment Associated with
Severe Behavior Problems in American Inner-city Youth
Vladislav Ruchkin, Yale University
Robert Vermeiren, University of Leiden
Mary Schwab-Stone, Yale University School of Medicine
The objective of the present study was to assess changes in three major domains: psychopathology (anxiety and
depression), family (parental involvement and supervision), and other close social environment (friends’ delinquent
behavior, and attitudes of important other adults to deviancy) in relation to severe behavior problems in American
inner-city youth. A self-report survey, the Social and Health Assessment (SAHA), was conducted in a representative
sample of 2,382 14 to 17 year old adolescents from an urban inner-city community in the US. Using longitudinal
data, the study evaluated the transition from 6th to 8th grade in four groups of youth, based on their longitudinal
patterns of severe behavior problems (SBP). The study demonstrated that the patterns of change across the three
domains are different for boys and girls and vary depending on the level of youth’s involvement in the SBP, with
more psychopathology, less support from the family and important other adults, and greater involvement with
delinquent peers in those with highest levels of SBP. The study suggests that specific risk factors are differentially
related to severe behavior problems in boys and girls. Findings are discussed from both developmental and clinical
perspectives with some consideration given to implications.
vladislav.ruchkin@yale.edu
Gender Issues in Adolescent Psychiatry II
Psychic Trauma in Juvenile Delinquents: Gender Specifics
Elena Dozortseva, Serbsky National Center for Social and Forensic Psychiatry, Moscow, Russia
Psychic trauma consequences in adolescents with delinquent behaviour have been explored in a number of studies
(Boswell, 1995; Cauffman et al., 1998; Ruchkin et al., 2002 etc.). In some of them gender specifics in trauma
experience was discovered, in particular, higher prevalence of stress disorder in delinquent girls.
The goal of our study was to describe the character and prevalence of traumatic events and their psychic
consequences in juvenile delinquents in Russian closed educational institutions considering gender related
differences. The sample includes 61 adolescents (23 boys and 38 girls) from 13 to 17 years old who committed
various criminal actions and were placed into special closed institutions of the Ministry of Education. An inventory
developed for children and adolescent on the basis of DSM-IV criteria for PTSD assessment (Tarabrina, 2001) was
used, as well as questionnaires for evaluation of anxiety, depression and somatic problems. The data were processed
separately for boys’ and girls’ groups.
It was found that more than 70% adolescents of both sexes were physically victimized. The girls underwent physical
abuse mostly within their families, the boys – both inside and outside families. Both groups experienced emotional
trauma due to death of their close relatives, but the girls mentioned it more often (86,8% in comparison with 69,9%
in boys). 47,4% of the girls reported about sexual abuse in the past. The boys denied similar experiences, but
indirectly displayed some serious problems in this sphere. Other psychic trauma causes (traffic accidents, falling
down, drowning etc. as well as witnessing such incidents) were more often found in delinquent boys. It was more
common for girls to mention multiple traumatic events in their past. The scores of the most PTSD criteria were
higher in girls than in boys. Emotional and somatic problems were also significantly more expressed in girls.
Trauma indices correlated with emotional problems in girls and only with somatic problems in boys. It can be
supposed that somatization might be considered as a way of trauma stress reduction in male adolescents with
delinquent behaviour.
The data of the study were used in therapeutic work with adolescents in closed educational institution.
edozortseva@mail.ru
edozortseva@rambler.ru
Female Juvenile Offenders Compared to Male Ones: Later Recidivism Risk and New Results from the
Psychiatric Assessment of Personality and Offence Dynamics
Michael Günter, University of Tübingen
Anne Miller, University of Tübingen
A previous study of our group showed interesting findings with respect to psychiatric characteristics and offence
dynamics in young female offenders. Now these findings were re-examined by a more rigorous design comparing
them with a matched control group of male offenders.
The study included all female juvenile offenders who came to a forensic psychiatric assessment in our department
from 1970 to 1994. They were compared to a male control group matched according to age and offence type. We
compared characteristics from the intensive forensic psychiatric assessment after the index offence with later
recidivism taken from the criminal records. Forensic reports were evaluated systematically with an evaluation form
to assess the offence dynamics and social distress factors. Interrater reliability was established. Nationwide used
psychiatric basis documentation gave additional information.
N = 60 subjects could be evaluated. There were highly significant differences with respect to the offence dynamics,
especially the contribution of close relationships to the offence, some distress factors and recidivism compared to the
male controls. Differences in the psychiatric status could be detected.
Relationship and emotional conflicts should be assessed intensively in the forensic evaluation of juvenile female
offenders, especially when acute bodily harm or homicidal attacks are considered.
michael.guenter@med.uni-tuebingen.de
Sick Girls – Bad Boys: Gender Differences in Antisocial Behavior of Youth
Ulrich Preuss, University Bern, Switzerland
Marc Walther, Clinic for child and adolescent psychiatry, Lausanne, Switzerland
Daniel Gutschner, IFB Institute for forensic counselling in Children and Adolescents, Bern, Switzerland
Matthias Schmelzle, IFB Institute for forensic counselling in Children and Adolescents, Bern,
Switzerland
Monika Egli-Alge, Forensic Institute Eastern Switzerland forio & Clinic for child and adolescent
psychiatry, Weinfelden, Switzerland
The objective of our study was to review current literature on gender related differences of antisocial behavior in
underage individuals in youth. Based on a medline and psylit and psyindex search studies were compiled to give
information about the current body of knowledge in the forensic domain of gender differences. The available
literature on gender differences is restricted. A small number of study approaches are responsible for a larger
number of studies, e.g. the Dunedin longitudinal study on conduct disorder, delinquency and violence. It is evident
that the majority of delinquency is seen in young men while girls do not show such a high number of offences as
boys. In substance related offences, girls do not differ. Boys in the delinquent behavior and especially if girls are in
intimate relationship to older and social men, they show more overall delinquent behavior. The etiology of gender
differences in delinquent behavior is open. There exist a number of hypotheses but no unifying theory is settled now.
From our findings we can conclude that antisocial behavior in youth has less impact on lifetime course of women in
contrast to men. Further research is needed to solve a number of questions for example the increase of delinquency
in girls in the last decade etc. Especially research on protective factors for delinquency would probably offer some
approaches to prevention of antisocial behavior in underage men.
ulrich.preuss@kjp.unibe.ch
Physical Culture As Means Of Development Of Offender Personalities
Liudmila Rogaleva, Ural State University, Russia
Nowadays we can find many reasons of difficulties of offenders’ social adaptation. One of them is absence of their
abilities to self-realize and self-confirm.
At the beginning of this work we took into consideration a meaningful idea that a teenager forms his/ her personality
believing that it would be important for him/her. In this case we can witness the formation of a person who is able
to create, be responsible for his/her deeds, to solve problems and use these solutions in practice. All these aspects
characterize the basis of psychic health.. According to these principals we can help the offenders to form
psychological characteristics, mentioned above, if we manage to involve them into useful and meaningful for them
activity. We suppose it would work effectively in real life.
The research was carried out with teenagers (girls of 12-16 years old) in a special school. During the research we
defined these spheres of activities that the girls considered essential for them. In the basis of this work we put the
method of ranging analysis. As a result of work we found out that the most valuable things for girls are:
 Self-confidence
 Communicativeness
 Independence
 Ability to move gracefully
 Youth musical culture.
These data confirmed the idea that doing sports and dance aerobics, performance at aerobics festivals are the activity
that helps the girls to self-realize.
The fact is the preparation for festivals of sport and dance aerobics requested girls’ activity, self-dependence to
create the compositions, to select music, design costumes, cooperate, pay attention to each other, help if it is
necessary and support each other.
The result of this work appeared hopeful. Within 2 years of our work we observed improving of psychological
atmosphere: stresses, level of anxiety, conflicts in girls’ relationships decreased and self-confidence increased
sufficiently. Due to the research work we found that 67% of girls bettered their self-assessment.
On finishing the school 40% of girls continued to do sport aerobics. That is a very hopeful result of our work.
Malkin@mail.lyceum.usu.ru
A comparison of attachment styles between incarcerated adolescent females and a control sample
Joanne Grigor, St Nicholas’ Hospital, Newcastle-upon-Tyne, UK
The importance of childhood experiences in understanding juvenile delinquency is well recognised within the
literature. More recently attachment theory has been proposed as a valuable model for conceptualising emotional
problems and behavioural difficulties in children and adolescents. To date however little research has examined
these concepts utilising a control group methodology. A better understanding of the role that attachment styles
impact upon behaviour can assist with developing more comprehensive aetiological models and possibly also
improving intervention and treatment strategies. This study compared the attachment styles of two groups of
adolescents; one group being incarcerated in a medium secure setting and the other a control group. Significant
group differences emerged with the delinquent group were more likely to endorse the dismissive attachment style.
Significant group differences also emerged in regards to parental rearing styles: delinquent individuals perceived
parental figures to be more emotionally cold, indifferent and generally disengaged than the normal sample. The
juvenile sample were also more likely to have perceived themselves to have experienced an ‘affectionless
controlling’ type of parental style. The implications of these findings in regards to attachment theory and
aetiological models of juvenile delinquency are discussed. Finally potential clinical intervention strategies are
considered.
Joanne.Grigor@nmht.nhs.uk
Health Care Restructuring in South Africa
Children Infected and Affected by HIV/AIDS in South Africa: Legal, Ethical, and Mental Health
Issues
Gretchen Domek, University of Oxford
South Africa has been hit particularly hard by the AIDS epidemic, largely a repercussion of oppressive Apartheid
policies. Currently, one in five adults across South Africa is living with HIV/AIDS, resulting in a rapidly increasing
population of orphans. The most conservative estimates expect there to be over 2 million South African orphans by
2010. The HIV/AIDS epidemic impacts children in many ways. These children suffer trauma and grief as they
watch their parent(s) die, some contract HIV from their mother, many live in poorer households or childrens’ homes,
and most experience stigmatization and discrimination. This presentation will examine the multifaceted issues
facing children affected by AIDS in South Africa.
First, there are important ethical and legal issues involved in testing children for HIV who cannot give informed
consent. Establishing the HIV infection status early in a child’s life is important to facilitate adoption placement.
The younger the child, the more likely that child is to be placed in an adoptive home, and children with HIV or
unknown infection statuses are rarely adopted. However, because the South African government uses the cheap
HIV ELISA test that indicates whether an infant has been exposed to HIV rather than infected with the virus, many
children are wrongly identified as having HIV. In the absence of interventions to prevent mother-to-child
transmission, 75% of children exposed to HIV will be uninfected, most of whom will have positive ELISA results.
These false positives have devastating implications for both the child and the state. It is in the best interest of all
parties involved to use the more expensive but more reliable HIV PCR test for early diagnosis in children under 18
months old.
Second, while it has often been assumed that an HIV-positive child will die before the age of five, the advent of
improved treatments and increased accessibility to medications have resulted in children living longer and healthier
lives. As these children become adolescents and young adults, the issues of HIV disclosure, education, confinement
in a children’s home, and mental health and psychological well-being become increasingly important and must be
addressed.
gretchen.domek@balliol.ox.ac.uk
Health Promotion School approach to providing interventions for children with fetal alcohol
syndrome: a pilot project in South Africa
Piyadasa W. Kodituwakku, University of New Mexico School of Medicine
Rubin Adams, Western Cape Department of Education
Recent research has revealed disturbingly high prevalence rates of fetal alcohol syndrome, which is considered the
leading preventable cause of mental retardation among children, in some regions of South Africa. Among children
aged 5 to 9 years from a community of mixed ancestry (known as ‘colored’) in the Western Cape Province, the
prevalence rate of fetal alcohol syndrome was estimated to be 40.5 to 46.4 per 1000 (May et al., 2000). These rates
would have been even higher if those children without the full syndrome had been included in prevalence estimates.
There is evidence that children with prenatal alcohol exposure demonstrate a range of disabilities, including
behavioral problems, emotional disturbances, and poor academic performance. A significant number of these
children drop out of school and eventually become alcoholics themselves, continuing the vicious cycle. Contributing
to the poor outcome for these children are alcohol related brain damage, adverse conditions at home, and classroom
conditions that are not conducive to learning. Children with FAS experience a multitude of life stressors associated
with parental alcoholism such as poverty, domestic violence, and sexual/physical abuse. At schools, large classroom
sizes and limited resources further compromise the ability of these children to learn.
Therefore, a group of investigators from the community (Rubin Adams et al.) conducted a pilot project to investigate
the effects of intervention with parents and classroom modifications on the academic performance of children with
FAS. The project was based on the health promotion school model (World Health Organization, 1986), which
underscores the importance of improving the environment of the child for his/her academic success. Interventions
with parents were conducted in groups, the focus of which being on listening to feelings, building self-esteem, and
teaching problem-solving and parenting skills (e.g. having family meetings). In parallel to the interventions with the
parents, specific classroom accommodations such as reduced size and one –on –instructions were provided for the
children. Outcome data for those children who received interventions were gathered over a period of one academic
year. The results showed the children in the intervention group made good progress, with about one third of the
group moving into a mainstream placement at the end of the year.
Thus, this pilot project shows the utility of applying the health promotion model in improving school performance in
children with FAS living in an impoverished environment. This model is currently being tested in a larger
intervention study of fetal alcohol syndrome in South Africa.
pkodituawkku@salud.unm.edu
The Mental Health Care Act of South Africa; Implications for Mental Health Services
Rita Thom, University of the Witwatersrand
Since the establishment of a democratic government in South Africa in 1994, there has been a new culture of human
rights in the country. While major restructuring of health services has taken place in South Africa over the last 10
years, mental health policy makers and service providers have worked hard to ensure that mental health services are
integrated into general health services and that they receive a proportionately justified share of the available
resources. As part of this process, and to ensure that mental health legislation reflected a human rights approach, and
took account of new developments in the treatment of people with mental illness, a review of the existing mental
health legislation was carried out, and new legislation was developed. This resulted in the passing of the Mental
Health Care Act, No. 17 of 2002. This legislation is likely to be implemented in the first half of 2005. The
presentation will outline the main features of the legislation within the context of events and health services in South
Africa, will compare the legislation with that of other countries and will discuss some of the implications for
implementation in the present context in South Africa.
thomrg@medicine.wits.ac.za
Clinical Mental Health Care and the New Mental Health Care Act in South Africa
Bernard Janse van Rensburg, University of the Witwatersrand
New mental health legislation (The Mental Health Care Act, No.17 of 2002) was promulgated in 2002 and is
expected to be implemented during 2005. The aim of this act is to provide for the care, treatment and rehabilitation
of persons who are mentally ill; to set out different procedures to be followed in the admission of such persons; to
establish Review Boards in respect of every health establishment; and to determine their powers and functions. Main
aims of the act include: the promotion of human rights of people with (mental) disabilities; to improve mental health
services through a primary health care approach and an emphasis on community care; to protect the safety of the
public; to set out the framework and statutory roles with respect to: voluntary users, assisted users, involuntary
users, state patients and mentally ill prisoners.
Health services in general are rendered on three tiers: primary, secondary and tertiary level. Mental health services
are rendered in public and private contexts, in primary and community care clinics, primary (“Level
I”/General/District) hospitals, secondary (“Level II”/Specialist/Regional) hospitals and tertiary (“Level III”/Superspecialist) facilities.
The author is currently employed as a full time state psychiatrist jointly responsible for service delivery in state
hospital to the Gauteng Provincial Authority, but also to the University of the Witwatersrand for academic duties:
(under- and post graduate) teaching of health sciences students and research. An option for part time private work by
clinicians is also currently still maintained by the State Service through the so-called “Remunerative Work outside
the Public Service” (RWOPS) agreement and contract. This presentation will review the mental health care
environment (public and private) from a clinician’s perspective and will report on the changes in, implications for,
realities of and challenges for mental health care provision within the context of the new mental health legislation.
bernardj@gpg.gov.za
Complexities of the Discharge Process from Long-term Psychiatric Institutions in a Developing
Country
Marilyn Lucas, Monash University, South Africa
John Victor Weinkove, Witbank Hospital, South Africa
Bernard van Rensburg, University of the Witwatersrand
Prior to the 1994 elections in South Africa that brought democracy to the country, patients with chronic psychiatric
illnesses were usually cared for in large institutions. Care was generally custodial and along racial lines. Since that
time, it has been the goal of the Department of Health to provide accessible, equitable, adequate and appropriate
health services, which, for the mentally ill, includes deinstitutionalisation and reintegration into the community.
However, these interventions have proved difficult to implement for a variety of reasons including lack of
community facilities and support for the mentally ill. Health care professionals find themselves caught between
wanting to discharge their patients but not having the time or resources to find alternative satisfactory placements or
even track down the families of patients. This presentation has two components: First a case study about the search
for the family of one patient. He had been hospitalised for 20 years in various chronic institutions, and lost all
contact them when he had been transferred from one institution to another. This was not an unusual situation in
South Africa and this case study poignantly highlights how such alienation occurs. It also highlights the extreme
steps sometimes required to find and return a discharged patient to their family members. Second, the results of a
quantitative study carried out at a similar institution are presented. The results of this study explain the process of
identifying suitable candidates for reintegration into the community, and the efforts made to arrange and obtain
successful alternative placements. Problems encountered in this process included limited community resources,
reluctance of other organizations to accept psychiatric service users, and the nature of the time constraints placed on
the institutional staff to pursue successful alternative placement options.
Marilyn.lucas@arts.monash.edu
Advancing Advocacy for Schizophrenia in South Africa
Marilyn Lucas, Schizophrenia Foundation of South Africa, Gauteng, South Africa
The Schizophrenia Foundation of South Africa began in August 1999 with high expectations. South Africa had
been a democracy for five years and, at government level, conceptual shifts had been made in how mental illness
was viewed. The National Department of Health planned to address previous inadequacies in mental health services
by promoting deinstitutionalisation and reintegration of previously institutionalised persons into community life;
incorporate mental health care into the primary health system and revise the Mental Health Act. The goals of the
Foundation were to lobby both local and international communities for illness awareness, provide advocacy,
information and counselling to those with schizophrenia, family members and the larger community. Five years
later, the Foundation has, inter alia, produced numerous guidelines and public responses resulting in improved
knowledge and awareness in the media and general public but failed to reduce stigma surrounding mental illness or
motivate families to contribute to advocacy responsibilities. The reasons for these failures include i) schizophrenia
not being an “attention getting” disease, ii) lack of funding and iii) lack of implementation of policy changes. The
trials and tribulations of operating an Advocacy group in a developing world are discussed.
info@schizophrenia.co.za
Deintitutionalization, community care and the New Mental Health Care Act in South Africa
Dorothy Sekhukhune, Lifecare Special Health Services, South Africa
Lifecare Special Health Services with 9000 beds in 22 hospitals provides a specific range of acute, sub-acute and
chronic healthcare services on a contract basis to provincial government of South Africa. It is one of the largest
public-private partnerships in the Country. The large component of the services is for medium to long terms care,
treatment and rehabilitation of the chronic mentally ill and intellectually disabled patients with approximately 6000
beds in 12 hospitals across the province.
With the new Mental Health Care Act 17 of 2002 emphasising the importance of Community Based Care, Lifecare’s
reengineering of psychiatric services included the development of the model for intensive rehabilitation of chronic
psychiatric patients with the aim of integrating these patients back into the community.
Lifecare began the de-institutionalization programme post 1994 and has since reduced the psychiatric beds from
10,000 to 6000 and has placed the patients back into the community with either the family or the Non Government
Organisations ( NGO ).
This paper examines the issues pertaining to the role played by the multi disciplinary team, the patients, their
families and the community in preparing these patients for integration and their experiences in the implementation
of this model.
This paper will also highlight the patients' experiences living outside of the institution.
Data was collected using focus group discussions and in-depth interviews with the multi-disciplinary team, the
patients, their families and the communities in which the patients were placed.
The discussions/interviews included the following questions:
 What are your experiences living with the patients, with mental illness?
 What are the issues that hamper the patients to be fully integrated in the community?
 What support do these patients need whilst living with mental illness?
 How can we prevent relapse/prolong their stay in the community?
Adherence to structured rehabilitation programmes in hospitals and significant improvement in community
based care supported by the hospital, multi disciplinary team and family involvement within the Non Governmental
Organisations ( NGO ) structures in the community has resulted in patients who were institutionalised for years
being able to cope in the community with minimal support.
Dorothy.Sekhukhune@newname.co.za
Homicide and Mental Illness
“I’m Sorry I did it…But He Started it”: A Comparison of the Official and Self-Reported Homicide
Descriptions of Psychopaths and Non-Psychopaths
Stephen Porter, Dalhousie University
Mike Woodworth, University of British Columbia - Okanagan
Although psychopaths are notorious for their prodigious use of deception, little empirical research has examined the
manner in which they deceive. In this study, we concurrently examined the nature of violence in the context of
homicide and the manner in which the violent act is described by the perpetrators. Initially, official file descriptions
of homicides were coded on a series of factual details of the offence. Next, the incarcerated homicide offenders (N =
50), classified as psychopathic or non-psychopathic according to the Psychopathy Checklist-Revised (Hare, 2003),
were interviewed to elicit a detailed account of the murder. Each interview consisted of a free recall component in
which the offender was asked to describe their offence in as much detail as possible, followed by open ended
questions relating to the crime. The instrumentality/reactivity and major details of their violence were coded from
the official files, after which the offenders’ own accounts were similarly coded. Results indicated that psychopaths
were more likely to have committed instrumental (premeditated, goal-driven) homicides. However, this
instrumentality difference disappeared when the offenders’ narratives were examined. Psychopaths exaggerated the
reactivity of their violence to the extent that it appeared as reactive as violence by the non-psychopaths. Further,
psychopaths were more likely to omit major details of the offence.
sbporter@dal.ca
The Historical and Cross-National Study of Homicide and Other Social Issues
Leonard Beeghley, University of Florida
This paper makes use of the ideas of Max Weber, Emile Durkheim, Robert K. Merton, and others to suggest a
theoretically informed empirical strategy for understanding homicide. First, assemble data historically and crossnationally. Historical data allow for an assessment of change over time. Cross-national data allow for an
assessment of variation across nation states. Questions arise based on the data. Second, distinguish between social
psychological and structural explanations, noting that the explanatory variables differ at each level. Social
psychological explanations always focus on why individuals commit homicide (or some other behaviour).
Structural explanations always focus on how rates of homicide (or some other behaviour) vary over time and across
society. Structural variables are of interest here. We want to understand why rates of homicide vary over time and
across several societies, such as the United States, Sweden, France, and Germany. Third, develop a logical
experiment in which the key variables are identified and their mutual impact assessed. This “experiment” is
analogous to a regression analysis, except that the variables are manipulated logically rather than arithmetically.
This strategy is necessary because it is a paradox of criminology, sociology, and many other disciplines that some of
the most important issues are not susceptible to precise measurement, even though – as with homicide – their
component parts are measurable. Although imperfect, this strategy provides the only way to solve this dilemma.
Note that the issue, here, is not between a correct and incorrect answer, but between the best answer that can be
given and no answer at all. The result, especially when dialogue occurs, leads to a working hypothesis that explains
variations in homicide rates. As implied, this strategy can also be used with other problems of interest.
lbeegh@soc.ufl.edu
Characteristics of Homicide Perpetrators among Italian Forensic Hospitals Inmates
Angelo Fioritti, Department of Mental Health, Rimini, Italy
Vittorio Melega, Regione Emilia-Romagna,
Elisa Ferriani, Azienda USL Bologna,
The objective of this study was to identify distinctive clinical and social features of the psychiatric patients who
committed homicide among inmates of Italian forensic hospitals. Clinical and social characteristics of four cohorts
of patients were compared: 64 inmates who committed or attempted homicide (Hs), their 64 matched controls from
community services caseloads, 54 inmates who committed other crimes and their 54 matched controls from
community services caseload. When compared with other inmates, patients who committed or attempted homicide
showed less severe psychopathology (later onset of mental disorders, later contact with mental health services, lower
disability scores, but higher scores at BPRS hostility and suspiciousness factor), better premorbid adjustment
(socioeconomic status, employment), and surprisingly better behavioural profile (less compulsory admissions, less
previous criminal records, less substance abuse, less frequently in charge by community services). When compared
with their matched controls Hs had lower psychopathology, better adjustment, and similar behavioural profile.
Italian inmates of forensic hospitals who committed or attempted homicide have clinical features and personal
histories which are far from the stereotype of the violent and dangerous psychiatric patients. The risk assessment
procedures routinely performed in several countries may detect violent, but not homicidal behaviour.
afioritti@auslrn.net
salmen2@iperbole.bologna.it
Patricidal Juveniles and Questions of Early Abuse
Carl P. Malmquist, University of Minnesota
Parricidal acts by juveniles are one type of homicide which requires that specifics be elicited to understand this type
of behaviour in contrast to other types of homicides. In many cases it immediately raises a question of certification
to adult criminal courts when the perpetrator is in the juvenile age range and there is no requirement that he or she
be handled in the adult criminal system. In some cases legal issues of competency to proceed to trial or insanity may
be relevant.
In a good number of these cases another issue is frequently raised with respect to clinical and legal questions. After
the act has occurred, the issue of preceding physical or sexual abuse may be raised. This not only leads to questions
of determining alleged past facts in courtrooms, but the role of clinicians when this type of issue is raised. This
especially becomes a problem if an independent psychiatric evaluation cannot be conducted.
There is also the continuing debate on whether a specific syndrome regarding child abuse exists. While there is some
agreement in the psychological and psychiatric literature about the effects abuse can have on a child, the conclusions
are tentative in view of continuing investigations. The analogy is often used between battered child syndrome and
battered woman syndrome, but this is not based on empirical and clinical work but rather an analogy that is used in
legal proceedings.
Malq001@Atlas.Socsci.umn.edu
Housing and the Homeless
The Use of Compulsory Hospitalisation as an Intervention Strategy with Homeless Mentally Ill People
Tim J. Amor, Soho Centre for Health and Care, London, England
Wendy Harding, Soho Centre for Health and Care, London, England
The Westminster Joint Homelessness Team (JHT) was established in 1990 as part of the UK government’s
Homeless Mentally Ill Initiative (HMII) to address the growing recognition that a significant proportion (perhaps 3050%) of rough sleepers had a serious mental illness. The JHT is one of 5 such teams across London, employing a
range of professionals including social workers, mental health nurses and psychiatrists, that target the homeless
mentally ill who are not already in contact with existing mental health services.
The ethos of the team was initially to attempt to engage individuals on a voluntary basis, with those who refused
help being left alone unless they seemed to present obvious risks to either themselves or others. However, there has
been a gradual realisation that once such people have been hospitalised other interventions such as housing,
improving social skills and decreasing psychotic symptoms by the compulsory use of medication, become possible.
With such help it has been possible to move people into accommodation where they have been able to maintain a
higher level of functioning over time. This would seem to challenge the notion that those who sleep rough are
making a valid and rational ‘lifestyle choice’ and should be allowed to continue to do so. The HMII Evaluation
(Craig et al 1995) also found that most of the homeless mentally ill had only become homeless subsequent to the
onset of their illness and were therefore unlikely to be making informed choices about their lifestyle.
Research conducted by the JHT has demonstrated that clients who are difficult to engage and refuse initial offers of
help have a poor outcome in terms of moving away from street living. Those within this group, who also
demonstrate signs of serious mental illness, may benefit from a more assertive policy of considering the use of
planned compulsory detention in hospital for assessment under the Mental Health Act. In the JHT’s experience, this
tends to improve longer-term outcomes, enabling a significant proportion of individuals to move away from street
living to a more settled and secure lifestyle. However, the success of such a policy relies upon the accessibility of a
range of good quality housing and support service options.
timamor@doctors.org.uk
Charities and the Mentally Vulnerable in England and Wales: Housing Problems
Warren Barr, University of Liverpool
Nicola Glover-Thomas, University of Liverpool
This paper arises from research the Charity Law Unit is conducting into 'Housing the Mentally Vulnerable - The
Role of Charities', following an award from the Economic & Social Research Council (Award No: RES-000-220286). This empirical project seeks to gain a better perception of the current role of charities in the provision of
housing for the mentally vulnerable in England and Wales by seeking to classify the nature or type of housing
provision made for the mentally vulnerable by charities. It also aims to ascertain the legal and practical problems
experienced by those organisations that are involved in providing housing to this group.
The background to this research is as follows. The replacement of hospital based care of mentally vulnerable
individuals by care in the community environment did not recognise that housing would play an important role in
this policy's implementation. This oversight had led to many mentally vulnerable individuals living in
accommodation which is not appropriate to their particular needs or becoming homelessness. Inadequacies with the
current housing legislation also exacerbate homelessness. Consequently, charities are stepping in to meet at least
some of the housing needs of the vulnerable by assisting those individuals whose needs have not been met by other
means. Indeed, there is evidence to suggest that the actual role of charities goes well beyond the role that the
charitable sector might be expected to play in housing policy terms. Preliminary research has also indicated that
some possible legal problems are also faced by these organisations in the provision of housing but owing to the
dearth of empirical data on this issue, it is difficult to assess the day-to-day problems that are experienced.
Similarly, suggested reforms, which include a proposed legal reform of the housing system issued by the Law
Commission, do not have the benefit of informed evidence on this area.
The paper will present the findings of this project, and will be of interest particularly to those charged with dealing
with social housing management or providing suitable accommodation to vulnerable groups, or those considering
policy and/or legal reform of the area both within and without England and Wales. In the wider context, the
experience of the voluntary sector in England and Wales highlights at a micro-level the difference between policy
and practice in housing policy, and the dangers associated with the lack of a cohesive and well-supported housing
strategy at a governmental level.
wbarr@liv.ac.uk
nglover@liv.ac.uk
Mental Capacity Issues in England and Wales: The Housing Context
Nicola Glover-Thomas, University of Liverpool
The Charity Law Unit (which is part of the Liverpool Law School) is conducting research into 'Housing The
Mentally Vulnerable - The Role of Charities', following an award from the Economic & Social Research Council
(Award No: RES-000-22-0286). The empirical project seeks to understand the role of charitable organisations that
are involved in the provision of housing for the mentally vulnerable in England and Wales. The research project has
gathered qualitative data allowing a classification of the nature or type of housing provision made for the mentally
vulnerable by charities in England and Wales. The research project has also sought to ascertain the practical
problems experienced by those organisations in terms of implementing the law and executing housing agreements
with their vulnerable clients.
Housing the mentally vulnerable outside traditional social service support structures is increasing. Reliance on
charitable bodies and other housing management services is also increasing. Since mental health provision in
England and Wales became the subject of significant policy change over the last 25 years, care methods have
radically altered. Where the emphasis was once placed on psychiatric care being within an institutional setting, care
is now offered to the mentally vulnerable within the less restrictive environment of the community. Alongside this
policy shift, housing the mentally vulnerable has become an increasingly difficult proposition. The role of housing
in the community care policy was ill conceived; little thought was given to the nature and availability of housing
stock that mentally vulnerable individuals would need. This lack of foresight had led to many mentally vulnerable
individuals living in accommodation that does not meet their particular needs or exacerbates their mental
vulnerability.
Owing to this, charitable bodies are playing an important role in meeting some of the housing needs of this
vulnerable group. Initial research which was carried out in 2002 by the author (with Mr Warren Barr) indicated that
some legal problems were experienced by these organisations in the provision of housing.
This paper draws from this research project and its findings and in this context, seeks to consider how obligations to
house the mentally vulnerable living in the community are discharged in practice, narrowed with particular reference
to the difficulties associated with lettings being offered to those whose mental capacity might be subject to question.
This paper will interest those who work within the field of community psychiatry and social service provision. It
will also be of interest to legal academics and practitioners who are interested in policy development and legal
reform from a national and an international perspective.
In considering the issue of housing provision for the mentally vulnerable, the nature of mental capacity and its
impact on housing provision will be considered. How such capacity issues present difficulties for organisations
involved in making these arrangements will also be highlighted. In the wider context, consideration of the recent
reform proposals in the form of the Draft Mental Capacity Bill, and proposals to reform the law in order to facilitate
housing provision will also be considered. Reflections will be made as to whether these legislative reforms have
recognised the practical problems which stem from the psychiatric policy shift let alone whether it deals with the
issue of housing the mentally vulnerable effectively.
nglover@liverpool.ac.uk
Changing views of homelessness: Moving from a “management” to a “business” model
Mary L. Durham, Center for Health Research Kaiser Permanente Portland, USA
After twenty years of failed attempts to stem the rising tide of homelessness in American cities, a high profile group
of 39 U.S. Mayors signed an agreement in December, 2004 that changed the model for addressing homelessness in
cities across the U.S. The model, known as a Covenant of Partnership, commits signatory city and state
governments and the U.S. Interagency Council on Homelessness to a business model with a goal of eliminating
homelessness within a 10 year period. The business model is a departure from the typical “management” approach
for the homeless which has failed to produce results nationwide. The Covenant relies on the identification and
exchange of best-practices, the development and sharing of baseline data on homeless populations, outcome
tracking, and prevention policies.
This presentation analyzes the dimensions of the business model and compares it to the “management” approach
(e.g., paternalism, coercion) of the past. It further identifies key elements of a business model that will ultimately be
necessary in order to demonstrate value and a return on investment expected by major investors.
Mary.Durham@kpchr.org
Eating Disorders and the Law
Clinical Decision Analysis and Anorexia Nervosa
C. Laird Birmingham, University of British Columbia
Lawyers are frequently asked to help with decision-making in cases of anorexia nervosa, a disease characterised by
extreme weight loss due to a pathological fear of fatness. However, deciding when and how to intervene is difficult
in anorexia nervosa. Clinical decision analysis was first used by businesses to predict the potential profitability of
competing options. Clinical decision analysis can be used in anorexia nervosa to assist health- professionals to
make treatment decisions or to help lawyers understand the risks and benefits of each treatment option, without
detailed medical knowledge. A decision tree is constructed with each treatment option assigned to an arm. All
treatment alternatives, including no treatment, must be included. A numerical figure is assigned to each option
based upon the known value, or relative benefit of the possible outcomes (e.g. death is usually scored as 0 and good
health is scored as 1) and the probabilities of the various outcomes (it is adequate to have a range of the probability
(e.g. 0.2-0.6). Simple arithmetic or a decision analysis computer program can be used to calculate the value of the
various treatment arms and rapidly differentiate the best from the worst options for treatment. If there is uncertainty
about the probabilities and relative benefits you can either calculate each of the possible outcomes separately or
perform a sensitivity analysis. A sensitivity analysis produces a range of outcomes of the decision analysis over a
range of probabilities or relative benefits. Clinical decision analysis is quick, precise, forces discussion of the
likelihood and benefit of the treatment options and can be carried out with a computer and a decision analysis
software program.
clbirm@interchange.ubc.ca
Social Relations are a Catalyst for Change in the Treatment of Eating Disorders: The Hong Kong Vancouver Canada Experience
Patricia Kitchener, Practicing Psychiatrist, West Vancouver, Canada
By expressing 'world view' human rights values and beliefs of equality with diversity in treatment, a
therapist can foster relationships which welcome the opportunity to explore and examine culturally embedded
discrimination and practices. This exploration is particularly useful in the treatment of Eating Disorders as there are,
inherently, many hidden biases and underlying assumptions presented in the symptoms of the disorder. Although it
is always important that the therapist consistently model, respectful interactions, verbally as well as non-verbally,
the need for respectful role modeling is especially acute in therapy for the treatment of eating disorders. According
to author Susie Orbach, Hunger Strike, this is because eating disordered clients have a heightened sensitivity to, and
an absorption "from an early age, about the ways in which they are to live "as women”. Unable to articulate
intensely experienced internal needs and desires which contradict socialization processes designed to suppress those
needs, eating disorder clients act out the discrepancies. The Hong Kong - Vancouver, Canada experience will
illustrate that, when given language and voice, eating disorders clients 'acting out' can be understood as a
manifestation of a sense of ‘injustice’ or ‘unfairness’. The meaning of the symptoms of denying and
overriding hunger and appetite viewed as a metaphor for the demands that a young woman look a certain way, not
take up too much space etc., can illuminate eating disorders as clear reflection and expression that she curtail her
needs in general. The constructive use of the dynamics of social relationship between the therapist and client, the
therapist and family system, and other combinations of participants in therapy, to address embedded inequities and
practices becomes the catalyst for change. The advantage of cross-cultural therapy lies in a culturally sensitive
offering of an alterative lens to view contradictions and multiple realities. Previously unexamined issues such as:
gender inequality; hierarchy; individual versus group rights; cultural stereotypes; etc. can be seen from 'outside' the
cultural system. By increasing awareness, the therapy process facilitates a unifying perspective which brings about
fundamental shifts in the social systems, encouraging the tolerance of diversity and potentially reducing human
rights infringements.
patkhome@telus.net
Fraudulent Misrepresentation: Case Law and Regulator Rules in Relation to Eating Disorders
Patricia O’Hagan, University of British Columbia
The International Obesity Task Force (IOTF) found that at the global level, few countries report obesity rates below
10%. Moreover, IOTF reported that the rising international trend in obesity is now estimated at more than 320
million adults and 40 million children who are obese (BMI>30). These findings and the concurrent popular culture
emphasis on thinness have supported the growth of the weight-loss industry with marketing and sales in; dieting
programs, “magic bullets” – pills and capsules, and phoney devices and gadgets. The weight loss industry is a $40
billion-a-year business in North America where advertisements cover all areas of mass media (film, newspapers,
magazines, radio, and television); genre fiction such as mysteries; science fiction and romance novels; popular
music; fashion, websites and commercial e-mails.
These converging trends have found expression in courts decisions and regulator rules that represent a significant
and valuable expansion of case law related to disordered eating. Court decisions dealing with body shape, weight
and eating disorders are expanding to include the health and safety of clients related to the availability and
qualifications in the provisions of services. Regulator rules are protecting clients from false advertising when
marketing products or services directed at weight loss and physical appearance. Caveat emptor is currently the
standard by which clients are to judge the quality of community based for profit services. Consumers are
particularly vulnerable when it comes to unsubstantiated product performance claims related to weight loss.
Perhaps the best approach is to set out overriding principles for guidelines in the delivery of mental health services.
The U.S. Federal Trade Commission (F.T.C.) has identified weight-loss advertising claims that should meet the
standard of fraudulent misrepresentation because they are not scientifically feasible. The test of FTC findings has
been met in US settlements and now under NAFTA, Canadian marketers doing business in the US have settled
fraudulent weight-loss products as a result of the FTC charges.
pohagan@providencehealth.bc.ca
Experiences of 'Control' in Anorexia Nervosa Treatment: Delayed coercion, shadow of law, or
disseminated power & control?
Terry Carney, University of Sydney
Mim Ingvarson, Mental Health Legal Centre. Victoria, Australia
David Tait, University of Canberra
Anorexia nervosa is often chronic, with one of the highest death rates for psychological conditions. Law can compel
treatment, but is rarely invoked, at least formally (though the strategic possibilities of orders confers internal
authority within the clinical setting). Instead, 'control' (or management) is exercised diffusely, through disciplinary
practices embedded in everyday clinic life, such as daily routines of eating and washing, behavioural 'contracts',
regular surveillance and measuring, interactions with staff, visits and activities. The regulatory regime not only
touches on such 'practices' but also targets 'identities' (including self-image, and attitudes to the body) and what
Goffman called the 'moral career' of the patient (e.g. learning to play the 'patient role', to 'be' an 'anorexic'). We
argue that it is not the clumsiness of the law, or the success of less restrictive options which explains why law is so
infrequently engaged. Rather, based on an interpretation of Foucault, we concluded that the regulatory regimes that
shape treatment of anorexia nervosa, is 'the law', in a sense. The regime of governmentality within the clinic is
shaped by practices which operationalise 'duty of care', or translate medical expertise into medical authority, or show
how interactions between 'experts', 'carers' and patients are mediated through conventions and rules, or which
conscript 'empowerment' as control. The patient learns to provide consent 'freely', to make the 'correct' choices, to
accept the 'empowerment' regime that is made even more convincing by the threat of legal intervention. In time the
constraints learned in this way become part of the new role, that of the 'recovering' patient. The 'fiction' of acting
'responsibly', employed so hesitantly at first, becomes part of the new identity. The patient has become an active
participant in the governance of self.
terryc@law.usyd.edu.au
Ethical Issues in Clinical Nutrition: Obesity, Anorexia, Terminal Illness
Eugenio Rasio, Université de Montréal
The nutritional state of the patient is a major determinant of the outcomes of treatments and quality of life during
illness. Nutritional interventions need to be assessed in terms of their scientific validity and ethical appropriateness.
Achieving a negative calorie balance is a sine qua non requirement for reducing weight in the obese: the
psychological cost of failure to achieve and maintain a significant weight loss often prevails over the intended
benefits of reduced physical risks. Minimal but persistent weight loss in the obese, with a liberal and realistic
approach to dieting, can be beneficial without imparting the stigma of the inability to respond in visible fashion to
more aggressive food restrictions.
In anorexia nervosa, compulsory artificial nutrition and hydration may be lifesaving. However, metabolic
improvements can often be achieved in a natural and less dramatic fashion, which sustain the vital functions without
creating additional mental distress by an undue weight gain. A very modest positive calorie balance is often agreed
upon by the emaciated anorexic, if it is designed to increase the metabolic rate, and not to replenish the body energy.
Rehydration should be attempted cautiously as incongruous treatments result in excess water retention with rapid,
important and often prolonged body weight increments, which the anorexic cannot endure.
In the terminally ill cachectic patient, legal, medical and ethical issues on how to manage hydration and nutrition in
the context of palliative care, may be intricate and difficult to resolve. Withholding or withdrawal of water and
nutrients to incompetent patients is a most difficult decision. Among the factors to consider are the patient’s
comfort, the family members perceptions and the improvement or delayed deterioration of the clinical condition that
can be expected by providing optimal or minimal nutritional support. One should also eventually consider that
water retention and accelerated proteolysis preceding death in cachectic patients may be best dealt with by
withholding nutritional support, a decision which has no bearing on ethics.
Useful nutritional interventions can be achieved in harmony with ethical principles, despite apparent conflicting
situations.
eugenio.rasio@sympatico.ca
Lifelong Internment in Switzerland
Forensic-Psychiatric Criteria for the Indefinite Save-Custody of Dangerous Perpetrators. A
Retrospective Analysis
Andreas Frei, Psychiatrische Klinik, Lucerne, Switzerland
Marc Graf, Universitäre Psychiatrische Kliniken, Basel, Switzerland
Volker Dittman, Universitäre Psychiatrische Kliniken, Basel, Switzerland
At the beginning of the nineties, a series of spectacular crimes, committed by repeat offenders, was disturbing the
public mind. As a consequence, serious doubts about the competence of forensic-psychiatric experts arose. As a
consequence, a initiative to change the constitution was launched by some citizens, mainly relatives of some victims.
They wanted the introduction of a form of live-long safe custody without the possibility for a revision; up to now, a
revision of this measure had to be done regularly. In February 2004, this change of the constitution has been
accepted by the Swiss voters; the transformation of this decision in a new law has been due to insurmountable
difficulties in respect to the European Convention of Human Rights delayed. The authors of this paper feel, the
initiative passed through due to poor knowledge of the public mind in connection with the decision making of
forensic-psychiatrice experts. Between 1989 and 1998, 112 forensic-psychiatric expertises concerning attempted or
completed murder or manslaughter have been performed by the forensic-psychiatric department of the Psychiatric University Clinic (PUK) of Basle. Among them, there are all of the spectacular cases mentioned above, some them
being assessed in form of a revision. Aim of the paper is to make the decision-making by careful statistical analysis
of the criteria (sociodemographic data, psychiatric diagnosis, PCL-R) more transparent which led the expert to the
conclusion, a perpetrator was such a public danger that he had to be locked away indefinetly. This happened in six
cases.
andreas.frei@ksl.ch
Forensic Psychotherapy with detainees under Art. 43 fig. 1, sect. 2 Swiss penal code (timely unlimited
safe custody)
Ronald Gramingna, Interkantonale Strafanstalt Bostadel, Menzingen, Switzerland
The unlimited safe custody according to Art. 43 fig. 1, sect. 2 p. c. in Switzerland concerns two forms; the custody
for dangerous perpetrators who are neither treatable nor require care and perpetrators, who are treatable in principle,
the prognosis of such a treatment, however, remains still very insecure. Perpetrators under Art. 43 fig. 1, sect. 2 p. c.
must have been judged mentally abnormal by the court. At the end of 2003, 134 people were kept under Art. 43 fig.
1, sect. in Switzerland. The forensic-psychotherapeutic management of such people is difficult, of course. Basically,
each detainee under unlimited safe-custody has a right for psychotherapeutic treatment. their motive for treatment,
however, might not be genuine; they rather seek some loosening of their regime of the execution of the penal
regime. The authority on the other hand might ask the detainees to undergo treatment before granting gratification.
In this collusive netting, therapist are in a very delicate position, what contaminates additionally the already charged
therapeutic setting.
Ronald.Gramigna@Bostadel.ch
Lifelong Internment in Switzerland: Legal Issues and Considerations
Marianne Heer, Supreme Court of Lucerne, Switzerland
Since the introduction of the Swiss penal code, life-long internment was an option, but was until the beginning of the
nineties of minor relevance. Since then, this measure has, mainly in connecting with two spectacular crimes of two
perpetrators on parole, become more and more important. Then number of new defendants who were faced with this
penalty has, however, not increased, but it is now a frequent issue in forensic-psychiatric expertises and in
indictments as well and the number of detainees under this order increases since they are no longer discharged even
though it was legally possible: The authorities in charge are under enormous public pressure.
As in other European countries the idea of resocialisation has left the place to the idea of absolute security. This is
also the case with the revision of the Swiss penal code which is to become operate in the near future. Concerning
lifelong internment, the principle that only mentally disturbed perpetrators could be the object of such a measure has
been abandoned. Lifelong internment should be even possible with first offenders as long they, according to an
expertise, possess certain personality traits and that the circumstances of their crime and their biography as a whole
are such that further crimes are to be expected seriously. According to this notion the conditions for a release from
the measure have become more strict, detainees can't be released in order just to try whether they can prove
themselves outside custody; rather a proof of non-existing danger of recidivism is required.
The discussion about lifelong internment has become even sharper: An initiative to change the constitution has
passed a referendum asking the lifelong internment of so called extremely dangerous perpetrators without the option
of reassessment unless there are "scientifically proven" successful new methods of treatment. Here, a deep mistrust
of the general population towards judges and forensic psychiatrist becomes obvious. Most legal experts think, this
change of the constitution is not in accordance with the European Convention of Human Rights.
Apart from the implementation of this new law some more tightening of the legislation should be performed: The
additional life-long internment e. g. should be implemented if a convicted detainee proofs in the run of the detention
to be dangerous, the judgement can be changed additionally and a timely limited penalty can be changed into lifelong internment. According to the present legislation, only a measure (and not a timely limited penalty) can, if it is
not successful, additionally changed into life-long internment. By implementing this practice, important basic
principles of legislation would be seriously violated as e. g. "ne bis in idem" or the principle of final judgement.
Another important issue is the question which would be the index-crime for the consideration or the ruling of lifelong internment. According to the first proposition of the revision of the penal code, the index crime had to be a
capital crime. As a consequence, recidivistic paedophile perpetrators could not be life-long interned. This would be
not approved by the public opinion. The index crime should be according to the latest discussions be defined more
openly which is basically correct. It is not the crime as such which necessarily prove the dangerousness of the
perpetrator; it is his state of mind which becomes apparent through h the crime that matters.
Marianne.Heer@lu.ch
Memory under High Stress
Impact of Stress on Memory for Complex, Impersonal Information
Major Gary Hazlett, U.S. Army, Sanford, USA
Exposure to acute stress resulted in symptoms of dissociation (alterations of one’s perception of body, environment
and the passage of time), problem solving deficits (as measured by objectively assessed military performance) and
marked inaccuracies in memory (as measured by eyewitness identification). The present investigation was designed
to better define and characterize these stress-induced alterations. An enhanced understanding of the way stress
affects perception, cognition and memory is important because many battlefield errors (e.g., friendly fire incidents,
collateral damage, etc.) have been linked to a decline in cognitive operations.
184 active duty military personnel enrolled in Survival School Training were the subjects of this study. All subjects
completed pre-stress and post-stress measures of dissociation; all subjects completed pre-stress trauma history
questionnaires. Subjects were randomized to one of three groups (Pre-Stress; Stress and Post-Stress groups) and
were administered the Rey-Osterreith Complex Figure (ROCF) test. Subjects completed the Copy and 1 minute
recall phases of the test.
ROCF copy and recall scores were normal for the Pre-Stress and Post-Stress Groups. ROCF copy and recall scores
were significantly altered in the Stress group. In the Stress Group, the copy procedure shifted from configurational
to piecemeal in all but 4 subjects. ROCF recall scores for the Stress group were significantly lower and in a range
normally seen in individuals suffering from brain injury. A significant and negative relationship was observed
between symptoms of Stress-Induced dissociation and ROCF recall scores in the Stress Group; in addition, a
significant, negative association was observed between Pre-stress dissociation scores and ROCF recall in the Stress
Group. Finally a significant, negative relationship was observed between history of traumatic stress and ROCF
performance during stress.
These data enhance our understanding of stress induced cognitive deficits. The alteration in the ROCF copy and
recall tasks is consistent with stress induced impairment of pre-frontal cortex functioning. In addition the discovery
of a relationship between baseline variables (dissociation and history of trauma) and subsequent performance under
stress suggests that these may be used to predict real world difficulties and also assist in the development of
countermeasures. Such interventions might reduce error on the battlefield.
hazlettg@soc.mil
Accuracy of Memory for Voices of People Encountered during Conditions of High Stress
Heather Hazlett, University of North Carolina
This study assessed accuracy of voice recognition in humans exposed to highly intense, personalized stress. Active
duty military personnel (N= 120) enrolled in survival school training attempted to identify the person they
encountered during a high stress compared to a low stress interrogation. Recognition was assessed using a series of
voice recordings of the various interrogators. Subjects were given the opportunity to listen to each and rate their
selection and confidence levels of their selection. Accuracy rates were poor. Only 20% of subjects were able to
correctly identify the voice of the person who had conducted their interrogation. However, unlike the data from our
eyewitness studies, we found a significant, positive relationship between subjective ratings of confidence and
accuracy. The ability to recognize a person’s voice that subjects encountered during realistic, highly personal,
threatening stress was extremely poor. Additional research evaluating neuro-biological contributions to accuracy
may enhance our understanding as to why some individuals are accurate in voice recognition and others not.
Forensic examiners are advised to be aware that while subjective confidence levels are not related to eyewitness
accuracy for faces, it appears to be related to accuracy in the identification of human voice.
garyheather@hotmail.com
Eyewitness Identification for People Encountered Under Conditions of Acute Stress
Charles A. Morgan III, Yale University
This study was designed to extend the findings of our previous research in eyewitness memory for people
encountered during acute stress. We tested whether multiple exposures to a person would enhance eyewitness
memory. In addition, we tested whether people who are given a second chance to identify a person were more likely
to change their response to a correct or incorrect identification. These questions are relevant to issues that
commonly arise in eyewitness identification cases.
Study One: Sixty-two U.S. Navy personnel enrolled in Survival School were exposed to interrogation stress. 24
hours after stress exposure subjects were asked to identify the one interrogator who they encountered 48 hours
earlier during stress exposure. After making their selection, subjects were given an additional opportunity to make a
second identification. Study Two: 58 U.S. Navy personnel enrolled in Survival School were exposed to
interrogation stress. One hour later, they were re-exposed to the same person who interrogated them. 24 hours after
this, subjects were asked to perform eyewitness identification of the interrogator.
As in our previous studies, when presented a photograph taken at the time of stress exposure, only 58% of subjects
were able to correctly identify their interrogator. When given a second opportunity to view the serial photo line-up,
50% of subjects who had been wrong in their initial identification, switched to a correct ID. Of the subjects who had
been initially correct 40% switched to an incorrect response. Study Two: Eyewitness identification accuracy
improved from 60% to 80% when subjects were re-exposed to their interrogator.
The data from study one suggests that many people who are given the opportunity to make a second eyewitness ID
change their answers. Because none of the demographic variables predicted which subjects were more likely to
switch from correct to incorrect responses or vice versa, it is unlikely that asking witnesses to make a second guess
will clarify evidence in the absence of other objective information. The data from study two demonstrate that
memory is better if people have increased exposure to a person during stress. This must be taken into consideration
when evaluating the credibility of eyewitness identifications in court.
charles.a.morgan@yale.edu
Memory for People, Places and Events Encountered during Exposure to Acute Stress
Steven Southwick, Yale University
We have previously reported that eyewitness identification for high stress events is relatively poor. However,
memory for events and places may not be similarly affected by stress. Thus this study was designed to test the
impact of acute stress on the accuracy of human memory for people, events and places.
40 U.S. Navy personnel enrolled in Survival School were exposed to the acute stress of confinement for more than
36 hours. 20 subjects participated in a standardized test of memory prior to the stressful training; 20 subjects were
tested after exposure to the stressful training. All 40 subjects were videotaped during their stressful training. After
the training was complete, all subjects were debriefed about their experiences. Their reports were compared with the
videotapes of their experience for accuracy. Next we compared performance on the standardized test to accuracy of
their report for personally experienced events.
At the time of the writing of this abstract the data from the study are being analyzed. We will present the scores
from the standardized memory test and will also present the data from the debriefings. We will explore whether
accuracy of memory on the two separate tasks is related and also present the overall accuracy of memory.
The data from this study are highly relevant to forensic evaluations and to eyewitness testimony. Human memory is
not a uniform construct and it is possible that memory for faces is not the same as memory for events, or
space/locations. These different types of memory may be differentially affected by stress. Empiric data about the
accuracy of human memory will assist forensic examiners in forming their assessments.
Steven.Southwick@med.va.gov
Human Rights and the Mentally Ill I
Human Rights of the Mentally Ill
Julio Arboleda-Flórez, Queen’s University
Over centuries, persons suffering from mental conditions were regularly subjected to deprivations and abuses of
their most basic rights by virtue of laws or statutes aimed at taking them out of circulation in total institutions for
reasons that were more attuned to the protection of others than to their treatment, recovery and reintegration to
society. Institutionalization itself came fraught with abuse and deprivations beyond those meted out to common
criminals. Although much has been achieved to redress these abuses and improve on discriminatory policies and
statutes much remains to be done before mental patients regain full status as free members of society. This paper
will review historical antecedents and practices and map out a course of action to improve on the human rights of
mental patients.
Ja9@post.queensu.ca
Mental Fitness and the Right to a Fair Trial; A Comparison of Legal Doctrines
Peter Bal, Maastricht University
In Anglo-American or ‘adversarial’ criminal law systems (like the United States and the United Kingdom) a
person’s unfitness to stand trial is often raised as a defence. If a defendant is found unfit due to a mental disorder,
the criminal prosecution will be adjourned so that the defendant can be committed to a psychiatric hospital and
treated until he or she can later be rendered fit to stand trial. This adjournment of the prosecution can be of indefinite
time
A comparable option for adjournment exists in many European or ‘inquisitorial’ criminal law systems (like the
Netherlands and Germany). However, unlike Anglo-American criminal law systems where adjournment because of
a defendant’s mental unfitness, is fairly common, in the continental systems this ground for adjournment is not often
invoked.
Concerning the legal aspects of this doctrine a comparative analysis of differences and similarities in its practical
application in the diverse criminal law systems will be presented. In particular, this application will be analysed
from the perspective of human rights, more precise the right to a fair trial: Is the doctrine of fitness to stand trial a
guarantee or an obstruction of this right?
Peter.Bal@strafr.unimaas.nl
Mitigation Themes and Human Rights Abuses
Scharlette Holdman, Institute for Human Rights Investigation, San Francisco, USA
Mitigating factors stem from the diverse frailties of humankind and are presented to the fact finder and sentencer to
provide insight into the offender’s behavior. Mitigation is complex and multifaceted. Theories of mitigation are
governed by principles of individualized sentencing and allow for great variation in the information presented to and
considered by the court. Mitigation evidence is based on respect for the uniqueness of the individual and requires
thoughtful presentation of the character and record of the offender. It covers all relevant facets of the character and
record of the individual in order to minimize the risk that a penalty will be imposed in spite of factors which call for
a less severe penalty. It is based on the constellation of factors that give insight into the offender’s behavior and
functioning at the time of the offense and over the course of his life and places his actions in a larger social and
cultural context.
Although most mitigation evidence focuses on the offender, it also reflects the nature and circumstances of the
offence under the theory that punishment should be proportionate to the offence. Circumstances of the offence often
shed light on an otherwise inexplicable act and call for a less severe penalty. Facts of the offence may show that
others were equally or more culpable but were not charged or exploited the offender’s vulnerabilities. Relevant
evidence may contradict the prosecution’s theory of the offence and provide a basis for mitigation.
Ccascharlette@aol.com
Mental health and human rights law in the Americas: a new approach
Javier Vasquez, Pan American Health Organization/World Health Organization (PAHO/WHO)
According to recent studies and reports of international and regional human rights treaty bodies, in many parts of the
Americas, persons with mental disorders (and specially those who live in psychiatric institutions) continue to face
mistreatment and stigma. Persons with mental disorders are often isolated in psychiatric institutions, long term care
facilities for older persons, prisons or other public facilities under living conditions that often threaten their health
and in some cases even their lives.
