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5Table of Contents1. Pre-Congress: July 2, 2005............................................................................................................. 112. Pre-Congress: July 3, 2005............................................................................................................. 163. Advance Directives ........................................................................................................................ 204. Advocacy I ..................................................................................................................................... 235. Alterity – Our Relationship with the Other .................................................................................... 266. Assessment and Treatment of Sex Offenders in Switzerland......................................................... 307. Capacity and Consent I .................................................................................................................. 328. Capacity and Consent II ................................................................................................................. 369. Capacity, Consent and Advance Directives ................................................................................... 3910. Children and Mental Health Treatment.......................................................................................... 4111. Children and Mental Health: Forensic Care in Youth Prisons ....................................................... 4512. Children and Mental Health: The Elusive ‘Best Interests’ Principle?............................................ 4713. Children and Sexual Abuse ............................................................................................................ 5114. Children and Trauma I: Assessment and Intervention ................................................................... 5315. Civil Liability and Mental Health I ................................................................................................ 5616. Civil Liability and Mental Health I: Issues in Servicing Problematic Groups ............................... 5817. Civil Liability and Mental Health II............................................................................................... 6118. Clinical Criminology in the Italian Context I................................................................................. 6319. Clinical Criminology in the Italian Context II................................................................................ 6620. Clinical Criminology in the Italian Context III .............................................................................. 6921. Clinical Criminology in the Italian Context IV..............................................................................7122. Clinical Criminology in the Italian Context V ...............................................................................7223. Competency Issues in Law and Psychiatry .................................................................................... 7424. Compulsory Community Treatment Orders I................................................................................. 7725. Compulsory Community Treatment Orders II ............................................................................... 8126. Compulsory Community Treatment Orders III.............................................................................. 8327. Compulsory Community Treatment Orders IV: ‘The Ontario Experience’................................... 8628. Compulsory Community Treatment Orders V: ‘The Ontario Experience’ .................................... 8929. Contemporary Challenges in Law and Psychiatry ......................................................................... 9230. Corrections and Mental Health I .................................................................................................... 9431. Corrections and Mental Health II................................................................................................... 9832. Criminal Responsibility I ............................................................................................................. 10133. Criminal Responsibility II............................................................................................................ 10434. Cultural issues in Adolescent Forensic Psychiatry I .................................................................... 10835. Culture and Context I: Culture and Context in Programme Design............................................. 11036. Culture and Context II: Definitional Issues on Mental Health and Treatment ............................ 11337. Culture and Legal Insanity I......................................................................................................... 11638. Culture and Legal Insanity II ....................................................................................................... 11939. Death Penalty I: Historical and Theoretical Perspectives............................................................. 12140. Death Penalty II: Practical Concerns............................................................................................ 12441. Death Penalty III .......................................................................................................................... 12642. Definitional Problems in Forensic Psychiatry.............................................................................. 12843. Depressive Disorders: Trends and Challenges ............................................................................ 13244. Diagnosis and Treatment of Mentally Ill Offenders I .................................................................. 13545. Diagnosis and Treatment of Mentally Ill Offenders II ................................................................. 13846. Dignity Theory and Mental Health Policy ................................................................................... 14047. Diversion of the Mentally Ill from the Criminal Justice System.................................................. 14448. Domestic Violence I..................................................................................................................... 14749. Domestic Violence II: Domestic Violence and the Psychological Impact of theJustice System .............................................................................................................................. 149

106. Lifelong Internment in Switzerland ............................................................................................. 311107. Memory under High Stress .......................................................................................................... 313108. Mental Disability I: Exploring the Intersection between Mental Disability Law andInternational Human Rights Law .................................................................................................315109. Mental Disability II: Mental Disability and Human Rights: The Domestic and RegionalContext......................................................................................................................................... 318110. Mental Disability III: Rights of People with Intellectual Disabilities within Europe................... 321111. Mental Disability IV: Mental Illness and Community Integration............................................... 324112. The Role of Specialized Courts: Mental Health and Addiction I................................................. 328113. The Role of Specialized Courts: Mental Health and Addiction II................................................ 331114. Mental Health, Human Rights and Social Justice ........................................................................ 333115. Mental Healthcare Financing in the USA .................................................................................... 337116. Multiculturalism and Minorities I ................................................................................................ 339117. Multiculturalism and Minorities II............................................................................................... 342118. Munchausen Syndrome by Proxy................................................................................................. 345119. Narcissism and its Relationship to Civil and Criminal Law......................................................... 349120. Neuro-biology and Mental Health: Jurisprudential Issues ........................................................... 351121. Personality Disorders I................................................................................................................. 353122. Personality Disorders II................................................................................................................ 356123. Personality Disorders III .............................................................................................................. 359124. Police and Mental Health ............................................................................................................. 362125. Polygraphy with Sex Offenders ................................................................................................... 366126. Post-traumatic Stress Disorder and the Law I .............................................................................. 368127. Post-traumatic Stress Disorder and the Law II............................................................................. 371128. Psychiatric Morbidity in Corrections I......................................................................................... 374129. Psychiatric Morbidity in Corrections ll: ‘The Irish Prison Population’........................................ 379130. The Psychology of Terrorism....................................................................................................... 383131. Psychopathy and Justice: Critical Perspectives............................................................................ 386132. Psychopathy in Juveniles I ........................................................................................................... 388133. Psychopathy in Juveniles II.......................................................................................................... 391134. Rap, Hip-Hop, and Pop: The Impact of Popular Culture and Adolescent Behaviorin the USA and in Latin American Societies................................................................................ 394135. Recent Developments in the Treatment and Care of Chronic Offenders inGermany and the Netherlands ...................................................................................................... 397136. Recidivism ................................................................................................................................... 400137. Refugees and Asylum Seekers ..................................................................................................... 401138. Rehabilitation of Forensic Patients............................................................................................... 404139. Relational Ethics in Forensic Settings.......................................................................................... 407140. Research Ethics I: Research Ethics and Clinical Practice ............................................................ 410141. Research Ethics II: Research Ethics and Clinical Practice........................................................... 414142. Risk Assessment I: Psychometric Developments in Forensic Psychiatry ................................... 416143. Risk Assessment II: ‘Violence Profiling in Forensic Psychiatric Patients’.................................. 420144. Risk Assessment III: Risk Assessment in Forensic Practice........................................................ 423145. Schizophrenia in Forensic Populations ........................................................................................ 426146. Screening and Diagnostic Assessments of Young Offenders....................................................... 428147. Seclusion in The Netherlands....................................................................................................... 431148. Self-Destructive Behaviours in Prison I....................................................................................... 434149. Self-Destructive Behaviours in Prison II...................................................................................... 437150. Semiotics and Social Significance of Violence............................................................................ 440151. Sentencing of Juveniles Who Commit Serious Offences............................................................. 442152. Sex Offenders I: Key Issues......................................................................................................... 445153. Sex Offenders II: Law, Justice and Therapy ................................................................................ 448154. Sex Offenders III: Law, Justice and Therapy II ........................................................................... 452155. Sex Offenders IV: Law, Justice and Therapy III.......................................................................... 454156. Sex Offenders V: New Approaches ............................................................................................. 457157. Sex Offenders VI.......................................................................................................................... 4597

8158. Social Exclusion, Mental Health and Criminal Law .................................................................... 462159. SSRIs and Collisions Between Medical, Legal and Regulatory Worlds...................................... 464160. Stalking Current Clinical Challenges and International Perspectives I........................................ 467161. Stalking Current Clinical Challenges and International Perspectives II....................................... 470162. Stigma I ........................................................................................................................................ 474163. Stigma II: Experiences of Mental Disorder..................................................................................476164. Substance Abuse and Jazz............................................................................................................ 479165. Substance Abuse in Sweden......................................................................................................... 482166. Substance Abuse I: Amphetamines, Mental Health and Law ...................................................... 486167. Substance Abuse II: Forensic Aspects in Different Contexts....................................................... 490168. Suicide.......................................................................................................................................... 493169. Survivors of Persecution and Torture I ........................................................................................ 496170. Survivors of Persecution and Torture II ....................................................................................... 499171. Survivors of Persecution and Torture III...................................................................................... 501172. Survivors of Persecution and Trafficking: A Review of Current Issues ...................................... 504173. Terminal Illnesses, Euthanasia and Assisted Suicide I................................................................. 507174. Terminal Illnesses, Euthanasia and Assisted Suicide II ............................................................... 509175. Terrorism and the Unknown Enemy ............................................................................................512176. Therapeutic Jurisprudence I: Problem Solving Courts................................................................. 515177. Therapeutic Jurisprudence II: Problem Solving Courts II............................................................ 518178. Therapeutic Jurisprudence III: Problem Solving Courts III ......................................................... 521179. Therapeutic Jurisprudence IV: Expanding Problem-Solving Courts to the Family Court ........... 523180. Therapeutic Jurisprudence V: The Role of the Lawyer............................................................... 526181. Trauma and Torture: The Psychosocial Dimensions.................................................................... 529182. Treatment of Serious and Violent Juvenile Delinquents .............................................................. 532183. University and Research in the Netherlands ................................................................................ 535184. Treatment Programmes for Treatment Resistant Groups ............................................................. 538185. Work and Mental Health I............................................................................................................ 540186. Work and Mental Health II .......................................................................................................... 543187. Young Offenders.......................................................................................................................... 546188. Young Offenders: Diagnostic Assessment................................................................................... 549189. Young Offenders: Epidemiology and Follow-up I....................................................................... 551190. Young Offenders: Epidemiology and Follow-up II ..................................................................... 554191. Young Offenders: Neurobiology of Aggression .......................................................................... 556192. Young Offenders: Offending Through the Life Cycle ................................................................. 559Section Francophone.................................................................................................................................562193. Plénière......................................................................................................................................... 563193. Bloc 1, no 1 .................................................................................................................................. 563194. Bloc 1, no 2: ................................................................................................................................. 564195. Bloc 1, no 3 .................................................................................................................................. 565196. Bloc 1, nos 4 et 5.......................................................................................................................... 565197. Bloc 1, no 6 .................................................................................................................................. 566198. Bloc 2, no 7 .................................................................................................................................. 568199. Bloc 2, no 8 .................................................................................................................................. 568200. Bloc 2, no 9 .................................................................................................................................. 569201. Bloc 2, nos 10 et 11...................................................................................................................... 570202. Bloc 3, no 12 ................................................................................................................................ 571203. Bloc 3, nos 13 et 14...................................................................................................................... 571204. Bloc 3, nos 15 et 16...................................................................................................................... 572205. Bloc 3, nos 17 et 18...................................................................................................................... 573206. Bloc 3, nos 19 et 20...................................................................................................................... 574207. Plénière......................................................................................................................................... 575208. Bloc 4, no 21 ................................................................................................................................ 576209. Bloc 4, nos 22 et 23...................................................................................................................... 576210. Bloc 4, nos 24 et 25...................................................................................................................... 578

9211. Bloc 4, nos 26 et 27...................................................................................................................... 579212. Bloc 4, nos 28 et 29...................................................................................................................... 581213. Bloc, nos 30 et 31......................................................................................................................... 582214. Bloc 5, nos 32 et 33...................................................................................................................... 583215. Bloc 5, nos 34 et 35...................................................................................................................... 585216. Bloc 5, no 36 ................................................................................................................................ 586217. Bloc 5, nos 37 et 38...................................................................................................................... 587218. Bloc 6, no 39 ................................................................................................................................ 588219. Bloc 6, no 40 ................................................................................................................................ 589220. Bloc 6, no 41 ................................................................................................................................ 590221. Bloc 6, nos 42 et 43...................................................................................................................... 590222. Bloc 6, no 44 et 45 ....................................................................................................................... 592223. Bloc 6, no 46 ................................................................................................................................ 593224. Bloc 7, no 47 ................................................................................................................................ 594225. Bloc 7, no 48 ................................................................................................................................ 597226. Bloc 7, no 49 ................................................................................................................................ 598227. Bloc 7, nos 50 et 51...................................................................................................................... 599228. Bloc 7, nos 52 et 53...................................................................................................................... 600Author Index..............................................................................................................................................601