The understanding and application of constitutional and international human rights law to review the current
situation of admission and subsequent retention of persons with mental disorders in psychiatric or other kind of
institutions is essential to achieve the “de-institutionalization” of the referred persons and consequently to develop
community based services where the right to freedom and security of person can be exercised. Unfortunately, still
most of the countries of Latin America and the Caribbean have not enacted mental health legal frameworks which
specifically refer to the right to due process of law, judicial guarantees and other related human rights and
fundamental freedoms in the context of the above mentioned institutions. Thus, the first section of the presentation
will discuss the most relevant general human rights and fundamental freedoms which are intrinsically related with
the highest attainable standard of mental health and which shall be incorporated into national laws or mental health
policies and plans.
The second part of the presentation will focus on the initiatives that the Pan-American Health Organization/World
Health Organization (PAHO/WHO) is currently conducting to promote and protect mental health in the Americas
through international human rights principles, instruments and bodies and the impact that this new approach is
having on the reform of mental health policies, domestic legal procedures, practices and services. For instance, the
presentation will refer to the outcomes of the “national human rights training workshops” in areas such as the
monitoring of living conditions in public institutions and the empowerment of consumers, among others. In
addition, it will be explained PAHO’s technical collaboration with regional human rights bodies such as the InterAmerican Commission on Human Rights (Organization of American States) and the use of regional human rights
mechanisms to protect the right to the highest attainable standard of mental health and other related human rights.
vasquezj@paho.org
Mental Health, Obesity, and Human Rights Policy
Leo B. McGrady, Barrister and Solicitor, Vancouver, Canada
Over the past quarter century, one of the primary health policy instruments employed in Canada to address problems
with the mental health of populations has been human rights legislation. Many human rights regimes have
developed thoughtful and sophisticated analyses of mental disability as a prohibited ground, as it occurs in different
settings: publications, accommodation, landlord-tenant relationships, and employment.
That is not the case, however, with issues of obesity and mental health matters associated with obesity. The
approach of many legislators, human rights tribunals, as well as legal writers, has been muddled and contradictory.
Cases often fail over the requirement in some legislation, for example, that the disability have its origins in an
illness; or an inquiry into whether obesity is within the complainant’s control; or some similarly unproductive and in
itself often discriminatory inquiry.
Increases in obesity rates have been experienced for at least the past 20 years. However, obesity has reached the
point where a 2003 World Health Organization Food and Agriculture Report used expressions like “global obesity
epidemic”. Nor is the problem localized, nor peculiar to developed or undeveloped countries. The rapid
acceleration in problems flowing from obesity is being experienced in the United Kingdom, Ghana, Brazil, the U.S.,
and Canada, to name a few. Obesity appears in perhaps its most acute form in the U.S., where estimates suggest that
over 70% of older adults are considered obese or overweight.
The problems posed by the erratic approach of legislators, decision-makers, and legal commentators employed in
dealing with mental health and other issues flowing from obesity are exacerbated by the fact that obesity is often
associated with conditions of poverty. Recent U.S. and French studies suggest this may be the case. Yet other than
a rather oblique protection offered by the Québec Charter of Human Rights and Freedoms, Canadian human rights
statutes simply do not address issues of poverty, nor indeed of any economic rights. We thus have obesity-related
mental health problems only occasionally addressed by human rights legislation, and the associated problem of
poverty simply not covered at all. At the same time, the health problems flowing from obesity consume billions of
national health care budget dollars. - 7.8 % of national health care costs in the U.S.; 2.3% in Canada; and 4% in the
Netherlands for example.
This paper explores some of the myths and misunderstandings about obesity/mental health issues arising from
legislation and case law, in Canada, the U.S., and the European Community. It urges a consistent, evidence-based
approach, both in the statutory human rights protections afforded those suffering from mental disability and obesity,
and in the treatment accorded the issue by the courts and human rights tribunals.
lmcgrady@mbwlaw.ca
Mental Health Law and Human Rights: The Australian Experience
Bernadette McSherry, Monash University
In 1993, following a national enquiry, a report by the Human Rights and Equal Opportunity Commission (the
Burdekin Report) entitled Human Rights and Mental Illness made recommendations concerning changes to mental
health law in Australia. Its prime recommendation was the mental health should be evaluated against human rights
standards. Since then, while there have been attempts to measure civil commitment legislation against human rights
instruments, there have been significant developments that indicate a growing focus on dangerousness and
community protection at the expense of human rights.
This paper will critically examine contemporary mental health policy and practice in terms of human rights
principles. The analysis will approach the question of whether mental health law in Australia measures up to human
rights standards. Unlike other countries, Australia does not have a Bill of Rights. It has a Constitution which was
drafted at the end of the nineteenth century and which contains few references to individual rights. While Australia
has ratified the International Covenant on Civil and Political Rights (1966), it has never formally incorporated the
Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care (1991)
into domestic legislation. This paper reconsiders the recommendations of the Burdekin Report and assesses what
progress, if any, has been made in relation to mental health law and human rights.
Bernadette.McSherry@law.monash.edu.au
Human Rights and the Mentally Ill II
With restraint: Towards the Elimination of “Cage Beds” in Central Europe
Diana Beth Hoover, Mental Disability Advocacy Center, Budapest, Hungary
Oliver Lewis, Mental Disability Advocacy Center, Budapest, Hungary
This paper will outline the campaign by the Mental Disability Advocacy Center (MDAC) to end the use of cage
beds in the Czech Republic, Hungary, Slovakia and Slovenia. These ex Austro-Hungarian countries within the
enlarged European Union have all historically used cage beds – defined as netted or metal cages enclosing a hospital
bed – in psychiatric and social care institutions.
In 2003 MDAC launched a report in the European Parliament about the use of cage beds. The report lays out the
circumstances in which cage beds are used, justifications given by staff and testimony of victims of cage bed use.
The use of cage beds violates the absolute prohibition in international law of inhuman and degrading treatment. The
United Nations, Council of Europe and European Union – as well as the author of the Harry Potter books – have all
called for the eradication of this widespread and dangerous form of restraint. To what extent have these countries’
governments taken steps to meet their international legal obligations to eradicate cage bed use? Are cage beds
merely symptomatic of the broader issue, namely systems of institutional and custodial care, which place little
emphasis on integration and (re)habilitation?
dhoover@mdac.info
Proving Madness under Article 5(1)(e): The Burden and Standard of Proof
Paul Bowen, London, England
Until 2001, patients detained in England and Wales under the Mental Health Act 1983 were required to prove that
that they were no longer mentally disordered or dangerous before they could secure their freedom from a Mental
Health Review Tribunal. This rule was the subject of one of the first challenges under the Human Rights Act 1998
and in 2001 the Court of Appeal of England Wales ruled that this ‘reverse burden of proof’ was incompatible with
Articles 5(1) and 5(4) of the European Convention on Human Rights (R (H) v Mental Health Review Tribunal
[2002] QB 1). The Mental Health Act was subsequently amended. A similar challenge was made to the Scottish
Mental Health Act in the Strasbourg case of Reid v United Kingdom where the European Court of Human Rights
confirmed that Article 5(1) and 5(4) requires the State to prove the existence of the criteria for detention under
Article 5(1)(e), and so the burden of proving those criteria in Article 5(4) review proceedings rests upon the State.
No English or Strasbourg case-law has yet considered the question of what the appropriate standard of proof should
be in such proceedings. Prior to the change of the law in England and Wales it was accepted that the ordinary civil
standard of ‘balance of probabilities’ applied. In the USA, on the other hand, the US Supreme Court has ruled that
the 14th Amendment requires proof of mental disorder and dangerousness in civil commitment proceedings to a
higher standard of ‘clear and convincing evidence’, although the criminal standard of ‘beyond reasonable doubt’ is
not necessary (Addington v Texas). In a later case the US Supreme Court ruled that the same principle applies in
relation to mentally disordered individuals committed in criminal proceedings (Foucha v Louisiana). In a separate
development, the House of Lords of England and Wales has recently decided that in some civil proceedings where
what is at stake for the individual is very serious, the civil standard of proof may be a ‘heightened’ one that is
‘indistinguishable from the criminal standard’ of ‘beyond reasonable doubt (R (McCann) v Crown Court at
Manchester [2003] 1 AC 187). The question of whether, in the light of these developments, Articles 5(1) and 5(4) of
the Convention require that a higher standard of proof of mental disorder and dangerousness than the bare ‘balance
of probabilities’ has recently been raised in the Administrative Court of England and Wales in the case of R (N) v
Mental Health Review Tribunal. Judgment is expected shortly.
p.bowen@doughtystreet.co.uk
Legal Responses to Deaths in Psychiatric and Social Care Institutions in Central and Eastern Europe
and Central Asia
Oliver Lewis, Mental Disability Advocacy Center, Budapest, Hungary
Marit Rasmussen, Mental Disability Advocacy Center, Budapest, Hungary
There is disturbing evidence that in a number of countries within Eastern Europe and central Asia mortality levels in
psychiatric and social care institutions have at times been grossly elevated, effectively converting psychiatric
morbidity into mortality. Notwithstanding the limited financial resources devoted to treat and care for this
population, many of avoidable deaths are caused by deprivation of basic human necessities such as inadequate food
and shelter. Occasionally this has attracted crisis intervention from aid agencies, but in many countries where
reliable evidence suggests a serious problem there has been little response by outside organizations.
In case law developed in the 1990s, the European Court of Human Rights has interpreted Article 2 of the European
Convention on Human Rights – the right to life – as imposing on a State procedural obligations to investigate cause
of death by an open and independent system of inquiry, in addition to the substantive obligation reasonably to
preserve life. High and avoidable mortality rates undoubtedly violate the substantive rights of those at risk, but in
addition there is widespread non-compliance with the procedural obligations which the Court has developed. This
paper will outline the legal obligations on States, examples from around the region and strategies for challenging
cursory or non-existent death investigations and failures of the State to preserve life.
dhoover@mdac.info
mrasmussen@mdac.info
The Realization of the Austrian Commitment Law in the Mental Health Hospital in Graz: A Statistical
Comparison
Michael Scherf, Association for Guardianship and Patients’ Advocacy, Graz, Austria
The Austrian Commitment Law is in force since January 1st, 1991. Within periodical intervals the Patient Advocacy
carries out statistical investigations in order to show how this Act affects the in-patient treatment in the mental
health hospital in Graz which is – with 600 beds – the largest of its kind in Austria.
In doing so, the following most essential parameters are being investigated: Sexual belonging, duration of
commitment in the closed area, the manner and reason for the commitment, the frequency of re-commitment in the
closed area within one year respectively since the Act is in force and the result of the judicial review. By means of
such statistical recordings subjective perceptions in discussing the implementation of the Commitment Law shall be
evaluated.
graz@patientenanwalt.at
The Implications for People in Europe with Intellectual Disabilities of the Decision of the European
Court of Human Rights in L. v. U.K. (the “Bournewood Hospital” case)
Mark Mullins, Outer Temple Chambers, London, England
This presentation will analyse the judgement of the European Court of Rights in the celebrated case of L. v. U.K.
(2004) and consider its implications for people with intellectual disabilities in Europe. It will consider the Court’s
latest thinking on the meaning of “detention” under Article 5 of the European Convention of Human Rights, the
Convention’s procedural requirements for the detention of people with intellectual disabilities and the right of
detained persons to an effective judicial review of their detention. It will compare L. v. U.K. with the Court’s earlier
decision in H.M. v. Switzerland (2002) and ask if L. v. U.K. marks a move for the Court away from its recent
paternalism towards a more active upholding of the individual rights of people with intellectual disabilities.
mark.mullins@outertemple.com
Hunger Strikes: Ethical and Medico-psychological Implications
Medical, psychological and ethical aspects of prolonged hunger strike: consequences and follow-up of
the experience in Turkey, 2000-2003
Metin Bakkalci, Human Rights Foundation of Turkey (HRFT), Ankara, Turkey
Umit Sahin, Human Rights Foundation of Turkey (HRFT), Ankara, Turkey
In the year 2000, Turkey faced many hunger strikes in the prisons. The reason was launching new F-type type
prisons which were designed with high-security facilities and isolation cells. Thousands of prisoners went on
prolonged hunger strikes to protest the introduction of these new F-type prisons. Duration of hunger strike periods
was up to 300 days or more. Because of these hunger strikes, 112 people died, and hundreds of people lost their
health and became disabled.
As a result of the hunger strike actions, diverse number of health problems has arisen. Duration of the action, the
way the action ended (forced or willingly), the amount of food and beverages taken during the hunger strike and the
individual characteristics of the striker had particular effects on the type and severity of the health problem occurred.
Wernicke's Encephalopathy, Wernicke-Korsakoff Syndrome, nutritional peripheral polyneuropathy, common and
proximal muscle weakness, severe or temporary amnesia conditions, disartry, spasticity, hand tremors, vertigo, deep
sense disorders, digestive system diseases, posture problems and muscle and joint related pain are some of these
health problems. Among these clinical pictures, the Wernicke's Encephalopathy and Wernicke-Korsakoff Syndrome
are known as the ones which develop due to a decrease in the Thiamin (vitamin B1) supply. Other clinical pictures
mentioned are mostly related to malnutrition or to a lack of essential nutrients, primarily proteins, fatty acids and
other vitamins. Also PTSD, depression and other psychiatric pictures were to be occurred. These medical and
psychological conditions need intense and long term care and follow-ups.
HRFT currently offers medical and psychiatric treatment, physical therapy and rehabilitation to 614 hunger strike
survivors. 563 of such consist of hunger strikers who admitted to HRFT subsequent to the hunger strike actions
made in the year 2000 and later. Most of the admissions were made in the years 2001 and 2002 (in 2001, 338; in
2002, 185; in 2003, 40 admissions). 51 of the total admissions were made as a result of the similar hunger strike
actions made prior to the year 2000 (such as the hunger strikes made in 1996 and before).
In this paper, we present some detailed medical and psychological consequences of this specific period of hunger
strike actions. Also ethical aspects of hunger strikes in the light of the experience by the Human Rights Foundation
of Turkey and Turkish Medical Association are to be discussed.
tihv@tr.net
tihv-w@tr.net
Discussion: Guidelines for treatment and nutrition after starvation
Siroos Mirzaei, Wilhelminenspital, Institute of Nuclear Medicine, Vienna, Austria
Medical assistance after starvation includes nutritional and therapeutic measures to prevent side effects of a nonadequate food re-intake. Through discussion with other speakers and participants easy to use guidelines will be
presented.
mirzaei@gmx.at
Pathophysiology of hunger strike
Siroos Mirzaei, Wilhelminenspital, Institute of Nuclear Medicine, Vienna, Austria
Food deprivation for periods of several weeks has been reported whereby the average weekly weight loss is 2-3 Kg.
However, the more weight loss occur during the first week. During starvation there are pathophysiological changes
in the body which reflect the adaptation of the body to the situation of caloric deprivation. The protein synthesis and
immune response are altered. The body mass Index (BMI, weight in kg divided by the square of the height in m)
decreases. Reportedly, individuals with a BMI of less than 18.5 kg/m² should be regarded as undernourished and
evaluated for possible treatment. The disadvantage of BMI for monitoring of the individuals in hunger strike (as in
the case of prisoners on hunger strike) is that it is static and rather insensitive to small changes in weight. Measuring
of skinfold at one or more places on the body are indirect measure of the body’s total fat mass. The most common
technique used for this is the triceps skinfold, using a calliper on the back of the upper arm. A starved body attempts
to reduce protein catabolism, uses preferentially ketones and fatty acids and recycles glucose from gluconeogenesis.
It saves its more essential proteins, such as haemoglobin, albumin, cardiac muscle. In this paper we’ll discuss
measurable parameters for monitoring of individuals with food refusal, specially in case of prisoners on hunger
strike.
mirzaei@gmx.at
The hunger strike as political, medical, moral and human rights problem
James Welsh, Medical Program Amnesty International, London, England
Hunger strikes can pose acute difficulties to the striker, to the striker's supporters, to medical staff and to human
rights organizations. They represent a very particular form of protest in which the striker may gamble her or his
health, or even life, against the moral or strategic response of the power holder who has the means to grant or
withhold concessions. Most hunger strikes or other forms of food refusal resolve themselves in a short time, either
because the striker intended only a short symbolic protest or the experience of the strike causes the hunger striker to
end her or his action quickly. However extended periods of food refusal, including those conducted as part of a mass
political action, can lead to deaths or long-term physical and mental deterioration. They reflect politically motivated
action; a health and ethical dimension; they touch on the moral values of the striker, carers and state decision-maker
and challenge both supporters of the hunger striker and civil society organizations which work to promote human
rights. Current autonomy-based ethical standards call on doctors (and arguably others) to respect patient autonomy
and to abjure non-consensual feeding. However some professionals oppose acquiescing in the possible self-inflicted
death of a patient and are sympathetic to the involuntary feeding of the striker. Some governments require health
professionals to forcibly feed hunger-striking prisoners, raising issues of dual loyalty obligations. The ethical
considerations escalate as the hunger strike progresses and the questions of patient competence and best interests
become more complex and the political environment evolves. This paper discusses the hunger strike as a political,
medical, and moral and human rights problem.
jwelsh@amnesty.org
Indigenous Peoples’ Issues
Social Suffering: An Anthropological Analysis of the Embodiment of Inequity
Naomi Adelson, York University
The study of social suffering and structural violence emerges out of critically and socially
engaged social scientific theories that address the embodied effects of traumatic and protracted histories of social
inequalities. Medical anthropologists draw upon the category of social suffering as a way to examine, in both
theoretical and practical terms, the embodied expressions and effects of social inequities. In this presentation, I will
focus specifically on social suffering in the Canadian Aboriginal context. Using a specific ethnographic example, I
address the nuanced complexity of the social and cultural contexts of suffering at the interface of the body and
society and, through this, illustrate the ways in which a history of inequity impact on Aboriginal peoples’ presentday social worlds.
nadelson@yorku.ca
Western Genetic Researchers and Indigenous Populations as Human Subjects: Three Dimensions of
Indigenous Psychology That Influence Research
Janet K. Brewer, The Institute for Indigenous People's Rights, Lewes, USA
Increasingly, Western genetic researchers are looking to indigenous populations, deemed genetic isolates, as subject
pools for genetic research. But typical research protocols and consent guidelines embody Western culture and
beliefs, the implications of which have spawned heated international debate. Three dimensions of indigenous
psychology underlie the clash of cultures: self and non-self, locus of control, and temporal orientation. In essence,
many indigenous populations are collectivist cultures whose members are governed externally, termed “ensembled
individualism,” and conceptualize time as cyclical, oriented toward the past. A thorough understanding of
indigenous psychology is critical to ethically sound genetic research.
JKBrewer@indigenouspeople.us
Maori Gambling and Imprisonment: Interface of Addiction and Crime
Lorna Dyall, University of Auckland
Gambling is increasingly being used by Governments as a strategy to provide tax revenue to fund their priorities.
Gambling and problem gambling is now recognized as a serious public health issue especially for Maori the
indigenous population in Aotearoa /New Zealand. It is estimated that one in three prisoners in New Zealand have
had a gambling problem sometime in their life and over a third of women prisoners currently have a gambling
problem. Research in New Zealand has found that problem gambling is often the underlying reason why people are
in prison and this situation is made worse with considerable gambling taking place within prisons.
One in two New Zealander prisoners self identify as Maori. With this demographic profile this suggests that there
exists a close relationship between New Zealand Government gambling policies and the imprisonment of Maori.
This paper will discuss issues of gambling, criminal offending, imprisonment and interventions which are needed for
an indigenous population, such as diversion options. The mental health status of Maori and will also be discussed as
well as implications for recognition of problem gambling as a serious public health issue.
l.dyall@auckland.ac.nz
Aboriginal Community-Based Healing Initiatives in Canada: Making a Difference
Kimberley Fever, Aboriginal Corrections Policy, Ottawa, Canada
Issues of abuse within families and particularly Aboriginal families have been brought to the surface in Canada over
the last decade. Part of the legacy of the residential school experience, sexual and other forms of abuse are affecting
generations of Aboriginal families. As part of a community-based response to help break the cycle of abuse and
offending from being passed from generation to generation, Aboriginal communities and community-based
organizations are developing holistic models of treatment for Aboriginal victims and offenders with a focus on
healing families.
These projects are unique in that they offer culturally appropriate approaches to offender and family treatment. The
approach taken is one that addresses the root causes of criminal activity and proactively engages offenders, victims
and families to break the cycle of abuse.
These initiatives work within the current criminal justice system while bringing a unique alternative to imprisonment
that can lead to stronger and safer communities. Communities engaged in these healing approaches have seen
benefits in terms of significantly reduced criminal activity, improved physical and mental health of individuals,
attainment of higher education and an increase in positive parenting. All of these things contribute towards
personal, family and community wellness.
This presentation will highlight three models in Canada; two in first nation communities, and a third regional model
encompassing several small towns. While each process is unique to that community, there are some common threads
and lessons learned that could be utilized and adapted to other Aboriginal or non-Aboriginal communities.
kimberly.fever@psepc.gc.ca
What do we know about mental health (social and well-being) of Indigenous Australians within the
DSM context?
Yega Muthu, University of Technology, Sydney
The social origins of mental health problems of indigenous Australians are traced back to the legacy of colonization.
In Australia, cultural discontinuity and oppression have been linked to high rates of depression, alcoholism, suicide,
and in violence in many communities, particularly its effect on youth. Although research has catered for these
challenges, more research is needed to clarify the factors of mental suffering that promote wellness within the
context of the Diagnostic and Statistical Manual for Mental Disorder (DSM-IV-TR) classifications. This paper
argues as to whether DSM-IV-TR caters for the mental health of indigenous Australians. Such a consideration will
have to be balanced against the view of Indigenous mental health. This is viewed as holistic and embodies not just
the physical well-being of the individual but the social, emotional, and cultural well-being of the community, which
also incorporates a whole-of-life view. This paper also demonstrates that cultural psychiatry can contribute to
rethinking mental health services and further enhance the understanding of indigenous suffering within a clinical and
legal framework.
ymuthu@law.uts.edu.au
Crime Prevention and First Nation Peoples and Communities in Canada
Michelle Woods, National Crime Prevention Centre, Thunder Bay Detachment, Canada
The National Crime Prevention Strategy is situated within the Department of Public Safety and Emergency
Preparedness Canada. It is one of several federal (national) government initiatives with policies and programs
inclusive of Aboriginal peoples. The main focus of the National Crime Prevention Strategy is to build understanding
and knowledge on how to effectively address the conditions that can lead people to engage in criminal behaviour or
become victims of crime. This “crime prevention through social development” approach is based on identifying at an
early stage the factors in an individual’s life that can be changed to improve the quality of life and decrease the
potential for criminal involvement or chances of victimization. These factors are often inter-related and can include:
abuse, violence, unemployment, drug and alcohol abuse and low literacy. With respect to Aboriginal peoples, social,
economic, demographic and geographic factors as well as the negative impacts of historical decisions on this
population are important considerations that place this population at even greater risk of becoming victims or offenders.
The National Crime Prevention Strategy attempts to identify the unique risk factors in Aboriginal communities so that
it supports projects that address relevant risk factors and promote protective factors in culturally appropriate ways. The
National Strategy is committed to working with Aboriginal and non-Aboriginal peoples to better understand the crime
prevention issues of Aboriginal communities and to help provide the resources and supports to build understanding,
knowledge and practice. The presentation will provide an overview of the work that that National Strategy has
undertaken in Canada in Aboriginal communities, with a specific focus on its work in the Province of Ontario.
Michelle.Woods@psepc.gc.ca
Informed Consent in Psychiatry
Capacity to Consent to Treatment in Mania – A Cross Sectional Study
Jonathan Beckett, Springfield University Hospital
The involvement of patients with mental illness in decisions about their treatment is becoming increasingly
important. However, collaboration in making treatment decisions depends upon the patient’s capacity. Patients
with schizophrenia have shown a broad distribution of capacity in both the acute and chronic stages of the illness.
Depressed in-patients have shown relatively unimpaired capacity. The capacity of patients hospitalised with acute
mania has not, to our knowledge, been studied. It is therefore a clinical priority to investigate this group to
determine to what extent they can make joint treatment decisions.
Inclusion criteria were: an ICD-10 diagnosis of Manic Episode; a Young’s Mania Rating Scale (YMRS) score > 20;
and informed consent. Data was collected for length of illness; current level of symptomatology; alcohol and
substance use; Mental Health Act status; and other basic demographic details. Premorbid IQ was estimated using
the National Adult Reading Test (NART) and from their educational history. Capacity was determined using a
clinical interview by an experienced psychiatrist (the gold standard). Information about illness and treatment was
disclosed to the patient. Following disclosure, capacity was assessed on five different domains: The ability to (1)
retain; (2) believe; (3) understand; (4) reason with the information and (5) communicate a treatment choice. Patients
fulfilling capacity in all five domains were deemed to have overall capacity in making treatment decisions.
The study has recruited 49 of the intended sample of 50 inpatients by June 28 2004. 92 patients admitted during the
study period were considered for participation. 23 were excluded due to incorrect diagnosis or YMRS score < 20.
69 were therefore considered appropriate to include. Two of these 69 were subsequently considered too ill to
approach. Of the 67 approached to consent: 2 were unable to consent; 7 refused; 3 consented but subsequently failed
to meet the YMRS eligibility score and 6 were missed due to early discharge. 49 therefore completed the interview.
Patients were scored as either having or not having capacity on each domain, with subsequently a binary outcome
measure being obtained for overall capacity. Transcripts of the interviews were checked by a second psychiatrist
blind to the initial rating, giving 84% agreement on the first 40 patients recruited. Results of the patients’ capacity
status along the 5 domains will be available by September 2004. A logistic regression analysis will be employed to
investigate the relationship between illness and demographic variables and each domain of capacity, and will be
complete by October 2004. The relationship between Mental Health Act status and each domain of capacity will
also be determined by October 2004.
The implication of the study's results on capacity and its impact on clinical practice will be discussed, with reference
to possibilities for treatment collaboration and detention in hospital. The limitations of the methodology will be
presented.
jpdbeckett@aol.com
“Above all, do no Harm”: A Psychoanalytic Perspective on Inhibitions in the Work of Medical Mental
Health Practitioners Relating to the Ethical Oath that the Doctor must Avoid Damaging their Patient
James Johnston, Private Practice, Harrogate, England
'Mental health practitioners trained in the medical model tend to think in terms of illness, treatment and cure in their
relationship with their patients. Freud suggested that he had never considered himself a proper doctor because he
lacked sufficient sadism in his personality to feel driven to cure his patients. In this paper I explore the
psychoanalytic relationship between unconscious sadism and conscious desires to heal the other. I will use the oath
sworn by medical practitioners 'above all, do no harm' contains an unconscious fear about the damage we may inflict
on the patients we treat.
I will argue that effective treatment in terms of psychic change involves the capacity to relate to reality. To be in
contact with reality is to be in contact with the depressive realisation that we have damaged our good internal object.
the unconscious motivation to heal (a vocation) is borne from a reparative wish to repair our damaged objects. The
more the doctor is in conscious contact with the damage s/he has done to his object, i.e.; the more s/he is in a
depressive relation to their vocation to heal, the less the drive to undertake a cure of the patient. This is to argue that
the fantasy of cure involves an omnipotent unconscious wish to heal one's own internal damaged objects through a
manic repair of the damage in the other. If the doctor can tolerate the destructive aspect of his/her own personality
they will be less anxious that their love for their patient (shown in their wish to heal) will be overcome by their own
hatred. They will then be able to respond to their patient as a separate person with their own capacities to undermine
their own development and learning from experience. This will foster an attitude of profound respect for the
autonomy of the patient in the pursuing understanding of themselves. It is an attitude which embraces freedom and
responsibility with all the anxieties associated with such a liberation of the self.
The psychoanalytic approach to mental health work invites the patient to be an active rather than a passive
participant in their own process of potential change. It is an attitude which accepts the limitations of all practitioners
and all treatments and seeks to avoid the drive to 'cure' the other. It is an approach which recognises that the change
process causes inevitable psychic pain as the confrontation with reality is inevitably painful. In this sense 'above all,
do no harm' is replaced by an acceptance that we should be less frightened of the harm we fear we have already done
in order to feel less frightened of doing harm in the here and now. This liberates the doctor to becoming a more
robust practitioner who is not dominated by projected superego anxieties into legal or ethical external structures
because their internal ethical and legal structures are more closely linked to guilt which has been worked through.
Such a working through allows a more benign. (less persecutory) superego which is less susceptible to rigid and
inflexible expectations of the self or the other. Internal values guide practice rather than rules laid down by a
projected fantasy of a persecutory anonymous external authority.
'Above all, do no harm' then becomes a principle borne from one's personal recognition of the capacity to harm as
well as the capacity to heal the other.
a.bogle@zetnet.co.uk
Informing Patients about Tardive Dyskinesia
John Laugharne, Osborne Clinic, Stirling, Australia
Tardive dyskinesia(TD) is an involuntary movement disorder associated with the long term use of antipsychotic
drugs and is potentially irreversible. The introduction of “atypical” antipsychotic agents in recent years may have
reduced the risk of TD but evidence is currently limited. This presentation will review the data relating to the
attitudes and behaviours of psychiatrists internationally towards informing their patients under treatment for
psychotic disorders about the risk of TD.
In particular, data will be presented from a study of 230 psychiatrists from the United Kingdom (UK), the
Netherlands and Spain which investigated attitudes to informing patients about the risk of TD using a postal
questionnaire. Completed questionnaires were returned by 81(42%) of UK psychiatrists, 106(20%) of Dutch
clinicians and 43(22%) of Spanish Psychiatrists. 20% of Dutch respondents, 17% of UK respondents and 10% of
Spanish respondents indicated they would routinely inform patients of the risk of TD. Major issues to be considered
for clinicians in all three countries were risk of decrease in compliance with treatment, lack of capacity, the patient’s
rights and anticipated length of drug use. In regard to factors affecting a patient’s ability to make informed decisions
about treatment Dutch clinicians gave more emphasis to clinician-related factors than UK or Spanish clinicians. UK
respondents were the most concerned about the possibility of future litigation whilst less than 50% of respondents in
each of the three countries were in favour of standardised consent forms.
Overall there was considerable variation in views from clinicians from all three countries. There was no clear
consensus on many of the issues raised. These data will be discussed in the context of other related studies and
international recommendations in regard to informed consent in psychiatric practice.
laugharne@iinet.net.au
Patient Choice in Mental Health Care
Richard Laugharne, Wonford House Hospital, Exeter, England
Patient choice in mental health care has become a controversial issue in the NHS in the UK. This practical issue is
influenced by the philosophical spectrum between paternalism and autonomy in the relationship between the patient
and clinician. This presentation will present a literature review on the evidence for patient choice. This has
suggested that patients are keen to have more information about their care, but do not necessarily want to choose
what treatment they receive. A study, examining how much choice mental health patients want and how age, gender
and diagnosis influences desire for choice, will be described.
r.laugharne@exeter.ac.uk
Mental Health Law Reform in New South Wales, Australia
Milton Orkopoulos, Parliament of New South Wales
New South Wales commenced a review of its Mental Health Act 1990 in February 2004. This Act regulates the care,
treatment and control of mentally ill and mentally disordered persons in New South Wales. The review has been
conducted through calls for submissions from stakeholders on two discussion papers. There has been no
comprehensive review done of the mental health legislation in the fifteen years in which the Act has been
operational. In that period there has been substantial changes in the way that mental health services are organised
and provided. The two discussion papers were designed to stimulate discussion, public comment and suggestions for
reform. The next stage of the review will be the release of an exposure draft bill for further consultation in May
2005. Major areas of proposed change to the legislation include: information sharing with carers; the impact on
mental health services of developments in privacy law; admission to and care in hospitals; management of forensic
patients including the structure for their review and release; care and treatment outside hospitals; medical and
therapeutic treatments and the proceedings of the NSW Mental Health Review Tribunal. This presentation will
discuss the major issues raised in the review of the Act as well as significant changes proposed within the draft
exposure Bill.
catherine.watson@parliament .nsw.gov.au
Intellectual Disability I
Gender and Aggressive Behavior Among Individuals with an Intellectual Disability
Anne Crocker, Douglas Hospital Research Centre
Aggressive behaviour exhibited by individuals with an intellectual disability pose important management issues in
service delivery and is a large obstacle to social, educational and vocational integration. Studies have tended to show
that men are more likely than women to exhibit aggressive behavior. However, most of the research focuses almost
exclusively on higher levels of severity of aggressive behavior and do not distinguish between the different types of
aggressive behavior. The goal of this study is to examined gender differences and similarities in the type and
severity of aggressive behavior. Using the Modified Overt Aggression Scale (MOAS), four types of aggressive
behavior (verbal, property damage, self and physical) were surveyed within a population of 3,165 individuals (1,633
men and 1,527 women) with ID receiving services from three large agencies in the province of Québec. With 51.4%
of men and 52.3% of women displaying some form of aggressive behavior over the past year, few gender
differences were observed both in terms of prevalence and overall aggression scores. One notable gender difference
appeared: men were 1.5 times more likely than women to have displayed physical aggression causing injury over the
past year. However, among these individuals, women were as likely as men to have had police intervention as well
as to have had a history of arrest. These and other results will be discussed in terms of the importance of identifying
programmatic needs, training programs and systematic assessment and monitoring procedures.
Anne.crocker@mcgill.ca
Recent Trends in Services and Supports to People with Intellectual Disabilities: Implications for Law
and Policy
Valerie J. Bradley, Human Services Research Institute, Cambridge, USA
The changes that are emerging in systems of support for people with intellectual disabilities in many parts of the
world are part of a trajectory of reform that began decades ago. These reforms have encompassed the exposure of
the inhumane conditions associated with institutions, the creation of alternative residential and day supports in the
community, the passage of significant legislation supporting the legal and civil rights of people with disabilities, and
the provision of supports to families to maintain children with disabilities at home and in their communities. As
each component of reform has taken root, the power of ideas like normalization, inclusion, and participation to
criticize practice and to inform further change has increased. It is as if the closer we think we are to the realization
of these ideals, the more they demand of our skills and creativity.
This presentation will provide an overview of the changes that have taken place in over the past 3-4 decades and the
attendant legal changes that have both facilitated and resulted from major policy, programmatic and philosophical
milestones. This discussion will include a review of the institutional improvement movement of the 60s and 70s and
concomitant right to treatment entailments; the deinstitutionalization movement and resulting moves to instill rights
to education, least restrictive environment and community integration; the community membership movement and
the moves to include choice and access issues in policy; and finally emerging policies that recognize the rights of
individuals to control the deployment, character and configuration of their services and supports, and the attendant
changes in planning, financing and oversight. The presentation will conclude with speculation about future trends
and the ideas that may precipitate the next wave of change.
vbradley@hsri.org
Research on People with Intellectual Disabilities: The Vexing Problems of Capacity, Consent,
Surrogacy and Participation
Robert D. Dinerstein, American University
Increasingly, people with intellectual disabilities are in situations that call for them to give informed consent to
various kinds of intervention. Informed consent requires the person to have the capacity to make the decision in
question; to have sufficient knowledge about the decision; and to be able to decide freely and without coercion.
While many people with intellectual disabilities have the ability to give or withhold consent in a variety of
circumstances, others are unable to do so (at least some of the time). In such cases, policy-makers are called upon
either to forgo the proposed intervention or seek out a form of surrogate consent. There are numerous kinds of
surrogate arrangements, many of them problematic. One area in which surrogate consent for people with
intellectual disabilities raises particularly troubling issues is that of experimentation, especially experimentation that
does not offer the prospect of direct therapeutic benefit to the person with intellectual disabilities.
For many reasons, including the historical context of past efforts to get consent from people with intellectual
disabilities (many of whom were in institutional settings where they or their family members were subjected to
highly coercive circumstances), we are right to be skeptical about any form of surrogate consent in experimentation.
But at least some individuals with intellectual disabilities make the claim that they should be able to participate in
such experiments as an element of their citizenship and membership in the community. And whether one argues for
participation or not, the problematic nature of determinations of capacity, notions of consent, and the role of
surrogates makes this area a fruitful one for debate and discussion.
This topic is particularly well-suited to a panel that honors the extraordinary work of my friend and colleague the
late Stan Herr. Stan was one of the earliest scholars and advocates to focus on the importance of (and abuses
surrounding) determinations of competency and capacity, as well as on the abuses suffered by people with
disabilities who were institutionalized.
rdiners@wcl.american.edu
Protecting People with Mental Disabilities and Impairments against Biomedical Research Abuse
John H. Noble, Jr., The Catholic University of America
Vera Hassner Sharav, Alliance for Human Research Protection, New York, USA
People with mental disabilities and impairments have been targeted historically by biomedical researchers and their
governmental and industrial sponsors for exposure to risky experiments that impose high risks without offsetting
therapeutic benefits on the theory that the future good of society justified what was done to them. The final report of
the Advisory Committee on Human Radiation Experiments (ACHRE) (1995) systematically reviewed and
condemned much of what was done to institutionalized persons with mental retardation in such places in the United
States as Willowbrook in New York and the Walter Fernald School in Massachusetts. Since the ACHRE report
abusive biomedical research has continued.
This paper reviews several recent cases, including challenge experiments on schizophrenic patients, respirator tidal
volume experiments on unconscious patients with Acute Lung Infection (ALI) and Acute Respiratory Distress
Syndrome (ARDS), experiments on children with AIDS under state guardianship, artificial blood experiments on
unconscious traffic accident victims, and lead poisoning experiments on healthy poor children that caused ensuing
neurological impairments. It notes the ubiquitous invocation of "surrogate consent" to enrol persons incapable of
understanding the risks and benefits of the research into which they recruited.
The paper reviews the weaknesses of surrogate consent laws and practice, pointing out efforts by biomedical
researchers and their sponsors to weaken even the provisions that now exist. Further, members of the American
biomedical research establishment and officialdom have been systematically trying to weaken the provisions of the
Declaration of Helsinki (1964) that prohibit the conduct of non-therapeutic research.
The paper sets forth a number of recommendations to strengthen protections afforded to people with mental
disabilities and impairments, including definition of such human subjects as a "protected class" that would require
judicial registration and appointment of a court officer to assess the risks and benefits of the proposed research and
to monitor how the research is actually conducted.
jnoble4@cox.net
What are Appropriate Legal Responses to the Challenging Behaviours of Adults with an Intellectual
Disability With or Without a Dual Diagnosis of Mental Health?
Paula Scully, Department of Justice, Queensland, Australia
The Queensland Mental Health Act 2000 excludes adults with a sole diagnosis of intellectual disability, except when
they are the subject of a forensic order because of their involvement in the criminal justice system. The Queensland
Guardianship and Administration Act 2000 provides for guardianship orders for adults with impaired decision
making capacity. The Adult Guardian, an independent statutory officer, can be appointed as guardian of last resort
for such adults when there is a need to make decisions on accommodation, health care and services.
Some adults with an intellectual disability exhibit challenging behaviours which can result in violence to themselves
or others, but in most cases, a mental health diagnosis is excluded. There are disputes by disability workers with
psychiatrists as to whether the considerable abnormal behaviours of such adults are Axis I or II diagnoses under
DSM IV. If they are not Axis I, then compulsory psychiatric hospitalisation is not an option. They are left in the
community in their own homes, and in some cases accompanied by support workers on a 24 hour basis with
restricted community access.
Debates rage as to whether this amounts to civil detention, in breach of international human rights norms, or whether
there is a need for a new legislative regime based on the recent Victorian Law Reform Commission report on People
with Intellectual Disabilities at Risk: A Legal Framework for Compulsory Care Report. There is considerable
controversy over the shortage of suitable accommodation for the needs of these adults, and whether they should be
kept in secure accommodation under a compulsory order.
paula.scully@justice.qld.gov.au
Maintaining Integrity and Cultivating Compassion
Steven J. Schwartz, Center for Public Representation, Northampton, USA
The evolution and deepening of our work as advocates for persons with disabilities is informed by a variety of
personal experiences and the exploration of a number of different paths. These paths also have specific
characteristics associated with them which we can learn to cultivate, if we are interested in deepening our
understanding of the art of advocacy and our commitment to that path. I will try to name a few of these
characteristics, or states of mind, so as to encourage those who are interested in pursuing a particular path. This is a
peculiarly personal journey, walked by each of us at our own pace, in our way, for our own purposes. I do not
profess to understand why we pursue different paths in search of the same goals. I only know what I have
personally witnessed, and speak from that voice.
Sschwartz@cpr-ma.org
Intellectual Disability II
The E.M.D.R. Therapy for People with Mental Retardation and Challenging Behaviors
Irena Burdova, Hoeve Boschoord, Boschoord, The Netherlands
Eye Movement Desensitisation and Reprocessing Therapy is an efficient treatment for people with posttraumatic
stress disorder (PTSD). But does it also work for people with MR/DD and serious challenging behaviours? In our
treatment centre (Hoeve Boschoord the Netherlands) we provide a complex treatment for this population. One half
of our clients have been convicted of criminal offences, the rest volunteer the treatment. All our clients are
vulnerable and many of them have experienced very traumatic events in their past. In the consequence they feel
powerless, ashamed and guilty, they find themselves bad, weak and useless. The events are for them unspeakable.
Figuratively and literally. During the treatment we offer many therapies and training’s to increase their competence
and to get them ready to go back to the community and to lead the most integrated life possible. Yet we often have
to witness how their unprocessed traumas slow down or block their treatment. Would EMDR be the therapy to
‘unblock’ it? Can EMDR help to process their traumatic experiences and make their anxieties, intrusions and
flashbacks disappear? Can we combine the EMDR with other therapies? And what are the long-term results? In this
presentation/ workshop we would like to share our experience and give some answers to these questions. We will
offer some videotaped material to illustrate the EMDR sessions with our clients.
i.burdova@hoeveboschoord.dji.minjus.nl
Treating Adult Sexual Offenders with Mental Retardation
B. le Grand, Hoeve Boschoord, Boschoord, The Netherlands
This presentation will discuss the development and content of a program designed to treat adult sexual offenders
with mental retardation and developmental disabilities. Hoeve Boschoord is a treatment-clinic for mentally retarded
adults with severe behavioural disorders in the Netherlands. In this clinic we have developed a specific treatmentprogram for mentally retarded sex-offenders. This program is based on the cognitive-behavioural therapy and
makes use of elements of the relapse-prevention-model. The fact that the population is mentally retarded implicates
that many methods and techniques of the generally used ‘relapse-prevention-model’ have to be adapted to the
possibilities and limitations of our clients. And, what’s more, much attention has to be paid to the generalisation and
the integration of the learned behaviour. To realise this, we arrange a therapeutic environment in which new learned
behaviour often can be practised in various ways and in various contexts: the surplus of repetition. By means of
casuistic examples will be demonstrated how we make an analysis of the ‘offence-chain’ and how we strengthen the
vulnerable areas in the deviant cycle by increasing competences.
B.le.Grand@hoeveboschoord.dji.minjus.nl
Intellectual Disabilities and the Origins of Special Education Laws in the US
Jeff Kahana, Mount Saint Mary College
This paper offers a historical portrait of educational policy in the US for the disabled child in the nineteenth and
early twentieth century. Its main focus is how an awareness of intellectual disabilities at the turn of the twentieth
century sparked a legal agenda that sought passage of special education laws. These laws sorted the disabled child
into special classes by virtue of intellectual rather than physical disability. Through this case study we also see how
a public-private partnership approach to educating the blind and deaf child in the nineteenth century became
transformed into a primarily public initiative in providing educational services for the disabled child by the early
twentieth century.
Kahana@msmc.edu
Risk assessment off offenders with a mild Intellectual handicap or borderline Intellectual functioning
Bernadette Lutjenhuis, Hoeve Boschoord, Boschoord, The Netherlands
Results of the completion of several risk assessment instruments of round and about 70 offenders with mild
Intellectual Disability or borderline Intellectual functioning are presented. Among the instruments are the PCL-R,
SVR-20, HCR-20, STATIC and HKT-30. Practical and ethical problems concerning the correct/appropriate use of
the instruments on the target group are discussed.
B.Lutjenhuis@hoeveboschoord.dji.minjus.nl
Theory of Mind in individuals with an intellectual disability
Drs. A. Solodova, Booschoord, The Netherlands
The presentation will address the concept of Theory of Mind (TOM) and the development of a new instrument,
measuring this concept. This instrument is specifically designed for the population of intellectually disabled adults
with severe behavioural problems. Theory of Mind is a concept which has been the object of research during the last
couple of decades. Mostly the focus has been on children with autistic features and normally developing children.
There are hardly any instruments designed to measure TOM in adult individuals and as far as we know there are non
specifically developed for individuals with an intellectual disability. The need for such an instrument for the above
mentioned population will be addressed during the presentation. Next, the pilot-version of the instrument will be
presented.
A.Solodova@hoeveboschoord.dji.minus.nl
Evaluation of a 4 phased treatment in a therapeutic environment for offenders with developmental
disabilities
Drs. Anke C. ten Wolde, Boschoord, The Netherlands
Results of the research project ‘Interaction as Assignment’ will be presented. The research was carried out in Hoeve
Boschoord, a Dutch centre for the study, assessment and treatment of offenders with below average intellectual
functioning. In-patient specialised treatment is given according to a 4 phased treatment model in a purposeful
arranged therapeutic environment. In a longitudinal study treatment procedures of socio-therapists with their patients
were portrayed and evaluated. Outcome of the Best Index, program integrity, effects and side-effects of the 4 phased
treatment model are discussed. Special attention is given to the way in which the treatment program and the staff
deals with patient deficiencies.
A.ten.Wolde@hoeveboschoord.dji.minjus.nl
Cultural issues in Adolescent Forensic Psychiatry I
Experts’ Opinions on Diversity in Legal Conflict and Forensic Assessment for Court: Do Intercultural
Issues Matter?
Karen Jahn, Westfälisches Institute, Hamm, Germany
Wolfgang Bilsky, University of Münster
Semi-structured expert interviews were conducted with police officers, lawyers, state attorneys, judges, correctional
staff, interpreters and psychologists/psychiatrist experts.
According to semi structured expert interviews with police officers, lawyers, state attorneys, judges, correctional
staff, interpreters, psychologist- and psychiatric experts occupation centered problems, actual operation possibilities
and demands regarding intercultural activities within the German Criminal Law are being examined. Differences
exist by the various occupation branches regarding the description of specific intercultural activities which are
mainly seen by participating persons and their interaction. Regarding forensic evaluation inadequate bases and
desiderative or false cultural and lingual knowledge are criticised. The results allude to structure quality (bases, etc.),
process quality (education, networking etc.), and quality regarding intercultural activities. Demands are problem
awareness, flexibility, participation of native speaking experts, as well as changes of social-legal general conditions.
andrea.faust@wkp-lwl.org
On Intercultural Victimology, Honour and Shame: Lessons Learned from an Inner-ethnic-minority
Rape Case Judged by a Majority Culture Court
Renate Schepker, Westfälisches Institute, Hamm, Germany
On behalf of psychiatric experts, too little is known about adolescent male and female sexuality in ethnic minorities
like the Turkish minority in Germany. While in public life virginity, marriage and traditional eastern values like
seref and saygi prevail, adolescents growing up in the midst of a western society find their own bicultural ways, thus
creating different spaces of reality which usually do not interfere. They only clash in the case of conflict or crime,
and this is only very seldom processed through legal institutions of the majority culture, because the preferred
solutions are intra-ethnic ones.
The unusual case of a bicultural rape victim assessed for credibility by a child and adolescent psychiatrist
demonstrates that aspects of female sexual autonomy in ethnic minorities warrant more research and attention.
Whereas from an intra-ethnic point of view, the perpetrator was not to blame, the majority court convicted him to a
prison sentence.
Support for the victim as well as opening up the investigation was in danger to create a new intercultural dilemma
and new dangers for her. The psychiatrist’s role as an expert in these cases may include a partiality in favour of an
affirmative action for human rights. An elaborate understanding of such cases relies on the proficiency for an
“intercultural code switching” on the side of the expert that parallels this ability on the side of the examinee.
r.schepker@wkp-lwl.org
Family Risks and Resources in Migration – Their Impact for Adolescent Delinquency
Mehmet Toker, Westfälisches Institute, Hamm, Germany
117 families in Germany (patient and field families) originating from Turkey were investigated as to risks and
resources by means of semi structured family interviews and expert ratings, based on the contextual family theory
approach. A family typology was drafted from family theory characterizing successful families with nonsymptomatic, non-delinquent offspring and non-successful families. The typology developed for dysfunctional
families with delinquent behavior of adolescent boys rendered three main risk types: monoculturally frozen families,
uprooted families and co-dependent families. Uprootedness proved to be a specific risk factor for delinquent
behavior of the offspring. Parents’ views on the prevention of delinquent behavior referred to control and strictness
on one hand, on care and support on the other hand. Lack of parents’ insight in the rules of teenage mainstreaming in
the dominant culture caused another specific risk especially if the family did not “allow” bicultural attitudes.
The typology is commented by a bicultural family therapist and will be illustrated by case studies on adolescents
who have committed severe crimes and were assessed by the authors for court.
mehmet.toker@wkp-lwl.org
Ethnicity and Its Relevance in a Seven-year Admission Cohort to an English National Adolescent
Medium Secure Health Service Unit
Nathan Whittle, Bolton, Salford & Trafford Mental Health NHS Trust, Manchester, England
Case notes detailing individual, clinical and family background information on 61 inpatients in a medium secure
adolescent NHS psychiatric forensic unit were analysed with the primary aim to determine the distribution of
patients from different ethnic backgrounds. Inpatients from ethnic minority backgrounds (N = 22, 36.1%) were
significantly over-represented when compared to Census data, due to the significant over-representation of Black
inpatients (21.5%). These results are discussed in relation to control and restraint, and serious incidents during
inpatient stay. The results are compared with data from studies of prison and community populations and
recommendations are made for the improvement of service provision and future research. The primary finding of the
study is consistent with previous studies in adults, which is that there is a significant over-representation of ethnic
minorities (36.1%) and more specifically a significantly increased prevalence of psychiatric admissions in the Black
population compared to White. This is also comparable to data from adolescent psychiatric secure units in Holland.
There are on-going debates about the shortfalls in present day psychiatric services when dealing with ethnic
minority cultures and fears about such ethnic minority patients being over-diagnosed with psychotic illnesses due to
a lack of awareness about cultural norms. Progress is being made in the development of services and provision for
young people from ethnic minorities in terms of meeting their mental health needs, although there are many areas
that still need to be addressed.
njwhittle@gardener.bstmht.nhs.uk
The Expert’s Role in Juvenile Court in Turkey and Germany – An Intercultural Dialogue
Cahide Aydin, Ege Üniversitesi Tip Fakültesi
Renate Schepker, Westfälisches Institute, Hamm, Germany
Legal and cultural differences have a great influence on possible roles of psychiatrists as court-appointed experts in
special cases.
A total of 2 x 25 consecutive referrals for psychiatric assessments from juvenile courts in Germany and Turkey were
analyzed as to possible intercultural differences. The cases were studied in a joint effort by two different Child and
Adolescent Psychiatry institutes (Ege university Adolescent department, Izmir,Turkey, and Westfalian Institute,
Child and Adolescent Psychiatry, Germany) according to the following criteria:
Enquiries of the court towards the expert, debate about maturity (Germany) or social responsibility (Turkey);
psychiatric history and symptoms, age and gender of the offender, type of offense, expert opinion, expert suggestion
for intervention and expert prognosis.
The expert’s role in the different legal systems is discussed pointing out intercultural similarities and differences:
punishment vs. educational aims of the legal system, role of substance abuse in the assessment of liability, cultural
explanations for behavior of an adolescent, possibility of court-ordered therapy instead of a prison sentence, severity
of psychiatric disorder vs. severity of offense in determining the judges’ verdict.
caydin@egenet.com.tr
cahideaydin@yahoo.com
r.schepker@wkp-lwl.org
renate.schepker@wkp-lwl.org
Interdiciplinary Issues in Mental Health Law Arbitration
Cultures of Law and Medicine in the Service of Those We Serve
Michael Bay, McMaster University
It is now accepted wisdom in our multicultural world that a great deal of effort must be invested in order to bridge
the cultural gaps created by ethnic, linguistic, racial and national differences. Programs designed to address these
problems have become matters of high priority across in nations across the globe. Perhaps the time has now arrived
to understand that equally profound cultural chasms exist in the sphere of law and mental health. It is impossible to
deny that policy makers, legislators, lawyers and psychiatrists each exist in their own parallel universe with little
communication and less respect between them. They speak different languages and carry on their work on the basis
of profoundly different ideologies and assumptions. Nor is it possible to refute the proposition that this situation
leads to unpleasantness, bad policy, and, indeed, dysfunctionality in the sector. If progressive public policy is to be
formulated and our mutual clients and patients are to be well served, then urgent, positive, and ongoing steps are
required on all sides to find common ground and establish mutual respect and communication. While it may not yet
be necessary to bring in the cultural anthropologists, sociologists, or mediators, ways must be found to accomplish
this. This paper will discuss the evolution of mental health law in Ontario, Canada, and how it has affected the
culture, conduct and relationships of the various professional/cultural groups in the province. It will also make some
modest suggestions for addressing the problem.
baylaw@sympatico.ca
Implications for the Community of Professional Identities and Approaches to Collaboration in the
Practice of Mental Health Law
Sharon Carson, Psychologist, Toronto, Canada
The member on the community panel has equal weight in the procedure and process of the Board, during the
Hearing and participating in the deliberation. There is the expectation that the Community member is familiar with
the mental health law relevant to a given Hearing, and that there is some understanding of the type of illness to
which the psychiatrist refers in the clinical presentation. Educational sessions are part of the preparation after
appointment to the Board. .
The equal membership of the Community member helps to ensure that the purpose of the Hearing remains
in focus. The independent perspective of the non-professional member is added to experience and other expertise,
and can overarch the worldviews inherent in the formation of the identities of the professionals engaged in their
differing tasks.
The perspective of the client-patient may be understood differently by the Community member, together
with the additional information brought by family members and other “witnesses” called by either side. The
psychiatrist is concerned with preservation of therapeutic alliance required for ongoing care, and the lawyer with the
conduct of the current case. Enquiry by the Community member may assist the professionals participate as
“cultural” consultants in the respecting of rights, safeguarding of society and taking into account the type and stage
of illness of the individual, which brings about the Hearing.
splec@rogers.com
Ethical Issues and Professional Tasks in Mental Health Tribunal Hearings
Joseph Glaister, University of Toronto
Examination of the tension between the legal profession and the psychiatric profession requires an awareness of
ethical dimensions in mental health law. The differences in perspective of the professions offer the potential for
misunderstanding, with frequent misconceptions about the roles and functions of the protagonists. The mental health
law bridges the gap, albeit not integrating these worldviews.
The psychiatrist, as physician, attends to the task of treating the disease of the body and mind of the patient, a blend
of cognitive and emotional engagement, whereas the task of the lawyer relates to a more general, even abstract,
cognitive interest dealing with abstract principles as codified in mental health laws. The psychiatrist’s task is to
focus on interaction with an individual patient, mind and body, in a personal context which includes the internal
values of the person. The lawyer relates to external principles, in the context of the legal frame work specific to the
Hearing in which the client is placed.
It is argued that these two approaches can be reconciled by maintaining the focus on the purpose of the Hearing, so
that the values of each side can be applied in the hearing of the client-patient’s case.
Joseph.glaister@utoronto.ca
Development of Professional Identity and «Cultural » Competence in the Service of Mental Health
Law
Rosemary Meier, University of Toronto
The differing perspectives of Law and Medicine reflect the different developmental journeys of their practitioners,
the degree of assimilation of individuals in the culture of their profession and the context of their practice. Lawyers
esteem liberty, while psychiatrists value thinking and functioning. The Law is invoked when there is an infraction,
or rights need protection. Medicine is involved when knowledge of pathology is required or skills for treatment of
illness.
As in the development of personal identity, a sequence of developmental tasks leads to the manifestation of
professional identity, and the competences needed for professional practice. “Cultural” competence is required in
the encounter of the professions, epitomised in the mental health law forum, here interprofessional tension may be
inevitable in the process of a Hearing. Cross-examination, for example, may be experienced by the psychiatrist as
culturally dissonant adversarial at a personal level, and disrespectful of the case presented on behalf of the person
whose functioning is compromised by an illness. The environment may be a natural habitat for the lawyer and an
unaccustomed milieu for the psychiatrist.
Analysis of the situation in cultural terms may help to reframe the positions of the psychiatrist and lawyer, and offer
an educational approach to appropriate preparation for the tasks required. The professional members on the Board
can serve as “cultural” consultants in their area of experience and expertise when taking into account the evidence
provided to support the certification and the grounds for the appeal to the Consent and Capacity Board, adding the
value of professional and cultural competence to the adjudication of the client-patient’s rights to liberty and care,
and the safeguarding of society as experienced by the community.
Hmr.meier@utoronto.ca
Human Rights and the Mentally Ill III
International Aspects of the Human Rights of Mental Patients
Marianne Kastrup, Centre Transcultural Psychiatry, Copenhagen, Denmark
According to the UN Human Rights Declaration, a basic assumption is that all men have certain fundamental rights.