111. Pre-Congress: July 2, 20051.1. Animal Models of Addiction: Relevance for Understanding the Neurobiology ofAddictionGeorge Koob, Scripps Research Institute, La Jolla, USA (gkoob@ucsd.edu)Drug addiction has been conceptualized as compulsive drug taking with a loss of control over intake thatreflects an impulse control disorder beginning with positive reinforcement and shifting to a compulsivedisorder with negative reinforcement. Under this framework, drug addiction is composed of threecomponents: a binge/intoxication stage, a withdrawal-negative affect stage, and apreoccupation/anticipation (craving) stage. Animal models for various stages of the drug abuse cycle havebeen developed and are providing a rational basis for our understanding of the neurobiology of addiction.Animal models of the binge/intoxication stage include drug self-administration, place preference, brainreward thresholds, and escalated drug intake associated with extended access. Animal models for thewithdrawal/negative affect stage include place aversions and brain reward threshold measures. Animalmodels for the preoccupation/anticipation (craving) stage include drug-, stress- and cue-inducedreinstatement and drug taking following abstinence and withdrawal. Common neurobiological elementsthat follow the shift from impulsive to compulsive dysregulation in drug addiction include compromisedbrain reward and stress systems and is comprised of key elements of a basal forebrain macrostructuretermed the extended amygdala and its connections. Neuropharmacologic studies in animal models ofaddiction have provided evidence for the dysregulation of specific neurochemical mechanisms in specificbrain reward systems in the extended amygdala (opioid peptides, γ-aminobutyric acid, glutamate anddopamine). There also is recruitment of brain stress systems (corticotropin-releasing factor andnorepinephrine) and dysregulation of brain anti-stress systems (neuropeptide Y) that provide the negativemotivational state associated with drug abstinence. The changes in the reward and stress systems arehypothesized to maintain hedonic stability in an allostatic state, as opposed to a homeostatic state, and assuch convey the vulnerability for development of dependence and relapse in addiction. Future challengescenter on identifying the molecular and cellular changes that contribute to the neuroadaptations withinspecific motivationally relevant neurocircuits associated with transition to dependence, motivationalwithdrawal, protracted abstinence and vulnerability to relapse.1.2.Processing of Reward Information by Dopamine Neurons and Other Brain StructuresWolfram Schultz, Cambridge University (ws234@cam.ac.uk)Information about rewards is processed in a number of brain structures, such as the dopamine system,striatum and orbitofrontal cortex. We found in formal learning paradigms that dopamine neurons detect theextent to which rewards occur differently than predicted, thus coding an 'error' in the prediction of reward.Together with their anatomical organization and influence on postsynaptic structures, dopamine neuronsmay thus serve as explicit teaching signals mediating changes in immediate responses and learning.Neurons in the orbitofrontal cortex discriminate well between different rewards irrespective of the positionsand objects of the stimuli predicting them and may serve as a highly sensitive reward-discriminatingsystem. Neurons in the striatum incorporate reward information into activity related to the preparation andexecution of movements leading to the reward, thus possibly reflecting a neural mechanism underlying

12goal-directed behavior. We then investigated how reward neurons in these structures might code basicmicroeconomic decision variables and deal with uncertainty. Reward neurons are sensitive to variablessuch as magnitude and probability of reward, as well as their combination (expected reward value:probability x magnitude of reward). Neurons in all mentioned reward structures adapted their coding rangeand input-output gain to the uncertainty of rewards determined by predictions. The coding of predictionerrors by dopamine neurons further improved the coding of reward information. In addition, we found thata slower response in dopamine neurons signalled explicitly the uncertainty of reward, being maximal at aprobability of 0.5. These results suggest common neural mechanisms underlying the efficient coding ofbasic variables of learning theory and game theory.1.3. Dopamine and Drug Addiction: Focus on the n.accumbens shellGaetano DiChiara, University of Cagliari (diptoss@tin.it)Microdialysis studies in animals have shown that addictive drugs preferentially increase extracellulardopamine (DA) in the n. accumbens (NAc). Brain imaging studies, while extending these finding tohumans, have shown a correlation between psychostimulant-induced increase of extracellular DA in thestriatum and self-reported measures of liking and `high´ (euphoria). Although a correlate of drug rewardindependent from associative learning and performance is difficult to obtain in animals, conditioned tasteavoidance (CTA) might meet these requirements. Addictive drugs induce CTA to saccharin most likely as aresult of anticipatory contrast of saccharin over drug reward. Consistently with a role of DA in drug reward,D2 or combined D1/D2 receptor blockade abolishes cocaine, amphetamine and nicotine CTA. Intracranialself-administration studies with mixtures of D1 and D2 receptor agonists point to the NAc shell as thecritical site of DA reward. NAc shell DA acting on D1 receptors is also involved in Pavlovian learningthrough pre-trial and post-trial consolidation mechanisms and in the utilization of spatial short-termmemory for goal-directed behavior. Stimulation of NAc shell DA transmission by addictive drugs is sharedby a natural reward like food but lacks its adaptive properties (habituation and inhibition by predictivestimuli). These peculiarities of drug-induced stimulation of DA transmission in the NAc shell result instriking differences in the impact of drug-conditioned stimuli on DA transmission. It is speculated that drugaddiction results from the impact exerted on behavior by the abnormal DA stimulant properties acquired bydrug-conditioned stimuli as a result of their association with addictive drugs.1.4. Cognitive Sequelae or Correlates of Chronic Drug Abuse in Humans andExperimental AnimalsTrevor Robbins, Cambridge University (t.robbins@psychol.cam.ac.uk)Considerable evidence exists of severe cognitive sequelae following the chronic abuse of psychomotorstimulant drugs such as cocaine and amphetamine, which are potentially relevant to rehabilitation outcomeas well as to the exacerbation of addiction. However, establishing the neural correlates and causal basis ofthese is difficult because of interpretative problems of controlling drug exposure, and multivariate factorsassociated with addiction including polydrug abuse and premorbid traits. This presentation reviews ourprevious evidence for impaired decision-making cognition and extends it by describing the results of arecent in press study (Ersche et al) in which a group of stimulant abusers volunteered for a functionalimaging study of decision-making cognition using PET. We also report new neuropsychological evidenceof executive and memory deficits in groups of amphetamine and opiate users and ex-users. We probedcausality by testing rats on a fronto-executive test of cognition before and after chronic i.v. self-