All men have a wish to live free from violence, famine, disease, torture and discrimination as pointed out by the UN
Secretary General, and such rights belong not to a chosen few, but to all of us.
In recent years, we have in recent years witnessed an upsurge in the attention paid to the ethical and human rights
aspects of the psychiatric profession.
Today, the psychiatric profession is guided by a number of rules and declarations. Some are common to all medical
professionals like the WMA Tokyo Declaration. Others reflect the specific role and problems of the psychiatric
profession with the Madrid Declaration providing the key guidelines for psychiatrists.
The paper will discuss pertinent issues with respect to human rights violation. One issue has always been of specific
concern for our discipline contrary to other medical disciplines, namely the potential risk of the psychiatric
profession to take part in any abuse of the profession.
Much attention has been paid to alleged political abuse where psychiatric care and psychiatric diagnoses have been
used on non-mentally ill persons. To avoid this, it is decisive that a psychiatric diagnosis should be determined
according to internationally accepted standards and difficulty in adapting to certain moral, or social values in it self
should not be considered a mental illness.
marianne.kastrup@rh.hosp.dk
Patient Rights in Psychiatry : Clinical Guidelines and International Perspectives
Federico Allodi, Consent and Capacity Board, Ministry of Health, Toronto, Canada
In the last decade the international human rights movement has had a profound effect on the practice of psychiatry
across the globe. Primarily, UN legislation concerning the rights of persons, and specifically the rights of the
mentally ill, has found its way into national and provincial or state legislations. This paper reviews this international
legislation as well as other mental laws existing in English speaking and other countries at different stages of
development, and the mechanisms existing in various countries for the administration and the implementation of the
law. It offers to the clinician with the required knowledge of the legislation with emphasis on involuntary admission
or detention in an institution and on the patients’ capacity to consent to treatment. The legislation also refers to the
assessment of the mental competence to examine or consent to the disclosure of the patient’s own records, managing
property and admission to a health care facility.
Specific guidelines are given to the practicing psychiatrists to examine the patient, assess grounds for involuntary
detention or admission and capacity or competence to consent, to document findings and procedures and inform
patients of the findings and consequences of the same. Should the patient, next of kin or substitute decision maker
challenge those decisions the doctor has the legal responsibility of justifying them in front of government officials or
legally constituted board or tribunal. The paper emphasizes the need for training of the psychiatrist in the
preparation and presentation of his/her case in the quasi-judicial or adjudicating nature of the hearings. To this
purpose a number of principles and guidelines are offered. The paper concludes with the proposition that these
historical and critical changes in our clinical field represent in fact a great opportunity to maintain and enhance our
tradition of humane concern for our patients, cement our leadership in the mental health field and accrue the
recognition that the new services provided truly deserve.
fallodi@pobox.com
Mentally Ill Offenders and the European Court of Human Rights
Pauline M. Prior, Queen’s University at Belfast
Mentally ill offenders find themselves at the intersection of the healthcare system and the criminal justice system in
most countries. Decisions on their care often involve lengthy discussion on the more general debate on care versus
control in society. In this paper, we focus on one aspect of this debate - that of human rights. Though governments
have a duty to protect the rights of all their citizens equally, it is often the case that where offenders with mental
illnesses are concerned, the emphasis is on the protection of society from possible danger rather than on the needs of
the individual offender. An analysis of cases taken to the European Court of Human Rights (ECHR) by mentally ill
offenders, from a number of countries throughout Europe, demonstrates the difficulties inherent in ensuring
appropriate care to individuals and safeguards to the public at the same time. The countries represented in this
selection of cases include the United Kingdom, Belgium, Norway and Austria. The issues debated in the ECHR
relate to the right to assessment and to a review of treatment and detention, the right to appropriate treatment at all
stages of the detention, and the right of the state to intervene in the life of an individual in order to prevent suicide.
Many of the ECHR judgments have led to clarification of the issues involved in the imprisonment of mentally ill
offenders during and beyond the tariff time for their offence. They have also led to improvements in services for this
group of people, some of whom are serious offenders and some of whom are not.
p.prior@qub.ac.uk
Prisoners’ Rights: Protection by Inspecting Judges
Albert Kruger, High Court, Bloemfontein, South Africa
Prisoners are a vulnerable group. Their rights can easily be abused. The Constitution of South Africa, Act 108 of
1996 in section 35(2) guarantees certain rights for all sentenced prisoners, including the right to conditions of
detention that are consistent with human dignity. The Inspecting Judge of Prisons, Judge Fagan, in his annual report
2003/04 says that these rights are continuously being infringed.
Prisons in South Africa are in the words of the Inspecting Judge “grossly overcrowded. With space for 114747, we
have 184806 prisoners crammed in, i.e. 70000 above capacity.” Goyer, Prison Privatisation in South Africa, says
that overcrowding inevitably leads to poor sanitation and hygiene, and impacts on the provision of basic services
including adequate nutrition and hygiene. She says that due to poor medical treatment of contagious diseases which
thrive in the prison environment, prisoners return to the community sicker than they left and take their sicknesses
with them. She estimates the current HIV infection rate in South African prisons to be at least 30%.
Chapter III of the Correctional Services Act 111 of 1998 contains provisions for minimum conditions regarding
accommodation, nutrition, clothing and bedding and health care. The Department must provide adequate health care
services. Chapter IX of the Act provides for the judicial inspectorate, an independant office under the control of the
inspecting judge, who inspects prisons in order to report on the treatment of prisoners and on conditions in prisons.
A prisoner may not, even with his or her consent, be subjected to any medical, scientific experimentation or
research. A prisoner may not participate in clinical trials except with the Commissioner’s approval given on
application made by the prisoner (reg 7(7)).
The Inspecting Judge of Prisons and all high court judges visit prisons. During the 2003/04 year, 15 prisons were
visited by judges. The only power which the Act gives judges, is to report to the minister. During the same period,
Judges ordered the release of two terminally ill prisoners. Judges can make an important contribution to ensure that
prisoners’ rights are respected, in reporting abuses and ordering release in appropriate cases.
albertkr@global.co.za
Protecting the Human Rights of Patients: The International Legal Framework
Anna-Lena Svensson-McCarthy, Lawyer, Human Rights Consultant and Trainer
More detailed knowledge about international human rights law and practice is becoming increasingly important for
medical health professionals, including, in particular, specialists in mental health. Law, whether national or
international, is not a purpose in itself, but a means towards an end. International human rights law is applicable to
all persons, and thus also protects the rights of medical patients, including those deprived of their liberty for
whatever reason that might be. Lawyers and physicians share the duty to work for the best interests of their clients,
and inter-professional exchanges of knowledge can be indispensable for purposes of increasing the understanding of
the patient’s/client’s problems and for ensuring the effective protection of his or her rights. This presentation will
focus on the major sources of law of interest to medical health professionals and will also introduce the participants
to A Manual on Human Rights for Judges, Prosecutors and Lawyers published jointly in 2003 by the United Nations
Office of the High Commissioner for Human Rights in Geneva and the International Bar Association in London.
This Manual, while not addressed to medical health professionals, as such, still provides essential basic information
for all professions regarding legal texts and jurisprudence on a considerable number of relevant human rights and
fundamental freedoms.
al.svensson.mccarthy@bluewin.ch
Compulsory Community Treatment Orders I
Social and Structural Dimensions in the Implementation of Community Treatment Orders
Lisa Brophy, University of Melbourne
This paper will explore the demographic characteristics of approximately 170 people on Community Treatment
Orders (CTOs) in one area mental health service in Victoria, Australia. The results of a cluster analysis will be
presented and discussed in relation to whether this analysis can inform the question of whether there are particular
‘types’ of people who are most likely to be subject to a community treatment order. The data will be compared and
contrasted with the author’s qualitative research that is exploring key stakeholder perspectives on the current use and
purpose of CTOs. Preliminary identification of themes suggests that resource management, along with risk
management, form significant foundations for decision making. These findings are important in the context of policy
and practice in Victoria, where the use of CTOs is common practice and orders are generally made for a 12 month
period (it is estimated that at any one time at least 3,000 people are on community treatment orders). There is a
significant challenge to ensure that those subject to CTOs are not subsequently ‘languishing’ on them due to
resource restrictions that inhibit the development of less coercive treatment options. The potential of recent law
reform to be able to meet this challenge will be considered, including the introduction of treatment plans as an
attachment to CTOs.
Lisa.Brophy@mh.org.au
Involuntary Care and Treatment in the Community: Policy and Practice Across Three Jurisdictions
Jim Campbell, Queens University at Belfast
Lisa Brophy, University of Melbourne
Bill Healy, Queens University at Belfast
Ann-Marie O’Brien, Royal Ottawa Hospital, Ottawa, Canada
As we move into the twenty first century, many nation states are increasingly using laws to compulsorily treat
mental health service users in the community. In some ways this is an understandable trend, given the consensus that
institutional care should only be used as a last option; a corollary is that the state is obliged, parens patriae, to
manage risk in the most humane, least restrictive environment. This drift towards control, however, has profound
implications for the role of social workers and other professionals, we believe that there is a need to examine such
developments in the context of national and international contexts and standards of professional practice and human
rights law.
The paper will begin by briefly reviewing the literature on the subject, including arguments around the efficacy of
such procedures and their impact on professional ethics.
The authors then compare and contrast law, policy and practice in three contexts:
 The state of Victoria, Australia. This is a jurisdiction which has experienced rapid deinstitutionalization,
coinciding with expanded use of CTOs over the last decade. It is argued that client rights have not always
been best protected because of a tendency to retreat to a medication only regime and failures in care
planning processes. Recent reforms in Victorian legislation around mandatory treatment plans may help to
address some of these limitations.
 The province of Ontario, Canada. Unlike Victoria, the use of CTOs in Ontario is a more recent experience.
Although there is differentiated use of CTOs, including a split between urban and rural practice, there is
some evidence to suggest that the strategic use of hospital beds and the care/treatment planning process can
enhance patient autonomy.
 The United Kingdom. Only one jurisdiction – Scotland – will have introduced CTOs by 2005. In this
section a discussion will take place about the relative merits of Scottish mental health law and proposals for
change to English and Welsh and Northern Irish legislation, when compared to other international
experiences.
The paper will conclude with a proposed typology which highlights areas of convergence and divergence between
systems.
jim.campbell@qub.ac.uk
An International Comparison of Health Service Use in Two Jurisdictions With And Without
Outpatient Commitment
Stephen Kisely, Dalhousie University
Neil Preston, Fremantle Hospital and Health Service, Perth, Australia
Jianguo Xiao, Health Department of Western Australia, Perth, Australia
Mark Smith, Dalhousie University
We examined whether outpatient commitment (OPC) reduces in-patient health service use for patients from Western
Australia in comparison with control patients from a jurisdiction without this legislation (Nova Scotia). We used a
population-based record linkage analysis of an inception cohort using a two-stage design of matching and
multivariate analyses to control for socio-demographics, clinical features and psychiatric history. All discharges
from inpatient psychiatric services in Western Australia and Nova Scotia were included covering a population of 2.6
million people. Patients on OPC in the first year of implementation in Western Australia were compared with
controls from Nova Scotia matched on date of discharge from in-patient care, demographics, diagnosis and past
inpatient psychiatric history. We analysed time to admission using Cox-regression analyses and number of bed-days
using logistic regression. We matched 196 OPC cases with an equal number of controls. On survival analyses, OPC
cases had a significantly greater risk of readmission. Comorbid personality disorder and previous psychiatric history
were also associated with readmission. However, on logistic regression, patients on OPC spent less time in hospital
in the following year, with a reduced risk of inpatient stays exceeding 100 days. Although outpatient commitment
does not reduce hospital admission rates, increased surveillance of patients on OPC may lead to earlier intervention
such as admission, so reducing length of hospital stay. However, we do not know if it is the intensity of treatment, or
its compulsory nature, that effects outcome.
Stephen.Kisely@cdha.nshealth.ca
Community Treatment Orders: Profile of a Canadian Population Project Update
Ann-Marie O’Brien, Royal Ottawa Hospital, Ottawa, Canada
Susan Farrell, University of Ottawa
Sylvie Faulkner, Montfort Hospital, Ottawa, Canada
Community Treatment Orders: Profile of a Canadian Experience (project update) is a continuation of a study
published in the Canadian Journal of Psychiatry (O’Brien and Farrell, December 2004). Our study represents the
first published outcome study of CTOs using Canadian Data.
CTOs in the province of Ontario are unique for several reasons. CTOs issued in the province of Ontario are based
on a comprehensive plan of community based treatment or care. This plan must be developed and agreed to by all
parties involved prior to the CTO being issued. CTOs in Ontario are consent based. The patients being issued the
CTO or their substitute decision maker (if they are without capacity to consent) must consent to the order. Both
parties must receive independent rights advice and have the opportunity to contest the order before the Consent and
Capacity Board, prior to the CTO being issued. CTOs are only issued by physicians, not courts. CTOs in Ontario are
in effect for 6 months, and there is a mandatory review of the CTO every year
Our study reports on the first 50 patients of the Royal Ottawa Hospital issued CTOs. Using a mirror image design
this study reports on hospital utilization patterns, involvement with community resources, and housing one year
prior to first issuance of the CTO and 1 year post 1 st issuance of the CTO. A standardized information collection
tool was developed based on the data requirements of the ministry of health and long-term care in the province of
Ontario. This tool was completed at the time the first CTO was issued and then updated to reflect the patient’s
ongoing involvement with the legislation as well as related clinical outcomes. This study found a statistically
significant reduction in both the number of hospital admissions and the length of admissions following issuance of a
CTO. Issuance of a CTO was also associated with increased involvement with community based resources such as
ACT teams and case-management. 82 CTOs were issued for these 50 patients and only 2 were contested before the
consent and capacity board. 4 patients had their CTO renewed or re-issued following one year.
At the time of writing ours is the only published outcome study of CTOs using Canadian Data. Although CTOs in
Ontario are unique our data is consistent with findings of other international studies of a similar design. CTO
legislation in Ontario has been described as “showing an admirable degree of respect for patients’ autonomy”
(Dawson et al International Journal of Law and Psychiatry, 2003). Respecting patients’ autonomy will be discussed
in light of findings of our study. Future directions on examining coordinated collaboration between mental health
and judicial systems connected to CTO legislation will be reviewed.
aobrien@rohcg.on.ca
The Utility of Early Intervention Community Treatment Orders
Steven P. Segal, University of California at Berkeley
Outpatient commitment has become controversial procedure, some viewing it as an infringement on individual
rights others as a needed intervention to protect patients unaware of their own care needs. While much has been
written on the generalized use of the procedure, little discrimination is made as to how it has been used, for what
clinical purposes, and to what clinical ends. Further, no one has looked at its use in the context of the patient’s total
treatment experience. This study considers early-intervention outpatient commitment—i.e. orders issued following
the patients’ first hospitalization and/or within ninety days of entry into the mental health system as a possible
reasonable scheme for pre-emptive use of outpatient commitment orders. Such a procedure may be considered pre-
emptive in that it represents an effort to establish a structured treatment relationship with the patient early on in their
treatment career rather than awaiting failure in the treatment relationship before using involuntary orders.
Victoria Australia has had an extensive experience with the use of outpatient commitment. This study uses the data
from the Victorian Psychiatric Case Register to consider nine years of early intervention experience with outpatient
commitment among patients placed on orders (N=8979) and a matched control sample (N=8979). Descriptives on
the frequency of the use of this intervention are presented and the utility of the intervention as an alternative to
hospitalization is discussed.
Consideration is given to the pros and cons of using this involuntary care mechanism early in the patients’ treatment
career.
spsegal@uclink4.berkeley.edu
Compulsory Community Treatment Orders II
What Determines Compulsory Community Treatment? – A Logistic Regression Analysis Using Linked
Mental Health and Offender Databases
Neil Preston, Fremantle Hospital and Health Service, Perth, Australia
Stephen Kisely, Dalhousie University
J. Xiao, Health Department of Western Australia, Perth, Australia
Western Australia has one of the highest published rates of the use of compulsory treatment orders in the Englishspeaking world. Differences in patient characteristics, legislation and service setting may explain variations in the
reported efficacy of compulsory community treatment. The objective was to investigate predictors of Community
Treatment Order (CTO) placement in the first year of implementation in Western Australia and see if there were any
differences in the type of patients placed on these orders compared to other studies.
A population –based record linkage study of Mental Health and Offender Databases comparing 265 patients on a
CTO with a consecutive control group (CCG) of equal number matched on date of discharge from in-patient care or
CTO placement.
Previous health service use, after-care placement, mental disorder history including schizophrenic history, a positive
forensic history of violence to others as well as patient’s marital status were the significant predictors of CTO
placement.
Studies of compulsory community treatment appear to be of similar populations. In spite of the comparatively high
rate of use, psychiatrists in Western Australia do not appear to be applying community treatment orders to different
type of patient compared to elsewhere. We need further research to establish the relative contribution of patient
characteristics, legislation and service setting towards the use and outcome of compulsory community treatment.
neil.preston@health.wa.gov.au
The Use of Involuntary (Surreptitious) Psychiatric Medications in Law Enforcement Emergencies—
Yes, No or Maybe ?
Victoria Dreisbach, Yale University School of Medicine
Involuntary psychotropic medications have been used in psychiatric emergencies when a person has been assessed
to be imminently dangerous to him/herself or others. However, the use of psychotropic medications in law
enforcement emergencies has received little attention. Surreptitious drug use in law enforcement emergencies, such
as the Moscow theatre hostage disaster (with the use of a gaseous sedative) illustrate the dangers associated with
surreptitious drug use. Additionally, there are ethical concerns about the risks and benefits of medication use in
such circumstances versus individual rights and community safety.
This presentation will examine a case in which a psychotropic medication was surreptitiously administered by police
to a violent person with a known psychiatric history during a life-threatening law enforcement emergency that
threatened the life of the alleged perpetrator, the police and innocent bystanders. A review of the community legal
standards regarding psychotropic medications and informed consent, medical standards regarding medical
involvement with police interventions, and the ethics about the use of psychotropic medications in law enforcement
will be explored.
In this case, while the medication use was not typical of medical, psychiatric or police standards of care, the police
emergency was resolved without loss of life to the alleged perpetrator nor the police. But it does raise questions
about whether the use of surreptitious medications is justified in certain situations.
Victoria.Dreisbach@yale.edu
A Question of Numbers : introducing community-based treatment orders in England and Wales
Simon Lawton-Smith, Senior Policy Adviser, Mental Health The King’s Fund, London, England
The UK Government intends to introduce community-based treatment orders in England and Wales through new
mental health legislation. This is primarily driven by concerns about public safety and a desire to provide mentally
ill people living in the community with treatment when they need it.
The Government has stated that it is not its intention to increase the numbers of people subject to compulsory
powers. There are many opponents of the legislation, including professional bodies, legal organisations, charities
and service user and carer groups. These organisations claim that such powers will, in fact, significantly increase the
numbers of people under compulsion. However neither side has cited specific evidence to support their position.
The King’s Fund is undertaking a piece of research that aims to estimate the likely number of people who would be
subject to compulsion - both in the community and in hospital - should the new legislation be passed by Parliament.
This will enable policy-makers and service providers to plan for the introduction of community-based treatment
orders more effectively, and to distribute resources appropriately.
The King’s Fund’s research is looking at the experience of community-based treatment systems in, primarily, the
United States of America, Canada, Australia and New Zealand. It has conducted a literature review, distributed a
questionnaire to those countries, and undertaken interviews with individual policy-makers, academics and service
providers in England and Wales.
The findings from the research are expected to be made public in April 2005.
s.lawton-smith@kingsfund.org.uk
The Voice of the Community: The Role of Citizens’ Advisory Committees
Sean Taylor, Correctional Service of Canada at Saskatoon
Citizens’ Advisory Committees (CACs), through voluntary participation in the Canadian federal correctional
process, contribute to the protection of society by actively interacting with staff of the Correctional Service of
Canada (CSC), the public, and offenders. Since their inception in 1965, CACs have contributed to the overall
integrity of correctional services and programs in Canada by providing impartial advice, acting as impartial
observers, and through liaison with the community at large.
Addressing the diverse and complex needs embedded within correctional systems, requires specialists, specialized
agencies, and community partners working collaboratively in building healthy, safe communities for all concerned.
Currently, more than 600 volunteers are members of the 106 CACs across Canada. Members represent various
social, cultural and demographic backgrounds and occupations.
Contemporary contributions made by CACs to correctional systems in Canada will conclude the presentation. As
representatives of their communities CACs have important roles to play in facilitating the successful reintegration of
offenders into society.
Objectives:
1. Examine issues that impact on the creation and maintenance of successful CACs.
2. Discuss the impact of CACs on the community, offenders, and correctional staff
3. Review strategies for recruitment and retention of volunteers for CACs.
sean.taylor@sasktel.net
Compulsion in New Zealand Mental Health Care
Anthony J O’Brien, University of Auckland
Mental health care in New Zealand moved from an institutional to community focus between the 1970s and 90s. In
1992 mental health legislation was significantly changed with the introduction of the Mental Health (Compulsory
Assessment and Treatment) Act. This Act introduced Community Treatment Orders, a form of involuntary
outpatient treatment, further reinforcing the notion that mental health care should be provided in the least restrictive
environment, ideally in the community. Since the changes over the latter period of the 20 th century there has been no
systematic study of the rate of use of compulsion in mental health care, or of trends in the use of compulsion. This
presentation will outline a study aimed at providing a quantitative description of the use of compulsion in New
Zealand, and will present initial data mapping the use of compulsion. Data describing compulsion in relation to
region, demographic characteristics of patients, and clinical presentation will be presented. The data are part of a
PhD study aimed at modelling the use of compulsion in terms of geographical, service, clinician and patient
characteristics. The presentation will include an outline of the latter part of the study.
a.obrien@auckland.ac.nz
Intersexuality I
A Changing Intersex Paradigm: Has It Changed Standard of Care among Pediatric Endocrinologists
in the United States?
Stephen F. Kemp, University of Arkansas
The traditional clinical paradigm for treatment of intersex children was developed in the mid-20th century, and was
founded on the principles that 1) gender identity is neutral at birth and 2) up to the age of 18-24 months a child’s
gender identity can be determined by appropriate rearing. This paradigm is well described in a Pediatric
Endocrinology textbook from 1969. Since the late 20 th century this clinical paradigm has been challenged. An
ethical analysis favors the new clinical paradigm in that the new paradigm shows greater respect for autonomy and
is more likely to meet the demands for beneficence and nonmaleficence. In order to determine whether a change in
the clinical paradigm has resulted in a change in standard of care, an analysis was undertaken of the
recommendations for treatment of intersex children in five standard pediatric endocrinology textbooks published
since 2002. The most progress has been made in the area of disclosure; no longer is it recommended to keep details
from the parents, or to evade disclosure by using phrases such as, “the child knows its gender, we only have to
discover it and finish development of the incomplete genitalia.” There seems to be a recommendation that the
determination of the sex of rearing should involve the parents as part of the team. Further, a clear difference is the
dismissal of old notion that in the absence of a penis of a certain size, a female gender should be assigned. The area
where there is still persistence of the traditional paradigm is whether there should be genital surgery in the newborn
period. A text in 2002 recommended early genital surgery, and, while softening the recommendation, the same
author in 2004 still recommends clitoral recession before the age of one year in some situations. Two texts (2003
and 2004) recognize that this area is controversial, while another (2003) acknowledges that it may be preferable to
postpone genital surgery until the intersex individual can participate in such a decision. Reasons for the slow
acceptance of delaying genital surgery include 1) resistance to change, 2) lack of outcome data, and 3) the
recognition that physicians themselves are a part of a culture that abhors sexual ambiguity. The pediatric
endocrinology community along with ethicists and other interested parties needs to collect outcome data, participate
in the development of protocols, continue to discuss the issue of the appropriate treatment of intersex infants, and to
be prepared to revise our paradigm as new information becomes available.
KempStephenF@uams.edu
International Legal Developments Protecting the Rights of Sexual Minorities and Their Effect on the
Doctrine of Informed Consent as it is Applied in the Clinical Management of Intersex Infants
Julie A. Greenberg, Thomas Jefferson School of Law
Medical decisions made by parents on behalf of their minor children are generally accorded great deference to
protect family privacy and parental authority. Courts rarely intervene in a parental decision about a child’s medical
treatment, even though the child’s long-term interests may be seriously compromised. In some circumstances,
however, courts will carefully scrutinize parental decisions because judges are concerned that parents are not able to
objectively distinguish the interests of their child from their own self interest.
Few actions have been brought challenging a parental decision to have an intersex child surgically altered, even
though the treatment may result in the child’s involuntary sterilization or decreased capacity to achieve sexual
satisfaction. This paper will explore recent legal developments in South America, Europe and the United States that
may indicate an international trend to accord greater respect to the autonomy rights of sexual minorities.
Recently, the Constitutional Court of Colombia specifically addressed this issue. The Court severely limited the
ability of parents to consent to genital modification surgery on behalf of their intersex children. The court
recognized the need to protect the human rights of the intersex infant. Although no high court outside of Colombia
has specifically addressed this issue, the Convention on the Right of the Child, adopted by the General Assembly of
the United Nations in 1989, recognizes that children, because of their vulnerability, need special care and protection.
In addition, the European Court of Human Rights and the European Court of Justice recently issued rulings that
provide greater protection to transgendered individuals. Finally, a recent United States Supreme Court decision also
recognized that the Fourteenth Amendment to the United States Constitution protects some decisions relating to
sexuality because these decisions are central to personal dignity and autonomy.
This paper will explore the doctrine of informed consent as it applies to parental consent to surgical alteration of an
intersex child. It will analyze recent international developments that portend a trend toward greater legal protection
of those individuals whose sex, gender and sexual orientation do not conform to the norm.
julieg@tjsl.edu
From Guilt to Injustice: Towards a Discursive Recognition of Intersex
Iain Morland, University of London
Are clinicians who have performed genital surgery on intersexed individuals guilty of negligence? To answer this
question, I analyze the contemporary debate over the traditional surgical management of intersexuality—conditions
of “mixed” or “ambiguous” sex—as an instance of the politics of recognition. Specifically, my discussion of
intersexuality’s changing exemplificatory position within feminist studies of science explains how its medical
management has emerged as an exemplary injustice of recognition. The surgical protocol that aims to make unusual
genitalia invisible, and the medical obfuscation of intersexuality’s ramifications for the cultural construction of
gender, have been written by feminist scientists Anne Fausto-Sterling and Suzanne Kessler as a failure of
recognition. However, this is not to suggest that intersex surgery is purely “rhetorical,” nor is it to deny that such
surgery has been experienced as injurious by many patients. Instead, by mapping intersex treatment as a discursively
produced injustice, I argue that it is accordingly within discourse that the wrongs of intersex treatment may be
redressed—not by undoing past surgeries, or by punishing clinicians as personally “guilty.” In this way, it is
possible to understand intersex treatment as a genuine injustice of recognition without confrontationally calling into
question doctors’ competence and intentions—an approach that facilitates dialogue between all involved.
iain@icfm.freeserve.co.uk
The Use of Dexamethasone to Prevent Virilization of Female Fetuses at Risk of Congenital Adrenal
Hyperplasia
Sharon E. Sytsma, Northern Illinois University
Dexamethasone (Dex) has been used as a prenatal treatment to prevent virilization of female fetuses caused by
Congenital Adrenal Hyperplasia (CAH) in the USA since the 1980’s. Many studies have indicated that its use is safe
and effective in either preventing or minimizing virilization. However, there have been some reports, both in the
United States and abroad, of ill effects of the drug in children having been treated as fetuses. Further concern about
the effects of fetal Dex treatment comes from recent reports that premature infants treated with Dex to prevent
pulmonary problems later manifest neuro- developmental impairment and a higher incidence of cerebral palsy. Little
follow-up has been done to determine whether fetuses treated in utero are at risk
later in life for neurological problems.
The justifications for Dex use for CAH are the following:
1. It would spare the child with CAH the trauma of going through life with ambiguous genitalia,
2. It would spare the child the need for genital surgery, and
3. In the case of severely virilized female fetuses, it will prevent the possibility of assigning the child to the
male gender.
The following objections to these justifications will be examined: First, given that unacceptable risk has not been
ruled out, it is questionable whether the burdens of virilization justify that risk. Second, in most cases there is no
actual medical need for genital surgery. Third, for those infants so severely virilized that they might be mistakenly
assigned to the male gender, it is not clear at present that going through life as a male would be a worse alternative
than being subjected to vaginoplasty, especially since vaginoplasty is of dubious benefit and is associated with
significant burdens. Finally, given that the drug must start to be administered as soon as pregnancy is established
and before tests can reveal the sex of the fetus or whether the fetus is afflicted with CAH, 7 out of 8 fetuses treated
with Dex are being subjected to risk but do not stand to benefit from it.
ssytsma@niu.edu
Intersexuality: Exploring its Challenges for Christian Sexual Ethics
Patricia Beattie Jung, Loyola University Chicago
There is a growing consensus that new scientific data and experiential insights about intersexuality have raised
several, very important bioethical questions about the need for, control over and timing of various “treatment”
options. Less attention has been given to the challenge this same data poses for many religiously grounded systems
of sexual ethics. In this paper, Jung critically reexamines Christian axioms about heterosexual gender
complementarity in light of these emerging accounts of this paradigmatic expression of human sexual diversity. She
explores the implications of new scientific and experiential accounts of intersexuality for the reinterpretation of key
biblical passages (especially Genesis 1-2 and Ephesians 5) and conventional “natural law” teachings about gender
considered foundational by many Christians to sexual ethics.
pjung@luc.edu
Authenticity and Intersexuality
Herman Stark, South Suburban College
This paper examines the phenomenon of intersexuality in light of the philosophical concept of authenticity. The
overriding aim is to see if standard medical “treatments” of infants and children born with ambiguous genitalia and
so forth is in fact a threat to their authenticity. The standard treatment, roughly, is to decide on what sex the
intersexual should be and then to perform surgery accordingly, i.e., to operate on the genitalia. In recent years there
has been a growing movement, composed in part by people who have undergone such procedures, that advocates
rethinking this standard response. The reasons offered are varied, but in them one finds a definite strain that
hearkens to, without invoking the concept explicitly, authenticity.
The basis for my discussion of authenticity, one of the major concepts of twentieth century philosophy, especially
when thinking about the “quality of life” or nature of existence, is Martin Heidegger’s analysis in Being and Time,
which is the locus classicus for contemporary philosophers. Heidegger’s analysis is intriguing and germane because
he is careful to separate authenticity from moral concepts, such as good and bad, and thus it might be just the right
way to articulate the problem with the standard procedure. (Numerous opponents of the standard procedure, in other
words, are quick to claim that they do not think the doctors are immoral and indeed admit most doctors are trying to
do the right thing). But one thing Heidegger’s analysis lacks is a tracing out of implications, especially to biomedical
ethical type issues, and thus I turn to subsequent philosophers who attempt to do precisely this, i.e., trace out the
ethical implications of Heidegger’s analysis. The paper then applies authenticity and its ethical implications to
intersexuality, and consider, along the way, related ideas such as autonomy as well as the mutually instructive way
that authenticity helps us think about intersexuality and intersexuality helps us think about authenticity.
hermanestark@yahoo.com
Intersexuality II
The Infant with Ambiguous Genitalia: Surgical Perspectives
Ian Aaronson, Medical University of South Carolina
The birth of a baby with ambiguous genitalia is a particularly distressing event as the fundamental question as to
whether it is a boy or a girl is in doubt. Traditionally, such babies have had their gender assigned according to the
best judgment of the involved physicians and the appropriate surgery carried out on the genitalia to normalize the
baby’s appearance.
Over the past decade, this approach has been increasingly challenged on ethical and legal grounds. It has been
argued that such surgery is often mutilating and may impair subsequent sexual function. There are also examples in
which an appropriate gender was chosen. Furthermore, social reconstructionists argue that society must be educated
to accommodate individuals whose genitalia do not conform in appearance to the norm and who subsequently do not
identify themselves as either male or female. The validity of obtaining consent from parents for surgery on their
child for a non-life threatening condition has also been questioned.
This paper will place the subject of the intersex infant in a biological perspective and will describe the underlying
biological mechanisms which lead to the development of the internal and external genitalia in the normal male and
female fetus. It will point out various aberrations that can occur in these pathways and illustrate the variety of
resulting genital appearances that may consequently be found at birth.
The history of gender conforming surgery will be briefly outlined and the current techniques used will be illustrated.
The arguments for advocating that such surgery be carried in infants born with ambiguous genitalia will be
presented.
aaronson@musc.edu
Telling Children about a Physical Intersex Condition: What Stops Us?
Patty A. Carmichael, Great Ormond Street Hospital for Children, London, England
It is generally agreed that intersexed individuals should be fully informed about their medical history and treatment.
However how, when and by whom this intent is best translated into action remains uncertain. There is relatively
little consistent psychological research to help parents with the disclosure of the details of an intersex condition to
their child (Viner, 1997). It is apparent that the process of disclosure does not begin with telling the individual.
There is evidence that psychological support as soon as a diagnosis is made is associated with a better outcome
(Slijper et al. 1998). The timing and content of ‘support’ requires evaluation as despite apparently being given
information, parents often remain confused about their child’s diagnosis and have fears about the impact of giving
information, sometimes many years after the initial diagnosis (Carmichael & Ransley, 2002).
The sparse published recommendations for sharing information with an intersexed child suggest a staged approach
taking into account the stage of cognitive development (Goodall, 1991, Warne, 1997 & Slijper, 2000). It is proposed
that information about karyotype when it is discordant with gender of rearing should be given last at about the age of
16 or 17. This is potentially problematic if children are to be fully involved in treatment decisions such as removal
of ‘gonads’ at adolescence or the introduction of hormone replacement therapy. It therefore needs to be ascertained
if current practice is informed by adult concerns about the impact of information on the developing child and
adolescent rather than the child’s ability to understand.
Carmip@gosh.nhs.uk
Cultural Differences in Medical Risk Assessments during Prenatal Genetic Diagnosis: The Case of Sex
Chromosome Anomalies in Israel and Germany
Yael Hashiloni-Dolev, The Hebrew University
The paper reports findings from a comparative study of Israeli and German genetic counsellors, focusing on
counselling concerning Sex Chromosome Anomalies (SCA). SCA are a collection of atypical diagnoses involving
too many or too few sex chromosomes. The specific SCA addressed in this study are Klinefelter syndrome (XXY)
and Turner syndrome (X0 or 45X). Males with Klinefelter syndrome have an extra X chromosome. They are tall
and infertile. In rare instances they may also be mentally retarded, though the majority of people with Klinefelter
syndrome lead completely normal lives, and their condition is only discovered when they wish to have children.
Women with Turner syndrome have only one X chromosome, and thus 45 instead of 46 chromosomes. Many
women with Turner syndrome are relatively short. All are infertile. In some cases, the syndrome involves other
physical irregularities, such as heart problems. The paper starts with a theoretical discussion of the medical concept
of risk. Subsequently, data collected by questionnaires (N=297) that address reproductive genetics and which were
distributed among genetic counsellors in Israel and Germany at two different time periods (1994-6 and 2000-1), as
well as data collected through in-depth interviews with counsellors in both countries (N=32) are presented. The
findings show that Israeli genetic counsellors are for more supportive of selective abortions of fetuses with SCAs
than their German counterparts. In order to understand this difference, the types of claims experts deploy in their
personal and professional estimation of the risks involved in SCA are analyzed. The paper concludes by suggesting
that the counsellors' estimations of risk, and their rhetoric concerning SCA, whose major manifestation is the future
infertility of the unborn child, should be situated in a broader cultural context, that of local Israeli and German
understandings of the importance of fertility, and not in their professional non-directive global ethos. Hence, in order
to understand the practice of genetic counsellors in two late-modern societies, one must understand the unique
relationship between the individual bodies of pregnant women and the body politics of their nations, a relationship
which is mediated by the counsellors, who are the bearers of knowledge and expertise in this field.
hashi@post.tau.ac.il
Vaginal Reconstruction and the Role of the Psychologist
Lih-Mei Liao, Elizabeth Garrett Anderson Hospital, London, England
Historically, reconstructive surgery has been the main treatment option for intersex and non-intersex women with a
small vagina. More recently, dilation has been recommended as the first line of treatment. In the literature,
successful outcome of reconstruction is, if it is defined at all, based on surgeons’ perspectives. There is little
knowledge of women’s own evaluation of cosmetic and sexual outcome. Women’s decision to undergo treatment is
deceptively straightforward. The aim of this paper is to raise awareness of complex psychological issues in vaginal
(re)construction and to outline the important role of the psychologist.
Pre-treatment, reconstruction is often understood by women as an unproblematic means of conferring normality. But
reconstruction in itself often fails to deliver a ‘normal’ (female) identity, and many women become acutely aware of
their distress only after surgery or during their dilation treatment. These fears act as barriers to normative
relationship experiences – the implicit goals of vaginal reconstruction. Furthermore, emotional barriers often
interfere with women’s ability to adhere to a dilation treatment regime which could lead to stenosis, thereby having
exposed herself to the risks of surgery without deriving any benefit.
The role of the psychologist is three-fold. First, women may require implications counselling relating to diagnosis
and treatment. Secondly, psychological interventions can help to explore thoughts, feelings and behaviour relating to
relationships and intimacy, to foster a positive self identity and to increase personal control in sexual situations.
Lastly, the psychologist also has responsibility to contribute to the building of a clinical team that is sensitive to the
expressed and unexpressed needs of women. Within such a clinical context, examination of the genitals should be
kept to a minimum and, where repeat monitoring is necessary, patients should be given a genuine choice and
debriefing must follow each occasion. Negative experiences of professional consultations could undermine the
positive sexual outcomes that reconstruction seeks to create. Finally, it is well to remember that a decision not to
have reconstruction is also a viable option.
lih-mei.liao@uclh.nhs.uk
Discordant Sexual Identity: Genetic Males with Severely Inadequate Genitalia Reared Female
William G. Reiner, University of Oklahoma
Because genetic male neonates with a severely inadequate penis have long daunted clinicians (unable to construct a
functioning penis), a clinical paradigm developed in the last half of the 20 th-century assigning such newborns to
female socially, legally, and surgically with orchiectomy and feminizing genitoplasty at birth. The Standard of Care
for about 30 years, this approach presupposes a tabula rasa of psychosexual development and especially of sexual
identity development. Outcome data on psychosexual development in these children has been sparse.
77 genetic male subjects with severely inadequate genitalia due to cloacal exstrophy (a severe error of
embryogenesis leading to complex pelvic organ anomalies including virtual absence of the genitalia) or intersex
conditions were assessed for gender role behaviors and for declared sexual identity. 68 subjects (88%) experienced
female sex-assignment at birth and were reared female. Follow-up assessments of subjects ranged from 1 to 10
years and included longitudinal mental status assessments.
46 subjects (60%) declared themselves male some time before or at varying times after follow-up from initial
assessment, including the 9 reared male; 3 refused to discuss sexual identity; 1 died at age 16 years. Thus, of 76
living subjects only 31 (40%) declared themselves female, representing 46% of those reared female from birth. All
77 displayed mostly male-typical behaviors and interests. All subjects transitioning to male reasonably old enough
to discuss sexual orientation expressed exclusive orientation towards females. Only 3 subjects living as female were
willing to discuss sexual orientation, expressing sexual orientation towards females. Mental status of those subjects
transitioning to male improved longitudinally, with no suicidal ideation elicited from any subject living as male. In
subjects living as female mental status remained stable or intermittently deteriorated; 4 subjects experienced
recurrent suicidal ideation.
This study demonstrates that prenatal active-androgen exposure in genetic males may have a powerful influence on
an ability to recognize male sexual identity despite assignment to female at birth, female sex-of-rearing, and female
genitalia. Additionally, genetic males with a severely inadequate penis reared male or transitioning to male may
experience improved mental status.
william-reiner@ouhsc.edu
Adult Outcomes of Feminizing Genital Surgery
Sarah Creighton, Elizabeth Garrett Anderson Hospital, London, England
Traditional surgical management of the virilised female infant has centred on restoring “normality”. Once the infant
is assigned to a female sex of rearing, feminising genital surgery almost inevitably follows. Indeed, the “ease” of
feminising surgery when compared to masculinising surgery is cited as a major factor in the selection of sex of
rearing. Only recently have reports by adult intersex women of poor outcomes of feminising surgery focused
research on adult outcomes including effects upon sexual function and sexual satisfaction.
There is now an expanding literature and current studies provide more information although as the policy of
feminising surgery has been so widespread, control groups are usually small. Vaginoplasty is an integral part of
feminizing genitoplasty and is currently performed during the first year of life. This is despite the fact that the child
will not menstruate for a further 10 or so years (if she has a uterus) and is unlikely to be sexually active until after
puberty. Early infant vaginoplasty may be justified if there were good evidence that it produced better long-term
anatomical, cosmetic and functional outcomes than later delayed surgery however this does not seem to be the case.
Recent studies have demonstrated high rates of introital stenosis and frequent requirements for repeat reconstructive
surgery in adolescence before tampon use or intercourse. Other vaginoplasty techniques such as using an intestinal
segment involve major surgery and long term problems such as persistent vaginal bleeding and mucus discharge are
not uncommon. Clitoral surgery has shown to have a detrimental effect on sexual function particularly on the ability
to orgasm. Both clitorectomy and nerve sparing clitoral reduction have been shown to damage genital sensation.
In the absence of firm evidence that infant feminising genital surgery benefits psychological outcome, the role of
such surgery needs a radical re-evaluation.
Truthful information must be given to the patient and their family from the outset on the aims of the surgery and the
risks to their daughter’s future sexual function. The option of specialised psychological and peer support as a
realistic alternative to surgery must be made available to all families.
Sarah.Creighton@uclh.nhs.uk
Japan’s New Legislation for Mentally Disordered Offenders
Japan’s New Legislation for mentally disordered offenders: From the point of view of comparative law
Miwa Kojimoto, National Institute of Mental Health, Tokyo, Japan
The Act for the Medical Treatment and Supervision of Insane Persons who Caused Serious Harm, Japan’s first
legislation for mentally disordered offenders, will go into effect in July 2005. The Act emphasizes the importance of
the rehabilitation of offender patients and creates a system where community treatment will be promoted.
From the point of view of comparative law, the Act has two significant characteristics. One is that the Act is
strongly linked to the system of criminal responsibility. That is, it is applied to only three kinds of people who have
caused serious harm to others: people who have been found not guilty by reason of insanity, those who have been
given a suspended sentence due to diminished responsibility, and those not prosecuted because of insanity and
diminished responsibility. Mentally disordered prisoners and those who are not competent to stand trial are excluded
from the scope of the Act.
The other characteristic is the wide discretionary powers given to prosecutors, and this feature is also reflected in the
Act. If prosecutors find, as the result of a psychiatric evaluation, that the accused is insane or of diminished
responsibility, the charge will be dropped even if the act committed is murder or manslaughter. Those accused will
then become the subject of the Act, and it is expected that most of the offenders dealt with by the Act will be this
group of people.
More legal characteristics of the Act will be discussed in the presentation.
kojimoto@ncnp-k.go.jp
kojimoto@gem.hi-ho.ne.jp
The Evolution of Mental Health Legislation in Japan: Continuing Pressures and Needs
David N. Weisstub, University of Montreal
Mikiko Hasegawa, Hasegawa Hospital
Tsunemi Hasegawa, Hasegawa Hospital
Since the late 1980’s Japan has undergone a series of reforms pointing towards more progressive modalities of
dealing with the large institutionalized population of civil patients. The introduction of more responsive
guardianship provisions as well as the creation of a new Forensic System have created expectations of a more
humane and benign treatment of the mentally ill. Review procedures have also held out potential for greater ethical
sensitivity towards individuals whose liberties have been curtailed. Despite cultural, familial and social differences
criticism remains of the actual system in place from both internal and international perspectives. Despite repeated
efforts for reforming the mental health system there has still been a reluctance on the part of Government to initiate
overdue changes. Despite movement in certain sectors, such as social work and nursing, the provision of medical
services and related payments have frustrated achieving the stated goals of the mental health law reforms. Policies
must be put into place to encourage progressive hospitals to undertake increasing responsibilities, with adequate
remuneration, for addressing the myriad of problems that exist not only in the context of high-risk civil patients but
also in view of new pressures that will be forthcoming as side effects of introducing a Forensic System in Japan.
admin@ialmh.org
The Medical Treatment and Supervision System under Japan’s New Legislation for Mentally
Disordered Offenders
Saburou Matsubara, Matsubara Hospital, Ishikawa, Japan
This paper illustrates the treatment system for mentally disordered offenders under the new legislation in Japan. The
Act for the Medical Treatment and Supervision of Insane Persons Who Caused Serious Harm of 2005 stipulates that
the district court shall provide two types of treatment: compulsory admission to hospital and outpatient treatment
under supervision. The Act also offers the guidelines for psychiatric evidence, hospital treatment, and community
care for such kind of patients. (1) Psychiatric evidence shall give not only medical diagnosis but also assessment of
treatability and risk of dangerous act. (2) Given that approximately 300 persons are estimated to be hospitalized
annually under the new system, 24 public hospitals are scheduled to establish a special ward equipped with 30 beds.
The guideline recommends that treatment shall be segmented in accordance with the recovery of patient: acute
phase, stabilizing phase, and rehabilitation phase. In principle, the duration of inpatient treatment shall be 18
months. (3) The guideline indicates that outpatient treatment shall be carried out following three stages: initial stage,
intermediate stage, and end stage. It is recommended that patients shall be diverted to the ordinary mental health
system within three years (4) The probation office shall be staffed with professionals who coordinate community
care for each case, making rehabilitation plan and collaborating with staff of hospital and community mental health
center, and officials of local governments.
matsubarahospital@ishikawa.med.or.jp
Managing Mentally Disordered Offenders: A Japanese Solution
Yoji Nakatani, University of Tsukuba
After a long debate and repeated attempts Japan has finally reached a solution for the management of mentally
disordered offenders. The government enacted an act that is going to effect from July 2005. The new act, named the
Act for the Medical Treatment and Supervision of Insane Persons Who Caused Serious Harm, aims at giving
intensive psychiatric treatment to mentally disordered offenders and enabling them to return to the community
without repeating offence. The debate on the problem dates back to the 1960s when the Ministry of Justice
attempted to revise the Penal Law to provide special management of offenders with mental disorder. However the
plan faced strong objection of human rights movement that suggested possible exclusion of patients from society.
After several years of exchange of opinions between proponents and opponents the Ministry of Justice suspended
the plan. The second attempt was made in the late 1980s while the Mental Health Law was revised to develop
community-based psychiatry. The Ministry of Health conducted a plan for the management of refractory patients
including offenders. The plan intended to set up public facilities with sufficient security and staff for such kind of
patients. The Ministry of Health’s plan also confronted a criticism maintaining that the establishment of special
system would inevitably intensify the role of psychiatry in social defence. The plan had to be suspended. Thus two
attempts failed. The first intended to solve the problem within criminal justice system, while the latter aimed to treat
a particular group of patients within the framework of mental health system. These circumstances may account for
the eclecticism of the new legislation. According to the act the court orders application as well as conclusion of
treatment, whereas the committee established in the court for judgment includes a psychiatrist who is equally
empowered as judge. Besides, a greater importance seems to be attached to the patient’s opportunity of
resocialization than to his/her future dangerousness. The author will discuss the distinctiveness of Japanese system
in comparison with some European systems.
ynakatan@md.tsukuba.ac.jp
On the New Law for the Mentally Disordered Offenders in Japan
Isao Takayanagi, Arisawabashi Psychiatric Hospital, Toyama, Japan
The Criminal law and The Mental Health and Welfare Law of Japan had not provided for well for the
treatment of the mentally disordered offenders. Ninety percent of these persons had been involuntarily
admitted to the mental hospital without judicial procedure. This situation has brought a lot of problems to many
mental hospitals. Since the Draft for the amendment of the Criminal Law to improve the legal deficiency
issued in 1961, serious conflicts has occurred among the psychiatrists, lawyers, etc. As a result the
operation had been interrupted more than two decades. Immediately after the tragedy of Ikeda elementary
school, public opinion has moved to restart the operation. After all, the Law titled “The Treatment and
Observation Law for the persons who commit serious offence under the incompetent, or partially competent
condition” was enacted on 10th, July 2003. The Law is independent from Criminal Law and Mental
Health & Welfare Law. Under the New Law, district courts promote the legal procedure after the proposal
of a prosecutor. For the evaluation of his/her criminal act and psychiatric condition, a committee of a
judge and psychiatrist is formed. More details of the Law will be presented and discussed.
yagiisao@aqua.ocn.ne.jp
Current Priorities in Japanese Mental Health Policy; Two Special Populations
David N. Weisstub, Université de Montréal
Both the aging population in Japan as well as mentally disordered offenders represent challenges not only to the
public budget of the State but as well present serious challenges to the society. In the case of the aged it is
recognized that Japan’s population will be among the oldest in the world by 2020 and there will be less than three
persons to support one elder. The exponential increase of health costs for the elderly coupled with profound social
transitions in the culture means that Japanese policy makers must concern themselves with multiple factors ranging
from hospital stays, policies with respect to medications and optional living arrangements. Interestingly the creation
of a new Forensic System for Japan, although from a very different perspective raises many of the same elements in
public policy. Japan has the highest rate among industrialized countries of institutionalized patients suffering from
mental disorders. Until now however there has been no clear policy or special provisions to account for the
criminally offending group. Finally the Japanese government has committed itself to a substantive alteration of
existing conditions, not only with respect to the criminal population, but as well for the civilly committed. Special
policies are being put into place for community discharge. At the same time the new Forensic System will create a
host of new stresses and priorities. Establishing a properly coordinated set of systems, between criminal and civil
populations, will become a preoccupation of mental health policy planners in Japan during the next decade.
Whatever the outcomes, the treatment of Japan’s vulnerable populations will have far-reaching consequences not
only of a financial but also ethical nature. Specific recommendations will be made about this can be best achieved.
admin@ialmh.org
tsunami@hw.catv.ne.jp
Juvenile Sex Delinquency
Juvenile and Adult Sexual Offenders Compared: Psychiatric Characteristics and Recidivism Risk
Michael Günter, University of Tübingen
Susanne Leutz, University of Tübingen
Simone Vees, University of Tübingen
Klaus Foerster, University of Tübingen
There is not enough empirical knowledge about the differences between adult and juvenile sexual offenders. This
study was aimed at getting more data about the differences between the two groups with respect to psychiatric
status, developmental problems and recidivism risk.
The study included all juvenile and adult offenders charged with sexual offences who came to a forensic psychiatric
assessment in our department or in the adult psychiatric department respectively from 1983 to 1994. We compared
characteristics from the intensive forensic psychiatric assessment after the index offence between the two groups and
with later recidivism taken from the criminal records. Forensic reports were evaluated systematically with an
evaluation form.
N = 60 subjects could be evaluated in each group. Clear differences between the groups with respect to the index
offences were found. Recidivism with sexual offences was significantly lower in the adolescent group especially in
the sub-group of developmentally retarded adolescents. It was difficult to detect further risk factors for re-offending
sexually from the forensic reports.
Adolescent sexual offenders show clear differences to adult ones and have a better prognosis. Prospectively only a
small sub-group which is difficult to identify seems to account for the retrospective finding from other studies that a
considerable proportion of adult sexual offenders already have records back to adolescence.
michael.guenter@med.uni-tuebingen.de
Young sex offerdes: Assessment and Treatment Models
Vera Cuzzocrea, University of Modena and Reggio Emilia
Gian Luigi Lepri, University of Modena and Reggio Emilia
The literature review revealed that between 20-30 per cent of sexually abusive behaviour was committed by persons
under 18 years; over 50% of incarcerated adult offenders had offended before the age of 20 years and that over
10,000 children were sexually abused by another child or young person. Young sex offenders differ from adult sex
offenders. The majority of young sex offenders are adolescent males, between 5 a 15 per cent of these offences are
committed by women. Half the sample reported a history of physical or sexual abuse and his home environment was
characterized by overcrowding, alcohol abuse and domestic violence. A significant male relative of his was likely to
have committed a criminal offence. In his community environment, he regularly witnessed violence and sexual
activity. The sex offences were usually carried out with a co-offender in a variety of venues. The victim was usually
known and younger than the offender.
However, despite the introduction of intervention programmes internationally (over 300 in the USA), the assessment
of success has been lacking. Establishing the success of these interventions is made difficult by the lack of control
groups. However, some studies of established programmes over five-year periods show that recidivism rates are
between 5% and 14%. They appear to respond to cognitive behaviour and relapse prevention interventions.
Intervention should begin with an assessment of the child, specifically to determine children at high risk and the
needs of the particular child.
The aim of this presentation is to underline that intervention programmes for young sex offenders should be
delivered in within the framework of a forensic clinical approach.
The ASOAP-D as an instrument for personality assessment and measurement of effect of therapy in
juvenile sex offenders
Ron van Outsem
The ASOAP-D is a multidimensional personality assessment questionnaire. It focuses on those personality
characteristics which, in literature, are generally considered as relevant for the development and perpetuation of
sexually abusive behaviour in juveniles. In this presentation the instrument will first be presented. After this, the
preliminary results will be discussed of comparative research between several categories of juvenile sex offenders,
juvenile violent offenders and non-delinquent youth. Lastly, the measured changes in relevant personality
characteristics of a group of juvenile sex offenders who followed specialised treatment will be discussed.
info@dewaag-denhaag.nl
A developmental approach to psychopathology in adolescent offenders: subtyping sex offenders and
assaultive offenders
Peter Hummel, Klinik für Kinder, Arnsdorf, Germany
Research in Germany concerning juvenile sexual delinquency is mainly only done by medical professionals, i. e., by
assessing case histories. In Canada, Great Britain and in the USA this research is mainly only done by psychologists,
i. e., by means of psychometric assessment. The purpose of this study was to compare adolescent sex offenders with
adolescent assaultive offenders by combining both assessment methods.
Three
offender
groups
were
compared:
Adolescent
Sex
Offenders
(ASO)
whose victim/s was/were female adolescent/s or adult/s, called victims women, n = 38. ASO whose victim/s
was/were (a) child/ren of both sexes, called victims children, n = 36. Adolescent assaultive offenders, whose
victim/s was/were male adolescent/s or adults, called victims men, n=33. All male subjects were matched as follows
(to restrain confounding variables): German nationality, average intelligence, only hands-on offences, single
perpetrators, age at the time of the offence between 14 and 20 years.
Development of the individual, his family, his sexuality (case histories) and his personality (psychometric
inventories) was examined. Reclassification was done after factor analysis and subsequent discriminant analysis.
Victims women were best predicted by the sexual development (63%), respective by individual, familial and sexual
development (71%). Victims children were best predicted by the individual development (78%), no combination
was better. Victims men were best predicted by familial and personality development (67%), no combination was
better. Conclusion: Assessing defined groups of juvenile offenders with different assessment tools seem to be a
helpful method to describe the profile of the respective offender group. Items of the case histories seemed to be
more powerful than psychometric inventories. Limitation of the study concerns the choice of the psychometric
instruments, the possibility of concealed offences not going with the respective group, and other aspects of
developmental psychopathology within the respective group (e. g. impulsivity).
Peter.Hummel@skhar.sms.sachsen.de
The Adolescent Sex Offender Assessment Pack – useful applications in German speaking Countries
Richard Beckett, Forensisches Institut Ostschweiz, Weinfelden, Switzerland
Constanze Gerhold,
Matthias Schmelzle,
Monika Egli-Alge,
Lieselotte Türkmen-Barta,
Ulrich Preuss
Objective: To describe a current research project, founded by Richard Beckett in UK for the assessment of juvenile
sex offenders. The Adolescent Sex offender Assessment Pack – ASAP – will be described, also its psychometric
construction and the current use in some European Countries as Switzerland, Germany and Austria.
Method: The prediction of sexual abusing behaviour is quiet difficult and object of this international research
project. Because of the little number of recorded sexual abusing juveniles in several countries, it is necessary to
promote an international cooperation. The ASAP is used in the named countries since some years and now adapted
and improved. For the measurements of treatment outcome, the ASAP is a useful instrument. In this study with 11 –
12 questionnaires personality-profiles of the juvenile sex offenders are established, for example: self-esteem,
emotional loneliness, anger management, general empathy and also delictoriented marks as attitudes to children and
sex, cognitive distortions, sexual deviancy. The questionnaires are partial known and validated, partial new
developed and revised in the frame of this project on N=479 juvenile sex offenders at the age of 12 to 18 years and
standardized at the norm-control-group.
Results: We will present first results of the running study, using the ASAP in the named countries, focusing the
personality structures of the juvenile sex offenders. A cluster analysis showed some effects and especial factors of
the personality and typology of the offenders. Also some risk factors and determinations can be described.
monika.egli-alge@forio.ch
Legal Consciousness: I
Tortured Women in Seneca the Elder
Victoria Pagán, University of Wisconsin-Madison
Seneca the Elder heard the best orators of the last years of the Roman republic; in his old age, his sons persuaded
him to write down his recollections of these great speakers. The result is a collection of controversiae, in which an
invented legal case was argued on both sides before an imagined jury. The cases are drawn from a world of unlikely
situations involving tyrants and tyrannicides, wicked stepmothers, pirates, and identical brothers. These cases are
fundamental to our understanding of ancient Roman rhetoric, education, and law; however, because they are fiction,
they also have much to teach us about the relationship between narrative and law.