13administration of cocaine, heroin or amphetamine. Results indicated significant, but not long-lasting,deficits in executive control in the drug self-administering groups. However, profound and long-lastingdeficits were observed in a sub-group of rats previously shown to be impulsive on the cognitive test.1.5. Drug Addiction: The Neurobiology of Loss of ControlNora Volkow, National Institute on Drug Abuse, Bethesda USA (volkow@bnl.gov)Drug addiction manifests as a compulsive drive to take a drug despite serious adverse consequences. Thisaberrant behaviour has been traditionally viewed as bad ‘choices’ voluntarily made by the addict.However, recent studies have shown that repeated drug use leads to long-lasting changes in the brain thatundermine ‘voluntary control’. This, together with new knowledge on how environmental, genetic anddevelopmental factors contribute to addiction, is changing how we prevent and treat addiction.1.6. Imaging of Learning and Memory with AddictionB. J. Everitt, University of Cambridge (b.everitt@psychol.cam.ac.uk)The ways in which associative learning influences the establishment of addictive behaviour will bediscussed. Both pavlovian and instrumental conditioning contribute to the development of compulsivedrug-seeking and this will be illustrated by experiments that define the major impact that drug-associatedconditioned reinforcers have on compulsive cocaine-seeking in rats. These cocaine-associated conditionedreinforcers can support the learning of new, instrumental drug-seeking responses and also have a persistenteffect on drug seeking behaviour that is difficult to extinguish. Conditioned reinforcement effects on drugseeking can readily be demonstrated months after the last drug taking experience and this underlies theimpact of drug cues not only on drug seeking, but also in models of relapse. The neural mechanismsunderlying the conditioned reinforcing properties of cocaine-associated stmuli have been shown to dependupon interactions between the basolateral amygdala and nucleus accumbens as well as upon dopaminergictransmission in the amygdala and glutamatergic transmission in the nucleus accumbens. Understanding theneural and neurochemical basis of conditioned influences on drug-seeking and relapse has suggestedpossible therapeutic approaches to the treatment of addictive behaviour, especially the prevention ofrelapse. Data on the effects of a selective antagonist at D3 dopamine receptors in the amygdala willdemonstrate this point Finally, a novel procedure for studying the transition between drug use and drugaddiction in rats, by modelling the development of resistance to adverse environmental contingenciesduring the seeking of cocaine will be discussed.1.7. Social Context, Cocaine Abuse and Brain Function in a Monkey ModelMichael A. Nader, Wake Forest University (mnader@wfubmc.edu)Animal models vary in their ability to resemble the human condition in terms of etiology, symptomatologyand prognosis. Animal models of drug self-administration are valid and reliable models of human drug

14addiction. The present studies utilize a novel model involving socially housed monkeys and intravenouscocaine self-administration. In addition, the use of the non-invasive imaging procedure positron emissiontomography (PET) has allowed for the study of brain changes due to drug use. This presentation willhighlight the use of nonhuman primate models to better understand the neuropharmacology of cocaineabuse related to vulnerability, maintenance and relapse. In particular, these data will be used to betterunderstand the influences of genetic predisposition and environmental determinants of cocaine addiction,with a primary focus on dopamine (DA) D2 receptors. Social rank of monkeys influenced D2 receptorfunction and vulnerability to the reinforcing effects of cocaine, suggesting that environmental variables(both stressors and enrichers) can impact vulnerability to drug use. Chronic (up to 1 year) exposure tococaine resulted in changes in brain function and in the reinforcing effects of cocaine. Finally, duringabstinence, there were individual differences in rates of recovery of D2 receptor function as measured byPET, and in measures of relapse. The goal of future studies is to better understand how environmentalvariables impact on a hallmark of drug addiction, namely individual differences in susceptibility andrelapse to drug addiction, with the goal of designing better treatment strategies for drug addiction.1.8. New Treatments for Addictive DisordersCharles O’Brien, University of Pennsylvania (obrien@mail.trc.upenn.edu)The definition of addiction has changed markedly since the 1980s. Whereas drug tolerance and physicaldependence (evidenced by withdrawal symptoms on abrupt cessation of the drug) were previouslyemphasized, with the publication of the DSM-IIIR criteria, the presence of compulsive drug-seekingbehavior became recognized as the essence of addiction. These criteria provided a reliable diagnostic toolthat has been adopted, along with ICD10 with which it is consistent, by clinicians all over the world.Tolerance and physical dependence are now known to be normal adaptive phenomena that occur in allpeople who are treated chronically with a wide range of medications including beta-blockers andantidepressants, as well as all opioid drugs. The presence of tolerance and physical dependence does notimply addiction.There is increasing evidence that addiction is a disease of the brain with an underlying physiology similarto other long-term memories. Using brain imaging techniques, it has been demonstrated that cuesassociated with drug-taking provoke limbic system activation long after drug taking has stopped.Moreover, changes in brain receptors with chronic drug use have been observed. Research has alsodemonstrated deficits in frontal lobe inhibitory mechanisms in addicts that could either be a consequence ofdrug use or a vulnerability factor that predisposes to addiction.The course of addiction is similar to that of other chronic diseases such as asthma, diabetes, orhypertension. There are remissions and relapses and there are now a wide range of medications for each ofthe addictive disorders. Behavioral treatments have been improved and the best therapy is now consideredto be a combination of medications and behavioral treatments. Even with the best treatment, however,cures are rarely obtained and relapses continue to be a problem for years after the initiation of treatment.As with other chronic diseases, therefore, it is not logical to simply stop treatment at some point and expectthe patient to have no further relapses. The data on medications for the prevention of relapse as obtainedfrom randomized, controlled, clinical trials will be reviewed.