Because the cases are imaginary and the speakers are guided by their professors of rhetoric, controversiae provide a
safe place for Romans to talk about disturbing social and moral transgressions, a comfortable place to speak the
unspeakable, with rules and regulations that keep both speaker and audience from the perils of an unsettling reality.
In his psychoanalytic study of declamation, Gunderson (Declamation, Paternity, and Roman Identity, Cambridge
2003) presses beyond sanctioned subversion to show how the practice of declamation creates and sustains authority.
Gunderson rightly forces the conclusion that the elaborate artifice, the playfulness, and the artistry that define
declamation are not harmless or insignificant. They are implicated in the creation and maintenance of the psychosocial system of inequality at the foot of Roman socio-economic institutions.
Absent from Gunderson's analysis are the tortured women of declamation. This paper argues that the explicit
descriptions of the torture women suffer, besides bearing witness to the institutionalization of violence toward
women, provide stock, acceptable ways of describing the physical mutilation of women's bodies. While the
audience's attention is diverted by the disturbing images of violence, the speaker sidesteps the more disturbing
possibility of female autonomy. The fictional legal cases are thus implicated in sustaining a particular-male
dominated-reality. While fictional controversiae demonstrate that law is deeply embedded in narrative forms, this
case opens up the possibility that the particular narrative form of the controversiae creates and sustains not legal
practice, but legal consciousness.
vepagan@wisc.edu
Manumission and the Assimilation of Freedmen in the Roman World
Marc Kleijwegt, University of Wisconsin-Madison
The process of manumission in the Roman world, in crude terms, entailed the social and legal metamorphosis of a
being devoid of all human rights into a Roman citizen. The frequency with which Roman masters engaged in
manumission is a hotly disputed item, as is the scale on which full citizenship rather than an incomplete set of rights
was granted. This should not withhold historians from recognizing that in the ancient world the Roman willingness
to free their slaves and to grant them certain rights which brought them on a par with citizens was without parallel.
The Roman custom stood in strong contrast to the procedure adopted in the Greek world, where slaves became
‘metics’, that is, foreigners, rather than citizens. Furthermore, the level of manumission in the Roman world is
assumed to have been the highest of all slave societies in world. Because of their lack of free birth, however, exslaves had very few routes for social advancement. All status-groups as well as the most prestigious state
priesthoods were closed to them. They were prohibited from serving in the Roman army and could only enlist with
the vigiles, the fire-brigades of seven thousand men formed in AD 6 by the emperor Augustus. In the communities
of the Roman West their only opportunity for gaining public status was by serving as priests of the imperial cult,
better known as the Augustales. Their only hope of improving their status was by accumulating property and
transferring it intact to their freeborn off-spring. The latter encountered no legal impediments to social mobility,
even though the social codes made the rapid rise of freedman’s sons undesirable.
mkleijwegt@wisc.edu
Regulation of Memory in Classical and Early Christian Rome
Charles Hedrick, University of California Santa Cruz
Conversion is among the most striking ideas in the history of Christian culture, and it has never suffered for lack of
attention. Almost without exception, modern scholars have dealt with it as an "actuality," that is, as an event,
something that happens at a particular time and place to particular people. In the earlier part of the twentieth
century, scholars tended to concentrate on conversion as a psychological or existential event. Since the 1960's it has
been more often treated from the perspective of social status.
My goals in this paper are speculative and generalizing. I will consider conversion as an ideal, a social value that
that relies on a novel conception and practice of memory, and see where this approach leads. Those who treat
conversion as an event tend to think of it as a transitory phenomenon, and find its importance in its effects – the new
enlightenment or status that results. If we think of conversion as a value, however, then its importance is abiding.
What people think about conversion matters at least as much as the fact they have converted. For example, in the
course of the first four centuries of our era millions of inhabitants of the Roman world converted to Christianity:
these are events, and have in aggregate important consequences. At the same time, conversion becomes one of the
core values of Christian identity. Christians are not simply those who have converted, they are those who identify
themselves as converts: the distinction is something like that between a "teetotaler" and a "recovering alcoholic."
The sense of "being a convert" is realized through memory: present self-identification cohabitates with recollection
of a conflicting past identity. For the upright Christian there is a paradoxical virtue in having once been truly
wicked. The ideal of conversion introduces an inconsistency or fissure into the sense of self, which is negotiated
through memory. This inconsistency is at the heart of much Christian thought in Late Antiquity.
hedrick@ucsc.edu
Personal Freedom and Social Constraint: Athenian Democracy and the Modern Liberal State
Robert Wallace, Northwestern University
Personal freedom, "living as you like," was a cardinal principle and daily reality in Athens' democracy. From
Perikles to Aristotle, many texts both emphasize and document citizens' freedoms. No laws prohibited, e.g.,
prostitution, drunkenness, or homosexuality. Coarse, libellous, impious language filled the stage. Brilliant
politicians lived unconventional lives and were reelected. On core liberal values, Athens was far more tolerant than
modern liberal states.
However, Athens offered no guarantees of freedom, like our rights. What guarded freedoms? Also, no modern state
would dare tell citizens to live as they liked. What kept Athens from falling apart?
Athens' freedoms were guarded first by the absence of laws regulating private conduct, and second by powerful
ideologies that no one tell another how to live. Principles, ideologies, and mentalities are positive promoters of
freedom; rights are passive and weak.
Athens cohered because Athenians also accepted the ideology that the community's material interests came before
the pleasure of any person. Furthermore, unlike modern capitalist societies, self-control was a central virtue.
Enslavement to passions was seen not to yield happiness. Personal freedoms were self-regulated; hence social
regulation was superfluous.
rwallace@northwestern.edu
The People’s Justice: Law, Litigation, and the Jury in Ancient Athens
Andrew Wolpert, University of Wisconsin-Madison
In contrast to modern representative democracies, ancient Athens had neither a professional class of judges and
jurists nor a system of precedent and appeal. The ordinary citizens selected by lot in the thousands to serve as jurors
had, therefore, enormous discretionary powers. Unfortunately, they did not leave written records about the cases
that they had heard. Hence, their silence is a serious obstacle for the study of Athenian law and society. This paper
seeks to resolve this problem by examining the framework that litigants used to present their cases.
Although few Greek historians insist on a strict dichotomy between legal arguments and rhetorical appeals that
appear in Athenian court speeches, they tend to prioritize one over the other. Some suggest that jurors tended to
ignore irrelevant information introduced by litigants and focused primarily on questions of law while others believe
that jurors assessed more generally the act and the actor, taking into account the moral, political, and social context
of the dispute and the parties involved. Attempts to create sharp distinctions between the types of proofs and
appeals seriously distort their use in the courts and their reception by jurors.
All arguments had the same purpose, to prove that the litigant’s case was just and that the jury should therefore vote
in his favor. To ask whether the litigant depended more upon legal or rhetorical arguments to persuade the jury is
simply the wrong question. Each litigant used whichever arguments he thought would help his case, and no litigant
dared to lay his claim solely on matters of law or exclusively on emotional and ethical appeals. We can better
appreciate Greek forensic oratory if we apply theories from the law and narrative school as well as theories on trial
advocacy to the workings of the Athenian courts. Litigants sought to persuade the jury to believe their particular
story about the dispute and its impact on the wider Athenian community in order to justify the resolution that they
proposed. They then selected whichever laws, whichever proofs, whichever appeals, and whichever facts about the
events would fit within that particular framework.
awolpert@wisc.edu
Legal Consciousness: II
The Development of the Jural Perspective in the Ancient World
Gabriel R. Ricci, Elizabethtown College
This paper explores the development of the jural perspective in Greek literature from the jurisdictional divisions in
Hesiod’s Theogony, in which the concept of Fate receives a spatial and topological interpretation, to the dialectical
method for which Socrates is renowned. The general argument is that the Greek literary tradition, whether it be the
epic genre, tragedy, the religious cosmologies or the metaphysical tradition originating with the pre-Socratics, is a
concerted effort to articulate the legal foundations of existence. In some cases this developing perspective appears
as a detail, as in the case of the judicial setting depicted on the shield made for Achilles, or in more dramatic form,
as in the institutionalization of the jury system by Athena at the Areopagus in Aeschylus’s Oresteia, or in the legal
conflict between Creon and Antigone in Sophocles’s Antigone. Along the way, there is the emergence of the
rhetorical disciplines that ground political and legal life in the polis and inform Plato’s literary style; particularly as
it is represented in the cross-examination style of conversation associated with Socrates. The thematic unity of this
historical development is embodied in the opposing worldviews represented by the phyusis and nomos controversy
that occupied natural philosophy as well as political and moral speculation.
riccigr@etown.edu
Examination of Contemporary and Historical Manipulation of Religious and Legal Iconography
George Robert Ash, Madison, Wisconsin
The history of law and history of religion both have visual and symbolic representations. This paper will explore the
enduring nature of some these images and trace their use and evolution through time. The paper will consider
variations of the primary iconography of the three major Abrahamic religions and their relationship to the
iconography of law. Often law and religion were aspects of the same entity and at times they were subtly or
diametrically opposed. Regardless of the relationship between these entities battles for legitimacy and authority
often were centered on common acceptance of one’s right or capacity to appropriate symbols and icons. These
images draw on often unconscious historic weight to lend prestige to their users regardless of the authority or
integrity of the users be it unethical advertisers or fascist states. The paper will trace the historic manipulation of one
or more icons to illuminate the primitive power that the visual retains. Finally we will examine contemporary
examples of this historic tradition in politics, marketing, law and religion. One current example is the power of the
American flag and the accompanying sense of quasi-divine authority as used in contemporary American politics and
the battle between the primary political parties to be viewed as the legitimate heir to that power and legacy. One can
also trace the migration of the use and authority of that symbol from one group and ideology to another. The states
are currently associated with the Democratic party are the states that composed the Union and were represented by
the American flag during the civil war. Today the American flag is closely associated with the Republican Party
which is strongest in the southern states that had made up the Confederacy. This example illustrates the durability
and historic power of icons and the continuing battle to appropriate them to further and validate radically different
agendas.
Grash2@gmail.com
From Anarchy to Monarchy: King Saul and the Shaping of Legal Consciousness
James A. Diamond, University of Waterloo
The Old Testament book of Judges covers a period characterized by a legal consciousness that is identified by its
final verse "In those days there was no king in Israel; everyone did as he pleased". The lack of a centralized
governmental authority encouraged an anarchic tribalism associated with the rampant lawlessness of its concluding
narrative involving rape, civil war, genocide and kidnapping. The book of Samuel marks a transition to a monarchic
autocracy with its implicit rejection of prophetic authority, which concedes to a new popular legal consciousness
cognizant of membership in a community of nations ("appoint a king for us to govern us like all other nations" I
Sam. 8:5). That consciousness finds its first expression in the reign of King Saul, a figure whose external perfection
(handsomest, tallest) is incongruous with his internal instability where he is prone to periodic bouts of manic
depression (e.g. “an evil spirit from the Lord began to terrify him" 16:14) and possibly schizophrenia ("Then he
stripped off his clothes, spoke in ecstasy and lay naked all day and night" 19:24). A royal administration that is
distinguished by legal incapacity culminates in suicide, an act that ironically, may have been the king's most lucid
moment. Although ancient Israel's initial experiment with monarchy may have been a dismal failure, its literary
account is a superb portrayal of the challenges faced by radical changes in legal consciousness. This paper will
explore the hermeneutics of a biblical narrative intended to shape popular legal consciousness.
jdiamond@uwaterloo.ca
Legal Primitivism and Its Discontents
Steven Wilf, University of Connecticut
How do we interpret the continuing preoccupation among Anglo-American jurists with primitive law, and more
particularly with lex non scripta, from Henry Maine’s Ancient Law (1861) to Bronislaw Malinowksi’s Crime and
Custom in Savage Society (1926)? In the second half of the nineteenth century and through the early twentieth
century, an immense literature was created which charts the evolution of legal systems parallel to our own. These
include works of sociologists and political theorists like Herbert Spencer, prominent Yale sociologist and reformer
William Graham Sumner, and practicing lawyers, James Coolidge Carter, Guy Carleton Lee, and Henry Wilson
Scott. Sometimes the legal systems described are archaic, sometimes belonging to tribal societies, and sometimes
simply conjured out of thin air. At times legal primitivism is valorized–as is the case in celebrations of Teutonic
forests as the birthplace of republican legalism; at other times, it is portrayed as barbaric or totemic. Nevertheless,
despite its vastness, and variety, the legal primitivism literature has attracted remarkably little scholarly attention–in
part, perhaps, because there is so often the whiff of pseudo-science, orientalism, and a discomforting number of
racial assumptions embedded in these works.
But my interest in legal primitivism is not a venture of antiquarian cultural recovery. For these nineteen and earlytwentieth century thinkers, their fascination with legal primitivism betrayed their need for a laboratory of ideas.
Legal primitivism is the doppelgänger of legal modernism, the place where legal modernists, caught between an
increasingly formal common law and an increasingly insistent thrust towards codification, shunted their own
anxieties. It was unease with legal modernism’s focus on written text, for example, that animated the identification
of orality as a core characteristic of the savage legal mind. James Coolidge Carter mined legal primitivism as a focal
point of dealing with the troublesome problem of competing and contradictory legal precedent. Primitive law
presented rudimentary legal systems–ideas, in the words of Henry Maine, which are to the jurist what the primary
crusts of the earth are to the geologist.
Legal primitivism is quite relevant to the major debates over the genealogy of modern legal consciousness. Some
scholars–especially those associated with the law and economics movement–have identified the origins of legal
modernism with the rise of the surety of social science. Others, notably Critical Legal Studies scholars, have
pointed to the modernist impulse of grappling with indeterminacy in a disenchanted world. My paper focuses upon
the anxiety of legal change. It seeks to situate legal modernism within cultural modernism as a whole, and, more
particularly, within the scope of the larger cultural project of identifying the primitive legal mind. This late
nineteenth-century turn towards legal primitivism is telling. One cannot understand what legal modernism wanted
to be without understanding what it so desperately sought to see as its other.
swilf@law.uconn.edu
Before a Boundary: A First Essay in Antiquity
Jonathan Boyarin, University of Kansas
This speculative paper seeks out possible resources in late antiquity for another attempt to overcome the perception
that law in society and culture is inescapably dogged by a split between letter and spirit, or between doxa and reality.
It does so by attempting to reach “behind” the complimentary formation, during the first Christian centuries, of
rabbinic Judaism as an orthodoxy of the “letter” and Patristic Christianity as an orthodoxy of the “spirit,” a process
that has recently been analyzed in Daniel Boyarin’s Border Lines: The Partition of Judaeo-Christianity.
In Border Lines, Daniel Boyarin suggests that before this partition, "the habitus of both earlier Christian and Jewish
groups [was] rational decision-making processes through dialectical investigation." He further suggests that this
habitus drew on the tradition of Sophist discourse, a movement that was in some valid sense devoted to a
disinterested search for truth, while enjoying some measure of social authority As Susan Jarratt earlier explained, in
her Rereading the Sophists,
With the sophists, nomos, a self-conscious arrangement of discourse to create politically and socially significant
knowledge, enters as a middle term between mythos and logos. This addition to classical rhetorical terminology
might be used to displace the Aristotelian focus on rhetorical arguments with heightened attention to narrative
structure, changing dramatically the status of arrangement and collapsing the discrete categories of logos and pathos.
Accordingly, this paper begins by explaining the split between letter and spirit as an effect of the dichotomization of
Judaism and Christianity in the West, recuperates the Sophist “middle term” of nomos, articulates that ancient term
with its use in the recent legal-literary theory of Robert Cover, and opens finally into a suggestion that equally
potent ideological dichotomies today--such as that between "secularism" and "religion"--might not be undermined, if
not transcended, by a recuperation of the idea that a nomos can be both powerful and at the same time a conscious,
responsible human production.
jonathanboyarin@yahoo.com
Legal Consciousness: III
American Law and Native American Indigenous Peoples: Equivocal slippages Between Consciousness
and Conscience
Richard A. Monette, University of Wisconsin-Madison
Perhaps the greatest human rights abuse of all is to subjugate an entire peoples, incorporate them without norm or
logic, suppress their outward cultural attributes, tear apart their cultures, and sear the seams of their values and
beliefs B and keep them alive to systemically suffer it. When Felix Cohen wrote “AThe Legal Conscience@,
speaking truth to American law, he chose Native Americans as his benchmark. If democratic law is indeed based
upon the norms and values of the collective, then Cohen was speaking truth to an American collective
consciousness. In the slippages, equivocal and unequivocal, between the American conscience and an American
collective consciousness, between American law and justice, reside the human rights abuses of the Native American.
In a recent case concerning the US Supreme Court’s position on the powers and authority of American Native
Nations (Lara), US Supreme Court Justice Clarence Thomas referred to the Court’s jurisprudence in this area as
“schizophrenic”, an accurate assessment of the collective consciousness of the Court and its jurisprudence. This talk
will illustrate the historically divergent and increasingly diverging doctrines leading to Justice Thomas’ label of
“schizophrenia.” One development is founded upon and would adhere to America’s highest ideals, the other to
America’s worst practices. The questions for American Native Nations are: can we survive with two Americas? Or
which path of the divergent jurisprudence will America and the US Supreme Court choose to provide the cure for its
“schizophrenia”?
rmonette@wisc.edu
The Problems of Legal Consciousness in Russian Culture: Past and Present
Gary Rosenshield, University of Wisconsin-Madison
Almost immediately after the fall of communism in 1991, the Russians began to show an interest in reforming the
judicial system and reviving the jury trial for criminal cases. But it has been a slow and arduous process. Russia
cannot just resume from where it left off in 1917 when the jury trial was abolished by the Bolsheviks. Much of the
culture and tradition of the pre-Revolutionary legal system has been lost in the last eight decades. It is not only a
matter of reviving old institutions but of developing a legal consciousness among the public, the pool of potential
jurors. When the jury trial was introduced in 1864 in tsarist Russia, it immediately became the nation's most
democratic institution. A bar developed, judges became completely independent of the administration, trained
counsel represented defendants and clients, evidence was presented in court, proceedings were public, and juries
responsibly deliberated the fate of their peers. Nevertheless, before the reforms were enacted there were sceptics
who doubted that the jury trial could succeed in Russia. The country, they argued, was unprepared for it; the Russian
people had not developed the necessary legal consciousness for the reforms to work. Writing in 1850, fourteen years
before the enactment of the judicial reforms, the English philosopher, Herbert Spencer, scouted the possibility of a
successful jury system in Russia. "It is not trial by jury that produces justice," he argued, "but it is sentiment of
justice that produces trial by jury, as the organ through which it is to act; and the organ will be inert unless the
sentiment is there." Most would argue that the relative success of the jury system proved that Spencer was wrong.
Yet Russian political theorists throughout the nineteenth century, despite the judicial reforms, worried that the
absence of a true legal consciousness, especially among the intellectual elite, would prevent Russia from developing
the democratic institutions of Western Europe. The same worries exist today. In this paper I shall discuss the
problem of legal consciousness in pre-revolutionary Russia and attempt to show how the same problems of
undeveloped legal consciousness that existed in the nineteenth century are making the task of modernizing and
democratizing the legal system especially difficult in our own time, a task made even more difficult with the
government's turn to more authoritarian rule as a means of dealing with political terror.
grosen@slavic.wisc.edu
Legal Consciousness in Western Culture
David N. Weisstub, Université de Montréal
The emergence of a legal consciousness was a natural occurrence following the central place given to law in the
foundational cultures of the West. Legal consciousness, thereafter, took on a force of its own in the development of
both common law and constitutional regimes. Most recently, the idea of a mainstream legal consciousness has been
challenged by two major critiques: feminism and multi-culturalism. Despite the many transformations of the
concept of legal consciousness, the question is posed whether there is a sustained content which remains.
admin@ialmh.org
On Crime and the Scottish Enlightenment
Leonard Kaplan, University of Wisconsin-Madison
The Scottish Enlightenment constituted a particularly lucid moment in the history of political philosophy and law.
Figures like Adam Smith, Francis Hutcheson, Adam Ferguson, Thomas Reid, Dugald Stewart, David Hume among
others reduced natural law sentiments to rational and empirical consideration. Without denying God they took God
out of the discourse so that humanity would through reason make sense of and constitute politics, jurisprudence,
economics and psychology.
Post modern consciousness and theory has lost the confidence in reason shared by that significant moment situated
in Edinburgh where capitalism was seen as a political economy that could effectuate considerable wealth without
too much economic impoverishment but certainly some. In fact the thinkers within this rhetorical and actual space
had a grasp on the limits as well as the possibilities of man as maker through reasoned discourse. These Enlightened
thinkers are in fact the enemy of many who resurrect old, frequently flawed and ideological metaphysics for interest
group gain against Enlightenment optimism.
In recent years crime writers who are to be found throughout the world have also established a rich body of work in
contemporary Scotland. These writers are sophisticated about their enlightenment heritage. Their work constitutes a
rich source of narrative critique of the gap between Enlightenment hope a current cultural corruption and despair.
The gap between the stories told in these representations present the difference between liberal jurisprudential
longing and aspiration and current reality. This paper will consider that gap and the constraints, theological and
jurisprudential from the attainment theorized from the Scottish thinkers.
The paper will summarize the Scottish thought aspirations. Several Scottish crime novelists will be considered, e.g.,
Paul Johnston, Christopher Brookmyre, Ian Rankin, Val McDermid, Denis Mina, and Agnes Owen.
lvkaplan@wisc.edu
An Ethical Rip Current
William King, Pastor Emeritus, Covenant Presbyterian Church
I will be telling the story of the collision of cultures, of ecclesiastical and civil law, and organized religion with the
innate assumptions of its followers.
A minister of a Korean Presbyterian Church was the subject of a formal complaint signed by 38 of his parishioners.
The complaint was submitted to the Presbytery (the organization consisting of all the ministers and an equal number
of laypeople [elders] in the geographical area that includes the Korean Presbyterian Church. The Presbytery holds
much of the same authority as does a bishop in an Episcopal ordered denomination.
The complaint was investigated by a task force of Presbytery which functioned like a grand jury—determining
whether there was probable cause to charge the minister or dismiss the complaint.
The task force determined that the complaint was a chargeable offence and filed the charge with the Permanent
Judicial Commission.
The minister was found guilty of spousal abuse, sexual and financial misconduct; and was removed from the
membership of the Presbyterian Church and, with that, his ordination was taken away.
No civil charges were filed. The minister’s wife felt that he was justified in hitting her, and that the Presbytery and
members who filed the complaints were acting under the influence of Satan. The victims of sexual misconduct did
not wish to bring these acts to the attention of the law. The church board has taken no action to inform the Internal
Revenue Service that the minister misrepresented his income in order to avoid paying income tax—for 24 years.
The ex-minister is demanding remuneration for his years of service as an act of respect. He is held in fear by some
because he is a Shaman who claims the power to curse. The church is embarrassed, feels obligated and is also full
of anger and certain that the American Church has not well comprehended the Christianity of the Korean Church.
A westernized Near Eastern religion that meets the far Eastern understanding of the same denomination has created
an ethical rip current which is fascinating and complex.
Lurgana@aol.com
Cruel and Unusual Places: The Death of the Prison
Patricia Likos Ricci, Elizabethtown College, U.S.A.
After two centuries of progressive ideals and innovative designs, the American prison has been found guilty of
crimes against humanity and sentenced to death by an increasing number of churches, social reformers, political
activists, and architects. Founded by Quakers in 1983, ICOPA (International Conference on Prison Abolition),
maintains that prisons have not only proved incapable of their mission to deter crime and rehabilitate criminals, in
the last twenty years, their proliferation and privatization have produced a “prison-industrial complex” with minority
convict labour. Recently the California-based Architects, Designers and Planners for Social Responsibility
(ADPSR) have called for a national boycott on prison design as a protest against the highest rates of incarceration in
the world. Drawing on the insights of Alexis de Tocqueville and Gustave de Beaumont’s On the Penitentiary
System in the United States and its Application in France (1832) and Michel Foucault’s Discipline and Punish: The
Birth of the Prison (1977), this paper analyses the goals and results of three influential prison models constructed in
the United States from the 19th to the 21st century: the Panopticon plan designed by British philosopher Jeremy
Bentham and interpreted by architect John Haviland at Eastern State Penitentiary (1823) in Philadelphia; the
“telephone pole” plan designed by French architect Francisque-Henri Poussin for the prison at Fresnes (1898) and
adopted by the American architect Alfred Hopkins at Lewisburg Federal Prison (1932) in Pennsylvania; and the late
twentieth-century “podular” plan represented by Pelican Bay Security Housing Unit in California.
riccipl@etown.edu
Legal Consciousness: IV
Rights: Heteronomy not Autonomy
David Novak, University of Toronto
Current ethical/political/legal discussions are enamored of autonomy. The Greek etymology of “autonomy” admits
of two different meanings. One, “law [nomos] of the self [autou];” two, “law [nomos] itself [autos].” Here I
concentrate on its legal meaning: how one is conscious of being autonomous in a legal context.
One, autonomy means “the capacity to command oneself.” That is, I am only obligated to do what I have
commanded myself to do. Contracts presuppose this: a contract obligates me because I have obligated myself to the
contract. Since the most persistent justification of democracy and its law has been that it is founded in a social
contract among its citizens, I am thus obligated to the legal system in its particulars because I have obligated myself
to the system in general. In this sense, legal consciousness is consciousness of my autonomy.
However, in a constitutional democracy, not everything may be contracted — like slavery, for example. That is
because the social contract is made by persons already having rights derived from somewhere else prior to their
making the contract. These rights are “inalienable.” No one may revoke them from anyone else — even from
oneself.
Two, autonomy is the idea of law itself (nomos - autos), for example: Justice is fairness (John Rawls). It precedes
the actual institution of law that emerges from the social contract as a political agreement. It is the right that the
parties to the social contract bring to the agreement before they take anything away from it. Nevertheless, this
confuses a right with an ideal. An ideal is the projection of an idea onto a future horizon; one’s attraction to it then
moves one to treat other persons in certain definite ways as part of the overall movement towards that ideal.
However, it is extremely doubtful whether I can derive legal consciousness from my ideal trajectory. For if, at times,
law necessitates the coercion of others, how can I justify coercion of somebody else if my ideal is not their ideal?
A right, conversely, is a claim of one person upon another. A right/claim on oneself is unintelligible. A right is
justified if it is exercised by someone entitled to that right, and it is justified when that right-holder is exercising his
or her right for the reason/purpose for which that right was given to its rightful holder. So, if a right is a justified
claim, the result of an entitling transaction, then even though there is a right to exercise autonomy in many public
and private acts, autonomy itself is not the foundation of that right or any other right. Hence legal consciousness is
the consciousness of heteronomy, viz., that which entitles one to have a right. But can fundamental heteronomy be
justifiably exercised by anyone less than the Creator God who has given moral law to humans as an integral part of
his governance of the universe.
david.novak@utoronto.ca
Statutory Interpretation in the EU : The Augustinian Approach
Lawrence M. Solan, Brooklyn Law School
The European Union now has 25 members and 20 official languages. Directives enacted by the EU are promulgated
in all 20 official languages, and each version is authoritative. This creates a seemingly unmanageable problem:
When a dispute arises over a business transaction between say, Finland and Spain, which versions of the applicable
law should “count” when the court has to make a decision?
The European Court of Justice has adopted a policy that permits any version of the statute to be used in argument in
any dispute before it, whether or not any of the parties to the dispute speak that language. In this paper, I call this
practice “the Augustinian approach” to statutory interpretation, and defend it as sensible.
In On Christian Doctrine, Augustine, an essentialist, advocated for examining all translations of the Bible to
determine God’s actual message. By searching for differences among the translations, it became possible to infer
just where human language has interceded. When that happened, triangulating among the various versions, and
employing extra-textual strategies became appropriate.
Much the same strategy is used by the European Court of Justice and by other tribunals that interpret multilingual
statutes. The success of this approach depends largely upon the extent to which word meaning is similar across
languages and cultures. The paper looks at advances in linguistic lexical semantics and the psychology of concepts
to argue that this Augustinian approach has a strong underlying basis in contemporary learning.
larry.solan@brooklaw.edu
Legal Consciousness and Ricoeur’s Theory of Imagination
George Taylor, University of Pittsburgh
One of the most striking conclusions of the United States’ September 11 Commission Report is that the attack that
day revealed a failure of imagination by members of the U.S. government. Indeed, the Executive Summary to that
report states that the failure of imagination was the government’sA ‘most important failure’. My paper seeks to
assess the nature of that failure as an issue of legal consciousness and offers some possible remedies. I take as my
primary text a set of lectures on imagination by philosopher Paul Ricoeur that I am currently editing for potential
publication.
For Ricoeur, too much of the history of philosophy and psychology reflects the predominance of reproductive
imagination. Reproductive imagination identifies the mental impression or image as a replica of an outer reality.
David Hume’s theory is representative. Building in part on Kant, Ricoeur instead emphasizes the role of productive
imagination, where the mind creatively opens new vistas of reality, as in literary fiction.
My argument is that the differentiation between reproductive and productive imagination can be fruitfully applied to
legal consciousness. All too frequently legal consciousness, at least in the United States, is reproductive, relying on
what has gone before. Most typically, this characterization is applied to judges, but as the September 11 Report
reveals, it can be applied more generally to virtually all governmental actors. The September 11 Commission
concludes that it is ‘crucial to find a way of routinizing, even bureaucratizing, the exercise of imagination’.
I will show how Ricoeur develops his theory of productive imagination as applied to fictions. Then I will pursue, as
both a philosophical and psychological matter, how a productive imagination may be inculcated as a matter of legal
consciousness. How is a productive legal imagination possibly different from the hermeneutic concept of
application, where meaning changes in B is open to the new experience supplied by B new situations? Can cognitive
psychology, such as Howard Gardner=’s work on how minds change, inform concretely how productive legal
imagination may operate? Similarly, may work in comparative psychology by Richard Nisbett help us determine
how to overcome the perdurance of legal categories and categorization?
taylor@law.pitt.edu
Feminist Consciousness and Mental Health
Candice Hoke, Cleveland State University
In light of the theoretical divisions among feminist scholars generated over the past two decades, is it possible to
speak of “feminist consciousness”? Although the term may have had a generally agreed content during the 1960s
and 70s, the epistemological divide occurring during the past two decades between essentialist and postmodern
feminists (as well as other theoretical strands) can be argued to have obstructed a unitary conception of feminist
consciousness. That feminist political activists transnationally espouse widely divergent perspectives and political
programs traceable in part to the vectors of race, class, and culture, underscores an arguable lack of common
conceptual or political ground that can be characterized as feminist consciousness.
This paper argues that despite the theoretical, practical and political differences among feminists, some common
ground can be identified. I draw predominantly upon feminist economic development scholarship and classic
feminist psychological theory to establish this argument. Transnationally, feminist scholars working on economic
development issues in concrete cultural situations offer empirically grounded insights into elements of feminist
consciousness. These scholars have catalogued as effects of feminist consciousness (and of the structures
supporting economic empowerment of women) a positive sense of self and self-possibilities as well as an enlarged
perception of acceptable social, familial, economic and political roles. Transculturally, commonalities emerge that
can be typed feminist consciousness despite the range of social differences between communities and individuals.
This economic development scholarship supports theoretical insights offered by classic feminist psychological
theorists. Feminist psychologists have long argued that mental health for women and girls, and their capacity to
fend off depression, substance and physical abuse, avoid other mental disorders, and achieve healthy psychological
positions, rest in self conceptions and gender conceptions that we can term “feminist.” Additionally, certain
psychological pathologies have been identified in those possessing excesses of power (manifesting a tendency
toward physical and psychological abuse) which arguably can be allayed by feminist consciousness and practice by
men.
shoke@law.csuohio.edu
Practicing Psychiatry in the Shadow of the Law
Guy Lord, Medical College of Wisconsin
Legal issues can be considered a sixth axis in a multiaxial diagnostic system. In each clinical encounter, a practicing
physician must place himself or herself, the patient and other aspects of the situation within a matrix of legal
concerns. The patient is also aware of a legal context to this clinical encounter. In my own speciality of child
psychiatry, considerations may include: informed consent, custody and placement matters, malpractice worries, and
the legal minefield of psychopharmacology. Traditional forensic psychiatric topics such as legal insanity and
competency are less common concerns. The sources of information are not usually professional journals, but
newsletters, communications from professional societies and from one’s own attorney or malpractice carrier. Can
all of this be distilled into a single legal consciousness? This can be viewed in the context of the current American
sense that we are continually being taught to live in fear. One’s legal consciousness can be seen as the mixture of
dread and reassurance that one encounters in many areas of life. The physician fears being seen as incompetent,
being sued, perhaps being attacked by an angry father. The physician is reassured by the knowledge that he/she is a
licensed professional that he/she knows what rights a fourteen year old or a non-custodial parent has. Legal
consciousness, in the immediacy of a clinical encounter, is primarily affective rather than cognitive. Knowledge
serves mostly to allay fears. The consciousness also has a dramatic quality. At many points in clinical decision
making, the image arises of oneself in court defending the step one is taking. These and other aspects of legal
consciousness in the treatment setting will be discussed.
grlord@execpc.com
Legislating the Reformation
Lee Palmer Wandel, University of Wisconsin
In 1846, Aemilius Ludwig Richter published The Protestant Church Ordinances of the Sixteenth Century (Die
evangelischen Kirchenordnungen des sechzehten Jahrhunderts (Weimar). The volume arose out of a broad
nineteenth-century interest in publishing the sources of the Reformation, of which the Corpus Reformatorum and the
Weimar Ausgabe of Martin Luther’s works are the most famous products. Like so many of these publishing
projects, Richter’s gathered from dispersed local archives documents which were then arranged according to
categories of primary interest: in the case of the volume, geography and chronology. Richter’s earlier work had been
on canon law and Gratian; he envisioned this as an extension of what he then termed Protestant ecclesiastical law.
Richter’s volume, along with those Emil Sehling edited beginning in 1902, brought together what had been local
documents, promulgated by either Free Imperial Cities, such as Nuremberg or Augsburg, or Principalities, such as
Brandenburg. Together, these volumes speak to a stunning innovation: the use of civil law to define and institute
religion. Prior to the sixteenth century, local bishops and the papal curia had jurisdiction over the practice of
worship—liturgy, the sacraments, forms of prayer. In the fourteenth and fifteenth centuries, increasingly, various
secular authorities had moved to take over the regulation of morals. But with these Church Ordinances, secular
authorities—those authorities explicitly not ecclesiastical—extended their jurisdiction and legislated “religion”: the
form of the liturgy, the number of sacraments, the definition of a sacrament and its precise liturgical form; the use of
a specific catechism; and, in the case of Geneva, the content and timing of prayers.
lpwandel@wisc.edu
Legal Consciousness: V
The Social and Legal Conscience of the American Labor Movement B Has it Gone Astray or Been
Simply Left Behind
Richard Kirschner, Kirschner & Gartrell, P.C., Washington
This presentation will briefly trace the roots of the American labor movement and ist role as the principal architect
of virtually every piece of social welfare legislation enacted within the past 75 years designed to protect not only
those in the work force but the unemployed and imposverished as well. The protection which the legislation was
designed to accord – whether it addressed the right to unionize, the right to be free of racial, sexual, age or disability
discrimination and whether it was enacted to guarantee a safe workplace or secure a protected pension is under an all
out attack by a Bush administration determined to dismantle the legislation by either repeal or simply benign
neglect. An embattled labor movement finds itself in the crosshairs of the Bush all out assault and appears as but a
lone and singular voice in the fabric of the American economy as it seeks to fend off governmental and employer
opposition to unionization and thwart the exportation of jobs while attempting to recoup its loss of strength. The
American public has stood idly by and watched jobs disappear, unions neutralized and tolerated an economy where
a family of four requires two wage earners each working two jobs to stay financially afloat. The Walmartization of
the economy bodes ill for the working middle class. A reawakening of the social conscience of the working class is
the major challenge faced by the labor movement today – can or should it pave the way for others who have situated
themselves in the neoliberal culture of today?
leaglerk@aol.com
Scare You to Death, Work You to Death, Bore You to Death: The Development of Legal Consciousness
in American Law Schools
Katherine Lord, Valparaiso, Indiana
In order to make effective conclusions or predictions about “The Law” as it relates to various other aspects of
society, it is crucial to examine how future lawyers and lawmakers are taught to view the law. This presentation will
investigate factors and influences in the cultivation of legal consciousness in American law schools today. I will
discuss what impact the teaching philosophies of professors can have, as well as the availability of extra-curricular
influences, such as clinical experience, internships and student organizations. As a case study, I will describe the
process of founding a new student group on my law school campus, the experience of working with the
administration to make the organization successful and how members of the organization feel it has shaped their
outlook on the study and practice of law.
katherinelord@1stcounsel.com
The Legal Rights of Individuals Seeking Assistance from the Government: Does the Perception Reflect
Reality?
Paul M. Schmidt, Attorney-at-Law, Madison, Wisconsin
This paper discusses our current legal consciousness concerning the existence and importance of individual legal
rights in situations where a mentally impaired individual encounters governmental controls and procedures.
Specifically, this paper explores specific areas where individual rights are tested by institutional objectives such as:
1) qualifying for entitlement benefits, such as Social Security Disability benefits; 2) qualifying for welfare
payments, such as Supplemental Security Income payments; and 3) appointing a legal guardian for an incompetent
individual. This paper compares the current societal beliefs and attitudes about the rights of individuals in these
situations, with the realities and shortcomings of the system. As a higher percentage of our population (the “BabyBoomers”) ages, and suffers afflictions of old age, such as dementia and Alzheimer’s disease, a shift in emphasis
may occur: there will be increased demand on institutional resources, and society may not have the ability to
respond to this demand. The pressures to compartmentalize and streamline the process will increase, further
jeopardizing individual legal rights in the process. This paper explores how our legal consciousness may evolve in
the near future as a result of these pressures, and suggests some alternatives for addressing the current and potential
future shortcomings in the “system.”
pschmidt@boardmanlawfirm.com
Expert Psychological Evidence on Eye-Witness Identification
Frank M. Tuerkheimer, University of Wisconsin-Madison
Psychological evidence as to the limitations of eye witness testimony has undergone a checkered history in
litigation. Traditionally, the view was that a jury was capable of assessing credibility issues obviating the need for
expert evidence. Over the past several years, this view has been eroded in three distinct areas: trans-racial
identification, a certainty-accuracy correlation, and double blind identification techniques. In each instance, largely
irrefutable psychological studies have resulted in the law moving away from the traditional concept that a jury needs
no help.
In instances of trans-racial identification, courts have accepted psychological studies which show that where the
identifying witness has had no substantial contact with persons of the same race as the person being identified, such
identifications have a greater incidence of unreliability than either in intra-racial identification or trans-racial
identification where the identifying witness has had considerable contact with the persons of the race being
identified.
Psychological studies have also shown that there is very little if any correlation between the professed certainty of
an identification and its accuracy. Here, the traditional notion that the jury can decide on its own is easily countered
since the non-connection between certainty and accuracy is counter-intuitive. It therefore becomes difficult to argue
that the jury needs no help.
Psychological studies have also attacked the very basic mechanism by which identifications take place: a line-up in
which the suspect is included, or a photographic spread containing the suspect. The double blind technique,
developed after numerous studies on eye-witness reliability, require that the person handling the line-up for the
investigative agency not know who the suspect is. In addition, it requires that when a photographs are shown, they
not be shown in a spread but rather one at time and that the suspect not necessarily be in those shown.
The changes in the law on this subject reveal a dynamic and useful interplay between the disciplines of law and
psychology.
fmtuerkh@wisc.edu
Law Enacted & Law in Action – The Case of Internet “Spam”
Gerald J. Thain, University of Wisconsin-Madison
It is uncontroverted that unsolicited commercial e-mail messages (spam) are a major concern for efficient operating
of e-mail on the internet. The belief that this is a problem that can be addressed satisfactorily by enacting laws and
enforcing them is wide-spread, notwithstanding significant evidence that law cannot be effective in dealing with this
issue. The classic example of this is the so-called ‘Can Spam’ legislation adopted in the United States, with great
attendant publicity.
This issue will be addressed as follows:
1. Summarization of the problems created by Aspam@ e-mail, noting the very low cost of using this medium
for the senders and the heavy burden that the abundance of such messages has placed on internet
communications;
2. Reviewing the provisions of the ACan Spam@ act recently enacted with considerable publicity that it will
be essentially effective in combating the spread of spam;
3. Noting the reasons why the act cannot be effective to any noticeable degree, including the limitations of the
reach of the law (much spam is allowed under it so long as it is not deceptive nor pornographic) and the
ease with which present technology can over-come the law easily by such means as masking the sender=s
address;
4. Considering some suggested alternative approaches to the problem of spam, especially in other countries,
and noting that none so far overcome the technological methods of evading legal controls or the problems
of international enforcement;
5. Treating the way this situation illustrates a common mentality in the U.S. that enacting a law will solve a
social problem with the impact this concept has on the legal process, when enforcement is unlikely;
6.
7.
Noting how the approach to this problem illustrates the “Athere-ought-to-be-a-law” mentality of many in
the U.S. that views law as a primary solution to social problems;
Considering this failure of the general public to divide law enacted from law in action in terms of legal
consciousness.
gjthain@wisc.edu
Temporality and Jewish Legal Consciousness
Jonathan W Schofer, University of Wisconsin Madison
This paper examines the formation of consciousness through law and legal imagery according to classical Jewish
sources. In the late ancient rabbinic communities that in many ways created the canons of Judaism as it has
developed to the present day, study of legal materials and practice according to legal norms not only were central to
religious ideals, but they were seen as crucial to the creation of ideal selves. Such ideals were conveyed through the
teachings and models of early sages; the cumulative tradition of this transmitted instruction was known as Torah;
and rabbinic practice was ultimately framed as the appropriate way to orient towards their deity.
Specifically, in my presentation I will focus on temporal elements in this process of self-formation. In particular, I
will identify and examine three interweaving temporal frameworks: (a) the growth, weakening, death, and decay of
the body, (b) the gradual development of rabbinic legal consciousness through study and practice of Torah, and (c)
the theology of divine justice, according to which the deity is a judge who in the future will enact decisive judgment
upon each human, based on assessment of character and action, that will determine existence after death. I will
examine specific literary materials showing the complex ways that these frameworks are intertwined, and then I will
reflect upon the broader implications of this descriptive study for our understandings of temporality, law, and
consciousness.
jwschofer@wisc.edu
Legal Consciousness: VI
Media Violence: Entertainment, Art, or Threat
Thomas D. Barton, California Western School of Law
Dozens of empirical studies over several decades have warned about seriously harmful effects–especially on
children–of violence in the media. Yet little has changed, and the prospects remain dim. We possess the legal
authority to regulate. We lack the political will. In the face of such serious risks, why are we doing this to
ourselves?
The answer may be that portrayals of violence are often socially classified in ways that insulate the portrayals from
serious regulatory scrutiny. Violent images often win labels that suggest they pose little danger to mental health or
to social stability. Crucially, these labels do not correlate well with how graphic the images are, or how densely they
appear in a portrayal. Works employing the same levels of violence may be categorized as either “entertainment,” or
as “art,” or as “threat/illicit expression.”
Each category calls forth quite distinct social and legal responses. “Entertainment” is tolerated as harmless. “Art” is
affirmatively embraced. Only when labelled as “threat” or “illicit” is a serious effort made to legally regulate the
images.
Yet what distinguishes these three categories, and by what criteria are violent images sorted into each?
My paper addresses these two questions, concluding that one significant variable for understanding the labelling is
the underlying social message that accompanies the violent images. Where the context of the violence reinforces
prevailing social relationships or authority structures, we tend to label the violence as “entertainment.” Where
violence appears in a work that challenges prevailing social arrangements, but does so in a way that most people
regard as thoughtful, legitimate, or controllable, then the work as a whole is regarded as “art.” Where violence
appears in a work that seeks social change, but does so in a manner or toward particular ends that many people
regard as uncontrollable, disruptive, reckless, morally offensive, or dis-empowering, then the portrayal is likely to be
labeled as “illicit.”
We should be aware of this social construction. We should also ask whether this labelling process neglects the
impact of these images on children whose understanding of the contexts may not be well developed.
tbarton@cwsl.edu
Legal Consciousness and Contractual Obligation
Kojo Yelpaala, University of the Pacific
The paper on “Legal Consciousness and Contractual Obligations” will explore the origins of contractual obligations.
The term contract is used in its non-technical and most inclusive sense to cover agreements, promises, undertakings
and other forms of consensus whether or not supported by consideration. Viewed within this broad conceptual
framework, where do human beings get the idea that they must keep their word or perform their promises? Is it, as
utilitarian theorists might suggest, simply a matter of careful burdens and benefits calculus for breach? Or, might our
consciousness in contractual obligations have deeper roots in religion, theology or the centrality of the supernatural
in the ordering of human social organizations? In the specific case of Judeo-Christian religions, might the sources of
contractual obligation be located in the “Covenant with God”? But the origins of contractual obligations might be
less a question of religion but more a question of evolved social norms of reciprocity or human biological need for
collaboration and cooperation. In a world of “efficient breach” and shifting moods in international relations, the
investigation of this question is both timely and important.
kyelpaala@pacific.edu
Some Implications of the New Brain Science for Fault in Criminal Law
Walter Dickey, University of Wisconsin at Madison
Recent developments in brain science, particularly regarding consciousness, raise serious questions about choice and
free will. The criminal law in the United States is based on the idea of free will and choice. This is the primary
vehicle for the expression of fault, usually in terms of intent, recklessness, and negligence. Historically, scientific
evidence was sought to be introduced to address the unconscious mind, often to try to establish that the desire of the
actor was not as it appeared from his actions, from which inferences about mental state and choice were made. This
paper will explore new findings from brain imaging and their implications for the expression of fault, based on free
will. I will argue that this new science casts further doubt on these concepts. This may merely suggest that we
abandon them, in favour of more straightforward expressions of impulse control, or not.
wjdickey@wisc.edu
Tort, torsion, torture
Jacques Lezra, University of Wisconsin
On what grounds can a "case for torture" be proposed? This was the matter of debate following the publication in
1982 of Michael Levin's article of the same name; a spate of columns in the US press following the World Trade
Center attacks in 2001 took up Levin’s brief argument again, and it lies behind the so-called « torture memoranda »
and associated opinions drafted by the United States’ Department of Justice and Department of Defense (Aug. 1,
2002: Justice Department Memo to the White House Counsel; April 4, 2003: Report of the Pentagon Working
Group; April 16, 2003: Rumsfeld Memo to the Head of U.S. Southern Command). On Levin’s description, the
principal justification for torture—(UN GA res. 39/46, 10-12-84: “[A]ny act by which severe pain or suffering,
whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third
person information or a confession, punishing him for an act he or a third person has committed or is suspected of
having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of
any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a
public official or other person acting in an official capacity”) hangs on the so-called “ticking-bomb” scenario. For
Levin, and for the Bush administration, the circumstance of impending, certain, and preventable catastrophe justifies
the use of torture, and the suspension of the “rights” of the subject who undergoes torture. My presentation
examines the specifically literary aspects of the "ticking bomb" argument (for instance, the normativization of
extreme or « representative » cases, anecdotal rhetorics of different sorts), and suggests that a problematical and
tendentious understanding of temporality vitiates efforts to convert such hypothetical arguments into justifications
for this or that juridical procedure ("torture warrants," for instance). This brief talk works between Henri Alleg’s La
Question, Gillo Pontecorvo's film The Battle of Algiers, a brief excerpt from Dante's Purgatorio, Jay S. Bybee’s
“Aug. 1, 2002: Justice Department Memo to the White House Counsel,” and Levin's essay.
lezra@facstaff.wisc.edu
Insanity Cycles: the regular misunderstandings of science and law
Victoria Nourse, University of Wiscounsin
How
does
the
criminal
law
conceive
of
the
self
and
its
consciousness?
The short answer is that the criminal law conceives of the self most insistently when the self is lost, when the law
deems the defendant insane. The law’s insanity defense has traditionally characterized the loss of self-control quite
literally as a measure of legal consciousness – whether the defendant knew whether his conduct was right or wrong.
This notion of consciousness has, in turn, been subject to relentless attack from experts in science, medicine and
psychology as an unrealistic portrait of the mind. Indeed, the purpose of this paper is to put battles between the
science of mind and the criminal law in some historical perspective. It will turn out, for example, that the great
debates of today are far from new, but have important historical analogues in the 19th century. Law has embraced
scientific definitions of mind, more than once, only to be met by popular rebuke, leading to retrenchment and
reinvigoration of seemingly crude and legalistic ideals of mind. If this is right, then we must entertain the possibility
that the law’s mind and science’s mind are really rather different ideas.
vfnourse@wisc.edu
Instrumentalism and Northeast Asian Legal Consciousness
John Ohnesorge ,University of Wisconsin Law School
Legal consciousness and culture have been at the center of political, economic and social interactions between the
West and Northeast Asia, meaning China, Japan and Korea, for at least 150 years. Differences in legal culture were
used by the West to justify imperialism in Asia in the Nineteenth and early Twentieth Centuries, and differences in
legal consciousness and culture are still cited by both sides when conflicts arise in trade and economic relations, as
well as in disputes over politics and human rights. More fundamentally, both East and West continue to define
themselves, to some extent, in terms of how their legal cultures differ from those of the other.
Recent changes to the legal systems of Northeast Asia have cast doubt on the validity of some long-standing
assertions about legal consciousness and culture in the region. For example, the argument that Northeast Asians are
culturally averse to litigation has been undercut by evidence that traditionally low local litigation rates rose
dramatically when procedural rules were made more favorable to litigation. Given this development, one might
argue that even if legal culture as public ideology is averse to rights assertion and litigation, the evidence suggests
that legal consciousness as reflected in legal system performance is guided by its own logic, which can be
understood in the universally applicable language of individual self-interest.
Reformers in Northeast Asia appear to have taken this message to heart, and are seeking to encourage rights
assertion and litigiousness in their societies in order to bring about broad social change. After providing an analysis
of the ways in which legal culture and consciousness have been used in various East-West interactions, this paper
will explore the motives and assumptions behind the attempts of reformers in Northeast Asia to remake local legal
consciousness in the pursuit of specific instrumental goals.
jkohnesorge@wisc.edu
Legal Consciousness: VII
Families and the New Legal Consciousness
Nina Carmic
It is no secret that the law has overshadowed customary practices and religious traditions in the vast majority of
societies in setting parameters of legitimacy for both family formation (through marriage), as well as when for its
dissolution (through divorce or otherwise). Even in places where the written law (through rules and court decisions)
tolerates practices that take place outside its institutional framework, an increasing number of families are drawn to the
legal process in solidifying their family relationships. There is, of course, no better example of this than in the U.S.,
where the laws no longer seek to criminalize private consensual sexual relationships, yet neither do they support it
between couples of the same sex. A primary goal for same sex couples has been in the past year the legalization of
marriage – as if the conferring of the legal label grants the much desired legitimacy to this form of family life. The
desire by same sex couples to legitimize a relationship through entry into marriage has certainly met with greater
resistance than support within the legal establishment, even as it remains a coveted legal status for the vast majority of
same sex couples in stable, enduring relationship. In my essay, I explore the vastly complicated relationship between
family formation and dissolution and jurisprudence. I note that families resolve the vast majority of their conflicts
outside of the legal system. I raise the question of why marriage and divorce remain so firmly entrenched within our
legal consciousness, given the law’s more capricious attitude toward regulating family behaviors in general. Why has
the state retained command of this ultimately private sphere of relational formation/dissolution? Is the goal of
protecting individual family members subservient to a political motivation, whereby the state is seeking to exert
influence for reasons having less to do with stabilizing family life and more to do with maintaining its coercive (rarely
channeled into progressive reform) hold on this vital institution? If that is the case, then are the interests of individual
family members, especially the less powerful within the family unit, likely to be well served? I address these questions
in the context of American family law, as well as with references to legal systems in other nation states.
nlcamic@wisc.edu
The Sympathetic Discriminator: Mental Illness and the Americans with Disabilities Act
Elizabeth Emens, University of Chicago Law School
While animus and stereotyping are common responses to mental illness, discrimination against people with mental
illness also occurs in part because of how those with mental illness may make other people feel. A person suffering
from psychosis may make others feel agitated or afraid, for example, or a depressed person may make others feel
sad or frustrated. One basis for discrimination in this context is therefore a desire to avoid negative emotion. More
pointedly, the phenomenon of emotional contagion—the largely unconscious process by which we absorb the
emotions of nearby others—may form a peculiarly intractable basis for discrimination against people with mental
illness. Research on emotional contagion indicates that the emotions of people with mental illness are likely to be
absorbed by those around them, and that emotional contagion increases the more we like someone. These data
suggest certain limitations to the application of the much-vaunted contact hypothesis to the context of mental illness
discrimination. The contact hypothesis posits that workplace integration increases liking and decreases
discriminatory animus and stereotyping, which are both much-needed interventions in the highly stigmatized area of
mental illness. But the literature on emotional contagion suggests that contact may never completely erase
outsiders’ impulse to exclude people with mental illness from the workplace. Instead, even if contact could
eliminate animus and stereotyping, coworkers who come to know and like their colleagues with mental illness may
still have a reason to want to avoid or exclude them: a desire to avoid negative emotional contagion. This thesis has
implications for doctrinal debates about the meaning and scope of the employment protections for people with
mental illness under the Americans with Disabilities Act. Specifically, it helps to resolve four questions: whether
employers may define the essential functions of jobs to involve effecting certain emotions in others; who must bear
the burden of effective accommodation negotiations; how the “regarded as” prong of the definition of disability
should be interpreted; and whether interacting with others is a major life activity for purposes of the definition of
disability under the ADA.
eemens@law.uchicago.edu
Colonial Madness, Legal Consciousness, and the Poetics of Suffering: Structural Violence in Algerian
Literature
Richard C. Keller, University of Wisconsin-Madison
Social scientists and humanists have exhaustively explored the production of biopolitical knowledge and its
implications. Yet fewer have examined medicine as an explicit source of suffering and disenfranchisement. This
essay explores these phenomena by examining the complicity of medicine in the structural violence of the colonial
situation. The intention is to explore the ways in which the medical and psychiatric clinic often operated as a literal
theater for colonial conflict and for the marginalization of indigenous subjects. For Algerian author Kateb Yacine,
psychiatry operates as a biopolitical machine for the regulation of a colonial order in which citizenship was the
privilege of the European settler. Kateb’s poetry, drama, and novels provide crucial sources for exploring literature
as a site of resistance to a psychiatric paradigm that cast the Algerian as a non-citizen, and for the articulation of
legal consciousness in a context of colonial oppression.
Kateb’s drama and fiction render the experience of colonial violence and suffering in a medicalized language. The
paper thus explores the possibilities of applying methodologies borrowed from the social history of medicine and
medical anthropology to literary works with the goal of shedding light on the relationship between health,
citizenship, and consciousness. By reading Kateb’s work alongside critical documents in the history of colonial
medicine, the paper points to the multiple axes of oppression that shape suffering, disenfranchise populations, and
preclude “healing.” By drawing on recent anthropological work on suffering and structural violence, the paper
argues that Kateb’s uses of medical language to reinscribe social experience are highly relevant in a world in which
legal citizenship and the right to health remain closely entwined.
rkeller@med.wisc.edu
The Concept of Evil: A New Look at Evil from the Vantage Points of Theology, Philosophy, and
Forensic Psychiatry
Michael H Stone, Columbia University
The concept of Evil has long been considered relevant only to the domains of theology and philosophy, as though
the Deity alone is privileged to make judgments regarding Good vs. Evil. The term “evil” has little currency even in
the domain of Law, where criminal acts that might be called “evil” in everyday parlance – are designated instead by
such terms as depraved, heinous, or diabolical.
This presentation will review the evolution of the concept from ancient times to the 20 th century, focusing on
conceptions stemming from religion and philosophy. The theodicies of Leibniz and those that came after will be
addressed. In addition, the parallels between contemporary notions about Evil and its forensic or jurisprudential
counterparts (in judgments concerning heinous crimes, for example) will be discussed.
In modern times, Evil is seldom invoked in the case of natural disasters (such as the Lisbon earthquake or the recent
Indonesian tsunami), being reserved instead for acts that violate the moral codes of humans. Human consciousness
and conscience are preconditions for making judgments about the quality (goodness or badness) of our actions. We
speak of Evil in two broad realms: one pertains to the behavior of groups, the other – to the behavior of individuals.
There is great fluidity and relativity in our judgments about groups. In wars each side sees the other as “evil”; only
occasionally is there universal condemnation of one side, even by those not directly involved – as in the case of the
Nazis or of Cambodia’s Pol Pot. As for individuals, we also distinguish between those who commit a criminal and
cruel (or “evil”) act once in a lifetime, that seemed uncharacteristic of their usual self – versus those who habitually
commit depraved acts (and who thus seem “evil” in general). Serial rapists and serial killers would fall into the latter
category. Many such persons are diagnosed as “psychopaths.” In recent years psychopaths and other types of
antisocial persons have been studied by imaging and other neurophysiological techniques, and have been found to
have deficits in key frontal lobe areas that subserve social decision-making and compassion. Though there are no
“evil genes” per se, there may, in such persons, be a physiological substrate that contributes to subsequent behavior
of a kind that we identify later on as “evil.” This area will also be discussed in the presentation – as part of the
complex set of interactions that underlie the uniquely human phenomenon of Evil. The ways in which ordinary
people caught in extraordinary circumstances can end up committing evil acts – with bland indifference and seeming
unawareness (à la Hannah Arendt’s “Banality of Evil”) – will also be touched on.
mstonemd@aol.com
Legal Primitivism and its Discontents
Steven Wilf, University of Connecticut School of Law
How do we interpret the continuing preoccupation among Anglo-American jurists with primitive law, and more
particularly with lex non scripta, from Henry Maine’s Ancient Law (1861) to Bronislaw Malinowksi’s Crime and
Custom in Savage Society (1926)? In the second half of the nineteenth century and through the early twentieth
century, an immense literature was created which charts the evolution of legal systems parallel to our own. These
include works of sociologists and political theorists like Herbert Spencer, prominent Yale sociologist and reformer
William Graham Sumner, and practicing lawyers, James Coolidge Carter, Guy Carleton Lee, and Henry Wilson
Scott. Sometimes the legal systems described are archaic, sometimes belonging to tribal societies, and sometimes
simply conjured out of thin air. At times legal primitivism is valorized–as is the case in celebrations of Teutonic
forests as the birthplace of republican legalism; at other times, it is portrayed as barbaric or totemic. Nevertheless,
despite its vastness, and variety, the legal primitivism literature has attracted remarkably little scholarly attention–in
part, perhaps, because there is so often the whiff of pseudo-science, orientalism, and a discomforting number of
racial assumptions embedded in these works.
But my interest in legal primitivism is not a venture of antiquarian cultural recovery. For these nineteen and earlytwentieth century thinkers, their fascination with legal primitivism betrayed their need for a laboratory of ideas.
Legal primitivism is the doppelgänger of legal modernism, the place where legal modernists, caught between an
increasingly formal common law and an increasingly insistent thrust towards codification, shunted their own
anxieties. It was unease with legal modernism’s focus on written text, for example, that animated the identification
of orality as a core characteristic of the savage legal mind. James Coolidge Carter mined legal primitivism as a focal
point of dealing with the troublesome problem of competing and contradictory legal precedent. Primitive law
presented rudimentary legal systems–ideas, in the words of Henry Maine, which are to the jurist what the primary
crusts of the earth are to the geologist.
Legal primitivism is quite relevant to the major debates over the genealogy of modern legal consciousness. Some
scholars–especially those associated with the law and economics movement–have identified the origins of legal
modernism with the rise of the surety of social science. Others, notably Critical Legal Studies scholars, have
pointed to the modernist impulse of grappling with indeterminacy in a disenchanted world. My paper focuses upon
the anxiety of legal change. It seeks to situate legal modernism within cultural modernism as a whole, and, more
particularly, within the scope of the larger cultural project of identifying the primitive legal mind. This late
nineteenth-century turn towards legal primitivism is telling. One cannot understand what legal modernism wanted
to be without understanding what it so desperately sought to see as its other.
'Lies Lawyers Live'
Richard B. Jacobson, University of Wisconsin-Madison
The pragmatics of lawyer-client relationships and lawyer-court relationships involve a number of partly-repressed
hypocrisies. Those this paper examines include:
1. The Lawyer-Client Relationship is Rational
A version of traditional Freudian transference underlies the relationship, profoudly affecting the disinteredness of
the lawyer and the capacity of the client for consultation, autonomy and informed consent.
2. Always Believe the Victim
Development and pragmatics of United States law relating to sexual abuse
The Expert is Always Right and Abdication of Judicial Responsibility
3. Best Interests of the Child Guide the Divorce Court
Role of the Guardian ad litem and Abdication of Judicial Responsibility
Role of the independent expert: the same
4. The Victim Must Always be Consulted
State and federal laws requiring consultation with the Victim Deny the Fundamental Role of the Courts in Criminal
Cases
Nine of ten victims demand harsh punishment
The delights of being a victim.
jmsc@itis.com
Legal Representation of Mental Health Patients in Israel
Legal Representation of Mental Health Patients before Regional Psychiatric Boards in Israel
Arie Bauer, Israel Ministry of Health, Jerusalem, Israel
Paola Rosca, Israel Ministry of Health, Jerusalem, Israel
Razek Haled, Israel Ministry of Health, Jerusalem, Israel
Alexander Grinshpoon, Israel Ministry of Health, Jerusalem, Israel
The Treatment of Mental Patients Law was issued in Israel in 1991 and includes paragraphs dealing with hearings of
patients at the Regional Psychiatric Boards. These Boards are statutorily empowered to decide for the continuation
of compulsory hospitalizations (whether the hospitalization order has been issued by a District Psychiatrist or by a
court of law) or for the release of patients. One of the major criticisms in the past few years was that mental patients,
due to their illness, are frequently incapable of representing themselves in front of the Boards and claim their rights
for liberty. Moreover the Boards tended to agree with the treating staff and comply with their requests for
prolongation of forced hospitalization.
In order to put an end to this unjust situation on March 2004 a new paragraph was added to the Israeli Book of Laws
(N.5) which stated that mental patients under compulsory hospitalization order and their families should be informed
of their right to be legally represented in front of the Regional Psychiatric Boards at the expenses of the State of
Israel.
Our purpose is to illustrate this project and its process which finally brought about the desired change, that is free
legal representation of mental patients. The paper will also discuss the pros and cons of this project and its
implications for what concerns the time perspective, the financial aspect and the improvement in mental patients
rights implementation
arye.bauer@moh.health.gov.il
Representation of Mentally Ill Clients at the Regional Psychiatric Committees
Yona Haier Levi, Office of the Public Defender, Tel-Aviv, Israel
Dorit Nachmany Albeck, Office of the Public Defender, Tel-Aviv, Israel
During the years 2000-2001, the Public Defender’s Office in Israel, which is part of the Ministry of Justice,
represented mentally ill clients who had been forcibly hospitalized under a criminal court order; the representation
was conducted at hearings held before the regional psychiatric committees, authorized to grant vacations and release
patients from psychiatric hospitals.
Up to that time, in most cases, the patients had not been represented before the committees, and the provision of
representation proved that without the presence of a lawyer the patient’s rights are unprotected: the rules of natural
justice are not observed, the hearing is short and laconic, no reasons are given for the committee’s decisions, etc.
This paper will present the principles of a report prepared by the Public Defender’s Office, summarizing the
ramifications of the legal representation with respect to the committees’ work, and the rights of the mentally ill. The
report’s findings proved that the chances of a person who has been forcibly hospitalized to be released from
hospital or go on vacation are higher when he is represented at the committee by a lawyer. In addition, it was
clarified that the presence of a lawyer at the committee favourably affects the proceedings and decisions of the
committee.
In addition, this paper will present the legislative changes that have recently occurred in Israel in this matter.
Yonah@justice.gov.il
Doritn@justice.gov.il
Mental Patients’ Legal Representation before District Psychiatric Committees in Israel: Justification
and Critic
Jacob Margolin, Eitanim Psychiatric Hospital, Israel
Eliezer Witztum, Ben-Gurion University of the Negev
The Israeli District Psychiatric Committee, acting on behalf of the Israel "Treatment of Mental Patients Law" of
1991, is provided with ample authority in the domain of civil commitment of the mentally ill. This committee has a
quasi-legal status. Recently, the Israeli Knesset (Parliament) has added the obligation of informing these patients
with the option of having the right to legal representation before the committee hearings. The presentation will
discuss the issue of legal representation of the mentally ill, its essence and its problematic aspects. Two case studies
will demonstrate some of the problematic issues concerning this new rule. The first concerns an earlier and
premature release from hospitalization due to formal and legal procedures in spite of medical opinion. The second
case study deals with the possibility of forming a conflict between the psychiatric opinion, as represented by the
attending physician, and the patient and his legal adviser. Such a conflict may cause a significant damage to the
therapeutic alliance, and reducing patient’s compliance. Some possible solutions will also be suggested.
kfrjacob@matat.health.gov.il
Study and Follow-up of the Use of Legal Representation of Psychiatric Patients in Regional
Psychiatric Boards in Israel
Roberto Mester, Israel Ministry of Health, Jerusalem, Israel
Yair Barel, Israel Ministry of Health, Jerusalem, Israel
Alexander Grinshpoon, Israel Ministry of Health, Jerusalem, Israel
Arie Bauer, Israel Ministry of Health, Jerusalem, Israel
The Israel Mental Health Act of 1991, which is still current today, states that a patient may be legally represented by
a lawyer when he appears before a regional mental health board convened to deal with the extension or cessation of
enforced psychiatric hospitalisation or outpatient treatment.
In recent years growing awareness of the civil rights of patients and frequent criticisms of the detrimental effect of
enforced hospitalisation has led the Ministry of Health to implement two pilot projects centred on granting patients
appearing before regional courts the services of lawyers paid by the government. The results of these projects
convinced the legislators that the procedure should be formalised and, as a consequence, at the beginning of 2004 a
law was passed granting all patients appearing before the regional boards in these issues, the services of a
government-paid lawyer. The unit for Evaluation and Auditing of Psychiatric Services of the Israel Ministry of
Health carried out a follow up study to determine the fate of patients discharged by the regional psychiatric boards,
against the recommendation of their treating professional teams. The study included patients using the services of
lawyers and those that did not use this service, and was carried out over a period of three years. Following the new
legislation, the study now includes all patients discharged by the regional psychiatric boards in Israel.
This presentation analyses and discusses the results of the first stages of the study.
rmester@netvision.net.il
Trends in Involuntary Psychiatric Hospitalization in Israel 1991-2000
Alexander M. Ponizovsky, Ministry of Health, Jerusalem, Israel
Arie Bauer, Ministry of Health, Jerusalem, Israel
Paula Rosca, Ministry of Health, Jerusalem, Israel
Alexander Grinshpoon, Ministry of Health, Jerusalem, Israel
Background: Involuntary Psychiatric Hospitalization (IPH) is defined as a restrictive intervention aiming at treating
the dangerous psychotic patient at a critical time. The legislative criteria for involuntary commitment in Israel are: 1.
acute psychotic state; 2. physical danger to self or others, and 3. a causative link between the psychiatric disorder
and the dangerous behavior. Thorough information about involuntary psychiatric hospitalizations (IPH) is crucial for
the planning of national mental health care policy and up to date very few studies have been carried out in Israel on
this subject.
Aims To identify trends in IPH to all inpatient psychiatric settings in Israel and its predictors. The predictors
identified in the literature include: male gender, young age, diagnosis of schizophrenia or other major psychosis and
most of all past involuntary admission.
Method The sample included admissions of adults (18 years and older) over the ten-year period, 1991-2000,
according to the registration of such admissions in the National Psychiatric Case Registry. We restricted our
population to first hospitalization whose legal status was defined upon admission only.
Results A 2.4-fold increase was found in first IPH over the decade studied. The typical profile of the involuntarily
admitted patient was that of a native-born Jewish male, aged 18-24 or 65 and older, single, with less than 8 years of
education, and with a diagnosis of schizophrenia or delusional psychosis.
Conclusions These findings suggest the need for improving the interfaces between hospital and community
services, and for preparing specific guidelines to extend the use of involuntary ambulatory treatment orders.
alexander.ponizovsky@moh.health.gov.il
Lethal Violence by Women
Maternal Filicide Offenders and Their Victims
Kristen R. Beyer, FBI’s National Center for the Analysis of Violent Crime, Washington, USA
Homicide is one of the five leading causes of death in the United States for children under 18 years of age.
Furthermore, homicide is the leading cause of non-illness death in children under age five. According to Bureau of
Justice Statistics (1999), it is reported that 57% of child homicide victims under age five are killed by their parents
or stepparents. Of those child homicides, a significant number (approximately half in most studies) of filicides are
committed by a child’s mother (Alder & Baker, 1997). From 1976-1997, FBI’s Supplemental Homicide Report
found that mothers killed 1,300 sons and 1,218 daughters, ages birth through five. Filicidal mothers are placed in
dichotomous groups of being either “mad” or “bad” (Wilczynski, 1991). Resnick (1969) further divided mothers
who kill into five categories: accidental, altruistic, acutely psychotic, unwanted child, and revenge.
The present maternal filicide research project has reviewed approximately 150 cases involving biological mothers
who have killed their children. The inclusion criteria include the victim being under 18 years of age and the
biological child of the offender. Women who have committed neonaticide, infanticide, and/or filicide have been
included in the study. Offenders were identified from FBI case files, VICAP, state and local law enforcement
agencies, prosecutor’s offices, and public source data. Case materials including investigative reports, psychological
reports, autopsy reports, and/or confessions were requested from various agencies. Data were extracted from the
files and recorded onto a protocol that was developed by the FBI’s National Center for the Analysis of Violent
Crime (NCAVC) and reviewed by the NCAVC’s extramural Research Advisory Board. The protocol consists of
questions relating to offender demographics, 2) victim demographics, 3) offense characteristics.
The results will provide descriptive and frequency statistics on offender demographics (e.g., age, race, SES, marital
status), religious ideation, psychiatric history, criminal history, abuse history, victimology, precipitating, motive,
weapon, cause of death, offender claims, confession, post-offense behavior, sentencing, suicide rate, and
adjudication. Long-term research goals will be discussed including how to expand the study to increase
generalizability, reliability, and validity. Case examples may be included to demonstrate research findings.
kbeyer@fbiacademy.edu
Involuntary Outpatient Treatment in Norway
Kjetil Hustoft, Stavanger University Hospital, Norway
Terje Houeland, Stavanger University Hospital, Norway
This presentation will address the Norwegian Law of Psychiatry (Mental Health Act) especially as it relates to
involuntary out patient treatment. The general aspects of involuntary in-patient admission which includes
observation for up to 10 days and admission for an unlimited number of days will be discussed in relation to the
criteria that are needed. In addition, and as a main focus, the criteria for involuntary outpatient follow-up, based on
the Mental Health Act, will be presented and discussed. A number of issues including practical arrangements for
involuntary outpatient follow up, treatment plans that are needed and the frequency of use of involuntary outpatient
follow up in Norway will be discussed.
KHU2@SIR.NO
THO@SIR.NO
Moving Beyond the Stereotypes: Women’s Subjective Accounts of Their Violent Crimes
Candace Kruttschnitt, University of Minnesota
This research builds on the recent scholarship that questions the anti-agentic depictions of women who kill
(Morrissey 2003; Gartner and McCarthy, 2005). Using women's narratives of their involvement in a range of violent
acts, this paper shows they justify their actions and the degree to which these justifications reify or deny common
popular, legal, and feminist depictions of them. Most often these depictions assume that women's violent offending
is a result of past or current victimizations or underlying pathologies. Yet, as Morrissey (2003, p. 17) argues, such
depictions "deny female agency and a concept of women as active, human subjects." The narratives are drawn from
a racially diverse sample of 200 women who are incarcerated in the Hennepin County Adult Detention Facility
(Minneapolis, Minnesota). A life events calendar was used to assess women's involvement as both victims and
offenders in violent and near-violent crimes over the 36 months prior to their incarceration. This sample permits a
comparison of narratives of violence from different racial groups (white, African-American and Native American).
Further, it contextualizes these violent experiences by examining how they are embedded in the personal, situational
and community circumstances of these women's lives. Ultimately, such analyses should help to refine our
understanding of women's subjective experiences of violence and the degree to which these subjectivities reproduce
various social constructs of violence.
kruttsch@atlas.socsci.umn.edu
Female Homicide Offenders – Psychotic or Personality Disordered?
Hanna Putkonen, University of Helsinki
The aim of this study was to examine what differences would emerge grouping the offenders by the presence of a
psychotic or personality disorder. The study group comprised all Finnish female homicide offenders in a forensic
psychiatric examination for homicide or attempted homicide during 1982-1992 (n=132).
The personality-disordered women killed more adults than the psychotic women, and the motive was more often a
quarrel (p<0.000). Alcohol intoxication was reported at the time of the crime for 86% of the personality-disordered
and 27% of the psychotic women (p < 0.000). The neonaticides tested out as a distinct group: three were considered
psychotic and all seven were diagnosed with a personality disorder. Of all the female homicide offenders, 56% had
committed some offense before the index offense, 33% with violence. Of these, 78% were diagnosed with a
personality disorder and 18% with a psychotic disorder.
The clearest difference between the psychotic and personality disordered women to emerge was that the former
killed proportionally more children and the latter were more likely to be drunk at the time of the crime. It seems that
personality disorders (cluster B) pose greater risk for homicide than psychotic disorders and are also indicative of
worse prognosis regarding re-offending.
Hanna.putkonen@hus.fi
hanna.putkonen@vvs.fi
Understanding the Risk Factors for Violence and Criminality in Women: The Concurrent Validity of
the PCL-R and HCR-20
Janet I. Warren, University of Virginia
This study explores the performance of 132 female maximum-security inmates on the Psychopathy ChecklistRevised (PCL-R) and the HCR-20 (Historical, Clinical and Risk Management Scheme) to examine the concordance
between these two risk assessment instruments, and to assess their potential usefulness in determining level of risk
for violent behavior and other forms of criminality. The two instruments demonstrated consistent and highly
significant correlations across Total Scores, Factor Scores and Subscale scores. When the two instruments were
entered into a multiple regression analysis to predict violent and non-violent crime, the HCR-20 did not add to the
variance explained by the PCL-R. These results confirm earlier research that suggests that there is little or no
difference between these two risk assessment instruments in their relationship to community or institutional
violence. Further, Receiver Operating Characteristics (ROC) analyses show that both instruments demonstrated an
inverse ability to predict convictions for murder, a close to chance ability to predict violent crime, but a shared
ability to predict property and minor crime. Broadly, these results suggest that psychopathic women are involved in
chronic patterns of non-violent criminality, while women charged and convicted of murder generally do not have
elevated scores on the PCL-R or HCR-20.
jiw@virginia.edu
Compulsory Community Treatment Orders III
Mandatory Outpatient Treatment in Australia
Ian Freckelton, Monash University
Mandatory outpatient treatment orders have become an orthodox part of the clinical and legal landscape in Australia.
They constitute the principal mechanism by which deinstitutionalisation has been accomplished and by virtue of
which treatment is provided in the community to persons who are adjudged likely without a formal order to
deteriorate significantly in mental health to their own detriment or to the risk of others.
However, few Australian empirical studies have been undertaken in relation to the effectiveness of such orders. Nor
is there much by way of guidance for clinicians or mental health review tribunal members as to when coercion has
become counter-therapeutic or when a patient should be extended the opportunity to resume autonomy in relation to
their mental health.
From the perspective of a review tribunal member, the paper will review the various statutory tests for mandated
outpatient treatment in Australia and will scrutinise a cross-section of cases coming before the Victorian Mental
Health Review Board in order to assess the criteria in practice for the issuing and re-issuing of such orders. It will
suggest that looseness too often attaches to the making of such orders, on the basis of a fallacious contrast with the
alternative – the making of an inpatient detention order. Having regard to the realities of limited resources for
provision of care to persons with mental illnesses in the community, it will analyse the real-world impact of
mandated outpatient orders in Australia.
I.Freckelton@latrobe.edu.au
Involuntary Outpatient Treatment in the USA: Conundrum to Quagmire
Jeffrey Geller, University of Massachusetts
In the U.S.A. the actual beneficiaries or victims of involuntary outpatient treatment (IOT) (depending upon one’s
point of view) have expressed a wide range of opinions about these interventions. IOT has been characterized by
considerably more opinion than fact: “involuntary outpatient commitment is a contemporary lightning-rod issue in
American psychiatry. Its assets and liabilities are all too often lost sight of in a cacophonous bluster that obscures
reasoned positions.”
While 40 states have outpatient commitment statutes, until recently few states made much use of them. One state,
Massachusetts, has an unusual variant: a nonstatutory-based, competency-rooted IOT that is used extensively.
IOT can be conceived of as having been researched through three generations of studies. First generation studies are
cases and represent the rare instances where the person conducting the treatment actually writes about it. Second
generation studies are best characterized as quasi-experiments and surveys. Third generation studies, to be
discussed in detail, involve three states’ efforts that have or will include controlled studies and their derivatives:
North Carolina, New York and California.
One of the common comments about IOT is that if a local mental health system had more resources and was better
coordinated, involuntariness in community treatment would not be necessary. This opinion is without foundation. It
is time that IOT in the U.S.A. move toward an evidence-based practice in the same manner as we are trying to move
all of psychiatric interventions.
jeffrey.geller@umassmed.edu
Canadian Approaches to Mandatory Community Treatment
John E. Gray, University of Western Ontario
Most of the 13 Canadian Mental Health Acts have a form of mandatory community treatment provision, either or
both conditional leave from hospital or community treatment orders.
The conditional leave criterion is, by definition, the same as that for in-patient admission. Where the in-patient
criteria are based on physical dangerousness very few people are placed on leave. Where the criteria include the
likelihood of significant mental or physical "deterioration" conditional leave is used more frequently. In the two
jurisdictions with community treatment orders the "deterioration" rather than a "dangerousness" criterion is used.
Unlike New Zealand and some other jurisdictions Canadian community treatment provisions cannot be used to
avoid in-patient hospitalization altogether. Avoiding or shortening hospitalization can be helpful for people with a
first psychotic break who require mandatory medication but can be managed safely in the community. In Canada the
person must have had at least the initial hospitalization to be placed on leave. Furthermore, the CTO provisions have
a pre-condition of two or more previous admissions.
In one jurisdiction CTOs are not "compulsory" because they are consented to either by the competent patient or
substitute decision maker. In all jurisdictions the services the patient is ordered to use must be available. In
formulating and signing off the treatment plan the involvement of people varies. Methods for triggering an
assessment if the conditions are breached and the consequences are discussed. Right protection mechanisms are
discussed. The extent of the use of mandatory community treatment in Canada is estimated.
jegray@shaw.ca
Involuntary Outpatient Psychiatric Treatment in Israel – Its Evolution and Evaluation
Roberto Mester, Tel Aviv University
Yair Barel, Israel Ministry of Health, Jerusalem, Israel
Involuntary outpatient psychiatric treatment (IOT) was introduced in Israel in 1991, through the implementation of
the 1991 Mental Health Act. Since then it has been used extensively all over the country. The law differentiates two
different types of involuntary psychiatric treatment: the civil outpatient commitment and the commitment based on a
court order for patients who have committed a legal offence. Both types will be presented and discussed.
The implementation of the specific section of the Mental Health Act which deals with enforced commitment has
been criticised from several points of view: the weakness of the enforcement procedure, the detrimental effect on the
civil liberty of the individual and its therapeutic efficiency. All these aspects will be discussed. Several follow up
studies have been carried out through the years. These will be analysed.
One of the Israeli associations of families of schizophrenic patients has been lobbying for modification in the Mental
Health Act to increase the legal power of the law to allow also preventive interventions to enforce treatment in
uncooperative patients at the very inception of psychotic decompensation. The controversial issues in this proposal
will also be discussed. The supervision of the IOT is carried out by regional psychiatric boards. This raises
interesting issues which will also be presented in this paper.
rmester@netvision.net.il
Statutory roles as a vehicle for advanced nursing practice in New Zealand: Progress or Problem?
Brian McKenna, University of Auckland
In New Zealand, patients subject to compulsory processes under the Mental Health (Compulsory Assessment and
Treatment) Act (1992) (the Act) are assigned a Responsible Clinician, defined as ‘the clinician in charge of the
treatment of that patient’. Responsible Clinicians must be:
a) a psychiatrist approved by the Director of Area Mental Health Services; or
b) some other registered health professional who, in the opinion of the Director of Area Mental Health Services,
has undergone training in, and is competent in, the assessment, treatment and care, of persons with mental
disorder.
While the Responsible Clinician is clearly defined in generic terms, the role has been assumed exclusively by
medical practitioners. The 1998 Ministerial Taskforce on Nursing noted that this role could potentially be assumed
by nurses. However at that time there was no clear pathway for nurses wishing to take the role of Responsible
Clinician. The Ministry of Health has recently defined the competencies of Responsible Clinicians, and it is clear
that those competencies are within the scope of advanced mental health nursing practice.
Despite this potential, there are only a few mental health nurses in general mental health services who have endorsed
the role. In the past, nurses have been ambivalent about acting in statutory roles under mental health legislation.
Statutory roles have been perceived as inherently coercive and supporting a custodial model of care. Furthermore,
statutory roles have been considered to threaten the therapeutic relationship, which is the foundation of mental
health nursing practice. However mental health legislation, with its power to intervene coercively in the lives of
patients, is a reality in mental health nursing practice. Rather than protest the assumption of statutory roles, nurses
might do better to explore ways in which these roles can be enacted in the interests of consumers. This would
involve considering how the power of mental health legislation could be used for therapeutic advantage rather than
as a tool of coercion. The alternative to assuming generic roles such as Responsible Clinician is to accept a position
of decision-making which is dependent on medical authority.
A strong case will be put in this presentation for advanced mental health nurses to actively pursue the potential for
adopting the role of the Responsible Clinician. The current need is for the development of a planned process of
implementation to give practical weight to the Ministry guidelines that determine competency.
b.mckenna@auckland.ac.nz
Mental Disability I: Exploring the Intersection between Mental Disability
Law and International Human Rights Law
Exploring the Intersection between Mental Disability Law and International Human Rights
Henry Dlugacz, St. John’s University
In this presentation, the author will explore the emerging connection between mental disability law in the United
States, and evolving international human rights principles in related areas. The notion of fundamental rights which
underlie U.S. mental disability law have been primarily developed by Federal Courts in landmark constitutional
jurisprudence beginning in the early 1970’s and extending to the present time. While attempts to effectuate the
concepts of dignity and self-determination which animated these decisions have been uneven in practice, they
articulate conceptions of human rights for the mentally disabled which have greatly influenced international
standards in the field. The author will compare and contrast two professional experiences to illustrate this
formulation: (1) his work in assisting to develop and later serving as court-appointed monitor of a federal class
action lawsuit challenging on constitutional grounds related to freedom from harm and the right to adequate
treatment the conditions in a forensic hospital; and (2) the experience in co-teaching a course on mental disability
law to Nicaraguan lawyers, doctors and activists. These situations will serve as a springboard for discussion on the
intersection between these U.S. constitutional principles and the international approach to human rights for the
mentally disabled. At the end of the presentation the audience will be able to identify the fundamental constitutional
rights articulated in federal mental disability cases and see how they influence international human rights law in this
area.
hdlugacz@gis.net
Advocating for the Rights of Individuals with Mental Disabilities in the Kyrgyz Republic
Debbie Dorfman, Washington Protection and Advocacy System, Seattle, USA
Craig Awmiller, Washington Protection and Advocacy System, Seattle, USA
The presenters will be speaking about their experience working on advocating for the rights of individuals with
mental disabilities in the Kyrgyz Republic. We will discuss the vast differences between the rights guaranteed for
individuals with mental disabilities that are written on paper and the actual implementation of these rights, as what is
written is not necessarily reality. Additionally, we will discuss barriers to implementation of these rights and
advocacy strategies that can be used internationally to ensure that these rights are implemented. In discussing these
issues, we will use our experience in the Kyrgyz Republic as a representative example.
debbied@wpas-rights.org
craiga@wpas-rights.org
Developments in English Mental Health Law Since the Incorporation of the European Convention on
Human Rights
Kris Gledhill, Barrister-at-law, London, England
The English legal system follows a dualist approach and so the European Convention on Human Rights was not part
of the domestic legal regime until incorporated into domestic law by the Human Rights Act 1998: this requires the
domestic courts to interpret the law so as to comply with the Convention as far as possible (including adopting a
strained interpretation of language), and allows them to declare the law to be incompatible with the Convention if
the language of the relevant statute cannot be interpreted in a manner consistent with the Convention.
Following the 1998 Act, there have been a large number of test cases which have lead to reinterpretations of the
Mental Health Act 1983 in order to seek to comply with the requirements of the European Convention, and (as at the
present time) three occasions in which the domestic courts have declared the 1983 Act to be incompatible with the
Convention.
The presentation will outline the main developments, which demonstrate how the mental disability law of a
supposedly advanced nation was in breach of the Convention in a number of respects and how, in consequence, the
incorporation of an international human rights instrumented was needed in order to provide the protection reflected
in that international human rights instrument.
krisgledhill@aol.com
Incorporating Therapeutic Jurisprudence into a New International Human Rights Law Externship
Keri K. Gould, St. John’s University
I am the Assistant Dean for Externships at St. John's University School of Law. In that capacity, I oversee the
creation and curriculum of all the externship programs. I have recently created a new International Human Rights
Law Externship. In this externship, students will be focusing on Trafficking of Human Beings, Child Protection,
Peacekeeping Operations and the United Nations System. The students will work 12 – 15 hours a week in not-forprofit organizations in this field.
In working with the adjunct professor who will be the classroom teacher, I am teaching the teacher about therapeutic
jurisprudence and its application to clinical legal education and the importance of including a TJ approach to the
work the students are doing in their placements and to the substantive areas of law that they will be learning.
happystarrs@yahoo.com
gouldk@stjohns.edu
Took a Stranger to Teach Me to Look into Justice's Beautiful Face: Mental Disability Law,
International Human Rights Law, and Distanced Learning
Michael L. Perlin, New York Law School
The past thirty years have seen a remarkable revolution in all aspects of constitutional “mental disability law” in the
United States (civil commitment, institutional rights, the right to refuse treatment, issues of patient sexuality, the
interplay between mental disability and the criminal trial process). For a variety of reasons (economic, social, legal),
this revolution has largely not been replicated in nations with developing economies. Through the technology of the
Internet-based education, the author (a professor at New York Law School) has created an on-line mental disability
law course for attorneys, activists, advocates, mental health professionals and governmental officials in such nations,
in an effort to both teach participants the bases of American constitutional mental disability law (principles that, by
and large, form the basis of international human rights law in this area), and to encourage and support the creation
and expansion of grass-roots advocacy movements that may optimally lead to lasting, progressive change in this
area. This paper will discuss this course, report on courses taught in Nicaragua and Japan, and consider plans to
replicate (in modified form) these experiences throughout other nations with developing economies in Central
America, Central and Eastern Europe, and Asia.
mperlin@nyls.edu
Human rights and procedural safeguards under mental health legislation: The Ontario experience
Joaquin Zuckerberg, Consent and Capacity Board, Toronto, Canada
Federico Allodi, Consent and Capacity Board, Ministry of Health, Toronto, Canada
This paper assesses the Ontario's mental health legislation and practice vis-à-vis international human rights
standards and describes the main legal, administrative and clinical issues presented in the implementation of the
newly amended provincial legislation. As a legal frame work it focuses on essential procedural safeguards provided
by the major international human rights instruments in the field of mental health law such as the UN Principles for
the Protection of Persons with Mental Illness (MI), the European Convention on Human Rights as interpreted by the
European Human Rights Court and briefly the Inter-American system of legislation of the Organization American
States. Against this background the paper analyzes the compliance of the mental health legislation of the province of
Ontario with international standards, and some of the practical problems arising from the implementation of the
legislation.
The data originated from telephone calls received by and consultations requested with the office of the counsel (J.
Z.) of the Consent and Capacity Board of Ontario. As a method all calls and consultations during a month of
operations were logged and later analyzed as to source, nature of the concern or problem, specific procedural
safeguards involved and applicable section of the legislation. As corollary and when possible, the paper will make
brief references to and discuss the way other domestic legal systems have dealt with the implementation of specific
standards. The paper aims to generate discussion for potential reforms in domestic legal systems and provide a
methodology to be used as a tool to assess similar mental legislation in other local contexts.
joaquin.zuckerberg@moh.gov.on.ca
Mental Disability II: Mental Disability and Human Rights: The Domestic and
Regional Context
Commemorating and Preserving Psychiatric Patients' History to Promote Human Rights Today
Geoffrey Reaume, York University
The history of psychiatry is full of examples of human rights violations imposed upon vulnerable people, from
involuntary treatments such as lobotomy, to decades long segregative confinements in horrible conditions, to
exploitation of patients' labour, to numerous physical and sexual abuses inflicted upon men, women and children
confined in mental institutions. Along with this these human rights violations within psychiatric facilities, there is a
long history of abuse and discrimination in the community towards people categorized and identified as mentally
disabled.
One of the many ways that can aid in improving the human rights of people categorized as mentally disabled today
is to acknowledge their history in public venues so that more people are made aware of this past. This public
education will serve as a long overdue commemoration of the people whose lives have so often been hidden behind
walls of silence. It will also offer a very public reminder to learn from the lessons of past abuses by making
connections between historical human rights violations and the contemporary struggle for people's human rights
today. History can be used as a forum for promoting social justice among the wider public who might not otherwise
come into contact with this previously hidden past.
This paper will discuss efforts in Toronto, Canada to publicly acknowledge and preserve psychiatric patients' history
and why this is relevant to promoting their human rights now and in the future. Themes to be discussed include
historical memory, anti-discriminatory practice, historical conservancy and involving the people who have lived this
history in the preservation and interpretation of their collective past. The main point of this presentation will be to
discuss how public historical preservation and commemoration can help to bring down walls of silence about the
lives of psychiatric patients from the past, while at the same time contributing to the fight against discrimination
experienced by people in the mental health system today.
greaume@yorku.ca
A European Code of Practice for the Protection of the Human Rights and Dignity of Persons with
Mental Disorder?
Mary Keys, National University of Ireland
The very essence of the European Convention on Human Rights and Fundamental Freedoms is respect for human
dignity and human freedom and the Court of Human Rights considers that it is under Article 8 that notions of the
quality of life take on significance. Article 8 provides that everyone has the right to respect for his private and family
life, his home and his correspondence and any interferences with such rights must be justified by reference to
specified limitations outlined in Article 8(2). The right to autonomy is expressed as a fundamental human right and
recognised by Article 8 and the Court in Pretty v United Kingdom (2002) considered that the notion of personal
autonomy is an important principle underlying the interpretation of its guarantees. The growing recognition of this
right to autonomy and self-determination for all persons requires that those with mental disabilities will have
procedures that will ensure fair and just decision-making in conjunction with or on behalf or such persons. This
paper will address the approach of the Council of Europe and the Court of Human Right to the protection of
vulnerable adults. The paper will refer to the Convention on Human Rights and Biomedicine 1997 along with the
recently published Recommendation (2004) 10 concerning the protection of the human rights and dignity of persons
with mental disorder as offering valuable guidance for law reform.
mary.keys@nuigalway.ie
The Case of HL v United Kingdom: When Can a Non-dissenting but Incompetent Patient Be Admitted
to Hospital Informally and Without Legal Safeguards?
Paul Bowen, Barrister-at-law, London, England
In 1999 the House of Lords of England and Wales rejected a claim for habeas corpus brought by a learning disabled
adult, HL (through his carers as litigation friends), in respect of his ‘informal’ admission to a psychiatric hospital for
a period of 3 months in 1997 (R v Bournewood Mental Health NHS Trust ex p L [1999] AC 458). The House
rejected the claim on the basis that (1) L had not been ‘detained’ during his admission to hospital because he had not
sought to leave hospital and (2) in any event, the ‘informal’ admission of incompetent but non-dissenting patients
was expressly authorised by the Mental Health Act 1983. They reached these conclusions notwithstanding the fact
that L lacked capacity either to consent or dissent to his admission and that his carers, who did object to the hospital
admission, had been barred from visiting L in case he chose to leave the hospital with them. Moreover, since his
admission was ‘informal’ there was no legal mechanism by which the necessity for his admission to hospital could
be determined by an independent judicial body.
L took his case to the European Court of Human Rights claiming that he had been ‘deprived of his liberty’ in
violation of his rights under Article 5 of the European Convention on Human Rights (HL v United Kingdom). The
ECHR’s judgment is expected in September or October 2004.
This paper will consider the impact that the ECHR’s judgment is likely to have upon the legal systems of State
parties to the European Convention. All State parties have a significant population of adults who lack capacity to
make decisions for themselves but have adopted different legal approaches in seeking to strike the right balance
between the provision of care to such individuals and the proper respect for their fundamental rights.
p.bowen@doughtystreet.co.uk
Canada’s ‘Beautiful Mind’ Case: Will the Supreme Court of Canada's Decision in Starson v. Swayze
Really Make a Difference?
Aaron Dhir, University of Windsor
In June of 2003, the Supreme Court of Canada delivered its much anticipated decision in the case of Starson v.
Swayze. This marked the first time that Canada’s highest court dealt with an appeal originating from a civil mental
health tribunal. The case has been referred to by the media as “Canada’s ‘Beautiful Mind’ Case”, given arguable
parallels to the life of famed mathematics genius John Forbes Nash, who was diagnosed with schizophrenia. Indeed,
Scott Starson is an extraordinarily intelligent man, who has excelled in physics (particularly in the areas of time
measurement, anti-gravity theory and the theory of relativity). Although he has no formal training, Starson has been
accepted as a peer by some of the foremost physicists in the world and has authored publications in leading scholarly
journals.
Starson was admitted to a psychiatric facility pursuant to a detention order of the Ontario Review Board after being
found not criminally responsible on two charges of uttering death threats. His attending psychiatrist found him
incapable of consenting to treatments such as anti-psychotic medication, mood stabilizers and anti-anxiety
medication. Starson rejected the proposed treatment, feeling that it hampered his ability to do scholarly work.
Although he was unsuccessful before the Ontario Consent and Capacity Board, both the Ontario Superior Court of
Justice and Court of Appeal concluded that the Board's finding of incapacity was unreasonable and set it aside. In a
decision that has been lauded by mental health consumer/survivor groups and denounced by members of the
psychiatric community, the Supreme Court of Canada ruled in Starson’s favour.
While the Supreme Court of Canada's decision is in some ways a step forward for the rights of psychiatric patients, I
will argue that in other ways it will have little effect on the lives of patients who are found incapable of consenting
to treatment. Drawing on my experience as co-counsel for two intervener groups before the Supreme Court of
Canada in this case, I will provide a critical analysis of the legal test for capacity under Ontario’s Health Care
Consent Act, which the Supreme Court of Canada was asked to interpret in Starson v. Swayze. As per the
legislation, an individual lacks capacity if he/she does not meet two criteria. First, a person must be able to
understand the information that is relevant to making a treatment decision. Second, a person must be able to
appreciate the reasonably foreseeable consequences of the decision or lack of one.
I intend to argue that the test for incapacity inherently places patients in an impossible position. The Starson
decision theoretically stands for the proposition that an individual should not fail the first branch of the test simply
because he/she denies having a mental illness. However, the fact that the second branch of the test essentially
requires individuals to “appreciate” that anti-psychotic medication could benefit them results in an absurd outcome:
an individual who does not believe that he/she has a mental illness must nevertheless concede that he/she could be
aided by anti-psychotic medication. Thus, patients are subtly forced to agree with their psychiatrist’s diagnosis. My
discussion of this absurdity will be informed by social science evidence calling into question the efficacy of antipsychotic treatment modalities and articulating the serious health risks they pose. I will also explore key procedural
aspects of the decision (such as the appropriate standard of proof before the Board) and will discuss the Supreme
Court of Canada's decision to avoid relying on relevant international human rights instruments submitted by the
interveners.
aad265@nyu.edu
The Legal Construction of the Disabled Person: Locating the Nexus of Constructions of Disability and
Theories of Equality
Marcia Rioux, York University
Issues of disability are issues of justice and equality. People with disabilities are both the most marginal of the
marginalized and are disproportionately unemployed and living in poverty. When one views how society
understands people with disabilities, one opens the window on how society understands itself. The extremes of
intolerance and of tolerance that various societies show are a reflection on their value systems.This presentation
considers two of these windows on disability -one grounded in the individual as the site of the disability (medical
and legal models) and one grounded in the environment (service and social models). It argues that models based on
concepts of equal treatment not only create inequality but rationalize the reduction of entitlements for people with
disabilities. The limiting of care and treatment are justified by the way in which both disability and equality are
understood as the responsibility of the individual both in cause and effect. The inherent biases in limited notions of
equality and in presumptions of disability as an individual pathology undercut the enjoyment of the fundamental
rights of citizenship and participation. Models based on concepts of equal outcome compel states to provide services
and care that include people in their communities.
mrioux@yorku.ca
Mental Disability III: Rights of People with Intellectual Disabilities within
Europe
The Protection of Rights of People with Intellectual Disabilities by the European Social Charter:
Autism Europe Collective Complaint
Evelyne Friedel, Attorney, Paris, France
The fundamental rights of people with disabilities are in particular defined in the Treaties and Recommendations of
the Council of Europe, and in the Treaties and the Charter of Fundamental Rights of the European Union. In order to
guarantee the respect of the rights of people with disabilities, several actions can be initiated before the institutions
of the Council of Europe and of the European Union.
In particular, in case of violation of social rights defined by the European Social Charter, collective
complaints can be lodged with the Committee of Social Rights of the Council of Europe.
The European Social Charter of 1961, revised in 1996, sets out rights and freedoms and establishes a supervisory
mechanism guaranteeing their respect by the States parties to this treaty. Under a protocol which came into force in
1998, collective complaints of violations of the Charter may be lodged with the European Committee of Social
Rights.
See for more information:
http://www.coe.int/T/E/Human_Rights/Esc/2_General_Presentation/SocialCharterGlance_may04%20.asp
#TopOfPage
In this respect, Autism Europe has filed a collective complaint in July 2002 with the Committee, alleging France’s
failure to comply with its obligation to provide people with autism with an education. Autism Europe's complaint
highlights the discriminatory treatment suffered by people with autism and denounces France’s failure to comply
with articles 15, 17 and E of the European Social Charter (to be distinguished from the Charter of Fundamental
Rights of the European Union). Under these provisions of the European Social Charter, States undertake to apply the
necessary, adequate and sufficient measures, in order to provide children and adults with disabilities with an
education in the ordinary system wherever possible, or where such integration is impossible, through specialised
public or private institutions. Autism Europe's complaint is in Europe the first collective complaint targeted to the
defence of the rights of handicapped people. On March 10, 2004, the Council of Europe rendered its decision
regarding the collective complaint of Autism Europe. The Council of Europe concluded that the situation of people
with autism constitutes a violation of the European Social Charter.
efriedel@jonesday.com
Access to Justice for People with Mental Disabilities in Central and Eastern Europe
Oliver Lewis, Mental Disability Advocacy Center, Budapest, Hungary
This paper presents focuses on the practical and legal obstacles of litigating human rights cases in mental disability
systems in central and eastern Europe. Since the fall of the communist regime in there has been low political will to
implement much needed systemic reform. The Mental Disability Advocacy Center (MDAC) is a international
organization which protects and promotes human rights of people with mental health problems and intellectual
disabilities in central and eastern Europe and central Asia. One of MDAC’s core activities is strategic litigation in
domestic and international courts which challenges inadequate law or the lack of implementation of law.
To bring cases to courts, lawyers and advocacy organizations need to proactively educate potential clients about
their rights, as well as find clients willing to litigate important human rights issues, and support clients through the
stressful and lengthy process. For people with mental disabilities in the central and eastern European region there are
numerous obstacles to seeking justice through the courts. These hurdles include isolated institutions far from urban
centers, low awareness of rights in mental disability service providers and the legal professions, legal incapacity,
retribution by staff, as well as any mental health problem or intellectual disability which a client might have.
MDAC’s approach to these difficulties will be outlined, as will examples from current cases.
olewis@mdac.info
Guardianship and Decision-Making Laws: A Comparison of the National Law of Five Countries to
Internationally Recognized Human Rights Standards
Marit Andrea Rasmussen, Mental Disability Advocacy Center, Budapest, Hungary
The project examines guardianship processes affecting thousands of adults with mental disabilities across Europe.
Guardianship laws are the legal framework within which important personal and financial decisions are made on
behalf of adults adjudged to have reduced decision-making capacity. While some measures may be necessary to
protect vulnerable individuals, only human rights compliant laws promote and respect the autonomy of people with
disabilities in decision-making processes.
Assessment of guardianship laws is based on comparison of national laws to a template of international norms
including the Council of Europe’s Recommendation (99)4 “Principles Concerning the Legal Protection of Incapable
Adults.” The template also incorporates elements of “best practice” alternatives to guardianship, such as supported
decision-making.
Results will highlight areas in national guardianship legislation of target countries which fail to conform to
internationally recognized human rights standards. These legislative weaknesses indicate areas of the law ripe for
reform and will provide guidance to governmental leaders and legislatures. Findings will also support the efforts of
non-governmental organizations and inter-governmental agencies involved in advocacy on behalf of users of
guardianship processes, will raise public awareness and will bolster litigation efforts on behalf of individual users
and survivors of guardianship practices.
mrasmussen@mdac.info
mdac@mdac.info
Rights and Incapacity
Peter Bartlett, University of Nottingham
Increasingly in recent years, there have been trends to bring people lacking capacity into the scope of formalised
legal régimes. The clearest example is perhaps HL v UK (Appl. 45508/99, decision 5 October 2004), where the
European Court of Human Rights accorded article 5 rights to compliant but incompetent patients admitted
informally to psychiatric facilities. There is cause for celebration in the fact that the needs of this marginalised
group were addressed by the Court, but at the same time, a ‘rights’ model creates theoretical difficulties in
application to this group. Is a right to legal representation, for example, the appropriate approach for an individual
who may lack the capacity to instruct counsel?
There will no doubt be other papers which will examine the practical ramifications of the HL case. This paper will
instead explore the theoretical difficulties of applying a rights model to people lacking capacity.
peter.bartlett@nottingham.ac.uk
Anti-Discrimination Legislation and Persons with Disability: A Norwegian Perspective in a
Comparative Context
Aslak Syse, University of Oslo
In November 2003 the Norwegian Government appointed a legal Commission to draft a new bill and/or proposals to
amend existing legislation in order to strengthen the protection accorded by the law against the discrimination of
disabled persons. The object is to promote full participation in society and equality between disabled persons and
other citizens. The Commission’s proposals should aim to provide a genuine strengthening of the protection
accorded by the law against the discrimination of disabled persons. Thereby, to determine who should be awarded
rights and duties, including whether individual rights should be awarded to disabled individuals in more areas than is
the case in currently applicable legislation. The Commission should discuss possible sanctions and take a stand on
rules concerning the burden of proof and forms of responsibility in the event of sanctions in civil law, and consider
whether special bodies should be responsible for effective following up the body of rules. The Commission should
ensure that the proposed legislation lies within the framework of Norway’s obligations in respect of international
law, including Article 14 of the European Convention on Human Rights as interpreted by the European Court of
Human Rights, Articles 2 and 26 of the United Nations International Covenant on Civil and Political Rights, Article
2 of the United Nations International Covenant on Economic, Social and Cultural Rights and relevant rules within
the European Economic Area. The Commission should also review anti-discrimination legislation in other countries,
and the work carried out in this field in international organisations, including work on a United Nations Convention
on the Rights of Disabled Persons. The Commission’s report to the Government is to be delivered April 2005. In this
paper I will, as the chair of this commission, give a short presentation of the findings and assessments in the report.
The Commission visited several other countries to review the actual legislation (Sweden, Finland, England, Ireland,
Australia, US, Canada), to be able to form proposals, which may be workable in practice. This explains the subtitle:
A Norwegian perspective in a comparative context.
aslak.syse@jus.uio.no
Mental Disability IV: Mental Illness and Community Integration
The Perils of Disclosure: Implications of the Americans with Disabilities Act on the Work Experiences
of People with Psychiatric Disabilities
Susan G. Goldberg, CESSI, McLean, USA and Fielding Graduate Institute
People recovering from psychiatric disabilities face a number of challenges in the employment arena, many of which
are related to the Americans with Disabilities Act (ADA). A particularly thorny issue involves the notice provision
of the ADA, which requires that employees disclose their disabilities to their employers in order to claim certain
ADA rights. But whether or not an employee chooses to disclose a disability is still a difficult question for many
people with psychiatric disabilities. In addition to the ADA protections, there are professional, personal, and policy
considerations that strongly favor disclosure. For these reasons, most social service providers who work with people
with psychiatric disabilities encourage them to disclose their disability at work.
Yet there are equally -- and sometimes more -- compelling reasons not to disclose. A person who discloses a
psychiatric diagnosis may experience isolation, discrimination, and prejudice at work. These important
considerations are usually not addressed by social service professionals. The ADA provides some options for
handling disclosure, but the range of options is rarely known by people with psychiatric disabilities or the counselors
and advisors who work with them.
This presentation will discuss the findings from two research studies funded by the National Institute on Disability
and Rehabilitation Research (NIDRR). The studies explored in depth the experiences of people with psychiatric
disabilities around employment and disclosure. I will discuss various approaches to the problems of disclosure that
were used by participants, including “selective disclosure” of time, person, place and content.
gsusan@earthlink.net
Does U.S. Federal Policy Support Employment and Recovery for People with Psychiatric Disabilities?
Mary Killeen, CESSI, McLean, USA and Fielding Graduate Institute, Santa Barbara, USA
Evidence suggests that the majority of people with psychiatric disabilities recover over time; they develop support
systems, learn to manage symptoms and medications, and participate fully in their communities. Evidence also
suggests that work is an essential component of recovery. However, few people with a psychiatric disability are
actually employed and most of those who are employed work only part-time at barely minimum wages.
To access the impact of United States federal programs such as Social Security Disability Insurance (SSDI),
vocational rehabilitation, medical insurance, and psychiatric services upon employment, we conducted a qualitative
study of 16 unemployed and 16 employed individuals with psychiatric disabilities. All of the participants had
disabilities severe enough to qualify them for Social Security Disability benefits.
We found that federal policy is still based upon the discredited notion of a downward trajectory for all individuals
with a psychiatric disability. Interviews regarding the impact of federal policies and programs on their lives of study
participants revealed a deep-seated assumption within these policies and programs that the participants would never
recover, or would recover from their illnesses only marginally. Federal programs played a crucial role for the
participants directly after the onset of their illnesses and for those whose symptoms were so unmanageable that they
were unable to work. However, these same programs often hindered participants as they began to recover. Rather
than offering a “hand up” to those who were ready to improve their situations, federal policies and programs often
placed roadblocks in the paths of those who wished to earn more than marginal incomes. These roadblocks take the
form of income and medical benefit loss, denial of funding for education, and placement in the most menial jobs
without regard for the individual’s work history and capabilities.
We found that current federal policies and practices encouraged employment and integration of only a few
participants, in a particular stage of recovery, and placed significant barriers in the employment path of others. This
presentation will discuss the results of this study and the barriers that current federal policies and programs
inadvertently create for people with psychiatric disabilities seeking employment.
We found that the sheer number and complexity of employment barriers inherent in today’s United States federal
disability policy had a tremendous impact upon participants’ lives. U.S. policies and programs sent contradictory
and confusing messages to participants about their ability to work, the kind of work they could do, and how much
income they could earn. Overcoming the hurdles necessary to become eligible for Social Security income benefits,
obtaining appropriate training from the state Vocational Rehabilitation agencies, understanding and using the Social
Security work incentives, finding and maintaining medical benefits, and obtaining assistance from mental health
agencies was daunting.
mkilleen@cox.net
To Sue or Not to Sue: Implications for Plaintiffs who Allege Serious Mental Health Impacts in Civil
Suits
Sandra B. McPherson, Fielding Graduate Institute, Santa Barbara, USA
In a civil suit where mental health becomes an issue, an individual is voluntarily placing him or herself, usually
without much knowledge of the consequences, into a category of people which in this society continues to be one
where significant prejudice may pertain. Where the individual is overstating or inaccurately presenting the presence
of mental health symptomology, he or she then may face the onerousness of being identified as a malingerer.
Further, the process may result in shame and humiliation since it documents in the most public of ways a condition
that is a basis for the lack of positive regard by other members of the society. Finally, due to the exposure involved,
there can be secondary impacts in which losses are inflicted. In such cases, even where the suit is successful, the
compensation may not balance the further injury that the process involves. A sample of civil suit records was
conducted to determine the categories of information, the evaluative procedures involved, and the types of data that
appeared in the expert report and/or other phases of the case. Anonymized samples of testimony were reviewed and
analyzed as demonstrations of the process and its potential for destructive impact. While the option of suit action
represents a corrective to unwarranted injury, the introduction of the mental health aspect may or may not be of
benefit to a plaintiff who is seeking redress for some grievance. From the perspective of therapeutic jurisprudence,
decisions involving mental health and civil litigation involve complex cost benefit considerations.
smcpher1@earthlink.net
Disability Civil Rights Law and Policy
Peter Blanck, University of Iowa
This paper examines civil rights laws and policies affecting persons with mental and physical disabilities, with focus
on the Americans with Disabilities Act (ADA) of 1990. The paper discusses, based on historical and contemporary
studies, the ways in which public acceptance and inclusion of persons with mental disabilities into society is at least
as much driven by political, economic, and attitudinal factors regarding conceptions of disability, as by law and
policy themselves. See, e.g., Blanck, P., Hill, E., Siegal, C., & Waterstone, M. (2003). Disability Civil Rights Law
and Policy, Thomson/West.
The paper also presents findings from a large cohort study, conducted in collaboration with University of Chicago
economist, and Nobel laureate, Dr. Robert Fogel. The research examines a massive amount of data in the
investigation of some 45,000 white and African-American Northern Army Civil War veterans. Birth, health,
military, pension, and census information is available for analysis. Our studies show that many Northern Army
veterans with disabilities who submitted their pension applications were seen as “unworthy” for pensions,
particularly those with stigmatized mental disabilities or infectious diseases. See Blanck, P. (2001). Civil War
Pensions and Disability, Ohio State Law Journal, 62, 109-249; Blanck, P.D. & Song, C. (2001). “With Malice
Toward None: With Charity Toward All”: Civil War Pensions for Native and Foreign-Born Union Army Veterans,
Journal of Transnational Law & Contemporary Problems, 11(1), 1-76. The findings illustrate that attitudinal
prejudice and stigma associated with mental disability may have influenced pension awards more than previously
documented.
The paper then discusses the relevance of the historical studies to contemporary society. Skepticism toward persons
with mental disabilities, and related criticisms of the ADA, have perpetuated attitudinal barriers and unjustified
prejudice. The analysis illustrates how these negative attitudes influence development of laws and policies toward
Americans with mental disabilities, which, in turn, affect the social construction of disability.
peter-blanck@uiowa.edu
Employment Prospects for People with Serious Mental Illness within the Context of the U.S. National
Labor Market: National Workforce Development Policy Implications
Richard C. Baron, OMG Center for Collaborative Learning, Philadelphia, USA
Based on qualitative research for the U.S. National Institute on Disability and Rehabilitation Research and the
University of Pennsylvania's Collaborative on Community Integration for People with Psychiatric Disabilities, this
presentation assesses the employment status of people with mental illness in the context of the comparable struggles
of low-wage workers without disabilities in the broader U.S. labor market.
People with mental illness in the U.S. are often quite poor, a result of staggering rates of unemployment. Their
dependence on both financial and medical support from the U.S. Social Security Administration (SSA) leaves them
with powerful disincentives to work, primarily because few of those with serious psychiatric disabilities have been
able to find jobs that pay better than or offer medical coverage comparable to what they are already receiving from
the SSA system.
Better jobs are scarce in part because those with mental illness, in common with 75% of the U.S. public, do not have
the college degree that is increasingly a prerequisite for living-wage jobs. The problem, research suggests, is the
nature of a U.S. labor market in which the low-skill jobs, such as in the manufacturing sector in the past, that paid
well and included adequate medical benefits have all but disappeared, and the absence of part-time or seasonal jobs
that provide an adequate income or medical coverage.
Nonetheless, there is no general push at the policy level to revise U.S. labor policy, even though those with mental
illness are joined by an increasing number of low-wage Americans with a modest or unsuccessful academic record
(e.g. welfare clients), looking for or toiling at entry-level or low-skills jobs (e.g., ex-offenders), and dealing with
significant barriers to full-time long-term work (e.g., those with literacy limitations).
The proposed presentation seeks to raise awareness that the labor market for people with mental illness is the same
labor market unresponsive to the needs of millions of other low-wage workers in the U.S. economy and to develop
strategies that match our current focus on disability-based barriers to employment (e.g., minimizing the disincentives
to employment in the SSA system; effectively ending employer discrimination against people with serious mental
illness; improving the effectiveness of training, placement, and retention programs for this population) with public
policy initiatives focused on labor policies more broadly: income supplements; heightened minimum wage
standards, improved educational programming; national health care; job creation strategies; etc.
rick@omgcenter.org
Globalization of Mental Disability Law
The Globalization of Mental Disability Law
Arlene S. Kanter, Syracuse University
This presentation will discuss recent international legal developments which address the plight and rights of people
with mental disabilities, including the current movement for the adoption of a United Nations treaty on the rights of
people with disabilities.
In 1990 the United States enacted the Americans with Disabilities Act which prohibits discrimination against people
with disabilities in nearly all aspects of life. This law is arguably the most comprehensive domestic law addressing
the rights of people with disabilities, including people with mental disabilities. Since its enactment, at least 39 other
countries have adopted their own domestic disability laws; some of which are modeled after the ADA, while others
differ greatly in structure, scope, and coverage.