172.3. Drug Abuse and Crime: The Intersection of Public Health and Public SafetyJames A. Inciardi, National Institute on Drug Abuse, Bethesda, USA (james.inciardi@mvs.udel.edu)Over 50 percent of adults incarcerated in U.S state and federal prisons acknowledge using alcohol or drugsat the time of their offense. It is estimated that 70 to 85 percent of the 6.9 million adults incarcerated or onparole have substance abuse problems, but only 13 percent receive treatment under correctionalsupervision. Without treatment, offenders with substance abuse problems often relapse to drug use andcriminal behavior. Research has demonstrated that providing treatment services to offenders withsubstance abuse problems is an effective strategy for reducing crime and substance abuse. Criticalquestions remain as to what types of substance abuse treatment programs and services work best withoffenders and how to integrate them into criminal justice settings. This presentation will provide anoverview of the connection between drug use and crime, examine key principles of effective drug treatmentwith offender populations, and highlight research efforts underway to integrate substance abuse treatmentand services within criminal justice settings.2.4. Drug courts: Using Treatment and Accountability to Stop the Revolving Door inJusticeKaren Freeman Wilson, National Drug Court Institute, Alexandria, USA (kfwilson@nadcp.org)Drug courts are special court dockets that treat non-violent drug offenders through the use of acomprehensive approach directed at changing offenders’ lifestyles. A dedicated team of judges,prosecutors, defense counsel, treatment professionals, therapists, social service professionals, lawenforcement personnel and others work together to monitor participants on a consistent basis. Participantsare required to participate in treatment and other mental health counseling, undergo urine tests, performcommunity service, pay program fees, obtain employment or further their education and engage inactivities that lead to sustain recovery.The first drug treatment court was established in Miami, Florida in 1989. Today there are 1600 in existenceand approximately 400 in the planning phase. There are also over 20 drug courts outside of the UnitedStates in Canada, Jamaica, Bermuda, Scotland, Ireland, and other countries. Evaluations of existing courtshave resulted in a reduction in recidivism, reduction in drug use, cost savings, and immeasurable socialbenefits.During this session, Judge Karen Freeman-Wilson, Chief Executive Officer of the National Association ofDrug Court Professionals will discuss the nuts and bolts of drug courts and their success to date.

182.5. Shaping Behavior among Drug-Involved Parolees: The Step’n Out: Study of CJ-DATSPeter D. Friedmann, Brown University (Peter_Friedmann@Brown.EDU)In the United States, the community correctional and outpatient addiction treatment systems have limitedcollaboration and communication, which may lead to a multitude of behavioral expectations with variablereinforcement. Research supports that behavioral outcomes are optimized when behavioral expectationsare few in number, clear, and consistently reinforced. This presentation will describe the development andearly implementation of the Step’n Out Study, a 4-state randomized trial that is part of the NIDA CriminalJustice Drug Abuse Studies (CJ-DATS) collaborative. The Step’n Out Study examines whethercollaboration between the parole and outpatient addiction treatment systems can improve treatmentadherence, drug use, and public safety outcomes among drug-involved parolees. The specific aims ofStep’n Out are:-To systematize collaborative assessment, treatment orientation, planning, and monitoring betweensupervision officers, treatment counselors and clients; and-To encourage therapeutic relationships and lasting behavioral change through a coordinated, supportiveapproach to supervision that emphasizes the client’s pro-social goals and positive responses to theirattainment.2.6. Functional Neuro-Imaging of Obesity: Lessons Learned from Addiction ResearchG. J. Wang, Brookhaven National Laboratory, Upton, USA (gjwang@bnl.gov)The increasing number of obese individuals in the US and many countries in the world adds urgency tounderstand the mechanisms underlying pathological overeating. Studies using Positron EmissionTomography (PET) implicate the involvement of brain dopamine in normal and pathological food intake inhumans. In normal body weight fasting subjects, food presentation that could not be consumed wasassociated with increases in striatal extracellular dopamine, which provides evidence of an involvement ofdopamine in non-hedonic motivational properties of food intake. Overeating in obese individuals sharessimilarities with the loss of control and compulsive drug taking behavior observed in drug-addictedsubjects. In pathologically obese subjects, we found reductions in striatal dopamine D2 receptors similar tothat in drug-addicted subjects. We postulated that decreased levels of dopamine receptors predisposedsubjects to search for reinforcers; in the case of drug-addicted subjects for the drug and in the case of theobese subjects for food as a means to temporarily compensate for a decreased sensitivity of dopamineregulated reward circuit. Different from drug-addicted subjects we found increased metabolism insomatosensory cortex. In the case of obesity the reduction in receptors coupled with the enhancedsensitivity to food palatability makes them at risk for food over-consumption as their most salientreinforcer.

192.7.Cultures of Knowledge, Cultures of RiskSheila Jasanoff, Harvard University (sjasanof@ksg.harvard.edu)Knowledge about health and illness does not simply accumulate in the abstract but takes shape withinproblem framings that reflect deeper institutional and cultural configurations. These framings, in turn,influence how inquiry is organized, what facts are known, and how these facts bear on the allocation ofresponsibility and blame. Drawing on comparative research in science and technology studies, this paperwill discuss the cultural underpinnings of the framing of such conditions as tobacco or alcohol dependenceand obesity in the United States. In particular, the paper will address the role of the law as a framing devicein relation to issues of public health.2.8. Mandatory Drug Testing for Adolescent Athletes: An Effective Method to ReduceSubstance Abuse or an Encroachment on Personal Freedoms?Linn Goldberg, Oregon Health & Science UniversityTimothy Volpert, Oregon Health & Science University (timvolpert@dwt.com)Alcohol and other drug (AOD) use results in more deaths, illnesses and disabilities than any otherpreventable health condition in the United States. AOD abuse by adolescent athletes is a significant andgrowing problem. In fact, sport participation may encourage use of certain athletic-enhancing substances,including anabolic steroids and a variety of stimulants. Despite a U.S. Supreme Court decision (Acton vVernonia, 1995) endorsing drug testing as a tool to reduce children and adolescent drug abuse, no researchhas ever determined if such programs work. A recent randomized control research study entitled SATURN(Student Athlete Testing Using Random Notification), based on the “out of competition” drug testingmethods used by Olympic agencies, was funded by the National Institute on Drug Abuse (NIDA), NationalInstitutes of Health (NIH). SATURN was designed as a landmark study to determine whether drug andalcohol testing provided a deterrent to 9 th -12 th grade students engaged in school sponsored sports. Despite arigorous review of the study’s methods, procedures, and safeguards by an accredited Institutional ReviewBoard, funding from NIDA/NIH, and the prior Supreme Court decision, a large advocacy group issuedlegal challenges and federal oversight regulators questioned the use of drug testing and its scientificevaluation. This presentation will review the 2 year research findings of the SATURN study, the courtdecisions, and potential effects of oversight regulators on scientific inquiry.2.9. Some Ethical Reflections and Policy Implications for AddictionRenzo Pegoraro, Fondazione Lanza, Padua, Italy (info@fondazionelanza.it)An ethical approach to addiction, particularly considering therapeutical issues, first of all requests to avoidforms of “criminalization” or “medicalization” or “reductionism”. A multidimensional and interdisciplinaryapproach could express some values and basic principles for decision-making process: Human person withown intrinsic dignity; Bio-psychosocial dimension of person; Respect of person without any form ofdiscrimination; Respect of the suffering of the person and search for relief; Freedom and therapeutical