Despite these worldwide legislative initiatives, significant gaps remain in the levels of employment, health, and
quality of life for people with disabilities throughout the world, particularly people with mental disabilities. People
with mental disabilities are more than twice as likely as their peers without disabilities to be poor and unemployed.
Many remain in institutions throughout their lives, and those who do live in the community and work earn
substantially less than their co-workers who do not have disabilities. Many adults with mental disabilities want to
work, with appropriate accommodations or assistance. As they know only too well, with unemployment comes
fewer opportunities to participate in the life of a community, and in recreational and social activities.
The plight of people with disabilities, including people with mental disabilities, has now become an international
human rights issue. The United Nations itself is on the verge of adopting a Convention on the Rights of People with
Disabilities. Consequently, at no time in history has the confluence of international efforts with and for people with
disabilities challenged policy makers, professionals, scholars, and activists to frame the meaning of human rights for
people with mental disabilities. This presentation will explore these recent legal developments, particularly the
potential international impact of the United Nations Convention on the Rights of People with Disabilities.
kantera@law.syr.edu
Globalisation of Disability Rights Law: The Impact in Australia
Lee Ann Basser, La Trobe University
The Australian Institute of Health and Welfare estimates that people with disabilities make up 19% of the Australian
population. In addition Australian Bureau of Statistics figures show that one in five people in Australia 19 years or
older meet a criteria for a mental disorder (ABS: The National Survey of Mental Health and Well Being, 1997). In
the early 1990’s the Australian Human Rights and Equal Opportunity Commission conducted a National Inquiry
into the Human Rights of People with a Mental Illness. The report emphasised the importance of economic, social
and cultural rights as well as civil and political rights The Commission’s final report was handed down in October
1993. It found that there were widespread human rights abuses of people affected by mental illness. A number of
positive outcomes followed this Report – an increase in resources, the development and implementation of a
National Mental Health Strategy and legislative reforms. At around the same time the Australian Parliament enacted
the Disability Discrimination Act 1992 (Cth) – aimed at reducing the inequality experienced by people with
disabilities in all aspects of their daily lives.
More than 10 years after the National Inquiry people with disabilities and people affected by mental illness continue
to be amongst the most marginalised and disadvantaged people in the Australian community. Human rights abuses
continue despite the fact that Australia is a signatory to the major international human rights instruments and despite
the fact that Australia has been a pioneer in many areas of disability rights laws including laws relating to antidiscrimination, alternate decision making and mental health. This paper will assess the extent to which the current
legislative regime gives effect to the human rights of people with disabilities and will consider the impact that the
proposed UN Convention on the Rights of People with Disabilities might have on domestic Australian law.
l.basser@latrobe.edu.au
Patient Rights in Seclusion and Restraints
Anne Koplin, Waukesha County Mental Health Centre, Milwaukee, USA
This presentation will discuss the issue of seclusion and restraint of potentially dangerous psychiatric patients as
practiced in the United States and in Israel, including new federal regulations implemented in the United States
regarding this treatment.
The nature of the practice of Psychiatry has changed with the development of the patient rights movement. An
example of the impact can be seen quite dramatically in the matter of seclusion and restraint. These actions can
clearly be seen as a temporary, yet necessary, denial of patient rights for the benefit of the individual and others.
Seclusion and restraint have been accepted forms of treatment for decades. Most recently, the United States has
implemented new guidelines regarding their use in certain settings. These changes are meant to protect the patient
from harm that may occur as a result of this form of treatment. These regulations clearly define the parameters for
using these measures and demand face-to-face physician evaluation within one hour of the written order for either
seclusion or restraint. Israeli law regarding seclusion and restraint will also be reviewed.
Protection of patient rights, while at the same time using forceful means of confining the patient can be a fragile
balancing act. The trend towards more limited use, a higher degree of supervision and monitoring regarding their use
has made an impact on patients and psychiatry in general. Increased regulation of the use of seclusion and restraint
is a positive, essential step towards greater patients’ rights while providing a necessary limit upon dangerous
behavior.
akoplin@hotmail.com
Economic and Scientific Determinism as a Means of Privatizing Disability: the impact of the
globalization of disability rights law
Marcia Rioux, York University
This paper looks at the limitations of economic and scientific rationalization of public policy decisions, and the
welfare state itself, to demonstrate that social citizenship needs to be re-thought within a framework of public good.
It explores the way in which the frontier between public and private is not static and demonstrates that what is
determinant for the lives of people with disabilities are the economic pressures to reduce redistributive policies.
This is important because in the area of social policy a necessary condition of social well-being is for society to
accept that social disability be treated as a public good. If, however, the market cannot be relied upon to correct the
imbalances between economic and social well-being then the development of binding international and national
disability rights law is imperative. The presentation will draw attention to the way in which the boundary between
the private and public falls is always dynamic and is a consequence of economic and legal pressures to shift the
responsibility for disability from one sector to another.
mrioux@yorku.ca
no title
Eric Rosenthal, Mental Disability Rights International
Mental Disability Rights International, based in Washington, D.C. researches abuse and mistreatment of people with
disabilities worldwide. Since 1993, MDRI has documented deplorable and inhumane conditions in institutions to
which people with mental disabilities have been subjected, published reports on human rights enforcement, and
promoted international oversight of the rights of people with mental disabilities. Drawing on the skills and
experience of attorneys, mental health professionals, human rights advocates, people with mental disabilities and
their family members, MDRI trains and supports advocates seeking legal and service system reform and assists
governments to develop laws and policies to promote community integration and human rights enforcement for
people with mental disabilities.
Prior to MDRI's involvement, few human rights organizations focused on abuse and mistreatment of people with
mental disabilities Even today, international human rights organizations are not always aware of the plight of people
with mental disabilities in the countries they investigate. But in recent years, the rights of people with mental
disabilities has indeed become an issue of global concern. MDRI alone has prepared reports about conditions of
people with disabilities in Uruguay, Hungary, Russia, Mexico, Peru, and Kosovo, and most recently in Paraguay. In
addition, the UN is now considering a treaty on the Rights of People with Disabilities, and governments of many
countries have now enacted laws and changed policies regarding the rights of people with disabilities, including
people with mental disabilities.
At the panel on Globalization and Disability Law, I will present an overview of MDRI’s recent activities in various
countries regarding conditions of people with mental disabilities, particularly in institutions and discuss
developments under international and regional law to protect and expand the rights of people with mental
disabilities.
erosenthal@mdri.org
Advance Directives I
Personal Identity, Authenticity, and Mental Illness
Heike Schmidt-Felzmann, National University of Ireland
In reflections on psychiatric advance directives, what is at stake philosophically has frequently been conceptualized
in terms of the question of personal identity. One problematic issue concerns cases where more than one personality
fulfils the basic criteria of competence – which of the personalities should be taken as authoritative? As I want to
argue, the notion of authenticity may be more suited than the notion of personal identity to conceptualize such cases.
That relying on the notion of identity is problematic with regard to cases of mental disorder becomes especially
apparent considering the frequency of changes in personality in mental disorder and their treatment. I will discuss
problems and advantages of using a weak notion of authenticity to understand what is at stake in these cases.
Heike.felzmann@nuigalway.ie
Advance Directives, Future Selves and Decision Making
Alasdair Maclean, University of Glasgow
An advance directive (AD) is a device that allows a competent individual to issue directions that prohibit possible
future interventions that may be carried out when the individual is no longer competent to make a contemporaneous
decision. The justification for respecting such a direction is grounded in the competent individual’s right to
autonomy. This justification is open to challenge from those who, like Parfit, believe that individual personal
identity is unimportant. These non-reductionists argue that what matters is the psychological connectedness and
continuity between the present and future selves. Where that relationship has been disrupted by, for example, the
onset of dementia, the previous competent self’s autonomy carries no particular weight and decisions for the present
incompetent self should not be bound by the AD. This argument approaches the issue from the perspective of the
individual’s right to autonomy. If, instead, the question is explored from the alternative perspective of the most
appropriate way to make decisions for incompetent individuals, then it may be arguable that the non-reductionist
view still supports, albeit in a limited form, reliance on an AD. It is this approach that I will examine in this paper.
A.Maclean@law.gla.ac.uk
Advance Directives – Relevance to Civil Commitment
Richard O’Reilly, University of Western Ontario
John E. Gray, University of Western Ontario
Advance directives were initially championed to assist individuals to plan the health care they receive at the end of
life. Over time advance directives increasingly came to be used to plan the management of chronic illnesses
including psychiatric disorders. A particularly difficult scenario occurs when a patient who is involuntarily
committed to a psychiatric hospital has previously made an advance directive stating that psychotropic medications,
needed to effect recovery and release from hospital, must not be given. Such an individual will remain incarcerated
in hospital until he or she has a spontaneous remission or dies. Society cannot be sure that this person, if capable,
would not have had a change of mind and chosen treatment over a lifetime of incarceration. Many observers believe
that this situation is unacceptable - but what mechanisms can be developed to prevent it occurring? We describe
three approaches. First, society can place the onus on the individual to prove that any advance directive, calling for
the rejection of standard medical care, was made when the individual was capable and that the directive was
intended to apply in altered circumstances (such as after committal). The second approach, taken by some
jurisdictions, is not to follow advance directives that reject psychiatric treatment for committed patients. The final
model permits an override of an individual’s advance directive where following the directive would endanger the
physical or mental health of the person or of another person. The advantages and disadvantages of these three
models will be discussed.
roreilly@uwo.ca
Parens Patriae, Autonomy and the Ulysses Contract: Pre-commitment Ambiguities and the Right to
Refuse Treatment
George P. Smith, The Catholic University of America
The United States Supreme Court’s recent decision in 2003 in the case of Sell v. United States provides the central
paradigm for investigating the extent to which the state may, under its parens patriae powers, forcibly administer
psychotrophic medications to the mentally ill. In Sell, and other precedents, the High Court—while recognizing a
“liberty interest” under the Constitution in avoiding unwarranted medical treatment—nonetheless allowed this
interest to be compromised by the state’s counter-vailing interest in protecting society from criminal activity.
Accordingly, under strict conditions, the government is allowed to restore a defendant’s decision making ability
which ameliorates his mental illness and thereby allows him to regain his competency and, thus, stand trial. This
paper’s analysis then turns to the use of the psychiatric pre-commitment Ulysses contract (or directive) as a way to
safeguard autonomy before the onset of a mental illness by either consenting in advance to certain medical
treatments or, for that matter, non-treatments. Of particular interest and concern here is the plight of the elderly in
long-term care facilities; and this becomes the context for testing the extent to which advance directives are effective
in this setting. After surveying the pertinent case law dealing with the rights of patients in mental institutions and
long –care facilities to refuse psychotrophic medications, and the Congressional response to this issue, the paper
concludes by offering suggestions for implementing a policy that seeks to codify a normative balance between
preserving the rights of the mentally challenged for self-determination and the responsibilities of the state to
safeguard the peace, stability and social order for all citizens.
smithg@law.edu
Autonomy for Incompetent Patients: Tension between Law and Social Practice
Cristiano Vezzoni, University of Groningen
Partly due to the aging population in Western societies, the attention to the rights of incompetent elderly persons has
increased. One consequence is the legal recognition of advance directives for health care. By means of such a
document, a person can refuse specified treatment, should she or he become incompetent. In this way, people are
legally empowered to exercise their right to autonomy for medical decisions even in a future situation in which they
have become incompetent. However the question whether the goal of recognition is achieved in practice is still open.
This paper analyzes the legislation concerning advance directives in the Netherlands and seeks to assess its effects
by means of a survey on the practice of advance directives among nursing home doctors and family doctors in the
Netherlands. A total of 206 doctors (77 nursing home doctors, stratified random sample; 129 family doctors, simple
random sample) were interviewed by means of a structured telephone questionnaire. These results confirm the
findings of the limited empirical literature (mostly North-American) showing that advance directive often fail to
achieve their target.
Despite the strong legal status of advance directives in the Netherlands, it is clear from our research that the right of
autonomy for incompetent patients is not effectively ensured. On one side, lack of information keeps potential users
from being aware of their right to draft an advance directive. On the other side, while doctors share the principle of
respect for autonomy, they are not ready to extend that respect unconditionally to incompetent patients. Doctors
appear to hold that the priorities of a patient could change in the post-competent phase, implicitly assuming a
discontinuity of the patient’s self due to impairment. Therefore they prefer to base their decisions on the current best
interest of the incompetent patient rather than on his previously expressed instructions contained in an advance
directive.
c.vezzoni@rechten.rug.nl
Capacity, Consent and Advance Directives
Psychiatric Advance Directives and the Right to Refuse Treatment in Canada
Daniele L. Ambrosini, McGill University
Throughout the 1990’s Canadian courts began to abandon traditional and paternalistic views that patients must
simply conform to treatment by doctors, irrespective of their individual personal rights. The parens patriae power,
traditionally the power of the State to act in the best interests of those unable to provide for their own welfare, must
be balanced with a patient’s prior wishes, bests interests and what constitutes the least intrusive manner of treatment.
Legal scholars, psychologists, and psychiatrists have recommended advance directives for mental health treatment
decisions as a legal method of treatment pre-planning, and to ensure that competent persons will have their capable
decision-making abilities respected in the event they become incapacitated. A Psychiatric Advance Directive (PAD)
is an extension of an advance directive that applies to individuals with mental health problems.
The article provides a review of jurisprudence, with its development in the right to refusal of medical treatment,
followed by a discussion of provincial legislative models, and an overview of potential arguments based on the
Charter of Rights and Freedoms and relevant sections of the Criminal Code. In addition, issues regarding patient’s
psychological perceptions of PADs, their benefits and potential obstacles in securing psychiatric patient’s rights will
be addressed.
daniele.ambrosini@mail.mcgill.ca
Mental capacity in psychiatric and medical in-patients
Matthew Hotopf, King’s College
In this presentation, I will describe three studies supported by the Wellcome Trust Biomedical Ethics Programme.
First, I will present data which suggest that mental capacity can be assessed with excellent inter-rater reliability
when using the MacArthur Competence Assessment Tool – Treatment (MacCAT-T). Second, I will describe our
general hospital study in which 159 consecutive patients admitted to medical wards were interviewed, using
MacCAT-T. 31% of the interviewed sample lacked capacity; this figure rose when taking into account nonparticipants who did not complete the interview because of severe cognitive impairment or unconsciousness.
Mental incapacity was strongly associated with cognitive impairment and advancing age, but not with ethnic group,
education or social class. Third, I will describe a similar study involving 112 psychiatric inpatients interviewed
within one week of admission. In this sample, 43% lacked mental capacity; incapacity in this group was strongly
associated with psychotic illness and with country of birth - those born outside the UK were more likely to be rated
as lacking capacity. Of the 63 patients who were judge to have mental capacity, 10% had been admitted under the
Mental Health Act; this group perceived their treatment to be more coercive than the remainder of the sample. Of
the 49 patients who were judged to lack mental capacity, 39% were not admitted under the Mental Health Act, and
would therefore fall in the “Bournewood gap”. This “gap” refers to incapacitated patients who are treated
informally – that is, without being sectioned under the Mental Health Act, because they accept hospitalisation and
treatment "compliantly". The European Court has ruled that such patients should be treated formally, which has
major implications for services, patients and carers.
m.hotopf@iop.kcl.ac.uk
Capacity - the parallel tracks of law and medicine
Sue Field, University of Western Sydney
Old age does not merely produce wrinkles. Longevity also increases the risk of dementia specific illnesses. The loss
of mental capacity - or the inappropriate diagnosis of incapacity - deprives an individual of the most basic of human
rights – that of making their own decisions.
Capacity is a legal concept. That is, ultimately the decision as to an individuals’ mental capacity - based on the
evidence submitted - will be that of the courts. It will be argued that often the evidence submitted is inconclusive
and demonstrates a lack of understanding of the processes engaged in to determine the mental state of a client or
relative.
This paper will address the following issues: the questionable validity of the assessment tools;
 the lack of consistency in the tools;
 the ad hoc manner in which these instruments are administered;
 the parallel tracks of medicine and law; and
 the lack of understanding – amongst professionals – of the implications of their assessment.
s.field@uws.edu.au
Psychiatric Advance Directives: A Qualitative Study of Informed Consumers Deliberating
Michaela Amering, University of Vienna
Established legal mandates and high expectations for Psychiatric Advance Directives (PADs) are not matched by
empirical evidence documenting their actual implementation. The aim of this paper is to explore the interests,
concerns and planning activities of informed consumers contemplating PADs. Standard qualitative research
techniques were used: field observations, interviews, focus groups, archival research, and key informant interviews.
33 persons participated. Transcripts were coded, analyzed for thematic content, and results were member-checked.
The results were that training set in motion labor-intensive projects that involved conceptualizing how a PAD would
work in one’s own life, mobilizing resources, reviewing past experiences, and assessing risks. Especially meaningful
was the prospect of being treated as a responsible agent in future interactions with the mental health system. PADs
are best thought of as complex planning tools for future crisis management, rather than focal interventions to
enhance compliance. Research is needed to explore the institutional response to this prospective decision-sharing
initiative.
michaela.amering@univie.ac.at
The true interest of the client: Dilemmas for attorneys in therapeutic law
Stefan Sjöström, Umeå University
Maritha Jacobsson , Umeå University
Anna Hollander, Umeå University
In therapeutic law, courts decide whether coercive intervention from authorities such as a psychiatric clinic or social
welfare office is warranted. The persons who are subjected to coercive interventions are typically in a position
where there capability to make rational decisions about their own well-being is questioned. Hence, attorneys
representing these clients face peculiar dilemmas, in particular with regards to what it means to “represent” under
such circumstances. Representing the client’s interest can be conceived in three major ways: 1) to “win” the case
(“defender”) 2) to give voice to the client (“mouthpiece”) 3) to accomplish the best solution for the client
(“therapist”). In the paper, we analyse the role of attorneys in Swedish court hearings concerning three types of
cases relating to coercive interventions against citizens: compulsory psychiatric care, compulsory care for drug and
alcohol abusers, and cases where social authorities question parents’ ability to care for their children. The analysis is
based on 45 court hearings and interviews with 31 participants. Findings indicate that the dominating roles for
attorneys are as “mouthpiece” and “therapist”, rather than “defender”.
Stefan.sjostrom@socw.umu.se
Juvenile Justice and Mental Health
Recent studies confirm the high prevalence of symptoms of mental disorders among youth in correctional facilities.
These symptoms include not only disruptive behaviors but also severe emotional difficulties. Specialized screening
tools for use in juvenile justice provide improved assessment and a more detailed picture of the symptoms
encountered, such as the MAYSI-2 in the United States and SIFA in England and Wales. Numerous procedural
issues still confront clinicians and agencies in appropriately assessing and treating mental disorders among
incarcerated youth, such as suicidal and self-injurious behaviors. In response to these concerns, professional
standards were recently developed for the proper assessment and care of youth held in the justice systems in the
United Kingdom and United States. This session will present an overview of the extent and nature of mental health
problems of incarcerated youth, the special issues in screening and treating them, and the development and
implementation of professional guidelines for mental health clinicians working with them.
Meeting the Mental Health Needs of “Hard to Reach” Young Offenders
Sue Bailey, University of Central Lancashire
A joint programme of research between the University of Manchester, UCLAN and clinical services at Bolton,
Salford & Trafford Mental Health Trust, the findings are presented of:
 The development, validation and implementation of a semi-structured interview to help identify key mental
health symptoms (SIFA) for all young people entering the Youth Justice System in England and Wales.
Based on the Salford Needs Assessment Schedule for Adolescents (SNASA) the screen covers, 8 areas of
mental health, alcohol misuse, substance misuse, depressed mood, deliberate self-harm, anxiety symptoms,
post traumatic stress problems, hallucinations, delusions and paranoid beliefs and hyperactivity. This
screen has from November 2003 been incorporated into the universal screening interview for all young
offenders, carried out by all professionals working with this group.
 The Mental Health Provision for young offenders, a study of 300 young people in order to establish:
1. The level of mental health needs among this population and
2. The current models and effectiveness of service delivery and the comparative needs of young
offenders, in the community and those in custody.
 Implications for practice parameters, service delivery and an integrated multiagency approach to young
offenders, by health, education, social care and justice will be discussed in the context of long term costs to
this group as they present to adult services in the future, bridging the transition of service delivery.
ntattersall@gardener.bstmht.nhs.uk
Mental Health Needs of Youths in Juvenile Justice Facilities: Results of a Nationwide Study in the
United States
Thomas Grisso, University of Massachusetts
Recent research in the United States has indicated that two-thirds of youths entering pretrial juvenile detention
centers meet criteria for one or more mental disorders. As a consequence, mental health screening at admission to
juvenile detention centers has become routine in the past five years. This presentation focuses on a screening
tool—Massachusetts Youth Screening Instrument-Second Version (MAYSI-2)—that was developed and validated
specifically to identify symptoms of mental and emotional disturbance upon admission to juvenile detention centers
(e.g., alcohol/drug use, anger, depression/anxiety, somatic complaints, suicide ideation, thought disturbance).
The instrument and its development will be described, as well as the four-year process of its dissemination, which
has resulted in statewide use of the MAYSI-2 in 36 of the 50 states in the U.S. Data provided by 18 of those states
has allowed for the analysis of 70,000 MAYSI-2 cases, focused on identifying reliable patterns of MAYSI-2
symptoms (generalizable across the United States) by age, gender, ethnicity, and type of juvenile justice facility.
Results indicate that on average: (a) girls manifest greater pathology than on almost all MAYSI –2 scales; (b)
younger adolescents score higher on anger and lower on alcohol/drug use than do older adolescents; (c) there are
some consistent differences between ethnic groups, with non-Hispanic white youths scoring highest on several
MAYSI-2 symptoms scales and African-American youths lowest; and (d) levels of symptoms on average decrease
as one moves from pretrial institutions to post-adjudicative institutional settings.
Thomas.Grisso@umassmed.edu
Surviving the Challenges of Juvenile Corrections: Suicide Prevention Strategies
Joseph V. Penn, Brown University
There is a high prevalence of suicidal and self-mutilative behaviors among incarcerated juveniles. Recent studies
suggest that there is an average of 17,000 incidents of suicidal behavior in U.S. juvenile correctional facilities each
year, and that youth suicide in U.S. juvenile detention facilities is more than four times greater than in the general
population. Intake screening, timely clinical referral, and ongoing assessment of all confined youth are critical to
suicide prevention efforts by correctional staff. Two essential components of a successful suicide prevention
program are properly trained staff, and ongoing communication among correctional and clinical staff.
This paper will present the existing literature on suicide attempts and suicidal behavior in the juvenile justice
population. It will review new guidelines for the identification of high-risk periods, systematic screening, clinical
assessment and management of youth presenting with self-mutilative behaviors and suicide attempts. Finally, it will
review unique challenges in juvenile correctional settings such as how to interface more effectively with juvenile
and family courts, medico-legal liability issues, strategies for detection and management of malingering, future
challenges for effective staff training, and the implementation of suicide prevention programs.
jpenn@lifespan.org
Practice Parameter for the Assessment and Treatment of Youth in Correctional Facilities
Christopher R. Thomas, University of Texas
Over the past decade the number of youth held in correctional facilities in the United States has grown considerably.
Up to 75% of these youth have a diagnosable mental disorder according to some estimates, but many do not have
adequate mental health services. In addition, psychiatrists providing treatment for these youth face a myriad of
challenges and pitfalls: potential role conflicts; confidentiality issues; working with families, social services, law
enforcement and courts; negative perceptions of delinquents; and the complex, multiple needs of these youth. In
response to the lack of standards and guidance in addressing these problems, the American Academy of Child and
Adolescent Psychiatry developed a practice parameter concerning mental health services for youth held in
correctional facilities. The parameter set forth 14 specific recommendations on the organization and delivery of
mental health care, including initial evaluation, ongoing monitoring of mental health problems, assessment of
violent or suicidal youth, and use of medications. Particular attention focused on the difficulties encountered in
treatment planning and implementation for these youth. The research on which the recommendations are based, the
process of creating the parameter and the implications for policy and practice will be reviewed. The parameter will
serve as a guide to individual practitioners as well as a model for policy makers and leaders.
crthomas@utmb.edu
Quality of Juvenile Forensic Diagnostic Assessment in the Netherlands
Nils Duits, Ministry of Justice, Amsterdam, The Netherlands
Juvenile forensic diagnostic assessment and decisions of the court can have far reaching consequences for juvenile
delinquents and Dutch society. Improvement of quality and guidelines are therefore needed. Quality management is
only possible if one has considered the concepts of quality and the organizational framework of the juvenile forensic
diagnostic system. In the Netherlands we developed a unique quality framework for the juvenile forensic diagnostic
assessment. It has typical ‘polder model’ characteristics as cooperation and networking with forensic partners.
Organizational and practical aspects will be presented in the light of the Dutch juvenile juridical context. Empirical
research stood at the basis of this unique quality framework. The concept of quality has been investigated by means
of a concept mapping among ‘users’ and ‘makers’ of juvenile forensic diagnostic assessment in the perspective of
Dutch juvenile penal law. Methodology and results will be presented and consequences on quality management will
be discussed.
NDuits@planet.nl
The Role of Specialized Courts: Mental Health and Addiction I
A Three Year Comparative Study of Behavioral and Criminal Justice Outcomes for Mentally Ill
Offenders Seen in a Mental Health Court
Gary Bess, California State University
Jim Myers, California State University
Judge Stephen Benson, Superior Court Judge for State of California, USA
The intersection between individuals with mental illness and their involvement in California’s criminal justice
system is well documented. According to Ditton’s (1999) review of federal Bureau of Justice Statistics data, 16
percent of local jail populations, 16 percent of probationers, and 16 percent of the state prison population have been
diagnosed with a mental illness. Although there is a high population of the mentally ill who are incarcerated, there
are even greater numbers that are arrested, jailed, and released, only to re-offend in a seemingly unstoppable cycle.
Research shows that approximately one-half of individuals who have a mental illness will be arrested at least once
while suffering symptoms
In Butte County, a rural California county (population 210,000) located between California’s north-eastern
Sacramento Valley and the Sierra Nevada Mountains, there was a 50 percent growth in the average daily jail
population between 1991 and 1999. During this period within the jail medical unit alone, on which inmates with a
mental illness are assigned, there was greater than a 200 percent increase in the average daily jail population.
A three-year mentally ill offender crime reduction program, funded by the California Board of Corrections, began in
July 2001 in Butte County. The program stressed treatment over incarceration for mentally ill offenders, and
utilized a multidisciplinary intervention team, which was composed of representatives from the County’s Sheriff’s
Office, Probation Department, Behavioural Health Department, District Attorney’s Office, Public Defender’s
Office, and Judicial Court. One hundred (100) mentally ill offenders were randomly assigned to either an enhanced
treatment program (experimental group) or treatment as usual (comparison group). Those assigned to enhanced
treatment appeared in a mental health court before a judge who mandated the defendant’s receipt of supportive
services provided by the team, as a condition of probation. Those assigned to the treatment group, while appearing
before the same judge, received the community’s standard of care. Participant criminal justice and behavioural
health histories were obtained, and data were collected at six-month intervals during and after probation.
At time of entry into the program, greater than three-quarters (78.2%) of defendants were assessed with alcohol
and/or drug problems, and nearly one-third (32.3%) were diagnosed with a Bipolar Disorders classification. An
additional one-quarter (24.7%) was diagnosed with a Schizophrenia and Other Psychotic Disorders classification.
There additionally was an escalation in arrests for the three-year period before entry into the program. Slightly
greater than 40 percent (42.9%) had at least one arrest three year’s prior to program entry, and 76.9 percent were
arrested at least once within 12-months of having committed an offence qualifying them for enrolment in the
program.
As a result of this intervention, it appears that enhanced treatment participants were booked into jail a fewer number
of times, averaged less days in jail, and had improved behavioural functioning and quality of life, based on
standardized measures, relative to comparative data for treatment as usual participants.
bess@sunset.net
callowaysdad@netscape.net
Mental Health Services in Toronto Courts
Steve Lurie, Canadian Mental Health Association (CMHA), Toronto, Canada
Mental health services have been available in the courts in Toronto Ontario Canada since 1997. A specialized
mental health court was developed in one of the five courts, while court support workers were placed in the four
regular courts. 2,300 people with mental disorders appear before Toronto courts each year. The experience
providing mental health service in the courts will be reviewed, using findings from a program review (Macfarlane
2002). The workshop will describe the history of court-based mental health services in five criminal court settings
throughout the city of Toronto and the results of a formal program review conducted in the spring/summer of 2001.
The results are described from two diverse perspectives. First, the data collected during the review are described
with the recommendations that followed from these data. Second, the broader and longer term effects of the review
are described, in terms of the development of the mental health services themselves, the impact on the courts, the
effect on the quality and timeliness of mental health services provided to the mentally disordered accused persons in
the courts in Toronto. Finally the subsequent work of the court support consortium that was developed following
the review will be discussed.
slurie@cmha-toronto.net
Court Outcomes for Clients of a Mental Health Court Liaison (MHCL) Service: The First Six Years
John Sharples, University of Newcastle, Australia
At the last conference we reported on a 3-year service audit of clients seen by the Newcastle MHCL service, which
documented client characteristics, service patterns and associated relationships. This paper examines court outcomes
for all clients referred to the service between 1997 and June 2003.
Outcome data were extracted from Court records for all clients referred to the service. There were approximately
1,773 clients involved in 2,246 service episodes. For each service episode, basic socio-demographic, clinical, service
contact, and criminal charge details were collected. Court outcomes recorded included: punishment received;
charges dismissed; Apprehended Violence Orders (AVOs) received; and warrants issued. Details of sentencing,
including length and type of bond, goal term, weekend detention, and community service were recorded.
Court outcomes will be reported by socio-demographic characteristics, diagnosis and offence type. Preliminary
analyses (N = 1,139 service episodes) revealed that 70.3% of clients incurred a punishment (among whom 45.9%
received a bond, 34.7% a goal term, and 19.6% were fined). A further 24.2% had their charges dismissed (61.3%
under S32 of the MH Act).
Previous studies have identified relationships between gender, diagnosis, patterns of offending, and court outcome.
By examining such relationships in the court liaison data, we may be better equipped to identify service needs and
improved intervention strategies for our clients. We need to continue to strengthen links already forged between the
mental health and criminal justice systems.
John.Sharples@hunter.health.nsw.gov.au
Establishing a Mental Health Docket
Melissa A. Knopp, Supreme Court of Ohio
A revolving door problem has developed in the United States of America. Jails and prisons have become the de
facto mental health system of our day. The number of mentally ill offenders has been increasing steadily in the Ohio
court system. Specialized Dockets, defined as a therapeutically oriented judicial approach to provide court
supervision and appropriate treatment for offenders, has been the solution to alleviating this problem.
Ohio has served as a leader in the United States in the specialized dockets area with the most drug courts per capita
than any other state in the country. Currently the state boasts over 57 drug courts, 20 mental health courts, 3 reentry courts, and one domestic violence court. Much of Ohio’s success in this field is attributable to the
collaborations formed to produce policies conducive to these specialized dockets.
The Supreme Court of Ohio has been a staunch supporter of the development of specialized dockets in Ohio trial
courts. The Court has promoted the creation of these dockets primarily through offering direct technical assistance,
provided by staff of the Supreme Court of Ohio. In addition, the Supreme Court has developed, funded, and hosted
training events throughout the state of Ohio and in individual communities for vital individuals involved with
specialized docket programs. The key to the Supreme Court’s success in this area has been its joint efforts with
other crucial state stakeholders.
This presentation will focus in large part on the foundation and promotion of mental health dockets. In addition, this
session will outline the underlying policies created and advocated by the Supreme Court of Ohio and the processes
developed by the Specialized Dockets Section of the Supreme Court of Ohio to plan, implement, and operate a
mental health court program.
knoppm@sconet.state.oh.us
Creating a Community Mental Health Court: From Crisis Intervention Training (CIT) to the Mental
Health Court Docket
Karen E. Woods, Twin Valley Behavioral Healthcare, Columbus, USA
Creating a mental health court docket is a process that starts with the development of a community task force, the
training of Crisis Intervention Teams (CIT) composed of police officers who respond to calls identified as involving
a mentally ill individual and the development of a treatment team of professionals who work with mentally ill
defendants in developing a diversionary treatment plan. This presentation will focus on developing a task force that
includes community leaders and agencies to work on issues associated with Jail Assessment and Referral; CIT
training; Common Pleas Drug Court Processes and Procedures; Municipal Mental Health Court Processes and
Procedures; Availability of Community Resources; Funding and Grant Writing; and Publicity and Public
Awareness. The process of developing a training curriculum and the training of CIT officers will be outlined. The
benefits of CIT to the community will be discussed. Such benefits would be that the defendant or potential
defendant receives mental health services from which he/she would benefit; local jails and lock ups do not receive
mentally ill offenders that are difficult to manage and who may be disruptive to the usual institutional order; and
defendants are monitored and managed in the community in an appropriately restrictive environment which is cost
effective, humane, and more effective overall compared to purely incarceration based programs. The benefits,
positive outcomes and obstacles to developing a task force and in training of CIT officers will be explored.
krnewds@aol.com
The Role of Specialized Courts: Mental Health and Addiction II
Strategies for Addressing Co-occurring Disorders in a Drug Court Setting: «Treatment is Essential to
Success» (TIES) Program for felony offenders, Columbus, Ohio USA
Jennifer L. Brunner, Judge, Franklin County Court of Common Pleas, Ohio
There are approximately 1000 drug courts in the United States, and specialized court dockets have been used outside
of the U.S. Since their inception, there has been a dichotomy in the development of specialized court dockets
between substance abuse and mental illness, with many such courts including one diagnosis but excluding the other.
Substance abuse and mental illness co-occur more often than not, especially in the criminal justice setting. The
“TIES” or “Treatment is Essential to Success” Program is a pilot program of the Franklin County Court of Common
Pleas in Columbus, Ohio USA, that was developed to assess participants for co-occurring disorders from the outset
and connect them with appropriate and coordinated drug, alcohol and mental health treatment, along with
comprehensive community services to reduce the risk of relapse or non-compliance. It is a post-conviction program
that was developed within an existing court and probation program setting. This presentation will focus on a variety
of assessments used in the program; sharing of them between multiple treatment and service providers in an urban
setting of 1 million population; developing and implementing memoranda of understanding with multiple treatment
providers; imposing sanctions and awarding incentives for participants in the program; operation of the court and
treatment team, including staffing; strategies for managing participants’ appearances at court; and case flow
management and program integration within an existing court docket system.
Jennifer_Brunner@fccourts.org
brunnerforjudge@aol.com
The Adult Drug Court Model: The Effect of Structural Differences on Program Retention Rates
Natasha H. Williams, Morgan State University
Drug courts are a major innovation in penal responses to drug crime, and the first successful rehabilitation
movement since the mid-1970s. Drug courts are judicially supervised programs that place the drug-abusing
offender in an intensive community-based drug treatment program that not only provides treatment but other
rehabilitative services such as job training, parenting classes, and GED assistance. Upon program completion, the
court may dismiss the original charge, reduce the sentence, set aside the original sentence or offer a combination of
these remedies. The purpose of this study is to evaluate how structural differences among adult drug courts affect
program retention rates.
The sample was drawn from the Drug Courts 1999 Program Update Survey conducted by the U.S. Department of
Justice, Office of Justice Programs Drug Court Clearinghouse and Technical Assistance Project (DCCTAP). The
survey was mailed to 210 adult drug courts that were in operation as of December 31, 1999. The sample used for
data analysis consisted of 141 adult drug courts that had been in operation for at least twelve months. The data
analysis involved factor analysis and regression analysis.
Due to limitations of the drug courts’ various theoretical models and outcome measures, the research design was
unable to explain the interaction among the structural variables.
This research exposes inadequacies in current research and provides a basis upon which to develop more
pragmatically focused evaluation designs built upon theoretical models that better explain drug court functions as
well as generating a policy agenda that links research to policy development.
natwilliams@att.net
Behavior Modification in Drug Courts: A Normative Alternative to Therapeutic Understandings
Eric Miller, Western New England College
Social norms theory challenges the dominant justification of drug courts as a means of treating non-rational addicts
charged with drug offences. Drug courts utilize a form of behavior modification to keep the addict from reoffending. The court’s explicit goal is to reconfigure the addict’s internalization of acceptable norms of conduct; it
accomplishes this task by replacing the addictive community with the judge as an authoritative source of norms.
There are various points of overlap between social norms theory and the therapeutic paradigm underlying drug court
procedure. Drug courts are presented, often uncritically, as a form of “therapeutic,” “problem-solving” court. They
employ the medical model of addiction to treat rather than punish drug addicts. Judges are given tremendous license
to alter the offenders’ behavior patterns and value systems. Practitioners justify the judges’ tremendous discretion
over the administration of treatment regimes on the basis of this therapeutic goal. The expressed goal of drug courts
is to instil a sense of “self-esteem” in otherwise neglected individuals who have turned to drugs as a means of
solving their problems.
The drug court’s behavior-modification program implicitly depends upon a form of rational choice theory. Drug
courts often fail to target only those individuals with a physical or mental illness. The “malign” social norms that
drug courts do target — generally those approving of drug possession and use — are not associated with an illness
but often — through police practices — with communities identified by race, class, and geography. Policing
practices transform the theoretical norms emphasizing addiction and illness into executive norms emphasizing local
control of targeted urban communities. Without institutional checks on police and prosecutorial discretion, drug
courts risk justifying increasingly invasive and broad-sweeping police practices. The executive targeting possession
(rather than illness), and the relatively “soft” protections provided by pre-plea and pre-trial diversion, place
increasing numbers of offenders under the oversight of the criminal justice system. This counter-intuitive result
suggests that some re-evaluation of drug court process is urgently required.
emiller@law.wnec.edu
Long Term Outcome of Patients participating in Mental Health Court in Saint John New Brunswick
Canada
Vinod Joshi, Community Mental Health Services, Saint John, Canada
Increased criminalization of mentally ill has become a serious issue in most of the communities in the western
world.
Various studies have found 10 to 15% of Prison inmates have serious mental illness. Many jails are becoming
crowded with patients with serious mental illness with inadequate mental health care.
Mental Health Courts (MHC) are becoming increasingly popular as a way of addressing people with serious mental
illnesses. Mental Health Courts are attempting to divert people with serious mental illness from entering the
criminal justice system into a treatment program. This approach is based on Therapeutic Jurisprudence and Drug
Treatment Courts.
So far there are over 100 MHC operational mainly in the United States.
Even though all these courts are called Mental Health Courts there are a lot of differences among various Mental
Health Courts.
In Canada there are two such courts, one in Toronto and the other in Saint John, New Brunswick.
Mental Health Court in Saint John was established in November 2000 by Judge Alfred H. Brien. It operates on
every alternate Friday afternoon. So far almost 100 accused with serious mental illnesses have participated in
Mental Health Court. The Mental Health
Court team consists of Crown prosecuter, Defence counsil,Psychiatrist,Psychologist,Psychiatric nurse , Probation
officer and Member of community with Judge presiding. On an average participant is followed for 10 to 12 months
and make multiple apperances in court.
Despite growing popularity of Mental Health Court questions have remained if they are effective and if the benefits
continue in the long term.
We will present the results of an ongoing research that is being conducted in Saint John to provide some answers to
the question.
The presentation will compare data from two groups. First group is of those accused with serious mental illnesses
participating in Mental Health Court and the other group is accused with serious mental illness participating in
regular court. Mental Health Court group will have 25 participants and 21 in the Control Group.Both groups are
matched and participants agree by signing informed consent.
Data from both groups will be compared including demographic data, psychiatric data, psychiatric services
utilization data, criminal justice and emergency service utilization data.
Findings of this data will be presented and discussed.
Vinod.joshi@gnb.ca
Mental Health, Human Rights and Social Justice
Mental Health and Human Rights – A Social Justice Analysis
Kwame Akuffo, Thames Valley University
Professor Gostin has pointed out that “despite its rhetoric of ‘voluntarism’ and noncoercion, mental health policy
quintessentially involves the exercise of governmental power - the power to restrain, to treat, and deprive of basic
rights of citizenship.” This fact, along with the recognition that severe human rights violations adversely affect the
mental health of victims, means that mental health and human rights have a necessary and fundamental relationship.
This relationship is magnified by the fact that human rights, according to Douzinas, have triumphed on the world
stage as a new ideal, uniting even the most disparate groups. But, what does the subjugation of mental health law
regimes to this dominant phenomenon of human rights, in Western democratic states, for example mean and what is
its practical result? If the fabrication of mental health law in the new language of rights is adjudged to have largely
failed to secure the protection of the millions across the world who suffer mental ill health, then the high claims
made in the name of human rights require a serious questioning of the human rights concept itself. Meanwhile, in
many parts of the world, particularly in much of the developing world, discourse around mental health rarely
engages issues of human rights.
This paper offers a critique of human rights as they apply to mental health matters primarily in Europe and
North America and questions whether the dominant conception of human rights in the western world should provide
the model for the global evolution of mental health law. The paper will also seek to understand how the protection of
the human rights of people with mental illness in typical developing nations is conceived and implemented. The
paper will argue as its conclusion that dominant rights-based conception of human rights is too narrow and fails to
reflect social justice as the true test of the application of human rights
Kwame.Akuffo@tvu.ac.uk
Mental Health and Social Justice in Contemporary Britain
R. Balarajan, National Institute of Ethnic Studies in Health (NIESH), London, England
Mental Health presents one of the greatest disease burdens in modern Britain and consequentially a significant
challenge to the NHS. It is a domain where measures of outcome are not robust thus eluding the careful scrutiny of
the structures and processes involved. It is also a domain that is susceptible to human rights issues not only because
of the intrinsic nature of the underlying condition but also because of its presentation and the interpretation within
the social and legal framework of the country in question. This brings in the key question of diversity of the human
race - with people from different cultural roots, kinship patterns, perceptions of illness and related behaviours, and
such factors- into play with the professions and the medico-legal system of the country which in certain
circumstances arguably may not present the optimal setting for care and outcome. Further negative influences such
as discrimination and prejudice could very well come into play affecting pathways to care from recognition of ill
health to access to care to outcome. Mental health in the NHS of contemporary Britain thus would be taken as a
case study to explore the challenges faced by society in delivering equitable care and support for all its citizens.
profbalarajan@aol.com
The Psychiatrist as an Agent of Social Control or an Advocate of Social Justice? (In America, Three
Strikes and You're Out!)
Paul G. Organ, PsychiatryConfidential.com, Eureka, California
This presentation addresses the role of the psychiatrist as the primary medical-legal "gate-keeper" to the criminal
justice, mental health and substance abuse treatment systems in American society and culture.
Increasingly, the psychiatrist and his/her psychiatric evaluation and recommendations are the primary determinant of
how individuals in the society are admitted, treated or sentenced into one of the three systems of social justice/
social control. Individuals are diagnosed and categorized as "patients" to be treated within the mental health system,
"inmates" to be incarcerated in the criminal justice system or "addicts" to be rehabilitated in a drug abuse treatment
program.
Involvement in any of these systems creates permanent problems, limitations and obstacles for the individual and
their families that can have devastating and irreversible personal, financial, legal and social consequences. In many
cases, individuals are relegated to more than one of these systems and face a lifetime of exclusion, marginalization
and oppression.
In particular, the arbitrary and pernicious use of psychiatric evaluations and recommendations to remove members
of racial and ethnic minority groups from the society (especially the male population) and confine them for extended
periods of time, is being used to effectively neutralize large numbers of individuals and targeted populations.
In addition, the capricious and inappropriate use of psychotropic medications within the mental health, criminal
justice and drug abuse treatment systems represents an ongoing and ever-increasing threat to the integrity of
psychiatry as a healing profession. In many areas of American society and culture, psychiatry functions as a
mechanism and system for social control and injustice.
This presentation will address these and other issues pertaining to the current and future roles of psychiatry and
psychiatrists as agents of social control and injustice or as advocates for social justice and progress.
porganmd@aol.com
Mental Health: From a Medical to a Human Rights and Equitable Developmental Model
Zonke Majodina, South African Human Rights Commission, Johannesburg, South Africa
The paper advocates a paradigm shift in the approach to issues of people with mental health problems. By adopting
a human rights model, it envisions societies that encompass human diversity and the development of all human
potential. In this regard, the paper will make reference to the United Nations Standard Rules on the Equalisation of
Opportunities for People with Disabilities, as well as the political and moral foundations of the Rules as articulated
in the International Bill of Rights comprising the Universal Declaration of Human Rights and other international
human rights instruments. A full expose of the range of civil and political rights, as well as social and economic
rights and how they impact on the lives of people with mental health problems will be given. In all societies there
are still major obstacles preventing persons with mental health problems from exercising these rights and freedoms,
thus making it difficult for them to participate in the activities of their societies. It will be argued that States have a
responsibility to take appropriate action to remove such obstacles.
zmajodina@sahrc.org.za
What Universities are Doing to Accommodate Students With Disabilities
Donald Stone, University of Baltimore School of Law
American universities have the responsibility of providing reasonable accommodations in their educational
programs to physically and mentally disabled students. The Americans with Disabilities Act, a landmark civil rights
law, is designed to open up all aspects of American life to individuals with disabilities, including education.
Students with mental illness, drug addiction and alcoholism, learning disabilities, hearing and sight impairments, as
well as students who are wheelchair users are increasingly seeking admission and reasonable accommodations in the
educational program of universities. Examples of accommodations include testing adjustments, such as additional
time for completion of a final examination, separate and quiet test sites, modification in exam format and adaptive
equipment. Other accommodations include extending the exam period, waiver or substitution of course
requirements for graduation, extension of time for submission of written assignments, waiver or substitution of
class-work assignments, priority in course registration, authorization to tape lectures, modification of the add/drop
policy, auxiliary aids, taped texts, interpreters, readers and note takers, and modified class schedules. The law
mandates the provision of reasonable accommodations to disabled students to level the playing field to fairly
compete with non-disabled students but not to provide an unfair advantage. Discussions on establishing university
polices on addressing needs of disabled students will be highlighted. Implications for the employment arena are also
discussed. Focus on law students for illustrative purposed. School Discipline and Suspension, Safety Issues, and
Confidentiality in Student Records will also be explored.
DSTONE@UBALT.EDU
Dignity Theory and Mental Health Policy
Clarity or Confusion: The Use of Human Dignity as a Justification for Science Policy
Timothy Caulfield, University of Alberta
The concept of human dignity is often used as a justification for science and research policy. Indeed, recent
examples of the use of dignity in science policy abound. UNESCO’s Universal Declaration on the Human Genome
and Human Rights recommends a ban on “practices which are contrary to human dignity, such as reproductive
cloning” (1997). A 2003 WHO Report suggests that genetic databases create the need to balance “human dignity
and human rights as against public health, scientific progress and commercial interests in a free market.” Recent
Canadian legislation covering research involving human reproductive material, states that one of the primary
objectives of the regulatory regime is to protect the dignity of Canadians (Assisted Human Reproduction Act, 2004).
And, of course, the concept of human dignity permeates research ethics policy (Helsinki, etc). Canada’s primary
research ethics document declares that the “cardinal principle of modern research ethics ... is respect for human
dignity” (TCPS, 2003).
In many of these policies, the concept of human dignity is often used in the conventional legal and ethical manner,
as a means of empowerment that emphasises the rights of individuals (often with an emphasis on the right to make
autonomous choices). This is most apparent in the context of research ethics documents and informed consent
policies. Some scholars have gone so far as to suggest that this is the only appropriate normative use of dignity
(Macklin, 2003).
However, despite such claims, dignity is increasingly used in the realm of science policy as a justification for the
regulation of research by suggesting that some activities, such as human cloning and the commodification of human
tissue, are against or degrade some basic understanding of dignity (Beyleveld and Brownsword, 2001). The
UNESCO statement about human cloning stands as a good example of such a use. Likewise, in the area of stem cell
research, dignity is used as a rationale for limiting research on human embryos. When used in this manner, dignity
is meant to reflect a broader social or moral position about the unacceptability of a given scientific activity or
technological innovation. It is not used as a source of individual rights, but as a rationale for a constraining policy
response. Unfortunately, most policy documents and legal instruments rarely provide an explicit definition of
dignity or explain how human worth might be degraded by a given technology or scientific activity (Macklin, 2003).
“[Dignity’s] intrinsic meaning has been left to intuitive understanding, conditional, in large measure, by cultural
factors” (Schachter, 1983, 849).
In this presentation, I will argue that this vague use of the concept of human dignity creates a number of policy
dilemmas, including: obscuring the true social concerns motivating policy development and creating the impression
of social consensus when, in fact, no consensus exists. Further, I will suggest that in pluralistic liberal democracies,
it will often be difficult to use human dignity as a primary justification for a constraining regulatory policy
(Brownsword, 2003). I will end by making recommendations about the constructive use of the concept of human
dignity. For example, when infringements of human dignity are raised as arguments against a particular scientific
activity, it should cause us to question how, for this individual or community, human worth is degraded. It should be
viewed as an opportunity to debate the values at play and the cultural underpinnings of the concern. We should then
ask how the concern can be met and how it and any suggested regulatory responses relate to or conflicts with other
social norms.
tcaulfld@law.ualberta.ca
Human Dignity and Science Policy: The United Nations Cloning Convention Experience
Rosario M. Isasi, Université de Montréal
In 2001, following appeals calling for an international convention banning human reproductive cloning, the
governments of France and Germany launched a joint initiative in the United Nations to draw up an International
Convention against the Reproductive Cloning of Human Beings.
The General Assembly’s Sixth Committee—the legal committee— unanimously approved the proposal and added
its support to a ban on human reproductive cloning. In December 2001, by Resolution A/RES/56/93 the UN
General Assembly approved by consensus the establishment of an Ad Hoc Committee to consider the language of an
International Convention against the Reproductive Cloning of Human Beings.
Soon after the negotiation process began, two competing proposals were developed. The French and German
proposal (an international ban on reproductive cloning) faced a proposal sponsored by the United States, Spain and
the Philippines, which called for a ban on both reproductive and research cloning in a single treaty. Today, this sharp
division remains among two factions. In 2003, the governments of Costa Rica and the United States headed a
forty-nation block that derailed efforts to reduce the human cloning ban to cover only reproductive cloning.
Both proposals aimed at enshrining the principles asserted by the Universal Declaration on the Human Genome and
Human Rights (adopted by UNESCO and endorsed by the United Nations General Assembly in 1997), with
particular reference to article 11 of the Declaration which sanctions, as a practice contrary to human dignity, the
reproductive cloning of human beings; and invited States and international organizations to cooperate in taking, at
the national or international level, measures necessary to prevent it. Both proposals were “determine(d) to prevent,
as a matter of urgency, such an attack on the human dignity of the individual”.
Those factions appeal to the notion of ‘human dignity’ as the foundation of their position in favor of prohibiting
human cloning (whether for reproductive and/or therapeutic purposes), yet an analysis shows us a distinct, and
sometimes even conflicting, use of the notion of human dignity, understood either as ‘empowerment’ and/or as
‘constraint’.
The failure of the United Nations to act on its consensus against human reproductive cloning is principally due to
competing agendas on other related issues (politics regarding the moral status of the human embryo, abortion etc).
Nevertheless, it is necessary to pose the question of whether the stalemate at the UN could also be explained in
terms of opposing conceptual understandings regarding the notion of human dignity.
rosario.isasi@umontreal.ca
Why should we care about an ethic of care?
Kirsty Keywood, University of Manchester
The ethic of care has received scant attention in mainstream analyses of psychiatric ethics. In the academic
literature it is frequently represented as normatively flimsy and methodologically flawed. At best, it attracts
attention as an ‘also ran’ principle, which simply does not compete with the predominant ethical principles that
underpin and shape our understanding of psychiatry. Yet the ethic of care has been taken up by a host of disciplines
beyond the health domain, ranging from cultural anthropology to architecture and planning. In this paper, I seek to
re-examine the ethic of care and reassess its utility in psychiatric ethics and law by focusing on recent law reform
initiatives in England and Wales. The law relating to decision-making by, with and for people with mental
disabilities is to undergo considerable change in the light of the Mental Capacity Act 2005 and the anticipated
mental health law reforms outlined in the draft Mental Health Bill. I examine whether the ethic of care can provide
a credible foundation for the systems and models of decision making that are anticipated by these legal measures.
Kirsty.Keywood@manchester.ac.uk
Defining a Regulatory Role for Human Dignity in International Bio-law
Daryl Pullman, Memorial University
Although the concept of human dignity has served a general foundational role in international law dating back to the
Universal Declaration of Human Rights (1948), the particular role of that concept with regard to specific
international science policy has been given a higher profile in recent years. In the wake of rapid advances in the area
of human genetics and genomics in the past decade, appeals to human dignity have been invoked in various quarters
to justify specific conservative policies. Hence the Universal Declaration of the Human Genome and Human Rights
(1997) describes reproductive cloning as a practice contrary to human dignity. In a similar vein the title of the recent
U.S. Report of the President’s Council on Bioethics, Human Cloning and Human Dignity (2002) implies that the
issue of human cloning is fundamentally about human dignity.
As the concept of human dignity has evolved from something of a platitude to take on a more focused normative
force, numerous commentators have expressed concerns about the inherent ambiguity of the notion. Some have
complained that appeals to human dignity are something of a subterfuge employed to divert attention away from
more socially charged and politically motivated rationales for opposing a particular policy or practice (Caulfield,
2003). Others have simply suggested that the term is redundant and serves no useful function in contemporary moral
debate (Macklin, 2003).
While it is admitted that the concept of human dignity admits of a variety of interpretations, the purpose of this
presentation is to outline an appropriate role for human dignity to play with regard to international science policy
and biolaw. Far from being a political diversion or otherwise redundant and unnecessary, it is argued that the
concept of human dignity is absolutely essential to moral discourse in general and that it should play a central role in
framing the development of international biolaw in particular. Although this discussion does not arrive at explicit
policy recommendations regarding appropriate regulations for human cloning, research using embryonic stem cells,
the development of chimeras, or a plethora of other contemporary bioethical issues, it will demonstrate how a proper
understanding of the notion of human dignity can inform the larger policy debate concerning such issues.
dpullman@mun.ca
Occam’s Razor -- facing the legal and ethical issues of cloning in the 21st century
Robin Woellner, James Cook University
Julie Zetler, Macquarie University
Medical science has made amazing advances in cloning techniques over recent times, and clearly, there are great
benefits for humanity in the use of stem cells for medical research which creates the prospect of using cloned
materials to eliminate diseases such as TB, HIV, and even cancer.
There is however, another side to cloning research, reflected in the (perhaps dubious) claims in 2003 that human
clones had been successfully born. Whether or not this is true, it seem clear that we have – or soon will have - the
scientific ability to clone human beings. Inevitably, techniques will be refined, and over time science will be able to
create clones scientifically indistinguishable from the “original”. In this context, we will face questions such as
whether we should permit medical cloning to replace children and others killed by accidents or disease, and how to
deal with the use of cloning for genetic selection and manipulation.
Even if we can resolve these ethical issues, will our legal systems be able to cope adequately with scientists wanting
to clone human beings for either curiosity, or commercial purposes, and grieving (wealthy) parents who will spare
no expense to “recreate” a lost child? What will the legal status and rights of an “identical” clone be when the
original dies or becomes mentally ill? Will a clone (or disappointed parents) be able to sue for defects or deformities
caused by a bungled cloning process?
Will our ethical and legal rules and processes be able to adapt quickly enough to deal with emerging issues?
Equally important, does our experience with social problems such as illicit drugs suggest pragmatically that even if
we get the theory right, we may be unable to effectively enforce laws regulating cloning techniques?
robinhw@hotmail.com
The role of the consumer voice in mental health policy reform
Julie Mulvany, Swinburne University of Technology, Victoria, Australia
The rhetoric of consumer and carer participation in the development of mental health policy, including the planning
and the delivery of services, has strengthened during the last few decades. This rhetoric appears to be based on
monolithic conceptualizations of the concept of ‘consumer’, which assume the existence of a clearly identifiable
consumer voice. This paper examines the discourse surrounding consumer participation in policy development and
implementation as portrayed in recent national policy documents in Australia. It also examines the portrayal of the
needs of people with psychiatric disabilities within these documents. The paper further identifies a diverse range of
consumer discourses emerging in the twenty first century. These discourses are found in recent policy reports
published by consumer and carer groups, as well in more general consumer literature. The use, within these
discourses, of concepts such as normality, mental illness, treatment, community care, disability, impairment and
stigma is analysed. The paper concludes with an assessment of the relevance of existing mental health policy and
legislation to the needs of people with psychiatric disabilities, in light of these discourses. The implications of the
consumer voice or voices for future mental health policy and legislative development are explored.
jmulvany@swin.edu.au
Mental Healthcare Financing in the USA
Historical and Philosophical Context of Mental Healthcare Financing in the USA
Wynne Korr, University of Illinois at Urbana-Champaign
John Encandela, ORC Macro, Atlanta, USA
Determination of whether or not people with serious or severe mental illness (SMI) receive comprehensive,
uninterrupted mental health treatment is, in large part, determined in the U.S. by systems of financing. Making
decisions on the types and extent of care and treatment that people receive may be both a benefit and hindrance. For
example, a focus on financial mechanisms may be “prudent” and, therefore, advantageous in that it may assure that
adequate funding is available for the types of services promised. On the other hand, this focus may introduce
problems if the economic interests of groups with power take precedence over the needs of people with SMI.
This paper provides an historical and philosophical overview of systems of financing mental health care in the U.S.
since the early 1900s through the current time. We explore the relationship between philosophies of caring, legal
policy, and systems of financing, and raise the question of if and how the balance in this relationship has shifted
over the last century. This question lays the groundwork for the remaining papers in this panel and provides the
context for discussion at the end of the panel.
wkorr@uiuc.edu
John.A.Encandela@orcmacro.com
Financing Mental Health Services for Children with Serious Emotional Disturbance
Robert Stephens, ORC Macro, Atlanta, USA
Anna Kriveloya, ORC Macro, Atlanta, USA
In 2003, the Report of the President’s New Freedom Commission on Mental Health explicated the need for a
fundamental transformation of the fragmented, disconnected children’s mental health service delivery system in
America to achieve the promise of community living and continuous access to needed services. For this
transformation to be realized, the system will be required to provide a coordinated array of services designed to
address the specific needs of each child and family served--placing an emphasis on the strengths of the child and
family in developing an individualized service plan. Families will need to partner with providers, playing an
increasing role managing their children’s services, treatments, and supports. Policy and funding decisions, which
affect the functioning of systems of care, need to be driven by the needs and preferences of families and their
children, and systems of care must elicit the help of families in defining and running these systems.
A database exists with information that should aid policy makers and community planners in improving the
functioning of systems of care. This paper focuses on services and cost data from the national evaluation of the
Comprehensive Community Mental Health Services for Children and Their Families Program sponsored by the
Center for Mental Health Services in the Substance Abuse and Mental Health Services Administration. The
program provides grants to states, communities, territories, and American Indian tribes to improve and expand their
systems of care to meet the needs of children and adolescents with serious emotional disturbance and their families.
The grant communities are required to develop comprehensive community-based services that include diagnosis and
evaluation, case management, outpatient services, intensive day treatment, respite care, therapeutic foster care,
transition and family support services. To ensure program sustainability, the amount of matching non-federal funds
must increase over the course of the grant. Data from the national evaluation will be used to address the following
questions: What are the various funding sources communities use to implement the program’s innovative service
array? To what extent does service utilization vary among children and across communities? And what are the costs
associated with the implementation of a system of care? Results will be employed to develop recommendations for
policy makers and community planners to improve the functioning of systems of care.
Robert.L.Stephens@atlanta.orcmacro.com
Anna.Krivelyova@atlanta.orcmacro.com
Medicaid, Mental Health Service Delivery, and Managed Care
Robert Rich, University of Illinois at Urbana-Champaign
This paper/presentation focuses on the financing of mental health services and policy at the state level in the United
States. It focuses particularly on Medicaid as a program and its limitations. In this context, the analysis includes the
use of mental health carve outs in managed care settings. The Managed Care Organization is particularly important
because of its dominance in health and mental health service delivery.
In addition, the paper examines the use of Medicaid financing to support mental health service delivery in the
following settings: traditional in-patient settings, general hospital settings, community based settings, and
jails/prisons. The presentation addresses the question, “How has Medicaid policy changed over time in response to
financial constraints and the realities of managed care plans?”
Finally, the paper examines the impact of mental health parity laws on the financing of mental health services—both
the federal statute and the different state statutes.
rrich@law.uiuc.edu
Strategies for Ensuring Continuity of Care for Persons in IMDs and Correctional Facilities
John Encandela, ORC Macro, Atlanta, USA
U.S. Medicaid regulations stipulate that Medicaid funds cannot be used by states to cover the costs of (1) inpatient
mental health services to adults residing in Institutions for Mental Disease (IMD), or, (2) mental health services for
inmates in correctional facilities. The rationale is that these services are the responsibility of states rather than the
federal government. Critics have claimed that the Medicaid exclusion has compromised the ability of states to
provide integrated systems and continuity of care for individuals with severe mental illness (ISMI), has isolated
ISMI from other Medicaid-eligible populations, and relegates these individuals to “second-rate,” lower-cost care and
severe lapses in care and treatment. Critics have added that this is a recipe for interruption of pharmacological
treatment, increase in relapse, and re-hospitalization. Others have shown that Medicaid has funded an increasing
share of the operations of public psychiatric hospitals, but the real problem is states’ misunderstanding or lack of
knowledge about how they may best access and use such Medicaid support.
Strategies to address the above problems have been implemented. For instance, some states have begun to see the
importance of assisting IMD inpatients and correctional facility inmates to obtain Supplemental Security Income
benefits before they leave their respective institutions, and some IMDs and correctional institutions are beginning to
give higher priority to re-establishing Medicaid eligibility of individuals before they leave the facility. A few states
have begun to offer incentives to increase the number of people screened for Medicaid eligibility and reinstatement
when they are being discharged from IMDs and correctional facilities into the community. This paper provides a
review of states’ experiences in developing strategies and incentives to address the service gaps faced by patients
and inmates when they enter then are discharged from IMDs and correctional facilities.
John.A.Encandela@orcmacro.com
Implementing Evidence-Based Practice: Legal and Economic Considerations
Kraig Knudsen, George Warren Brown School of Social Work
Legal precedent and healthcare financing in the United States has influenced the implementation and dissemination
of evidence-based practices for persons with severe mental illness (SMI). Although there are a number of evidencebased practices available for use, they have been disseminated slowly across the United States due to restrictive laws
and financing. This presenter will report several findings from a study investigating factors that influenced two
states in their decisions to adopt and disseminate one such evidence-based practice, Assertive Community Treatment
(ACT).
Using a multiple case study design, the study examined two state mental health systems, one a high adopter of ACT
and one a low adopter. Over a period of eight months interviews were conducted with 22 stakeholders (e.g., state
administrators, family and consumer advocates, and academicians) in the two states. Using semi-structured
interviews participants were asked to explore their experiences in disseminating ACT. The presenter will report
findings that suggest that differing legal precedent and financing of mental health care in these two states directly
contributed to the decision to adopt and disseminate ACT. Specifically, the presenter will discuss how differences
between the two state’s regulatory systems were related to the adaptation of state Medicaid policy to include ACT as
a reimbursable service and the use of managed care principles to encourage the use of community treatment
alternatives over hospital care. In addition, the presenter will discuss why the high adopter state perceived ACT as a
cost-effective way to reduce state mental health expenditures, while the low adopter state found ACT to be cost
prohibitive.
kknudsen@gwbmail.wustl.edu
Corrections and Mental Health I
Treatment of Mentally Disordered Youth Offenders in Germany
Frank Haessler, University of Rostock
Mental retardation as it is described in ICD-10 and DSM IV is not a psychiatric illness, despite being part of the
psychiatric classification system. The quoted prevalence of psychiatric illness among adults with intellectual
disability varies widely between 10 and 60%. For example disruptive behaviour as well as self-injurious behaviour
occurs in 12 to 36 % of individuals with mental retardation who reside in institutional settings.
Impulsivity constitutes also a core symptom of attention deficit hyperactivity disorder reaching into adulthood.
Aside of this, a lot of other psychiatric disorders contain symptoms of impulsivity and disruptive behaviour. Besides,
lack of impulse control is also prevalent among sexual offenders, arsonists and young murderers. Given the
aggravating laws for criminal prosecution of violent and sexual offenders, questions of effective therapies using
psychopharmacological drugs are becoming more salient as such offenders are taken into custody more often and for
longer times.
Our presentation explores opportunities of treating disruptive behaviour with psychopharmacological drugs in
offenders taken into custody. There is some evidence that the conventional antipsychotic zuclopenthixol has a
positive effect on destructive behaviour. A few studies have described the successful use of the atypical
antipsychotic risperidone to control severe self-injurious behaviour and other behaviour problems in a variety of
diagnoses. Also anticonvulsants, antidepressants and anxiolytic medications may find an important place in the
treatment of some individuals with disruptive behaviour. Furthermore stimulants in monotherapy or in combination
with atypical neuroleptics are also effective for aggression related behaviour. Taking the example of the Rostock
youth forensic clinic our paper discusses various psychopharmacological therapies and lists different options of
psychopharmacological therapy for sexual offenders, too.
The principles of treatment in people with mental retardation are the same as for persons without mental retardation,
but modification of techniques may be necessary according to the individual patient’s developmental level, and
especially communication skills. Psychopharmacological, psychotherapeutic and educational interventions should be
coordinated within an overall treatment.
frank.haessler@med.uni-rostock.de
Prison Psychoses
Norbert Konrad, Free University of Berlin
With reference to mental illnesses with psychotic symptoms, a substantial proportion of German psychiatrists
maintain the distinction which originated in the last century between “true psychoses” and “prison psychoses”. The
disorders regarded as “true psychoses” generally fit into the category of schizophrenic illnesses, with
psychopathology which may be coloured by prison conditions in aspects such as the contents of delusions, whereas
“prison psychoses” are specific reactions to imprisonment. “Prison psychoses” have not entered international
classification systems (ICD 10, DSM IV) as a distinct clinical entity. Attempts to differentiate them diagnostically
from the early manifestations of “true” psychoses, especially schizophrenic illnesses for which imprisonment has to
varying degrees been identified as an important trigger, make reference to the narrowness of the scope of paranoid
beliefs in prison psychoses, with a tendency for delusions to be limited to the immediate environment but not to
relate directly to fellow prisoners (Nitsche and Wilmanns 1911). Another differentiating factor which has been
identified as crucial is the termination of prison psychotic phenomena with the interruption or ending of
imprisonment, even though there may be “remnants” in the form of “now affect-free remains of delusions ” or
querulant or hypochondriac character traits (Birnbaum 1931). The research project deals with the question whether
"prison psychoses" can be differentiated from schizophrenic disorders in prisoners and what special features are
demonstrated by prisoners with the diagnostic label prison psychosis with regard to sociodemographic, clinicalpsychopathological and forensic factors.
norbert.konrad@medizin.fu-berlin.de
Patient Safety in Secure Settings: The Critical Relationship Between the Perceptions of Forensic
Patients Regarding their Personal Safety and the Likelihood of Successful Treatment and
Rehabilitation Outcomes.
Shirley Pullan, Centre for Addiction & Mental Health, Toronto, Canada
This paper will address a critical factor in the successful treatment and rehabilitation of patients in medium secure
forensic settings. The degree to which forensic patients feel safe in their environment has a significant impact on
their willingness to participate in clinical programs, their therapeutic relationships with staff, the extent of
interactions with co-patients/interdisciplinary team members and their overall level of trust of the detaining facility.
Patients experiencing fear or uncertainty in a secure setting as a result of perceived/actual threats of harm from copatients may become withdrawn, isolated, reluctant to participate in clinical programs, and limited in their
interactions with both staff and co-patients. These coping strategies from the patient who is feeling unsafe present
challenges for the interdisciplinary team that impede the ability to assess mental status and level of risk. Suboptimal interactions with the patient, the patient’s absence from clinical/recreational/vocational programs and the
impaired ability to evaluate the patient’s relationships with co-patients may result in suspending decisions relative to
the granting of off-unit privileges, access to approved persons and considerations of increased freedom due to the
lack of current clinical and risk information. In this paper, the author will describe an evaluation system developed
to obtain feedback from patients in a medium secure setting regarding their personal perceptions of “how safe do
you feel” within their environment. This system addresses a range of dimensions relative to safety /security and
includes 1:1 sessions with patients, focus groups and a written survey. The purpose of the system is to elicit
information from patients that will assist in identifying possible offenders, ensure that all patients feel safe, provide a
venue for evaluating the unit’s milieu and protocols and to reinforce the procedures for reporting situations that are
unsafe or threatening.
Shirley_pullan@camh.net
Psychotherapy within the Prison System and the Role of Professional Secrecy
Vera Schneider, Institute for Forensic Psychiatry, Berlin, Germany
Treating prisoners in the German prison system, especially in so-called "social-therapeutic facilities", is carried out
in an institutionalized form. The aim of therapy is to resocialize the prisoner. In these institutions, treating sexual
offenders- with the corresponding indication – is mandatory but therapy is voluntary for all other offender groups.
In addition to social-therapeutic facilities, treatment can be obtained externally, from psychologists and the
corresponding projects in prison as well as in psychiatric departments in prison hospitals. However, therapeutic
capacities are estimated to be generally insufficient.
An alternative treatment institution has existed for about 20 years at the JVA (Correctional Facility) of Tegel prison
in Berlin, the largest in Germany. Three certified psychologists offer outpatient psychotherapy and counseling on a
voluntary basis there. An important feature of the institution is the guarantee of professional secrecy. Therapy
focuses on working out personal problems. Resocialization is another, but not primary, goal of treatment. Using a
quasi-experimental design, the treatment effects of this institution were evaluated for the first time after 13 years
based on the probation of former clients. We also examined the differential treatment effects in a control group
from the regular prison population and in two groups of former clients from the social-therapeutic facilities. The
following brief discourse discusses the findings of this study.
vera.schneider@charite.de
Inmates’ Reactions to Telepsychiatry Consultations : Legal Implications
William Tucker, Columbia College of Physicians & Surgeons
In 2001 the New York State Psychiatric Institute and Columbia College of Physicians & Surgeons began providing
consultations to mentally ill inmates of the state’s 12 maximum-security prisons.
Using high-bandwidth
videoconferencing equipment, Columbia faculty responded to requests from prison mental health staff regarding
particular clinical challenges. Consultations were real-time and interactive, including both case-presentation and
inmate interview. Inmates themselves appeared to respond so favorably to this medium that a follow-up research
study was undertaken, to assess which mental health services they preferred to have delivered in this way, rather
than by their on-site mental health team. Preliminary results of this study will be presented, along with a discussion
of the legal implications of this consultation service. Brief videotaped segments of selected consultations will be
included.
tuckerb@pi.cpmc.columbia.edu
International Standards and the Treatment of Mentally Disordered Offenders
Rosemary Wool, Directorate of Legal Affairs, Council of Europe
The mandate governing the treatment of prisoners, including their physical and mental health care, is included
within the substance of the UN Covenant on Economic, Social and Cultural Rights (Article 12), and the UN
Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (Article 16). Further,
the concern of the United Nations for the welfare of prisoners was manifest from its inception when the First UN
Congress in 1955 adopted the Standard Minimum Rules for the Treatment of Prisoners. These rules have stood the
test of time, and specifically comment on the treatment of ‘insane and mentally abnormal’ prisoners. Sadly, fifty
years later, there are numerous examples worldwide where the standards of mental health care fall well below these
recommendations, and indeed, in some instances, do not conform even to the UN conventions.
The paper will explore where deficiencies are found with examples given from personal knowledge of European
countries.
rjwool@wicken.nildram.co.uk
Conceptualizing Nursing Research with Offenders: Another Look at Vulnerability
Cindy Peternelj-Taylor, University of Saskatchewan
Nurses have historically “ministered” to vulnerable populations (Drake, 1998). Yet, prior to the late 1960s, very few
nurses gave much thought to working with offenders in correctional environments. Since then, nurses have slowly
and methodically, embraced a multitude of professional roles in their quest to provide offenders with quality nursing
care. And although correctional nursing has undergone significant transformations in role development in recent
years, correctional environments have attracted very few nurse researchers, even though a gold mine of
opportunities exists for nurses to make a significant contribution to the health care of the offender
Embracing a research agenda that focuses on offenders as a vulnerable population is fraught with ambiguities not
generally encountered in other settings. The dilemmas surrounding research with offenders as a vulnerable
population reflect a contemporary research problem that requires further exploration within nursing and the health
care community at large. Through this presentation, participants will: 1) differentiate vulnerability in general from
vulnerability that refers specifically to the protection of special populations; 2) discuss existing safeguards that are in
place to guide nursing research with vulnerable populations; and 3) review the idiosyncratic dilemmas encountered
when conducting research with offenders in correctional environments. Ultimately, it is hoped that nurses will
develop innovation and creativity in the conduct of ethical research with offenders. In doing so, nursing science will
be informed.
peternel@duke.usask.ca
Gender and Mental Health I
Normalizing Exclusions: Black Mothers as Inadequate Mothers
Anne Phoenix, Open University
Increasingly literature on parenting acknowledges that there has been an over emphasis on mothers as the people
who should be responsible for their children and that black and other minority ethnic mothers often 'fail' to meet
standards established as ideal on white American or European mothers. Despite concerns that inadequate parenting
(particularly mothering) is responsible for poor outcomes in black and Asian children, relatively little is known
about parenting and ethnicity. At a time when the demography of many countries is becoming increasingly
ethnically diverse, there is a need for research to clarify the relationship of ethnicity to parenting. Some recent
attempts to make allowances for cultural difference have led to tolerance of genuinely poor parenting as in some
celebrated cases of child abuse where social workers considered that harsh discipline was culturally appropriate.
This paper explores the ways in which psychological knowledge on mothers in general and about black mothers in
particular has exclusionary consequences. It uses a mixture of literature review and empirical data to argue that
much of the literature on motherhood continues a ‘normalized absence/pathologised presence’ focus where black
mothers are omitted in studies of ‘normal mothering’ but included when problematic mothering is the focus. One
result of this is that black mothers are often unfavourably compared to white mothers and constructed as inadequate.
From their own accounts, however, black mothers do not consider themselves to be providing poor mothering, even
though they sometimes view other black mothers as problematic. Furthermore, constructions of black mothers as
inadequate mothers frequently fail to analyse well the contexts within which mothers live and so lack ecological
validity.
a.a.phoenix@open.ac.uk
Munchausen Syndrome by Proxy: Contestable and Contested Assumptions
Fiona Raitt, University of Dundee
Munchausen Syndrome by Proxy is a psychiatric construct “discovered” in 1977. It refers to a psychiatric condition,
whereby a parent figure, almost invariably mothers, is motivated to cause deliberate harm to their child as a means
of gaining attention from others. The present paper seeks to unveil the assumptions about mothering that underlie
this association and the role that expert witnesses play in the courtroom in reinforcing those assumptions. In
common law jurisdictions many prosecutions for alleged maltreatment of children have been successful on the basis
of expert testimony offered in regard to the syndrome. In the UK a diagnosis of Munchausen Syndrome by Proxy
will often result in the public authorities seeking an order from the civil courts to remove any children from the care
of the mother. Such prosecutions and civil proceedings will be underpinned by many of the same cultural
assumptions concerning motherhood that underlie the construction of the syndrome itself, including innateness of
the maternal instinct and expectations about mothering capabilities. The paper explores the emergence of this
syndrome in law through the testimony of experts in the courtroom, and will illuminate the contestable assumptions
upon which the syndrome and its application in law are founded.
f.e.raitt@dundee.ac.uk
The Deployment of Motherhood in Psychiatric Treatment
Ralph Sandland, University of Nottingham
In this paper I shall argue that despite many apparent advances in the treatment of mental illness in women, it
continues too often to be the case that particularised notions of motherhood are operationalised by psychiatric
professionals and institutions in the treatment of female patients. The paper will suggest that there is, at least, a need
for greater awareness on the part of treatment providers of the gendered assumptions which underpin their
interventions.
ralph.sandland@nottingham.ac.uk
Why Should There be a Disproportionate Number of Black Women Having Abortions in the UK?
Salma Siddique, Napier University, Edinburgh, Scotland
The 1967 Abortion Act made abortion legal in the UK. However, as in many other countries, abortion remains a
controversial issue. This is demonstrated in the limited set of grounds that the Act allows a termination to be based
upon (i.e., injury to the mental or physical health of the woman, risk of the child suffering from physical or mental
abnormalities, and a pregnancy of less than 24 weeks), as well as in media coverage of recent abortion cases (e.g.,
termination of a foetus with a cleft palate; termination of a ‘normal sized’ foetus carried by a female dwarf). The
present paper examines an issue that has received relatively little attention in the literature or the wider culture: why
are a disproportionate number of abortions performed on ethnic minority women? Statistics obtained from health
authorities in England and Wales show that black women are seven times more likely than white women to have an
abortion. While Black Caribbean and African communities make up only 2% of the UK population, 14% of
abortions are performed on women from these groups. The present paper examines reasons for this inequity.
s.siddique@napier.ac.uk
The Role of Psychological Research Methods in Constructing Good and Bad Mothers
Suzanne Zeedyk, University of Dundee
Developmental psychology has long been concerned with the ways in which parenting, and particularly mothering,
practices impact on children’s emotional and cognitive development. One consequence of this focus is that mothers
are often judged, on the basis of those practices, to be either ‘good’ or ‘bad’. This paper explores the way in which
contemporary developmental research methodologies explicitly reflect and reinforce such judgements.
Observational video methods are now commonplace in infancy research, with experimenters coding and classifying
maternal behaviours through the application of labels such as ‘appropriate/inappropriate’, ‘sensitive/insensitive’, and
‘accurate/inaccurate’. Such classifications overlap with societal views about what constitutes good and bad
mothering, yet developmental researchers often seem unaware of (or unconcerned with) that correspondence,
because the labels derive ostensibly from theoretical frameworks accounting for children’s development. The paper
argues that coding behaviours in this associative fashion makes it impossible to disentangle the observed phenomena
from the range of interpretations that can be placed upon it. Such conflation yields misleading conclusions about the
nature of parenting, and it obscures the role that science continues to play in constructing motherhood.
m.s.zeedyk@dundee.ac.uk
Gender Issues in Medicine: The Role of a Psychiatrist
Carol C. Nadelson, Brigham and Women’s Hospital, Brigham, USA
This paper will discuss the roles and career advancement of women in academic medicine, including the differences
in the career trajectories of men and women, the disproportionate paucity of women at higher academic ranks, and
the challenges women face when seeking leadership positions. The paper will review issues of overt and covert
discrimination, intellectual and sexual harassment, differences in leadership styles and personality, as well as some
of the psychological factors that impede women’s progress in their chosen specialties. The facilitation of academic
advancement, especially the recruitment and retention of women, is the mandate for the Director of the Partners
Office for Women’s Careers at Brigham and Women’s Hospital in Boston, Massachusetts, a major Harvard teaching
hospital. This unique office works to identify ways to assist in the academic and administrative promotion of
women. In addition to women faculty, the constituencies include supervisors, department chairs, hospital
administration, and Harvard Medical School. Regular one-on-one meetings with the Hospital President, Chief
Medical Officer, Department Chiefs and Chairs offer an ongoing dialogue in which we jointly monitor women’s
career advancement and address challenges in incipient stages, often preventing loss of valuable faculty. Hospital
leaders encourage women to meet with the Director and women faculty refer each other or come on their own. The
office provides a major mentorship function. Working with both junior and senior women faculty, the office also
performs an ombuds role. The ongoing relationship with the hospital administration informs policy and influences
choice and direction of leadership. The office also works with hospital legal counsel on a variety of issues including
discrimination harassment, salary inequalities, intellectual property, disputes and unequal treatment. These are
among the issues that are the source of legal compliant and action. As a psychiatrist, there is an added dimension
brought to the role of Director. The professional experience, training and knowledge of a psychiatrist is valued,
especially in the recognition and approach to dysfunctional situations involving individuals and hospital
departments. Data will be presented on the promotion and advancement of women, as well as examples of effective
collaborations, communications, and interventions designed to facilitate progress.
carol_Nadelson@hms.harvard.edu
Gender and Mental Health II
Arrest Patterns of Women during Perinatal & Non-Perinatal Periods
Katherine Maeve, Private Practice, North Augusta, USA
Women's unique (and normal) brain and hormonal chemistry result in a vulnerability to mood disorders at critical
times in their lives, including the times when women give birth. There are many types of perinatal mood disorders
such as prenatal depression, and numerous postpartum disorders, including simple "baby blues," postpartum
depression (PPD), postpartum obsessive compulsive disorder, postpartum onset panic disorder, and postpartum
psychosis. There is a growing awareness that the risk factors for any perinatal mood disorder, and predictors of PPD
specifically, are overwhelmingly present among the aggregate of women (> 3 million) who go in and out of the U.S.
criminal justice system each year.
The purpose of this study was to examine women's arrest records before a perinatal period, and during a perinatal
period. The sample consisted of women (n=3454) who gave birth in a time frame that would allow access to arrest
records in the 21 months period immediately preceding conception, and for 21 months immediately following the
conception (9 months prenatal, 12 months postnatal). Only women who had been arrested at least one time during
this 42 month period were included in the study. Of the women in the sample, 37% only had arrests during the postconception period. Of the 37% (n=1865), women were twice as likely to be arrested during the postpartum period
than the antepartum period.
The physical limitations of pregnancy and birth, and caring for a new baby would seem to diminish women's ability
to engage in criminal activities and behaviors. The results of this study suggest, however, that women are more
likely to be arrested during their perinatal period. Further research with individual women is proposed as a way to
contemporaneously screen women involved with the criminal justice system for perinatal mood disorders and
connect findings with arrest events. Implications for prevention, early identification and early intervention are
discussed.
kmaeve@comcast.net
Battered Women, Equality and Feminist Lawmaking
Elizabeth Schneider, Brooklyn Law School
This presentation will examine the last thirty years of developments in the law of domestic violence in the United
States, focusing on law and mental health issues, based on my book Battered Women and Feminist Lawmaking
(Yale University Press 2000) and many articles that I have written. It will explore tensions in characterizations of
battered women’s experiences in law and mental health as reflecting themes of both battered women’s agency and
their victimization, and explain why issues involving battered women raise equality concerns which are frequently
ignored. It will critique notions of “battered women’s syndrome” that are common in many legal cases involving
domestic violence, and discuss a number of more accurate and nuanced psychological and social characterizations
that are based on the lived experiences of battered women. I will closely examine these problems in cases of
battered women and custody, battered women who kill their assailants, and even in treatment of domestic violence
in civil rights and international human rights legal contexts. The presentation will argue that both lawyers and
mental health professionals must incorporate these more complex perspectives into their work with battered women.
liz.schneider@brooklaw.edu
Criminal Law Ambivalence in Domestic Violence
Natalie Des Rosiers, University of Ottawa
The paper will review several developments in Canadian law in recent years dealing with domestic violence. The
thesis is that there are two contradictory law reform agendas that make formal legal pronouncements diverge more
and more from practice. One law reform agenda continues to value a strong criminal response to the issue of
domestic violence: it is anchored in a respect for victims’ voices, desire for accountability, and deterrence ideas. A
second agenda stems from the disenchantment with the criminal process. As police officers start laying complaints
on both women and men in cases of domestic violence and as jail terms are imposed in a way that isolate families
and communities, there is an anti-criminal law movement that is gaining momentum. As a result, a series of small
initiatives (diversion programs, restorative justice projects) operate at the margins, not secretly but disjunctively
from the official discourse. The paper explores the tension between the anti-punishment law reform movement and
the “equalization of criminal law” reform movement. It suggests that the tension can be resolved along certain
values and strategies. Among others, it presents the ambivalent development of domestic violence problem solving
courts as a symptom of the conflicts in law reform.
Nathalie.DesRosiers@uottawa.ca
ndesrosiers@lcc.gc.ca
The Importance of Positive Social Support for Children Who Have Experienced the Death of a Parent
by Intimate Partner Violence
Elaine Spencer-Carver, University of Missouri
Violence is an integral part of the American landscape. Urban communities reel from violent deaths in
neighborhoods, precipitated by mundane arguments. Violence infects families through intimate partner violence as
individuals misuse power and control. Violence erupts in relationships between adults and children leading to child
abuse. The impact of violence can be seen in the headlines of local papers in the newscasts of local media and in the
eyes and hearts of children.
When violence takes the life of a parent a child’s life is changed forever. When a parent is killed by that child’s
other parent or caretaker the change goes to the very core of the child’s existence. In 1998 there were 1,317 women
and 512 men killed by intimate partners. There is little known about the experiences of their children. The website
is dedicated to those children.
This qualitative study looks at the stories that adult participant’s share of their experience of having a parent killed
by a partner when these adults were children. Discussion will include recommendations for assisting children in this
situation and the role that both social service and the law can play in securing their future.
carvere@umkc.edu
Reproduction and the American Mind
Pamela D. Bridgewater, American University
In recent decades the public discourse regarding reproductive has simultaneously narrowed and broadened.
Abortion takes center stage in most public conversations about reproductive rights and policies regarding
reproductive choices while matters related to use of advanced reproductive technologies are largely seen as outside
of the public gaze. Other issues such as contraceptive and sterilization abuse are completely marginalized as they
tend to involve segments of American society about whom many Americans have already made up their minds.
The ability of compartmentalize these issues regarding reproduction is due in large part to the psychic split caused
by effects damaging affects of not focusing on the role class, gender, race and sexuality play in experiencing
reproduction generally and in making reproductive decisions individually.
This paper will posit that this compartmentalization of the varying aspects of reproduction in the American mind is
caused in large part by a negation of the policies of reproduction during the American slavery era. This era with its
practices and laws governing reproduction among and by slaves plays a large part in how the descendants of slaves
as well as the large American community experience their reproductive lives. Additionally, laws, practices and
policies regarding reproduction have established a particular relationship, oftentimes marked by incongruence,
between individuals and the government Finally, I will suggest that many of the insurmountable differences
between the reproductive camps can be addressed by incorporating a more complete and accurate historiography of
reproduction in America.
pbridgewater@wcl.american.edu
Multiculturalism and Minorities I
Racial Double Binds in American Legal Discourse
Reginald Oh, Appalachian School of Law
The thesis of this presentation is that legal and political racial discourse, by placing subordinated racial groups in
“racial double bind” situations, actively works to inflict psychological and psychic harm on members of
subordinated racial groups and to reinforcing dominant racial structures in society. This presentation will examine
the role of “racial double binds” in American constitutional legal discourse (e.g., Plessy v. Ferguson; Korematsu v.
United States, Grutter v. Bollinger).
According to psychologists, a “double bind” situation is one in which a person who is caught in a double-bind
cannot “win” no matter what that person tries to do. In short, that person caught in a double-bind cannot “escape”
the double-bind, and as a result, his or her psychology and existential well-being is threatened and undermined. A
“racial double bind” situation is one in which the dominant racial group engages in meta-communication with the
subordinate racial group in which the dominant group denies that it is treating a subordinate group in a racial/racist
manner at a literal-level of communication while simultaneously communicating at a meta-level that it believes that
the racial minority is indeed inferior and is in fact treating the group in a racial/racist manner.
A “racial double bind” puts the subordinate racial group in a no-win situation. If the subordinate group accepts the
truth of the literal message (that it is not being treated in a racist manner) then it must accept that its unequal and
inferior socioeconomic position is a result of its own doing and making. On the other hand, if the subordinate group
challenges the meta-level communication as racist, the dominant group will deny that it sent out any meta-level
message. Moreover, the dominant group will then raise accusations of racism against the subordinate group, by, for
example, accusing the subordinate group of “playing the race card” or of engaging in racism herself by raising
unwarranted accusations of racism. The end result is a denial of racism, an assertion that it “all in their heads,” and
thus, the conclusion that follows is that the subordinated racial group’s inferiority is a result of its own doing and
making – a no-win situation.
Roh@asl.edu
Antagonistic Cultural Ideology and the Protection of Mental Health
Richard Harvey, Saint Louis University
This research reflects the current zeitgeist within the social stigma literature that attempts to identify and explain the
various phenomena that victims of prejudice and discrimination employ to defend against mental health deficits (i.e.,
self-esteem, stress, etc.) A new model that seeks to encompass a range of “self-protective” strategies is discussed
entitled the “Antagonistic Cultural Ideology model.” The major premise of the model is that many self-protective
strategies are indicators of a more latent underlying collective ideology. Three mechanisms are hypothesized to be
indicators of an Antagonistic cultural ideology: Oppositional Thinking, Distrust/Threat of dominant group
members, and rejection of dominant group values. Felt stigmatization rather than mere stigmatized group
membership is considered the main antecedent to the endorsement of an Antagonistic cultural ideology. The
Antagonistic Cultural Ideology functions as a two-edge sword. On the one hand, the primary function of an
Antagonistic Cultural Ideology is to protect and enhance social identity; increased self-esteem is a bi-product of
increased identity. On the other hand, the endorsement of an Antagonistic Cultural Ideology may also be linked to
chronic hostility toward outgroups, low self-complexity, and decreased achievement motivation. The implications of
this model are especially linked to diversity, and how victims cope with perceived racial/sexual harassment within
organizations.
HarveyR@slu.edu
Multicultural Mindsets: Conceptualization, Measurement and Challenges
Frederick Leong, University of Tennessee
Through the confluence of several different factors, psychology has begun to recognize the increasing importance of
culture as a significant factor in understanding human behavior. In essence the changing demographics and
accompanying increase in more ethnic minority and cross-cultural research has produced a particular mindset in the
field of psychology. While by no means universal, this developing multicultural mindset has also come to exert an
increasing influence on psychological theories and interventions.
This multicultural mindset will be central to our understanding of the changing multicultural context for science and
practice of psychology. It has long been acknowledge that the psychotherapeutic enterprise is a cultural system with
its own set of values, assumptions and biases that often mirror that of society. In order to understanding how the
changing multicultural context will affect our research and our practice in the mental health delivery system, we
need to understand the process by which this multicultural mindset will develop in researchers, practitioners, clients,
and co-workers.
This paper, presents a conceptual model of the multicultural mindset that takes into account the recent development
in cross-cultural competencies. The paper will also address the challenges involved in the measurement of such a
mindset. In addition, it will also discuss the challenges and barriers in the development of such a mindset among our
scientists and our citizenry. Using a Lewinian force-field analysis, we discuss the various factors facilitating and
inhibiting the movement towards this multicultural mindset in psychology. Based on a chapter by Leong and
Santiago-Rivera (2001) I will describe a series of social-psychological factors that will serve as inhibitors for the
development of the multicultural mindset. These factors include ethnocentricism, the false consensus effect,
attraction selection-attribution (ASA) framework, psychological reactance, values as beliefs fallacy, and conformity
to majority influences as countervailing forces against the expansion of the Multicultural movement in psychology.
It will also argue that the combined action of these various social-psychological factors will significantly impede the
development of the multiculturalism movement.
fleong@utk.edu
The Legal and Behavioral Implications of the Term “Majority Minority”
Derek Humphries, Attorney-at-law, Washington, USA
The term "majority minority" has been applied to localities where Latinos are the majority of the population.
Recently, the term has been applied to describe population areas where Black Americans are the majority of the
population. A consultant's report submitted to the City Council in the city of Detroit, Michigan recently has
described the Black population there as a "majority minority". I plan to explore the legal and behavioral
implications for leaders of all cultures in a community where this term is used to apply to Black Americans. How do
"leaders" respond? Do the leadership paradigms change? Indeed, how would we describe the current leadership
paradigms for Black American, Black West Indian, Black African, Black Native American and Black Latino
leaders?
What are the implications for legal definitions which are based on customs, practices and privileges derived from a
white master/black slave culture? What are some of the self-affirming and self-destructive elements of current
governance models? Do they change in a community where the Black American population is now characterized as
the "majority minority"? There are a lot of questions. And probably a lot of different answers.
dhumphries@hblawyers.com
Cultural Application of the Profile Mood States with Arab Muslim Immigrant and Refugee Women
Anahid Kulwicki, Wayne County Department of Public Health, USA
Karen Aroian, Wayne State University
The purpose of this study is to determine the cultural applicability of the Profile of Mood States (POMS) in a sample
of Muslim Arab immigrants and refugee women in the metropolitan area of Detroit. As a result of political conflict
in several countries in the Arab world (Lebanon, Palestine, Yemen, Jordan, Iraq), Michigan has become one of the
major destinations for many Arabs fleeing their war torn countries. Consequently, providing appropriate mental
health services to a population with stressful life experiences has been a challenge to many American health
professionals. Specifically, health care professionals have become more aware of the benefits of using common
psychological measures that assesses mental health well being of clients across cultures. A valid and reliable tool
that measures mood states in diverse populations is imperative for the development of culturally appropriate mental
health services for clients experiencing disturbances in mood states. A POM have been translated in many languages
(Chinese, Korean, French, Latin) and is considered a reliable and valid tool in measuring mood states for the
Chinese, Koreans, French, Hispanics etc. POMS is a self-report designed to measure six dimensions of mood:
Tension-anxiety; depression-dejection; anger-hostility; vigor-activity; fatigue-inertia; and confusion-bewilderment
(McNair, Lorr & Droppelman, 1992). POMS was reviewed and modified for cultural relevance independently by
five experts on Arab culture. After modification, the measures were translated into Arabic and back translated into
English as a validity check by people who shared the same characteristics as the five experts. The measures were
administered to 30 Muslim immigrant or refugee women to assess for comprehension, cultural applicability, and
completeness. The internal consistency reliability of the total POMS with Arab women was .93 and ranged from .61
for the Confusion-Bewilderment subscale to .90 for the Fatigue-Inertia subscale. The next lowest internal
consistency reliability was .78 for the Anxiety subscale. An item from the Confusion-Bewilderment subscale,
“efficient” was negatively correlated (even after reverse coding). When this item was deleted, the internal
consistency reliability of the subscale increased to .74. The adapted Arabic version of the POMS was found to be an
appropriate measure for use with Arab immigrant women. The tool is being used to measure mood states with a
convenience sample of 650 Muslim Arab women as part of a larger by NIH funded study.
Kulwicki@oakland.edu
Multiculturalism and Minorities II
Responding to Black Children’s Mental Health Needs in the Juvenile Justice System: A Reparations
Perspective
Angela Olivia Burton, City University of New York
Mental health is paramount to personal well-being, family relationships, community cohesiveness, and successful
contributions to society. Focusing specifically on the mental health needs of Black American children, this
presentation will document the prevalence of racial disparities in the incarceration of Black children and the
unwarranted diagnosis of many of these children with mental illness and/or behaviour disorders. The presentation
will explore the consequences of this phenomenon, including the disproportionate use on Black children of more
severe forms of treatment such as psychotropic medications, restraints, and other highly intrusive and restrictive
approaches. Labelled as mentally ill criminals, many of these children are subjected to inappropriate, unnecessarily
harmful, and oppressive treatment under the guise of mental health care.
This maltreatment of Black children in the juvenile justice system has serious consequences not only for the
individual children who are subject to these gross abuses, but also negatively affects the families and communities
from which they come. For instance, the unwarranted or erroneous administration of powerful, mind-altering
psychotropic drugs can lead to long-term and sometimes irreversible damage to the child’s mental and physical
health, and negatively impact their future life prospects. From a communitarian perspective, the criminal
pathologization and displacement of large numbers of children away from their families and communities and into
detention facilities under state supervision undermines the Black community’s ability to address the children’s needs
with reference to our unique history and culture, and results in the loss of opportunities to shape what is perhaps our
most important means of eventual self-determination – our future generations.
Central to the presentation is the premise that institutional racism and the absence of culturally competent diagnosis
and treatment Black children are major contributors to this problem. It is argued that the situation of Black children
in the juvenile justice system described here represents a group-based harm that must be placed at the forefront of
the agenda of those advocating for reparations on behalf of African-Americans. As long as Black children are
subjected to these shocking abuses within the juvenile justice system under the guise of mental health treatment a
healthy, productive, self-determined Black community will remain elusive. To counteract this trend toward
increasing state control over the mental health of our children members of the Black community must take control of
developing policies and managing programs and procedures for addressing the mental health needs of our children,
with emphasis on enabling and empowering communities and families based on principles of self-determination and
extended community and family based care.
burton@mail.law.cuny.edu
Reducing Disparities of Care for Severely Mentally Ill African Americans
Trevor Hadley, University of Pennsylvania
This presentation will describe a project, commonly known as the Mental Health Disparities Initiative, which is a
four-year research initiative at four participating agencies along with the University of Pennsylvania and Lincoln
University, which make up the Philadelphia Consortium on Psychiatric Disparities. The intent is for members of the
PCPD to continue to collaborate on mutually beneficial projects in the future that will ultimately improve the health
and well-being of the populations served by these agencies. The vast majority of patients with serious mental illness
are cared for in the public mental health system. Despite the great advances in state of the art care and excellent
treatment guidelines for such patients there still exist documented racial disparities in the quality of care and
engagement of African American patients. This presentation will report on a major intervention to improve the
quality of care by training and engaging psychiatrists and patients in a process to follow these treatment guidelines
The four main components of the current project are:
1. Evaluating the process and impact of implementing automated prescription systems in mental health
agencies. This includes a pre- and post-automation chart review.
2. Using “academic detailing” to assist psychiatrists to better understand prescription patterns and choices,
especially as this relates to standardizing care across ethnic/racial groups.
3. Providing social skills training to clients (diagnosed with major depressive disorder or schizophrenia) to
facilitate improved client-clinician communication and client adherence to treatment plans.
4. Conducting a systems-level evaluation of organizational change to better understand the barriers to and
potentials of automated prescription systems, as well as getting a more in depth understanding of how each
agency has adapted to respond to the needs of its clients.
thadley@mail.med.upenn.edu
Ethnic Issues in Diagnosing and Treating Mental Disorders
William B. Lawson, Howard University Hospital
Misdiagnosis and underdiagnosis is common in some ethnic minorities in the United States. This persisting
phenomenon has important legal implications. First ethnic minorities, especially African Americans are
overrepresented in the criminal justice system. The mentally ill are overrepresented and could probably be diverted
to other settings for optimal treatment. Second a large percentage of these individuals may have variants of bipolar
and anxiety disorders such as post traumatic stress disorder. Specialized mental health treatment is often required.
Pharmacotherapy is often inappropriate as a result of misdiagnosis. Excessive use of antipsychotics and excessive
dosing is often seen. Pharmacological findings however suggest that minorities should receive lower doses of many
psychotropic medications. Side effects of older antipsychotic medications such as tardive dyskinesia and emerging
risks associated with newer medications such as diabetes mellitus increase litigation risk for the treating physician
unfamiliar with cultural and biological issues in ethnic pharmacotherapy.
wblawson@howard.edu
Of Eggshells and Thin-skulls: A Consideration of Racism-Related Mental Illness Impacting Black
Women
Camille Nelson, Saint Louis University
Recent research has indicated that the prevalence of mental disorders is estimated to be higher among Blacks than
among Whites, most likely due to the nexus of race and socioeconomic disparity. Blacks are under-represented in inpatient populations and more likely than Whites to use the emergency rooms for mental health treatment. Numerous
studies confirm that Blacks drop out of mental health services at a significantly higher rate than Whites and use
fewer treatment sessions for mental health issues. Furthermore, Blacks enter mental health treatment at a later, more
advanced stage than Whites, under-consume community mental health services of all kinds, are misdiagnosed more
often than Whites, and are more often diagnosed with a severe mental illness than Whites. People from diverse
ethnic backgrounds often are prevented from receiving adequate mental health treatment due to misdiagnoses and
lack of access to the services they need. Factors contributing to this disparity include a general mistrust of medical
health professionals, cultural barriers, co-occurring disorders, socioeconomic factors, and primary reliance on family
and the religious community during times of distress.
Unfortunately, the traditional institutions of racialized research largely ignore the disparate social and political
exposures confronting people of color, such as residential and occupational segregation, racial profiling, tokenism,
discrimination, racism, and the consequential physiological and psychological effects flowing from the macro and
micro effects of such interactions and intersectionalities. This article explores these issues and proposes civil law
legal frameworks for addressing these disparities especially as women of color are impacted. In particular, it is
suggested that renewed consideration be made of the Thin-Skull and Eggshell doctrines in the United States and
comparable traditional international doctrine.
nelsonca@slu.edu
Munchausen Syndrome by Proxy
Disscussant
Bernard Starkman, Ottawa
The Disciplinary Committee and the Judge in Munchausen by Proxy
Wilma Duijst, Radboud University
In this investigation we looked at the judgments of disciplinary committees about the way a physician or a nurse
handled in a Munchausen by proxy case. Also we looked at the judgments given by criminal judges in cases of
Munchausen by proxy. In the judgments an indication is given about how a physician or a nurse has to act when a
suspicion of Munchausen by proxy arises. We compared the indication given in the judgements with the policy of
the AMK (Advies an Meldpunt Kindermishandeling, An institution where child abuse can be reported and advice
can be given).
w.duyst@jur.ru.nl
The Dutch Child Protection Board and the Munchhausen by Proxy Syndrome
Margot Pot, Child Protection Board, Utrecht, The Netherlands
This paper examines how the Dutch systems (and especially the Child Protection Board) are structured around child
protection and the Munchhausen by Proxy Syndrome (MBPS).
In the Netherlands the Child Protection Board is a so-called second-line organisation. This implies that only a
limited number of organisations are authorised to make a direct contact with the board, such as the Bureau Juvenile
Care (or a section of it, the Advice and Registration Point Child Battery) and the Court. Only in extremely grave
situations, other agencies and persons are permitted to call in the Board assistance directly.
The Child Protection Board has not a special policy for cases where there is a suspect of the Munchhausen by Proxy
Syndrome.
There is one case of MBPS in the Netherlands that is important for the way of acting of the Child Protection Board.
This is the Case of Venema versus the Netherlands.
In 2002 the European Court of Human Rights came with their Judgement in this case.
In this case there was nothing wrong with the daughter of the family so there was a suspect that Mrs. V was
suffering from the MBPS. The Child Protection Board acted immediately and went to the court for a supervision
order and an order for the little girl to be placed away from her family. The parents started a procedure to get their
daughter back home and they also claimed compensation for non-pecuniary and pecuniary damage. They finally
went to the European Court of Human Rights in Strasbourg. The European Court came to the judgement that there
has been a violation of art. 8 (violation of family life) of the Convention on Human Rights.
m.pot@rvdk.minjus.nl
Munchausen Syndrome by Proxy: Bibliographical Update and Signalizing of Two Cases
Sara Sabatasso, University of Pavia
Fabio Buzzi, University of Pavia
The Munchausen Syndrome by proxy (MbPS) was identified in the second half of the Seventies and hence several
aspects of the nosological definition or the mechanisms of the abusers’ behaviour remain undetermined. This does
not enable a univocal definition of the MbPS which describes all aspects of the abuse which is inherent to the
syndrome. These aspects are dissimilar from those of other forms of child abuse. For this reason an analytical
description of all the clinical manifestations of MbPS is required.
The incidence of MbPS is unknown because a large number of studies do not give a common denominator. Yet, in
recent years there are numerous reported cases on MbPS, probably because of greater attention being given to child
abuse. Between 1998 and 2003, 250 cases were described in literature. Among them, poisoning cases are very
frequent, involving a great variety of substances, often drugs used by relatives at home. This study will present two
reports falling into this category, observed in the hospital (S.Matteo) of Pavia between 2002 and 2003.
The first is that of C.D., a 14 year old adolescent at the time of his hospitalization (2002), ordered by judges, in the
Department of Pediatry with a diagnosis of iatrogenic Cushing Syndrome and a weight of nearly 120 kilogrammes.
The Authorities of Protection and Justice were alerted by his teachers, following the adolescent’s unexplained
absence of about one and a half years.
During his period in the hospital he underwent a large number of chemical and instrumental examinations. Based on
the results physicians suspected the administration of drugs by his mother. This suspicion was confirmed by the fact
that on two occasions nurses found C.D.’s mother administering him cortisones (prevalently) and laxatives. This
situation had been going on for nearly two years, immobilizing the boy on a sofa due to his weight and bonearticular pain. C.D.’s clinical situation rapidly improved by eliminating his contact with the mother, limiting the
parental authority and entrusting the infant to the Commonal Service. The second case is that of R.A., a 11 years old
boy at the time of his hospitalization in the same Department of Pediatry, ordered by the “Tribunale Per i
Minorenni” (Court discussing cases involving juveniles) of Milan.
In this case, the paediatricians, who had been following the boy’s case since 1999 because there was no reasonable
explanation for the progressive increase of his weight and hairiness, suspected MbPS. The diagnosis was probable
iatrogenic cushing syndrome and cortical suprarenal glands secondary insufficiency. The “Tribunale per i
Minorenni” had been alerted by the paediatricians themselves and by the infantile neuropsychiatrist who was
treating R.A.’s cephalalgia. At the beginning of the hospitalization in the Department of Pediatry the child presented
a clinical condition highly similar to that of C.D. with the exception of his weight, which was only 34.4 kilograms.
However, in the case of R.A., neither the abuser nor any evidence of abuse was identified. An improvement in his
clinical condition was observed after first controlling the parents and then separating the boy from his parents
(especially the mother). In both cases the parents (especially the mother) hindered physicians’ actions and built
barriers, especially when they felt under suspecion. These “barriers” are one of the many difficulties met in
managing MbPS cases. Other difficulties arise from the need to individualize, as soon as possible, this syndrome and
to diagnose it with certainty, which are very important for medico-legal evaluation. MbPS diagnosis is up to
paediatricians, not to psychiatrists. However, psychiatrists play an important role in the approach to the abuser. A
close monitoring of the parent-child relationship – by close supervision and then videosurveillance – is needed in
suspected cases, although it raises ethical and legal questions.
After diagnosing MbPS, it is necessary to protect the child. It is important to take a co-ordinated, multidimensional
approach to comparing and evaluating the risks, and protecting and treating the child. In this area welfare workers
are important as well as physicians. The expert has to evaluate how the abuse is conducted, the identity of the
abuser and the probable damage suffered by the child. The active “building” of a disease during a long period of
time, giving medicines or active drugs, usually causes very serious damage. The “perverse” parent-child relationship
could also cause psychological damage. It is more difficult to value this type of damage and its long-term effects
than that of “physical” damage.
fabuzzi@unipv.it
Management of MBPS in Clinical Practice
R. Vecht-van den Bergh, Practicing Psychiatrist, Oegstgeest, The Netherlands
MBPS maltreatment is real. Though MBPS is no longer considered rare it is still under-identified
If MBPS is considered, it becomes important to apply the MBPS label so you can provide the victim with protection.
Presentation of MBPS is various. Many different diseases are fabricated like diabetes, infections, anemia, fever,
epilepsy. Between the first symptoms seen in the hospital and the diagnosis MBPS is in general a period of two
years. It is very important to try to shorten this period.
Because MBPS comes in disguise and the mothers/perpetrators are very good liars and strongly manipulative, it
takes time to recognise the abusive patron. Healthcare workers especially pediatricians can profit from knowledge
about personality disorders. It is assumed that the motivation of the behaviour of the perpetrator is self-serving
psychological needs, though they are often perceived as devoted parents. Some perpetrators seem to be motivated by
the need to manipulate and deceive authority figures like doctors, policemen or teachers. The abuse mostly involves
more children in one family. It looks like a serial crime. There is a high recidivism rate even after the perpetrator,
mostly the mother, is apprehended.
In many cases mothers are likely to continue to abuse their children, even in hospital while under surveillance.
Mothers stress on the point that the child cannot cope without her. This presentation will focus on the experience
with MBPS cases in the Netherlands. Covert video surveillance is sometimes required to make a definitive and
timely diagnosis; otherwise cases will go undetected placing children at risk. In the Netherlands this method has
been used in hospitals in cooptation with the police to get a legal proof.
rvecht@planet.nl
Munchaussen by Proxy Syndrome and Interventions
Jolande Schoonberg, Advice and Report Centre for Child Abuse, Amsterdam, The Netherlands
The Advice and Report Centres for Child Abuse in the Netherlands are the centres where suspects of child abuse and
also of Munchaussen by proxy syndrome (MBPS) can be reported since 1972. In these centres social workers and
confidential doctors are working. The confidential doctors are important for the cases of child abuse with a lot of
medical aspects as in MBPS. In the centres the confidential doctor can do an investigation after the report of cases in
which MBPS is suspected. Important are the parents, the child and the doctors who are involved in the treatment of
the child. We must answer the question if there is probably a case of MBPS. After the investigation the
interventions that follows can be a further diagnosis procedure with police Video-registration), protection of the
child by separating from the parent(s) or/and treatment of the child and the parents. MBPS is always a great danger
for the development or the life of the child. Helpful is the last definition of H.Schreier: MBPS is PCF (Paediatric
condition falsification) and FDP(factitious disorder by proxy). These two parts should been recognised for a real
MBPS. We see a lot of cases that seem to be MBPS but are in fact very similar or a look a like MBPS case.
jschoonenberg@xs4all.nl
Narcissism and its Relationship to Civil & Criminal Law
Narcissism and the Courts
Frank Herrmann, Boston College Law School
Narcissism is a frequent factor in a variety of disputes that are submitted to courts for judicial determination. The
diagnosis appears in employment and disability cases, parental rights issues, criminal sentencing, including death
penalty decisions, and cases involving predictions of future dangerousness. Professor Herrmann will review how a
diagnosis of “narcissism” affects courts in these areas and ask whether the approaches are consistent with one
another.
francis.herrmann@bc.edu
Narcissistic Character Pathology and Criminal and Civil Law: An Overview
Gerald E. Kochansky, Harvard Medical School
This session will focus on some of the ways in which an understanding of narcissistic character pathology can help
to explain certain phenomena that emerge in civil and criminal legal contexts. Underlying narcissistic vulnerabilities
and resulting injuries, along with narcissistic traits or defenses, may contribute to the emotional injuries which
litigants allege in various tort actions; may present complex challenges in employment situations, which in turn may
end up in the legal system; and can lead to criminal behaviors in individuals who are not fundamentally anti-social,
as in recent corporate scandals like those allegedly involving executives of Enron.
Narcissistic traits—such as grandiosity, sense of entitlement (recently measurable by a newly developed scale), lack
of empathy, vulnerability to experiencing shame and humiliation, and inability to bear and constructively use
criticism—can also enter into intellectual property disputes, slander actions, attorney efforts to destroy rather than
simply neutralize witnesses (including experts), and other legal situations.
Recommendations will be offered to aid attorneys and others (e.g., human resources professionals) in dealing with
individuals with narcissistic character pathology and the challenges they present as employees, clients, or potential
litigants.
dr.k@rcn.com
Dealing with Narcissists in Employment Litigation: Traps for the Unwary
David Wolowitz, Harvard Law School
Employers and lawyers who advise them are often unprepared to deal with problem employees who have
narcissistic character pathology. Typically, employers utilize progressive discipline to improve employee behavior
and performance. Employees with strong narcissistic traits will likely respond to such efforts as if attacked. If the
employer responds with discipline or termination, the narcissistic employee is likely to litigate. Human resources
professionals and employment lawyers would be well advised to obtaining training in recognizing narcissistic traits
in problem employees. By consulting with forensic mental health professionals in advance of intervention, human
resource professionals and lawyers may be able to reduce the likelihood of protracted litigation.
Employment litigation with a narcissistic employee presents special problems. Their vulnerability contributes to
such litigants responding poorly to the routine discovery process, typically feeling attacked. They are likely to
counter-attack to the perceived attacks. The result is even more ill will between the parties, prolonged litigation and
further obstacles to settlement. Their grandiosity and lack of insight make it extremely difficult for them to follow
the advice of their counsel or evaluate the merits of the opponent's case.
To complicate matters, a narcissistic employee who has been disciplined or terminated may suffer significant
narcissistic trauma in circumstances which would not traumatize another employee who does not have these traits.
The narcissistic employee will likely blame the trauma on the perceived unfair treatment and make the asserted
emotional distress a part of the damages claim. In most jurisdictions, the law does not support emotional distress
claims when the distress exceeds that which a reasonable person would exceed under the circumstances, unless it
results from a susceptibility of which the accused has knowledge. Therefore, it is crucial that the employer and its
counsel utilize a forensic mental health professional to advise and assist them in evaluating the employee and
contesting the alleged harm.
The presentation will focus on the benefits to employers, human resources professionals and employment lawyers of
utilizing knowledgeable mental health professionals to advise them on risk management strategies when dealing
with difficult employees with narcissistic character pathology both pre-litigation and during the litigation process.
david.wolowitz@mclane.com
Sexual Misconduct in Professional Relationships : What’s Narcissism Got To Do With It ?
Andrea Celenza, Harvard Medical School
There is widespread concern about the problem of sexual misconduct in professional relationships. This is
especially true for the therapist-patient relationship but is, in some measure, also true for any fiduciary relationship
or any relationship with a professional providing a service to a layperson in need. Among mental health
professionals, sexual misconduct is recognized as unethical due to the power imbalance inherent in the structure of
the therapist-patient dyad. In the mental health arena, the relationship is founded on an asymmetric distribution of
attention wherein the professional learns a great deal about the patient and not vice versa. This type of relationship
encourages transference-based illusions derived from early childhood, rendering the patient particularly vulnerable
to exploitation. The problem is intensified for any professional relationship that continues over time.
Eight precursors to sexual misconduct have been identified, many of which are features of the character of the
professional. Most of these are related to narcissistic pathology and bear on the professional’s temptation to exploit
the power imbalance inherent in the asymmetric structure of the professional relationship. These risk factors will be
highlighted in order that the professional may be aware of vulnerabilities and potential blind spots to consider
throughout his/her professional life.
acelenza@aol.com
Neuro-biology and Mental Health: Jurisprudential Issues
Neuro-Jurisprudence. The Brain and the Law
Ricardo Weinstein, Practicing Psychologist, Encinitas, USA
The last two decades have witnessed a convergence of the disciplines of brain science that has major implications
for understanding human behaviour. The neurosciences, including brain physiology, neurobiology, brain chemistry,
neuropsychology and techniques in brain imaging, have evolved at a rapid pace allowing for new understanding of
brain development and functions. Mental health and the law have always been difficult partners and many have
questioned if psychology has any place in the courts. With new and better understanding of brain/behaviour
relationships the neurosciences now have solid contributions to make to the theory and practice of law.