20approach; Solidarity. The principles of responsibility of the drug-addict, social-health workers, family,institutions... and the “ethics of care” with particular focus on relations are relevant principles, together theprinciples of beneficence, autonomy and justice; and the principle “hope”: therapeutical project without thecertainty of results and continuing work together and no renouncement for possible failure. At theoperative-practical level, some indications could be proposed: distinction of treatments and morepersonalized approaches; communication and informed consent in a flexible gradual way, cooperationamong social workers, families, institutions, volunteers...; “legal constrain” to enter in a therapeuticalproject but with involvement of the person, gradually free and more active in the decisions. With the taskof an “healing community”, empathetic in this particular suffering situation.2.10. Addiction and the LawLaurence Tancredi, New York University (lrtancredi@yahoo.com)The recent developments in the neuroscience of addiction are calling into question the extent to which theaddict is free to make choices around the use of drugs. This discussion will focus on the issues ofvulnerabilities to illicit drugs, free will, personal controls over one’s behaviour, and the extent to whichbiology determines the destiny of the individual around such personal choices. The discussion will explorethe way the law now handles drug addiction and related antisocial acts, and the implications of the newbiology for more scientifically appropriate models for handling individuals whose personal controls overtheir behaviour are seriously compromised. Intellectual understanding of the difference between right andwrong may meet the requirements of the current language of the “insanity” defense, but does not seem tobe a complete picture of the forces operating to influence and compel individual behaviours.3. Advance Directives3.1. Personal Identity, Authenticity, and Mental IllnessHeike Schmidt-Felzmann, National University of Ireland (Heike.felzmann@nuigalway.ie)In reflections on psychiatric advance directives, what is at stake philosophically has frequently beenconceptualized in terms of the question of personal identity. One problematic issue concerns cases wheremore than one personality fulfils the basic criteria of competence – which of the personalities should betaken as authoritative? As I want to argue, the notion of authenticity may be more suited than the notion ofpersonal identity to conceptualize such cases. That relying on the notion of identity is problematic withregard to cases of mental disorder, becomes especially apparent, considering the frequency of changes inpersonality in mental disorder and their treatment. I will discuss problems and advantages of using a weaknotion of authenticity to understand what is at stake in these cases.

213.2. Advance Directives, Future Selves and Decision MakingAlasdair Maclean, University of Glasgow (A.Maclean@law.gla.ac.uk)An advance directive (AD) is a device that allows a competent individual to issue directions that prohibitpossible future interventions that may be carried out when the individual is no longer competent to make acontemporaneous decision. The justification for respecting such a direction is grounded in the competentindividual’s right to autonomy. This justification is open to challenge from those who, like Parfit, believethat individual personal identity is unimportant. These non-reductionists argue that what matters is thepsychological connectedness and continuity between the present and future selves. Where that relationshiphas been disrupted by, for example, the onset of dementia, the previous competent self’s autonomy carriesno particular weight, and decisions for the present incompetent self should not be bound by the AD. Thisargument approaches the issue from the perspective of the individual’s right to autonomy. If, instead, thequestion is explored from the alternative perspective, of the most appropriate way to make decisions forincompetent individuals, then it may be arguable that the non-reductionist view still supports, albeit in alimited form, reliance on an AD. It is this approach that I will examine in this paper.3.3. Advance Directives – Relevance to Civil CommitmentRichard O’Reilly, University of Western Ontario (roreilly@uwo.ca)John E. Gray, University of Western OntarioAdvance directives were initially championed to assist individuals plan the health care they are to receive atthe end of life. Over time, advance directives increasingly came to be used to plan the management ofchronic illnesses including psychiatric disorders. A particularly difficult scenario occurs when a patientwho is involuntarily committed to a psychiatric hospital has previously made an advance directive statingthat psychotropic medications, needed to affect recovery and release from hospital, must not be given. Suchan 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 chosentreatment over a lifetime of incarceration. Many observers believe that this situation is unacceptable - butwhat mechanisms can be developed to prevent it occurring? We describe three approaches. First, societycan place the onus on the individual to prove that any advance directive, calling for the rejection ofstandard medical care, was made when the individual was capable and that the directive was intended toapply 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 modelpermits an override of an individual’s advance directive where following the directive would endanger thephysical or mental health of the person or of another person. The advantages and disadvantages of thesethree models will be discussed.

223.4. Parens Patriae, Autonomy and the Ulysses Contract: Pre-commitmentAmbiguities and the Right to Refuse TreatmentGeorge P. Smith, The Catholic University of America (smithg@law.edu)The United States Supreme Court’s recent decision in 2003, in Sell v. United States, provides the centralparadigm for investigating the extent to which the state may, under its parens patriae powers, forciblyadminister 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 protectingsociety from criminal activity. Accordingly, under strict conditions, the government is allowed to restore adefendant’s decision making ability which ameliorates his mental illness and thereby allows him to regainhis competency and, thus, stand trial. This paper’s analysis then turns to the use of the psychiatric precommitmentUlysses contract (or directive), as a way to safeguard autonomy before the onset of a mentalillness by either consenting in advance to certain medical treatments or, for that matter, non-treatments. Ofparticular interest and concern, here, is the plight of the elderly in long-term care facilities; and thisbecomes the context for testing the extent to which advance directives are effective in this setting. Aftersurveying 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 paperconcludes by offering suggestions for implementing a policy that seeks to codify a normative balancebetween preserving the rights of the mentally challenged for self-determination and the responsibilities ofthe state to safeguard the peace, stability, and social order for all citizens.3.5. Autonomy for Incompetent Patients: Tension between Law and Social PracticeCristiano Vezzoni, University of Groningen (c.vezzoni@rechten.rug.nl)Partly due to the aging population in Western societies, attention to the rights of incompetent elderlypersons has increased. One consequence is the legal recognition of advance directives for health care. Bymeans 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 ina future situation in which they have become incompetent. However, the question whether the goal ofrecognition is achieved in practice is still open.This paper analyzes the legislation concerning advance directives in the Netherlands, and seeks to assess itseffects by means of a survey on the practice of advance directives among nursing home doctors and familydoctors in the Netherlands. A total of 206 doctors (77 nursing home doctors, stratified random sample; 129family 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), showingthat 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 theright of autonomy for incompetent patients is not effectively ensured. On one side, lack of informationkeeps potential users from being aware of their right to draft an advance directive. On the other side, whiledoctors share the principle of respect for autonomy, they are not ready to extend that respectunconditionally to incompetent patients. Doctors appear to hold that the priorities of a patient could changein 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, ratherthan on his previously expressed instructions contained in an advance directive.

234. Advocacy I4.1. Mental Health Law, Information and Advocacy Services in Northern IrelandJim Campbell, Queens University at Belfast (Jim.campbell@qub.ac.uk)This paper describes a triangulated study into legal and information services for people with mental healthproblems in Northern Ireland. It explores both advice and information services for people living in thecommunity as well as legal and other forms of advocacy for individuals detained against their wishes inhospital, and appearing before mental review tribunals. The views of three constituents were sought using avariety of approaches - five focus groups with service users and carers (n=43), interviews with keyinformants who were experts in the field of legal and advocacy services (n=8) and a questionnaire survey of300 solicitors who claimed to be providing advocacy for clients who attended mental health reviewtribunals.The study revealed a growth in legal and information services available to people with mental healthproblems living in the community, but that this tended to be piecemeal and unstructured. Views on theoperation of the mental health review tribunal tended to be mixed, ranging from an appreciation of thesensitive and principled management of the legal process to criticisms about advocates being underresourced and lacking in key knowledge and skills. The paper concludes by arguing for a more robustsystem of information and advocacy in such a key area of human rights and at a time when the currentmental health law is being reviewed.4.2. Lessons Learned: The First Year of Mental Health Services in a StudentCommunity Legal ClinicLora M. Patton, York University (lpatton@osgoode.yorku.ca)As Ontario’s mental health system transitions from a centralized, institutional-based structure to one morefocused on increasing independence and home-care, persons defined as being seriously mentally ill arebeing treated more often within their own communities. With the change, persons previously living inhospital gain new independence but also must deal with new realities, often without the promisedcommunity support: a lack of safe and affordable housing, significant deficiencies in the social assistanceprograms, criminalization of behaviours related to their illnesses and discrimination in every form. Assuch, they are interacting with the law in an entirely new way, an interaction in which lawyers dealing withcommittal, 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 aprofession, we remain largely unprepared to meet this challenge. Typical legal training, clinical training inparticular, does not provide the knowledge of mental health systems nor the skills necessary to work withclients with mental health needs. In order for the profession to respond effectively, legal education, bothformal and clinical must adapt.

24In response to the recognized needs of the community and the educational needs of students, Communityand Legal Aid Services Programme (CLASP), a student clinic with a dual purpose of serving thecommunity while providing legal education to the student body, has created a priority program for personswith mental health needs. The initial goals of the program were threefold:• to increase awareness of mental health issues among law students thus increasing the numberof lawyers interested in the practice area• to increase mental health law knowledge and develop skills necessary to effectively work withpersons 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 matterswithin the clinicIn addition to describing the historical background and the broader context of the programme, the paperwill discuss the challenges of developing the mental health priority within the clinic: getting staff andstudent “buy-in”, identifying and meeting educational needs, addressing stigma/discrimination, conductingcommunity outreach and building and stakeholder support. It will note the lessons learned over the firstyear and will help to identify the first steps in building a foundation for clinical or skills developmentprograms trying to integrate mental health into the broader education structure.4.3. Engaging Law Students in Mental Health Issues: The Development of a Hospital-Based Legal Aid Clinic for Mental Health PatientsEvelyn Vingilis, University of Western Ontario (evingili@uwo.ca)Brenda Fuhrman, University of Western OntarioThe University of Western Ontario (UWO) Community Legal Services is a student legal aid clinic situatedat the law school. However, persons with serious mental illness are unlikely to attend this clinic, despite thefact that many have legal issues that need counsel. Moreover, law students have little contact with personswith serious mental illness in their education and practice, and a limited understanding of the issues andchallenges facing persons with mental illness as they try to navigate through the justice system. Thispresentation will describe a two-year evaluation of the program logic model for developing a hospital-basedlegal aid clinic for mental health patients and the implementation of the service. The purpose of the clinic isto provide a comprehensive mental health law program which includes service provision to hospitalizedpersons with serious mental illness and an effective education plan for both law students and health carestudents and professionals. The specific activities of the clinic include: 1) patient access point to lawstudents 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 lawstudents and physicians. The paper will outline the short, intermediate, and longer term objectives from thelogic model and identify the indicators by which to determine whether or not program objectives are beingmet. Additionally, the process evaluation will present data on program implementation, successes, issuesand challenges.

254.4. Strengthening the Patients’ Position: Patients’ Advocacy in Austrian PsychiatriesElke Beermann, Association for Guardianship and Patients`Advocacy, Vienna, Austria(elke.beerman@vsp.at)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 representall committed psychiatric indoor patients at court, and to support them in their communication with thehospital staff members. The patients` advocacy is subsidized by the ministry of justice and is independentof 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 12000 interviews withpsychiatric patients within the first days of commitment (“first interviews”) and 12000 court hearings ayear. 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 ofviews of judges, psychiatrists and other experts. On the other hand the networking helps patients and theirrelatives to express their points of view to the experts. Networking deepens transparency in psychiatry andhas an increasing impact through professional handling of complaints, for example against disregard andincursions.The Austrian patients` advocacy works at the interface of law and mental health and tries to reduce the gapbetween these two necessary, old and powerful social systems on behalf of psychiatric patients and theirnext of kin.4.5. A Madness for Identity: Psychiatric Labels, Consumer Autonomy, and the Perilsof the InternetLouis C. Charland, University of Western Ontario (charland@uwo.ca)Psychiatric labelling has been the subject of considerable ethical debate. Much of it has centered on issuesassociated with the application of psychiatric labels. In comparison, far less attention has been paid toissues associated with the removal of psychiatric labels. Ethical problems of this last sort tend to revolvearound identity. Many sufferers are reticent to relinquish their iatrogenic identity in the face of official labelchange. Some actively resist it. New forms of this resistance are taking place in the private chat rooms andvirtual communities of the internet; a domain where consumer autonomy reigns supreme. Medicalsociology, psychiatry, and bioethics have paid little attention to these developments. Yet these newconsumer-driven initiatives actually pose considerable risks to consumers. They also present complexethical challenges for researchers. Clinically, there is even sufficient evidence to wonder whether theinternet may be the nesting ground for a new kind of identity disturbance. The purpose of the presentdiscussion 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 ofpsychiatry where consumer autonomy and the internet are now powerful new forces in the ‘manufacture ofmadness’.