There is a gap between the current state of scientific knowledge and the law. Legal change generally comes about
very slowly. The most recent developments in neuropsychology, however, raise questions about whether the law
can actually promote justice if it does not consider new understandings of the brain. It has become evident that
many psychological concepts have become obsolete and philosophical questions regarding human behaviour need to
be re-examined.
This presentation will offer a review of brain development as it relates to legal issues. It will discuss concerns
relating to insanity, legal responsibility and competency, as well as issues of intent and the role of emotions. The
concept of free will, in light of the present knowledge of brain function, will also be examined. The assumption of
free will underlies most Western law; the presentation will include a discussion of free will as a relative, rather than
an absolute, concept. Finally, it will provide examples of how all of these issues become integrated in death penalty
cases in the United States by presenting a model of comprehensive evaluations of brain function, including
neuropsychological and neurophysiological measures.
rweins@pacbell.net
Conceptualisation of Violence as a Neuropsychiatric Disorder
Thomas C. Thompson, Thompson, Sak and Associates, Las Cruces, USA
The premise of this paper is that individuals who engage in violence suffer from a neuropsychiatric syndrome and
that this is largely ignored at the level of judicial and treatment decision making. This is conceptualized as a
developmental syndrome associated with abnormalities and atypical organization and development of the brain.
Violent offending is perceived as the end product of brain development in which higher-level cognitive/executive
and emotional regulatory systems have malfunction as a result of both neurochemical and structural deficits. These
deficits are believed to be the result of genetic, prenatal, and perinatal factors that can be magnified by the
interaction of early nonnormative experiences of abuse and neglect. In older adolescents and adults this leads to a
high prevalence of affective dysregulation, substance abuse, and impulsive violence.
The author proposes that we begin to systematically gather neuropsychological, psychophysiological, and
electroencephalographic data in order to establish databases. Databases would allow for the development of
standardized assessments that could be available at the level of community programs and practitioners allowing for
the more accurate identification of those individuals who are higher risk for serious repetitive long-term violent
behaviour. Further the development of databases and standardized assessments will begin to delineate alternative
treatment models, which emphasize violence as a neuropsychiatric syndrome. It is anticipated that such a project
would inform both treatment and judicial systems where there is a need for comprehensive differential diagnosis and
the development of differential treatment programming. The development of the database and its ability to inform
treatment and judicial sources will lead to earlier and more successful intervention reducing the high personal,
familial, and societal costs of violence.
tctmjs@zianet.com
The Brain, Emotions, and Family Law: High Conflict Custody Disputes Seen Through the New Lens
of Neuro-Jurisprudence
Janet Weinstein, California Western School of Law
High conflict child custody and visitation disputes are problematic for professionals involved in the legal system, for
the parties and for the children who are the subjects of the disputes. The legal system expects people to behave
rationally, but people in the middle of intense conflicts, particularly when they are fundamentally personal as these
conflicts are, may not be able to overcome their emotions in order to behave the way the courts expect. There have
been a variety of approaches to this problem, some more successful than others. These attempts to reduce the
problem have included unified family courts, parenting and divorce education programs, special masters, and other
counselling programs. The law and associated professions, particularly mental health, have examined the problem
from many perspectives including the psychology of these disputes, the economic burden it imposes upon the courts
and the families, and the developmental consequences to children.
This paper examines these difficult disputes from the perspective of the brain – what the brain does in reaction to
particular stimuli. From this perspective, the paper discusses possible explanations for the behaviour exhibited by
these parents and suggests possible approaches to reducing conflict by using information about the brain. Looking
at the problem through the new lens of neuro-jurisprudence provides the opportunity to develop new approaches or
to lend support to approaches that seem to be working.
jweinstein@cwsl.edu
The Biology of Money: Legal Implications
Laurence R. Tancredi, New York University
The relationship of the brain to how we handle money has become an area of interest in recent years. Parts of the
brain generate fear and anxiety over changes in monetary status. Other areas are concerned with repetitive and
alternating patterns and therefore, engage in forecasting. Still other areas of the brain - due primarily to the
neurotransmitter, dopamine - induce feelings of pleasure at the accumulation of money. Finally, money like cocaine
and drugs can become the object of addiction. This is most obvious in pathological gambling. This presentation
will examine the biological features of the brain that affect money, examine when our need for money and risk gets
out of control, and finally review the implications of impulsivity and compulsion with regard to money as they apply
to legal responsibility.
lrtancredi@yahoo.com
Lie Detection and Neuroscience: Historical and Practical Implications
Elizabeth Ford, New York University
Lying and deception have been discussed extensively in studies of ethics and morality, but the accurate and reliable
detection of such activity has haunted the scientific and legal communities for centuries. Lie detection techniques
have advanced considerably since the days of hot coals and witch trials, but there continues to be great difficulty
identifying a liar in the psychiatric and/or criminal population. Most professionals, including judges and
psychiatrists, perform no better than chance when attempting to identify a liar. This is an important issue because
legal decisions and psychiatric treatment recommendations are often based on a defendant or a patient’s self-report
and perceived sincerity.
Recent developments in lie detection, particularly the EEG-based technique patented under the name “Brain
Fingerprinting”, may provide a better chance at detecting liars. But does it offer what we need in a foolproof test for
the courts? Can this technique offer enough conclusive evidence about a defendant’s honesty? While the few
studies that have been done indicate that there may indeed be a role for this technique, the literature remains sparse
and limited. These issues, along with provocative questions about society’s preoccupation with lying, will be
discussed.
forde01@med.nyu.edu
Instinctual Trauma Response
Lee Norton, Norton and Moody, Inc., Tallahassee, USA
The study of trauma has evolved through several phases over the past 100 years. Recent decades have left
researchers and clinicians stymied as to the best means by which to resolve the myriad symptoms inherent to acute
and chronic trauma. Dr. Louis Tinnin, M.D., referred to by Bessel van der Kolk, M.D., as the “father of trauma”,
has studied trauma for more than 30 years and developed interventions that resolve not only the more common
intrusive, avoidant and arousal symptoms but, more important, the dissociation that often evolves into trait disorders
that frequently are mis-diagnosed and resistant to traditional interventions.
Among their many contributions to the study and treatment of trauma, Dr. Tinnin and his wife, psychologist and art
therapist Linda, developed a unique intervention that is remarkably effective in resolving symptoms of traumatic
stress conditions and dissociation. It is based on seven components of what Dr. Tinnin has termed the Instinctual
Trauma Response: startle response, thwarted intention, freeze state, altered state of consciousness, emotional
response, body/somatic response and self repair. Treatment consists of four modalities: non-abreactive linear
narrative of the event (video taped), review with client of video narrative, art work of event emphasizing each
component of the instinctual trauma response, and “video dialogue”, a powerful technique consisting of a “dialogue”
between conflicted parts of the wounded ego that resolves the “victim mythology” inherent to severe or chronic
trauma.
This presentation will define and describe the Instinctual Trauma Response and the intervention developed and
employed by Dr. Tinnin and his wife at their clinic, the Trauma Recovery Institute, in Morgantown, West Virginia.
leenorton@earthlink.net
Community Treatment Orders IV: ‘The Ontario Experience’
The First Four Years of Community Treatment Orders - The Experience of Physicians' Counsel
Patrick J. Hawkins, Barrister and Solicitor, Toronto, Canada
In this paper, I review my experience representing physicians at Community Treatment Order (CTO) hearings, and
consider whether physicians and patients are being well served by the law. CTOs have now been in use for four
years and a body of jurisprudence is being developped that considers the enabling legislation. The paper will
analyse that jurisprudence. I will test the jurisprudence against the purposes of the legislation - It is meant to be a
way to treat individuals with serious mental disorders in the community, as opposed to treatment in a psychiatric
facility. CTOs are meant to be less restrictive to the patient than treatment in a psychiatric facility, and a way to
maintain treatment in the community for that group of patients that is often lost to follow-up. They are designed to
assist the "revolving door" patient, who is treated in hospital, stabilised and discharged, only to be lost to follow-up
care, deteriorate and require re-admission. I question whether the needs of patients and the goals of the legislation
are being met at this time by the legal process - Is it becoming unduly complicated and technical? And, are the
purposes of the legislation being forgotten? After considering the existing jurisprudence against these questions, I
will offer some suggestions for the future and what I believe should happen with CTOs in the coming years.
phawkins@blgcanada.com
CTO Case Management Services in Toronto: The Hard Data - First Returns on the Efficacy of the
Ontario Experiment
Steve Lurie, Centre for Mental Health & Addiction (CMHA), Toronto, Canada
CMHA Toronto Branch has provided case management services to people on community treatment orders (CTOs)
in Toronto since June 2001. Once a CTO is issued, case managers work with clients to implement the community
treatment plan outlined in the order. Clients are seen one to three times per week and assisted with medication
management, activities of daily living and housing.
Client characteristics and outcomes will be described as well as the results of providing services to a comparison
group of hard to serve clients. CMHA has provided case management services to over 200 people and achieved a
94-96% reduction in hospital days after a year. 80% of clients stay engaged with the case management service
following the expiry of the CTO.
The results of a research project comparing perceived coercion and service satisfaction between the two groups will
also be presented.
slurie@cmha-toronto.net
Legal Oversight of Community Treatment Orders in Ontario
Theodore Nemetz, Consent and Capacity Board of Ontario, Toronto, Canada
The purpose of a Community Treatment Order (CTO) is to provide community based treatment to those people who
have a history of repeated hospitalizations followed first by improvement and then by deterioration. This treatment
plan is intended to be an alternative to using scarce hospital bed resources. The legislation provides that a person
subject to a CTO has the right to review the order to determine if all of the statutory criteria have been met. It
additionally mandates a review upon the second renewal of the CTO and thereafter upon each 2 nd renewal.
The purpose of this paper is to examine how the review process takes place; the effectiveness of this review process,
and a consideration of possible alternatives.
Ethical Concerns Arising from the Ontario Experience with Community Treatment Orders
Mark Handelman, University of Toronto
Community Treatment Order legislation seeks to balance the right of a person suffering serious mental disorder to
treatment with the right to make his or her own treatment decisions. A stated principle of the legislation is treatment
in the community, which is less restrictive than treatment in a psychiatric facility.
This paper examines whether or not that balance is achieved by this treatment regime, the compromises made and
the effect upon the dignity and autonomy of the individuals placed on community treatment orders.
IIt also
examines the ethical conflicts faced by physicians who place patients on treatment orders and the societal interest in
the allocation of the resources available for treatment of mental disorder in the community.
m.handelman@sympatico.ca
The Impact of Community Treatment Orders on Patients with Assertive Community Treatment and
without
Alison Freeland, University of Ottawa
Ann-Marie O’Brien, Royal Ottawa Hospital, Ottawa, Canada
Susan Farrell, University of Ottawa
Despite the paucity of research on Community Treatment Orders (CTOs) in Canada there is growing interest in their
use clinically. Those concerned with the use of CTOs in the context of unclear research outcomes recommend less
coercive forms of community based treatment, such as Assertive Community Treatment (ACT) teams, for patients
with severe and persistent mental illness. Clinical practice however suggests that use of CTOs in addition to ACT
may enhance clinical outcomes because of improved adherence to treatment and follow-up.
The purpose of this study is to examine the socio-demographic, psychiatric and service utilization profiles of
patients with ongoing ACT involvement who are placed on a CTO, compared to those on a CTO without ACT.
Preliminary findings at 6 months indicate no statistical difference between groups with respect to diagnosis,
concurrent substance abuse disorder and legal involvement. However ACT patients did not experience a significant
reduction in number of hospital bed days compared to non ACT patients who did. The value added of a CTO for
patients with concurrent ACT involvement is not obvious at 6 months post 1 st issuance of a CTO, if outcome is
measured by hospital days. It has been suggested in the literature that the efficacy of CTOs lies in the provision of
community based resources that accompany the CTO. Our study focuses on a group of patients who have the highest
intensity of community based service available prior to a CTO being considered. Our findings will be discussed with
respect to these issues.
afreelan@rohcg.on.ca
Importance and Methodology for Changing Public Perception about Community Treatment Orders
Cathy Plyley, Regional Mental Health Care London, Canada
Joe Skufca, Regional Mental Health Care London, Canada
This presentation will look at challenges and successes for Community Treatment Consultants in London Ontario.
London is an urban area with a large population of individuals with a serious mental illness. The negative
connotations for Community Treatment Orders in Ontario has been a barrier for preventing increased utilization of
this tool for treatment for the seriously mentally ill. This presentation will review methods used to change the
perception of Community Treatment Orders to make them a more acceptable treatment option for treatment teams,
community supports and Substitute Decision Makers. When legislative changes were brought to Ontario in 2000,
Community Treatment Orders were called Brian’s Law which refers to the murder of sportscaster Brian Smith by an
individual with a serious mental illness. Our presentation will review steps taken to correct the perception that
CTOs were only for violent patients by utilizing the Treatment Plan associated with CTOs in a creative and client
friendly manner. We will also review the use of CTOs with populations such as geriatrics, early psychosis,
adolescents and adult populations. We will review the feedback from clients, families and treatment teams
regarding enhanced opportunities for relationship building, which allows for more positive re-integration into the
community of choice while maintaining well being. In our area over 90 percent of the clients on Community
Treatment Orders are considered incapable to consent to treat. Potential reasons for such a high ratio of incapable
clients will be explored.
Cathy.plyley@sjhc.london.on.ca
Joe.skufca@sjhc.london.on.ca
Liam Scott, Ministry of Health and Long Term Care, Toronto -- Discussant
Community Treatment Orders V: ‘The Ontario Experience’
Community Treatment Orders (CTOs) and Forensics: The Sudbury Experience
Dianne Stewart, Northeast Mental Health Centre, Sudbury, Canada
Community treatment orders (CTOs) were introduced as an amendment to the Mental Health Act in Ontario, Canada
in December of 2000. The CTO was initiated as a tool to treat the seriously mentally ill (SMI) in the community, an
option less restrictive than being detained in a psychiatric facility. In Sudbury, a city located in Northern Ontario,
with limited community mental health resources, the use of CTOs has been quite innovative. The blending of CTOs
with forensics is one of the areas that has been very unique and successful. As well known, many individuals with
SMIs do not receive adequate psychiatric care in the correctional system. Through the implementation of Mental
Health Court in Sudbury, along with the need to treat these unique individuals in the mental health system, the idea
of the collaboration between the CTO program and the forensic mental health system arose. This partnership has
helped build a strong connection for these individuals within the mental health system. The goal of this presentation
is to introduce the successful outcomes of the marriage of these two distinctive areas. Also, to demonstrate how this
alliance has lead to prompt integration of the individual into the community mental health system, with a reduction
seen in the continuing need for incarceration. In other words, these exclusive individuals have successfully been
“taken out of the criminal system and solidly planted into the mental health system”.
dstewart@nemhc.on.ca
A Critical Analysis of Community Treatment Orders in Ontario, Canada: Clinical, Social, Legal and
Moral Implications
Ty Turner, St. Joseph’s Health Centre, Toronto, Canada
Achieving the right balance of autonomy and beneficence is a never-ending challenge for free and democratic
societies.
Complicating this, the fulcrum continues to move, sometimes at an accelerated pace. This can reflect cultural
change, law reform, or political dynamics. In Canada, all of these factors converged when the constitution was
patriated from the United Kingdom. A major elaboration of civil and political rights was enshrined in a new
constitution, which contained the Charter of Rights and Freedoms. First introduced in 1982, the Charter extended its
protections to mentally ill persons in 1985. The Charter has contributed to a major shift towards the ascendancy of
personal autonomy and civil liberty. Nevertheless, the beneficent impulse remains and post Charter attempts to
reconcile beneficence with freedom can generate a confused atmosphere for all stakeholders. In Canada, this shift
has most dramatically affected Ontario, its most populous province, where significant changes in mental health
legislation have taken place. Passing through the legislative process, the new laws were shaped by a political
process.
In the context of adversarial political dynamics, new factors were introduced. These include public fear of the
mentally ill, aversion to state intrusion and the government’s need to fulfill election promises by downsizing itself,
reducing spending and cutting taxes. From this, Ontario brought forth its first legislated attempt to coerce treatment
in community settings. The law is complex and difficult to use. Accordingly, it is underutilized and confusing to
consumers, families, clinicians and the public.
This paper will examine Ontario’s Community Treatment Order legislation, its strengths and weaknesses, and trace
its evolution back to the Charter of Rights and Freedoms and it influence over renewed attempts to strike the ethical
balance.
turnet@stjoe.on.ca
Use of Community Treatment Orders within a Context of Community Care: Experiences in Ontario
Pamela Khan, University of Toronto
Community mental health care in Ontario, Canada, has continued to evolve over the last few decades. Of late even
more emphasis is given to maintaining individuals with serious mental illness in the community, and to avoid
hospitalization whenever possible. Various configurations of community support teams exist, as do programs
providing hospitalization for acute episodes of illness, when required. One legislative effort to ensure continuing
care to those with persistent mental illness is the passing of Brian’s Law, which introduced Community Treatment
Orders in Ontario in 2000. This has met with mixed reviews from various sectors.
A large urban, multi-site addictions and mental health facility in Ontario offers a program for young adults who have
experienced early episodes of psychosis. This program includes both inpatient and community support services. In
an effort to provide care to some of these clients Community Treatment Orders have been used. This paper will
discuss various perspectives on the use of this approach to care. The experience of clients and health professionals,
in the First Episode Psychosis Program, with Community support services and Community Treatment Orders will be
a focus of the discussion.
pamela.khan@utoronto.ca
Community Treatment Orders : A Legal Tool to Recovery and Wellness in the Community
O. J Oluboka, University of Western Ontario
Kim Delarosbel, North Bay Psychiatric Hospital
Providing consistent and effective treatment for patients with severe and persistent Mental illness in the community
has been one of the most difficult challenges for the mental health care providers. The patients usually respond to
management interventions while in hospital but soon default follow up appointments in the community.
Subsequently recurrence of their illness is the rule rather than the exception. Frequent recurrences/relapses of a
psychotic illness have been shown to predict poor outcome and progressive deterioration of the illness. Hence the
patients deteriorate mentally, physically, and functionally with inevitable poor quality of life.
Following an extensive province-wide consultation, Brian’s Law (Mental Health Legislative Reform) was
introduced in Ontario, Canada in December 2000. This amends the Mental Health Act and Health Care Consent Act
to enable community treatment orders (CTOs) for persons with severe and persistent mental illness.
In this presentation we review the unique approach used by the “CTOs Team” from the North Bay Psychiatric
Hospital (A tertiary mental health facility) that serves the entire Northeastern Ontario. CTOs though a legal tool has
been used by this team as an inclusive, psychoeducating, and enhancement process that helped the patient embrace
wellness in the community. Not only has the CTOs in our experience assisted some patients to follow a treatment
regimen in the community, it has empowered them to remain well long enough in the community to enjoy a better
quality of life within the context of their illness.
ooluboka@nbph.moh.gov.on.ca
kdelarosbel@nemhc.on.ca
The Case Against Community Treatment Orders
Gary Chaimowitz, McMaster University
Community Treatment Orders (CTO) or their variants are now available in many parts of the world, yet their use
remains controversial especially outside the psychiatric profession. However whenever psychiatry claims to speak
for the rights of others, it is perhaps time to step back and re-evaluate the landscape for altruism has had, at times, a
dark heart.’ This presentation will outline the case against the use of CTOs. Several clear cautions seem to have
been ignored as a beleaguered profession resorts to what may be considered tools associated with being agents of
state control. Psychiatry is no stranger to coercive interventions – a utilitarian model attenuating the discomfort of
forced detention or treatment. Although making for odd bedfellows, the debate about the use of CTOs has also
highlighted the arguments of those who see treatment as a right and those who see it as a choice. The case for the
right to treatment has, perhaps disingenuously, been made to ‘force’ treatment on individuals whose psychiatric
illness arguably deprives them of choice.Various principles have operated in civil commitment, including the ‘least
restrictive alternative’. In fact, it is in the area of civil commitment, that psychiatrists are perhaps most often cast as
agents for state control. Moving from inpatient to ‘outpatient committal’ may often appear to be a less restrictive
alternative although the implicit expectation for medication adherence to maintain outpatient status – is a feature that
attracts the label of ‘coercion’. The view that CTOs represent paternalism, benevolent coercion respectful of
autonomy and liberty has been used to excuse the loss of liberty associated with this process. Ignoring the principles
of justice and fairness is the beginning of a slippery slope. The challenge to society is how to engage a marginalized
group in a treatment process without resorting to coercive measures.
chaimow@mcmaster.ca
Corrections and Mental Health II
Psychoimmunological Aspects of Imprisonment
N. Brandstätter,
B. Saletu,
E. Wienerroither,
S. Strnad,
T. Wenzel
Imprisonment must be assumed to be a live event impacting on the complex biopsychological system in a yet to be
understood way. To evaluate the effect of imprisonment 55 male prisoners from whom voluntary consent had been
obtained were compared to 55 age and sex matched healthy volunteers in regard to key immune and
neuroendocrinological parameters including Lymphocyte typing, Natural Killer Cell Activity, Zell-Aktivität, PHA
stimulation, Cytokins after PHA stimulation at baseline shortly after imprisonment and 2 months later (prisoners,
control group at baseline), parallel to questionnaires evaluating coping and coping strategies, including the german
language Streßverarbeitungsfragebogen (Stress Coping Questionnaire, SVF (Janke, Erdmann & Kallus
1984).Results indicate that in prisoners, natural killer cell activity was reduced both at baseline – shortly after
imprisonment and after two months. Heightened cortisol levels were accompanied by low natural killer cell activity,
while dysfunctional coping strategies in the SVF were accompanied by lower natural killer cell activity.
drthomaswenzel@web.de
Trauma, Dissociation and Posttraumatic Stress Disorder in Forensic Inpatients
Carsten Spitzer, Ernst-Moritz-Arndt-University
Manuela Dudeck, Ernst-Moritz-Arndt-University
Heike Liss, Ernst-Moritz-Arndt-University
Michael Gillner, Ernst-Moritz-Arndt-University
Harald J. Freyberger, Ernst-Moritz-Arndt-University
Given the high prevalence of trauma, dissociation and posttraumatic stress disorder (PTSD) in the general
population, psychiatric patients and criminal offenders, this study investigated the frequency of traumatic events,
dissociative symptoms and disorders and PTSD in forensic inpatients.
A total of 53 patients (51 men; 2 women) with a mean age of 32.6 years (s = 9.0) were studied with a structured
interview for the assessment of current and lifetime PTSD (Clinician Administered PTSD Scale, CAPS) and
dissociative disorders (Structured Clinical Interview for DSM-IV Dissociative Disorders, SCID-D). Furthermore,
participants were given a set of self-report measures on PTSD-related and dissociative symptoms as well as general
psychopathology (Modified PTSD Symptom Scale, MPSS; Dissociative Experiences Scale, DES; revised Symptom
Checklist, SCL-90).
We found that 64% of our study population reported at least one traumatic experience, and 56% of these met
lifetime criteria for PTSD. At the time of assessment 9 patients (17%) suffered from PTSD, which had not been
diagnosed prior to our study. The prevalence of dissociative disorders was 25% with the majority (8 patients of 13)
meeting criteria for dissociative disorders not otherwise specified (DDNOS). There was a substantial overlap
between PTSD and dissociative disorders with 20% of all participants suffering from both conditions. The findings
from the expert ratings were confirmed by the results of the self-report measures. Patients with PTSD and/ or
dissociative disorders exhibited significantly higher degrees of psychopathological impairment than those without a
comorbid PTSD and/ or dissociative disorders.
Our study indicates that traumatic events are often experienced by forensic inpatients leading to comorbid disorders
such as PTSD or dissociative disorders, which are frequently overlooked in the diagnostic process. However, these
conditions play a very important role for the therapy. For example, dissociative symptoms such as amnesia,
absorption, derealization and depersonalization as well as misperceptions of the environment might cause
difficulties in adequately understanding and responding to therapeutic interventions. Consequently, the therapist
must be aware that these patients tend to dissociate when confronted with trauma-associated cues which is likely to
result in a reduced responsiveness to therapeutic interventions. This, in turn, may result in a poorer medical and legal
prognosis.
spitzer@uni-greifswald.de
Taking the Mystery out of Designing Medium Secure Forensic Units: A Model of Collaboration
between a Clinical Program Administrator and an Architect
Shirley Pullan, Centre for Addiction and Mental Health, Toronto, Canada
Roman Mychajlowycz, Kleinfeldt Mychajlowycz Architects Inc., Toronto, Canada
The planning and design of medium secure forensic units poses challenges for Clinical Program Administrators and
Architects. Medium secure forensic units are complex in terms of the security features required to manage risk and
public safety, the needs of the target population and the additional components specific to clinical programming.
The ideal unit balances a therapeutic environment that is conducive to treatment and rehabilitation while ensuring
the secure detention of assigned patients. The combined expertise of the Clinical Program Administrator and the
Architect is essential to the successful design of a secure setting; however, initially obstacles may be inherent when
these professionals with such diverse backgrounds undertake to plan for these units. The optimal design and
planning process is dependent on the effective relationship between these individuals and is enhanced when a
reciprocal appreciation and understanding of the two complimentary levels of expertise exists between the two
participants.
The authors of this paper have collaborated on the design of a series of medium secure forensic units for over 10
years. They have developed an effective system that has resulted in the design of units that successfully incorporate
clinical program requirements with architectural concepts. The model adopted by the authors is based on the
premise that all security requirements for medium secure settings can be achieved without being unnecessarily
obstructive or inhibiting the needs of both patients and staff. The critical design features of a medium secure
forensic unit accommodate the effective monitoring of patient movement, the need for patient privacy, a secure
perimeter, the ability to segregate individual patients from the general population, adequate space dedicated to
social, recreational, clinical and vocational programs, and the ability to individualize privilege levels. The overall
design utilizes current technology and products that minimize the risk of self-harm by patients and the ability to
conceal or create potential weapons directed towards violence against others. The authors will outline a process for
the translation of clinical and risk management needs associated with medium secure settings into the design of an
environment that incorporates all of these elements.
Shirley_pullan@camh.net
roman@kma.to
Continuity of Care Models for Soon to be Released Offenders
Nancy A. Flanagan, University of Buffalo
In the last five years, there has been an increased focus on transitional planning in U.S. prisons for soon to be
released offenders. This interest in transitional planning is a result of increased numbers of offenders being released
from correctional facilities. Offenders have a higher incidence of mental health problems, substance abuse, and
concomitant communicable disease that occurs as a result of poor health promotion and disease prevention practices
before incarceration. Pre-release managed health care may increase ex-offender access to community health
services, ensure continuity of care, decrease the incidence of acute exacerbations, control the spread of
communicable disease, and reduce public health care costs. Outreach, discharge planning, entitlement applications,
and case management have been suggested pre-release managed health care methods for mentally ill offenders.
There are a variety of new and innovative US transitional health care programs for the mentally ill offender. In order
to identify the types of services, administrative complexities, and interdisciplinary activities of these new programs,
a field study of transitional health care models was undertaken. The results of a National Institute of Justice funded
study of models of transitional health care planning within state prisons in the United States will be reported. Study
subjects included chief medical officers in state correctional departments, coordinators of transitional health care
programs, and interdepartmental liaisons. The study design utilized field research observations and interviews to
assess current U.S. state prison models that provide continuity of care for soon to be released offenders with mental
illness.
The objectives of this presentation are to: 1. Compare procedures used to develop and implement current transitional
health care programs for soon to be released offenders with mental illness; 2. Describe current activities that provide
continuity of care for soon to be released offenders with mental illness; 3. Explain evaluation strategies for
transitional health care programs for offenders with mental illness; 4. Identify service provider recommendations for
transitional health care of the mentally ill offender; 5. Provide data that will assist correctional departments and
community public health care providers to develop managed re-entry health care for soon to be released offenders
with mental illness.
nf7@buffalo.edu
Group Psychotherapy with Bipolar Mood Disordered Forensic Patients
Sergio Santana, University of Alberta
The benefits of medication have dominated the literature on the treatment of bipolar disorder. However, even under
optimal clinical conditions, prophylaxis with well-established mood stabilizers, such as lithium, protects only 2550% of people with bipolar disorder against further episodes. In light of these findings, it is imperative that
clinicians explore other therapeutic avenues. Moreover, many authors have emphasized the benefits of using
different psychological interventions as adjunctive therapy. In the demanding field of forensic psychiatry, there are
only so many hours in the day with so many patients to see to develop and provide adjunctive psychotherapy. This
presentation will offer a relatively new approach to treating outpatients in forensic psychiatry that could potentially
alleviate acute symptoms, restore psychosocial functioning, identify early signs of relapse, and economically use
clinician’s time. A bipolar mood disorders group was established for forensic patients found not criminally
responsible for their crimes due to a mental disorder. Psycho-educative, psychodynamic, and narrative approaches
were the mainstay of the group. It appears that a psychotherapeutic group program for patients with bipolar disorder
may be established quite readily with the forensic population with positive implications for patient treatment
prognosis. The presentation will discuss the dynamics of establishing such a group and the implications for the
patient and for the treatment team, such as increased adherence to medication, greater acceptance of their illness,
treatment engagement, fewer hospitalizations, and improved efficacy of the treatment team.
sergio.santana@amhb.ab.ca
Personality Disorders I
Developing a new spectrum of services for people with personality disorders
Eddie Kane, UK Government Expert Advisory Group on Personality Disorder, London, England
Personality disorders are common and often disabling conditions. Whilst many people with personality disorders
are able to negotiate the tasks of daily living without too much distress there are others who, because of the severity
of their condition, suffer a great deal of distress and can place a heavy burden on family friends and those who
provide services and care for them. The stated objective of recent UK policy interventions in these services is to:

assist people with personality disorder to access appropriate clinical care and management from specialist
services

ensure that offenders with a personality disorder receive appropriate acre form services and interventions
designed both to provide treatment and to address their offending behaviour

establish education and training to equip staff across the wide range of agencies who deliver services
specifically or by default to people with a diagnosis of personality disorder
Following the creation of new high security units for Dangerous People with a Severe Personality Disorder (DSPD),
the UK government has promoted a set of further policy initiatives to improve services for people with a diagnosis
of personality disorder. In January 2001 national guidance on type, level and quality of services was published in a
document entitled ‘Personality Disorder: no longer a diagnosis of exclusion’.
This was followed by further national guidance on training and skills development for people from all agencies
offering services to individuals with personality disorder entitled ‘Breaking the Cycle of Rejection: the PD
capabilities framework’. This paper examines the impact of these policy initiatives and their impact on the
development of new services and the creation of a workforce capable of revitalising services for this socially
excluded group.
eddie.kane2@btinternet.com
Personality Disorder: From Diagnostic Category to Service Delivery – a Sociological Perspective
Nick Manning, University of Nottingham
'Personality disorder' has been a rapidly moving diagnostic category, but one which has attracted a range of new
service developments in the UK. In this paper some reflections are offered on the way such diagnostic categories
have evolved and on the development of services based upon them. These will be presented and analysed from the
perspective of the sociology of knowledge. Conditions that underlie the stabilisation of such categories, and the
policy and political consequences of basing services on them, will be reviewed.
Nick.Manning@notthingham.ac.uk
To move or not to move – that is the question! Some reflections on making critical decisions in the face
of uncertainty.
Conor Duggan, University of Leicester
Although the introduction of DSPD in Britain has been criticized, one major advantage is that it had attempted to
make explicit much of what has heretofore been implicit in psychiatric practice. For instance, in the future, the entry
criteria into the system will be anchored in the results from well-validated instruments and hence will be open to
challenge in a way that clinical impressions could never be. This ought to afford protection against inappropriate
detention for the individual assessed. This focus on entry criteria to the service while it is to be welcomed is
unfortunately not matched by a similar attention to exit criteria. If the purpose of the intervention is to reduce risk,
then how much does this risk have to be reduced to allow an individual to progress from one level of security to
another? This is a critical area as, without such movement, the system will inevitably silt up and thereby fail to meet
the expectations of service provider and user alike.
These decisions will inevitably be problematic given the lack of a proper evidence base that might justify them. For
instance, the evidence that interventions designed to reduce risk in those with a personality disorder (particularly
those who are most severely affected) or those who sexually offend, is almost non-existent. Given our current state
of knowledge, I argue that these decisions on transfer will inevitably be conjectural and seemingly arbitrary. One
consequence of this uncertainty is that the system will behave conservatively so that it is likely to detain more than
is necessary. This setting of the transitional bar at a very high level is likely to lead to very few being able to
progress. This has been the case elsewhere (e.g. the preventative detention of sex offenders in the U.S. where few
have met the criteria for release).
Given this state of affairs, we need to ask the flowing question: What are the conditions that a lower secure tier can
sensibly demand from the higher secure setting so that the patient can progress sensibly and safely from one tier to
another? One condition is that this lower tier will itself require an exit strategy of its own, that in turn will influence
(and be influenced) by the tier below it and so on until the patient reaches the community. With each reduction in
security, the demands are likely to become more stringent (as security decreases), thereby making the individual’s
journey increasingly problematic. How are we to overcome these barriers and thereby avoid the mistakes of the past
with silos of unwanted and unmanageable patients?
One consideration is that the traditional demarcation of services into autonomous tiers is unlikely to work within
such a system and a whole systems approach will be essential if the DSPD proposal is to be successful. To date,
mental health professionals have resisted this integrationist approach and this will be a major challenge to service
development in the future. In addition, a more explicit set of criteria need to be produced by lower tiers, again
ideally anchored by some evidence, that both patient and service providers are aware of from the outset and will
need to be attained in order to for the individual to progress. If this is taken to its logical conclusion, it will result in
the community provision setting the pace (a bottom-up approach) rather than the reverse. However, the
Government’s attention (wrongly in my view) has been to focus resources on the highest level of security rather than
that which is proposed here. Nestling uncomfortably between high and low security (i.e. in a medium secure
facility), is a useful position to reflect upon these tensions; this will be the focus of this presentation.
conor.duggan@nottshc.nhs.uk
Developing New Services for People with Personality Disorders: UK experiences
Nick Benefield, PD Development Programme, Department of Health, Manchester, England
Implementation in the UK of its Personality Disorder service development and training programmes has seen the
establishment of 17 new pilot services. These projects cover a range of service models for adolescents and adults in
the Forensic and non-forensic populations. Independent evaluation of these different services will be completed in
2006. Progress and preliminary findings will be described and key issues for learning discussed. The implications
for future strategic service planning in Personality Disorder services will be identified.
Joanne.Andrew@dh.gsi.gov.uk
Nick.Benefield@dh.gsi.gov.uk
Readiness for treatment, engaement and outcomes in the treatment of personality disordered offenders
Kevin Howells, University of Nottingham
It is increasingly accepted that psychological therapies have an important role to play in the management and
treatment of personality disordered offenders. There is some evidence to suggest that therapy can be effective in
bring about significant change for at least some offenders, although there are clearly also some individuals for whom
treatment is unlikely to be successful. In this paper I discuss what conditions (both intrapersonal and
situational) need to be present for therapeutic engagement and good outcomes to occur. It is proposed that the
concept of "readiness for treatment" is a useful one and that future research and clinical practice should focus on the
identification and modification of the various dimensions of readiness.
kevin.howells@notthc.nhs.uk
Personality Disorders II
A Multi-disciplinary Team Approach to Assessment and Individualised Treatment Interventions of
Personality Disordered Offenders within a High Security Prison
Caroline Doyle, Prison Service, Durham, England
Dave Matthews, Prison Service, Durham, England
HMP Frankland is one of eight High Secure Establishments within the High Security Directorate and is one of two
Prison Service DSPD Pilot sites. The Westgate Unit is a newly constructed 80 bedded unit within the establishment
that will deliver a structured DSPD assessment, treatment needs analysis, risk management package and a variety of
psychodynamic therapeutic individual based treatment plans to prisoners meeting the DSPD Criteria.
The DSPD assessment and treatment phases will be supported by a complementary regime delivered by a range of
multi-disciplinary team members. This regime is individually designed to address the personality disorder traits and
risk needs identified.
Each prisoner will have an individualised designed timetable incorporating formalised therapy with the
complementary regime supplementing this. Prisoners will also have optional sessions that will be discussed and
integrated into their treatment plans and targets. The complementary regime includes activities such as horticulture,
education, gymnasium, occupational therapies, primary care awareness, structured association and unit based work.
The multi-disciplinary team management approach ensures there is a flat structure, which leads to optimum levels of
communications. This team will be responsible and accountable for all decisions and negotiations within the unit.
Training on care and treatment of the personality-disordered prisoner within the DSPD Service will be provided and
delivered to all staff. The emphasis of recruiting staff through a structured core competency framework allows for
individual training analyses and appropriate skills utilisation.
The DSPD Service has developed intensive academic and clinical links with PCT’s, mental health services and
universities. Joint appointment and secondment opportunities enhance both the quality of staffs’ skills and care of
prisoners.
Caroline.doyle@hmps.gsi.gov.uk
Dave.matthews02@hmps.gsi.gov.uk
Research and Development: Plans and Progress
Matt Erikson, Dangerous and Severe Personality Disorder Programme, London, England
The DSPD pilot programme is aimed at providing protection for the public from some of the most dangerous
individuals in society, specifically those who present a high risk of sexual or violent offending and in whom a severe
disorder of personality is present. The DSPD programme also seeks to improve the health outcomes for this, often
neglected group, and work towards successful re-integration in to society. To support this ambitious and complex
programme of work a large raft of research has been initiated. The research programme has been determined
through consultation with a group of experts drawn from Psychiatry, Psychology, and Sociology. This group
provides invaluable assistance in a complex and developing field.
The research programme can be broadly divided into the following areas: The relationship between personality
disorders and serious offending. Dangerousness and personality disorders are complex areas. Improved
understanding the relationship between the two will be important to the effective treatment and management of this
group. The aetiology and development of personality disorder. This work is important in terms of the potential to
prevent the development of severe personality disorder and the behaviours associated with it. Additionally, greater
understanding may offer the potential to improve approaches to treatment. The validity and reliability of assessment
systems used in the programme. It is essential that the instruments that are used to identify this group are both valid
and reliable across different age groups, gender and ethnicity.
The development and evaluation of treatments for this often difficult, group is central to the aims of the programme.
Due to the challenging nature of this group they have often been neglected or excluded from treatment. Evidence
suggests that the efficacy of treatment for this group remains an open question. Robust evaluation of treatment forms
a large part of the research agenda. This presentation will provide an overview of current projects in these areas,
what will be delivered by them. Some recent results from this programme of work will also be presented.
Matt.erikson@homeoffice.gsi.gov.uk
Developing Services for Dangerous Offenders with Severe Personality Disorder
Savas Hadjipavlou, Dangerous and Severe Personality Disorder Programme, London, England
This paper will discuss the background, recent developments and future directions of the Dangerous and Severe
Personality Disorder Programme (DSPD). The Programme's aims are to create within the Prison and Health
systems in England and Wales the capacity to assess and treat the group of dangerous offenders with a high risk of
reoffending and whose offending is linked to severe forms of personality disorder. This group poses severe
challenges for prison, secure hospitals and in the management of risks in the community. The focus will be on the
lessons about the organisational challenges in putting in place such a programme, in terms of cross-agency working,
multiprofessional services and evaluation/research.
Savas.hadjipavlou@homeoffice.gsi.gov.uk
Attitudes, Training and Effectiveness in Working with Personality Disordered Offenders
Todd Hogue, Rampton Hospital, Nottinghamshire, England
Dr Karen D’Silva, Rampton Hospital, Nottinghamshire, England
Within clinical settings, there is an increasing recognition that the training and development of staff is an important
part of ensuring a competent workforce. However, beyond the development of the appropriate skills to undertake
relevant tasks, training also has an impact on the attitudes that individual hold to both their job and client group.
Such attitudes are likely to be particularly important when working with a difficult client groups such as individuals
with personality disorder or those thought to be dangerous and severely personality disordered (DSPD). This paper
overviews the possible effect that different attitudes towards personality disorder may have and discusses the need to
develop an effective measure of such attitudes. Initial work has been undertaken to develop a general measure of
attitudes towards personality disordered individuals, based on previous work relating to attitudes towards sexual
offenders. This measure was used as part of an evaluation into the impact of a training programme for new staff
working within The Peaks (DSPD) Unit. Using this as a measure, it was possible to examine the impact that
participating in a specialised staff training and development programme had on attitude change. As expected staff
attitudes towards working with a personality disordered population became more positive with training. The paper
discusses the implications of measuring attitudes towards a specific client group both in terms of measuring the
effects of training but also the possible effects those different attitudinal sets have for the development of therapeutic
alliance and patient change. The paper also discusses how these types of attitude measures might be used to examine
the general approach that clinicians across the health system take to working with personality disordered patients.
todd.hogue@nottshc.nhs.uk
karen.d’silva@nottshc.nhs.uk
Integrating Psychological Need and Public Protection in a Community Model for Personality
Disordered Offenders
Rob Leiper, Invicta Community Care NHS Trust, Kent, England
Jackie Craissati, Oxleas NHS Trust, Kent, England
The Department of Health has initiated a number of projects in the UK to develop medium secure and community
services for personality disordered offenders. These developments are independent of, but intended to complement,
the development of high secure services for Dangerous and Severely Personality Disordered offenders.
DHP – a six bedded hostel project with attached outreach team in southeast London – was specifically designed to
bridge the gap between community mental health services, criminal justice services and the voluntary housing
sector. Its aim is to target high risk, severely personality disordered offenders who already have a track record of
failing within the community and who are rejected from or not suitable for other community provision.
Existing models of care or agency co-ordination – for example, probation and police risk management procedures or
the care programme approach – do not address the full range of difficulties with which such offenders struggle, and
thus expose services to the possibility of splits and rivalries. Furthermore, the current climate of public protection
and associated media interest has meant that risk assessment has dominated the agenda, leaving little space for
consideration of psychological need.
The philosophy of care and containment adopted by the DHP attempts to address a model for personality disordered
offenders which integrates consideration of offending behaviour (and risk), mental health issues and psychological
need, and social adaptation and functioning. At the core of such a model lies individual formulation: informed by
actuarial assessments of risk, a clinical understanding of psychological functioning, and a physical and staff
structure which addresses interpersonal difficulties and social exclusion.
High risk personality disordered offenders often feel overwhelmed and disheartened when constrained by restrictive
avoidance strategies; their psychological difficulties often trigger a paradoxical effect in that risk unexpectedly rises
in response to external measures of containment. The DHP model reframes risk and need within a single model of
‘Good Lives’ (Ward & Stewart) which aims to collaborate with the offender in seeking a quality of life in which risk
variables are understood as obstacles to achieving an mutually agreed goal.
Jackie.craissati@oxleas.nhs.uk
Personality Disorders III
The Occupational Therapist’s Role in DSPD
Mark Spybey, St. George’s Hospital, Northumberland, England
Kimberley Pollard, St. George’s Hospital, Northumberland, England
Nicola Seddon, St. George’s Hospital, Northumberland, England
The DSPD programme is a joint initiative between the Department of Health, Home Office and Prison Service. The
programme involves working with some of the most difficult and dangerous people in society, and faces a range of
challenges in terms of assessment, treatment and management, as well as the delivery of effective services and the
longer-term prospects of reducing the risk of re-offending. (Home Office, 2004).
Traditionally, this client group has been deemed ‘difficult to treat.’ Livesley (2001) suggests that no single treatment
approach has a monopoly of success. Whilst a variety of psychological therapies and drug treatments are utilised,
other treatment models may be of use. Bateman and Tyrer (2001) suggest that it is overtly simplistic to believe that
personality disordered patients will respond to one particular form of therapy. Clients struggle to cope with chaotic
lifestyles, painful interpersonal functioning, social difficulties, vulnerability to self-destructive behaviours and the
complicating effects of being institutionalised.
Productive, sustained engagement in a wide variety of activities is a component of all DSPD programmes. In
addition to formal group and individual therapies, inmates will be encouraged to engage in activities, such as those
that relate to the enhancement of self-care, leisure and productivity skills. Occupational Therapy has been
recognised as a vital component of the rehabilitation process within forensic settings (Reed, 1992). Occupational
Therapy assessment will seek to establish the causes of occupational dysfunction, in particular identifying the
occupational risk factors impacting on the individual. Occupational Therapy theory refers to these risk factors as
critical deficits that result in both performance and volitional deficits that may complicate sustained engagement in
treatment (Whiteford, 2000). Through engagement in appropriate activity it is possible to assess and address some
of these factors. This paper will highlight how Occupational Therapists may contribute towards the assessment of
risk and the identification of strengths and needs; it will highlight some of the consequences of being able to access
activities that give structure and purpose to the lives of inmates and, by doing so, contribute towards the delivery of
a robust assessment and treatment programme.
mark.spybey@nmht.nhs.uk
High Security Services for Dangerous Severe and Personality Disorder – A Comparison of English
and Canadian Approaches
Tony Maden, Imperial College London
We describe the approach to risk reduction at the Regional Psychiatric Centre (RPC) in Saskatoon, Canada, making
legal and institutional comparisons with the new Dangerous and Severe Personality Disorder (DSPD) Service to be
established in high security hospitals in England and Wales.
The RPC applies cognitive behavioural techniques to reduce recidivism, and current evidence suggests the same
approach should form the core of the treatment regime in DSPD units. The key to success is the strict management
of programme integrity, to deliver intensive treatment that is tailored to the individual’s abilities and readiness to
accept change. The Stages of Change model, derived from addictions, allows the planning, monitoring and
evaluation of treatment. It plays an important role in maintaining staff morale by providing an objective measure of
success within a reasonable time frame. The DSPD service will require effective management and sophisticated
information systems to support these developments.
The RPC has the advantage of clear pathways through the service. Patients are able to return to an ordinary prison
whenever they wish, and the average length of stay is about two years. The DSPD service will have to guard against
beds becoming blocked by long-stay patients who have no way out of the service. Long term incarceration in
hospital is an expensive and inefficient way of protecting the public, and a unit with a high proportion of long-stay
patients would find it hard to sustain a therapeutic ethos, with a consequent threat to staff morale.
a.maden@ic.ac.uk
Dangerous and Severe Personality Disorder Unit (DSPD) in a High Security Hospital: The First Two
Years
Jose Romero Urcelay, Broadmoor Hospital, Berkshire, UK
Bicester Ward at Broadmoor Hospital was the first operational DSPD pilot unit in the NHS. This presentation will
give an open, honest and realistic account of the process of developing the unit in a climate of professional and
political controversy regarding the new concept of DSPD. It will describe the challenges we have encountered, the
lessons learnt from mistakes and the successes that we believe we have achieved. It will address the different
components of the process:
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Recruitment, Training, Support and Retention of Staff
Interaction with the rest of the Hospital
Patient characteristics
Treatment models and overall Therapeutic Programme
Future Challenges
Violence and Personality – Personality types in forensic patient with violent crimes
Alexandra Stupperich, University of Regensburg
Concerning the discussion about the connection of personality traits and personality disorders the study tested the
relationship between delinquency (non violent, violent and sadistic ), personality disorder and personality. We used
the Trierer Integrated Personality Inventory (TIPI Becker 2004), which bases on the 4PX factor model of personality
traits (Neuroticism, Extraversion / Openness, Agreeableness, and Conscientiousness). In addition, 34 facet scales are
measured. The TIPI was designed for the normal and disordered personality and was almost employed in
examination of perpetrators (Becker 2002).
We tested 94 male forensic patients with different crime backgrounds, but all sentenced to long ore lifelong
imprisonments (medium age 36, diagnosis categories: 49 Personality disorders, 33 mentally handicapped, 13
psychosis; crimes: 46 sexual offenders, 37 battery, 12 others; violence during crimes: 23 hands off, 57 hands on, 15
sadism). 104 conscript army soldiers serve as a control group (male, medium age 22, 15 with crimes, thereof 4 with
hands on violence).
Discriminant analyses separates forensic patients and controls by the “Big Four” (Chi2(4) = 57,9 p=.001; 75%
correct cl., kappa =.49), as well as by all 38 scales (Chi2(38)=169,9 p=.001, 93% c.cl., kappa =.85). Within patients,
diagnosis groups differed (Big Four: Chi2(8) =17,7 p=.03; 68% c.cl., kappa =.48; all 38 scales Chi2(76)=94,3
p=.08, 91% c.cl., kappa =.85). No differences between the groups hands on and hands off crimes appear, but sadistic
perpetrators are identified by the 38 scales (Chi2(38)=53,7 p=.05, 93% c.cl., kappa =.74). The crime groups didn’t
differ (Big Four Chi2(8)= 5,5 p=.69; 58% c.cl., kappa =.06; 38 scales Chi2(76)=68,7 p=.71, 80% c.cl., kappa =.65).
Logistic regression analysis shows 13 of the 34 facet scales as valuable predictors for group separation. Using
Cluster analysis for these selected scales four personality subgroup are identified. Cluster 1 and 2 are dominated by
patients with personality disorders (81 / 71 %) and patients who were sentenced cause of murder or battery. Cluster
2 and 4 were dominated by patients with intellectual disabilities (ID) (52 / 100%) which had as well sexual crimes,
as paedophilia as murder or battery.
Forensic patients present neuroticism, conscientious and a lack of agreeableness. However, this mostly holds for the
mentally handicapped; patients with personality disorders, as well as psychotic patients are not as outstanding.
Violence types are hart to peg, at least in the special patient group under study (high risk patients). Sadism relates to
a lack of companionability, self–confidence, and self-assertion, low zest for action and empathy, like almost
described in literature (Baumeister et al., 1999, Osterheider 2004).
Alexandra.stupperich@medbo.de
The Ripple Effect: The Evolving Alienation of Men with Disordered Personality Structure
Tom Gorman, Forensic Assessment and Community Services, Edmonton, Canada
While the treatment of abusive men has largely been conducted from a feminist or psychoeducational framework,
little attention has been paid to the fact that many abusive men, particularly those seen in forensic settings, have
personality disorders. Clinical experience suggests that men with different personality disorders show significant
differences in the nature, pattern and rationalization of their abusive behavior. Mr. Gorman will briefly review how
specific patterns of abuse are linked to specific personality disorders, in particular antisocial, narcissistic and
borderline personality disorders. He will also discuss ways to address these individual patterns within the group
context, and without losing the feminist and psychoeducational frameworks of family violence treatment. The goal
is to help men recognize and understand their particular personality characteristics and relationship patterns, and
how these characteristics and patterns impact themselves, their families and the community at large.
Mr. Gorman will also review the results of a pre- and post-testing instrument designed for the family violence group.
The instrument is based upon the Situational Competency Test designed for sex offenders. The men are presented
with, and asked to respond to, audio-taped descriptions of relationship situations depicting such issues as jealousy,
challenges to power, partner leaving, partner refusing sex, and conflict. Their responses are videotaped. The men
are rated on complexity and effectiveness of response, use of cognitive skills, use of social skills, evidence of
responsibility, evidence of empathy, and other factors. The men’s behavioural and cognitive responses will reflect
the above-mentioned link between specific personality disorders and specific behavioural patterns. Results of the
post-treatment tests will highlight which interventions are most likely to be effective in helping these men discover
and use alternatives to violent and abusive behaviours.
tomgorman@cha.ab.ca
Police and Mental Health
Alberta’s Provincial Diversion Program
Laurie Beverley, Alberta Mental Health Board, Calgary, Canada
The Mental Health and Justice Partnering Deputies Committee is the accountability structure for Alberta Mental
Health Board’s cross-ministerial initiatives related to individuals with mental illness who are in conflict with the
law. This committee consists of the ministries of Health and Wellness, Solicitor General, Justice and Attorney
General, Children’s Services, Aboriginal Affairs and Northern Development, Human Resources and Employment,
Community Development, and the Chief Executive Officers from the Alberta Mental Health Board (AMHB) and
Alberta Alcohol and Drug Abuse Commission (AADAC). Alberta’s Provincial Diversion Program amongst other
initiatives has been developed with cross-ministerial involvement and support. This has fostered an integrated
approach to improving service delivery to individuals with mental illness who are in conflict with the law.
The purpose of the diversion program is to ensure that, whenever possible, adults and adolescents with mental
illness who are in conflict with the law receive appropriate care, support and treatment from mental health, social
and support services thereby reducing reliance on the criminal justice system.
In 2001, in response to Alberta’s goal of supporting healthy and safe communities, the Provincial Diversion
Committee—consisting of numerous ministry and agency representatives—was formed to develop the Provincial
Diversion Framework (2001). Specifically, the framework was designed to guide the development of services and
targeted diversion strategies. Subsequently, a Proposed Implementation Plan (2002) and the Phase One
Development (2003) reports were completed. The overall goal is to provide a set of provincial standards and
guidelines for Alberta’s communities involved in the diversion of individuals with mental illness who are in conflict
with the law. The intent is to capitalize on the existing resources and expertise within communities, and if necessary
to augment resources as needed. AMHB co-chaired the committee along with Alberta Solicitor General.
In May 2003, the Partnering Deputies Committee approved the Provincial Diversion Implementation Plan: Phase
One Development document, along with the establishment of the Provincial Diversion Program Advisory
Committee with representation from current partners, regional health authorities, community stakeholders, and
consumer groups. The author, as co-chair of this committee and initiative, will present an overview of the process
incorporated, work completed, and activities currently in progress.
laurie.beverley@amhb.ab.ca
Learning the Hard Way: Inquest Findings from Police Shootings of Mentally Ill Individuals
Terry Coleman, Moose Jaw Police Service, Moose Jaw, Canada
One of the inevitable consequences of deinsitutionalization has been a significant increase in the number of
interactions between the police and individuals with mental illnesses. While the vast majority of these incidents are
minor and may not even involve any type of criminal activity, there are a few instances in which a mental health
crisis develops into something much more significant, with tragic outcomes. During the ten year period 1992-2002,
13 mentally ill individuals died in interactions with the police in Canada. While the specifics of the interactions
varied, in each case, an inquest followed and an examination of the factors that lead to the fatal encounters occurred.
The inquest reports varied from a single handwritten page, to over 400 pages of detailed analysis and
recommendations. A review of these recommendations suggests that remedies are complicated and entail much
more than simple training or service provision. This paper will review the inquest findings over the ten year period
and look at the themes that have emerged and their implications for both police services and mental health services,
both as individual agencies and as unexpected partners in the care of mentally ill individuals living in the
community.
tcoleman@city.moose-jaw.sk.ca
Police Interactions with Individuals with Mental Illnesses: Canadian Solutions
Dorothy Cotton, Correctional Service Canada, Kingston, Canada
Since the advent of the deinstitutionalization of individuals with mental illness in the last few decades, much of the
responsibility for attending to these individuals has fallen to the police--a group which has not traditionally been
viewed as mental health care providers. But what constitutes an appropriate police response when individuals with a
mental illness are involved? This paper will provide an overview of the components of a comprehensive police
response to situations involving a person with mental illness in Canada. Much attention has been paid to the
development of crisis response models--these include models that involved intensive officer training, joint mental
health/police response, and other cooperative and collaborative models. Examples of how these models are used in
Canada will be presented and how each different model suits different geographic needs, depending on population
composition and size, policing style, availability of mental health services and other local characteristics.
But crisis response is only one component of police response. Other essential components which will be discussed
include:
 the need of formal management level coordination between systems (e.g. clear policy development in both
police and mental health system, liaison committees for problem solving, development of specific outcome
measures, information sharing mechanisms)
 alterative police approaches for working with mentally ill individuals who may be victims of crime or may
be the subject of interrogation
 educational needs (including education at the student/recruit level and continuing education for senior
personnel; and the need for both professional specific and join training initiatives)
 diversion alternatives (including pre and post charge diversion as well informal alternatives)
 linkages between correctional facilities, police and mental health agencies including forensic hospital
settings in order to minimize recidivism and maximize community integration
 applied research and evaluation
 mental health legislation needs
The goal of the presentation is to provide a blueprint for police services, correctional/forensic services and mental
health agencies to work cooperatively in providing a comprehensive community response to individuals with mental
health problems who come in contact with the criminal justice system.
cottondh@csc-scc.gc.ca
Towards an Integrated Psychiatric Emergency Service @ the Ottawa Hospital: Integrating Emergency
Psychiatry, Mobile Crisis, Police Mental Health Unit and Early Intervention Programs
Colleen MacPhee, The Ottawa Hospital, Ottawa, Canada
Claudia Hampel, The Ottawa Hospital, Ottawa, Canada
Bruce Kennedy, The Ottawa Hospital, Ottawa, Canada
Peter Linegar, Ottawa Police Services – Mental Health Unit, Ottawa, Canada
Louis Soucy, The Ottawa Hospital, Ottawa, Canada
Paul Roy, The Ottawa Hospital, Ottawa, Canada
The TOH is a 1,060 bed academic Health Sciences centre. TOH has 3 campuses and provides health care services in
French and English to over 1.5 million residents of Eastern Ontario. Through the process of Mental Health Reform,
TOH has received dedicated funding for first-line mental Health services including: psy