265. Alterity – Our Relationship with the Other5.1. The Recovery Model: Discourse Ethics and the Retrieval of the SelfJoseph Fardella, Providence Continuing Care Centre, Kingston, Canada (joseph.fardella@sympatico.ca)The Recovery Model, as applied in mental health, is significant because it intends to foster a criticalretrieval by the subject of herself as a self-determining agent of change. As such, the Recovery Modelrecognizes the influence of internal and external circumstances toward a healthy retrieval of the self. Theinternal conditions include the individual’s ability to reflect on personal ideas, values, attitudes which mayinhibit 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, concerningthose individual and social conditions most conducive to her ongoing recovery and care of the self. Assuch, the client must be mindful of the ways in which she may have internalized concepts or expectationswhich impede her possibilities for positive growth. At the same time, professionals who support theRecovery Model must continue to ask themselves (and their clients) whether their approach invites clientsto greater freedom, or masks a misuse of power. Consequently, the paper will argue that the discourseethics of Jurgen Habermas provide moral and cognitive categories which assist both clients andprofessionals as they critically assess the extent to which agreed-upon interventions promote non-coerciveforms of recovery. It will also argue that this “dialogical” approach to decision making is intrinsic to ahealthy retrieval of self.5.2. Towards an Understanding of the Interfacing between Sociological andPsychological Alterity in the Case of BaudelaireJudith Spencer, University of Alberta (spencerj@augustana.ca)The concept of alterity as it relates to Baudelaire has, to date, been explored from a psychoanalyticalstandpoint. The will-to-failure on the part of the poet, whose permanent moral distress is now legendary, isnot new to critical scholarship: the syndrome d’échec postulated by Laforgue in 1930, and reiterated bySartre in his celebrated essay on the poet dating from 1946, resurfaces in Pichois and Ziegler’s more recentbiography of the poet which focuses, amongst other things, on the manner in which Baudelaire deliberatelybrought upon himself the cataclysmic events which shaped his life, namely the conseil judiciaire and thecondemnation of Les Fleurs du mal by the court in 1857 on the grounds of immorality. The latternotwithstanding, it is not without significance to underscore the fact that the fundamental alterity groundingthe poet’s being arguably finds its place in the context of the problematics of the romantic poet strivingtowards the infinite in a finite world, that permanent striving making of him the eternal outsider. Ourunderstanding of the concept of alterity from a psychoanalytical perspective, however, can in no way bedissociated from the problematics of existential alterity as manifest in the social pariahdom of the postmaecenicwriter on the post-revolutionary stage of History. The aforementioned problematics have beenanalyzed both by Sartre and by Benjamin who goes so far as to consider the lyric poet living in the era ofhigh capitalism as outcast and whore by virtue of the fact that he is obliged to make of his œuvre aneconomic commodity to be sold in the literary forum. This paper will examine the manner in which thedysfunctional relationship of the poet to his environment is exacerbated by the pathological social context

27facing the post-maecenic writer, the impetus towards self-destruction ingrained in the poet’s modus vivendiultimately finding allegorical expression in the pathological functioning of the self-consuming romanticaesthetic artefact.5.3. Moral Communities and Moral UniversalismDonald Ipperciel, University of Alberta (donald.ipperciel@ualberta.ca)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 foruniversalism. At the level of justification of norms, moral universalism is quite compelling. But at the levelof 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 anequal status of dignity. In so doing, it defines a “we,” a sameness or an identity lumping together all ofhumanity, leaving no space for otherness with a human face. “Other” applies then only to non-humanentities.Evidently, I will not be trying to do away with equal dignity, which is a fundamental tenet of Westernmorality. But on the other hand, morality has to be made relevant for our daily lives. It has to be practicaland reflect our daily experiences, especially our experiences of otherness. Moral arguments that eliminateotherness 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 universalismwhile finding a legitimate space for otherness in the sphere of morality. The goal will be to preserve thecomplexity 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 medicalpractitioner’s responsibility towards Third World populations?”; “Is there an order of priority regarding theservices and help rendered to patients?”; “While delivering care services, is it morally right to favour oneperson or one group over another?” etc.5.4. The Influence of Contemporary Media on the “Otherness” of the Mentally IllCheryl Webster, Capital Health, Edmonton, Canada (clw2@ualberta.ca)Contemporary media has a profound impact on the development of public opinion and public attitudestowards people with disabilities. These attitudes impact the lives of people with mental illness. Mentalillness is relatively common. Approximately 20 percent of the population in Alberta, Canada were treatedfor mental health problems in 2002-2003. Despite the banality of mental illness, media representations ofpeople with mental illness are so powerful that they override the public’s personal experiences in relation tohow they view mental illness. Inaccurate portrayals influence the generation of public opinion regardinghow a person with this disability should be treated and views of how this disability should be managed. Asconsumers of contemporary media we must think about the messages contained within this genre andrecognize oppressive, prejudicial, and discriminatory content that perpetuates stereotypes of people withmental illness. It is these stereotypes that typically result in power-over versus power-with dynamicsforming between people with mental illness and those without. The main consequence of this dynamic isthe de-humanization of the other. From a relational ethic perspective a relationship is unable to form when

28one of the participants is de-humanized. As a result there is not the capacity to make ethical decisions andfor those stigmatized they are often treated in an unjust and unfair manner resulting in biased decisionsbeing made related to healthcare treatment, resource allocation, employment opportunities, and availablesocial supports.5.5. Moral Distress and Moral Action: A Participatory Research Project to Enhancethe Moral Climate for Nursing and Interdisciplinary PracticePatricia Rodney, University of Victoria (prodney@direct.ca)As a result of more than a decade of fiscal restraint by governments, nurses and other health care providersthroughout Western health care--especially in North America--are confronting serious limitations in thestructural 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), andsocial supports (e.g. the expanding impact of poverty) mean that nurses and other health care providers arealso dealing with increasing acuity and distress of patients/clients, families, and communities. Suchdifficulties raise significant values-based questions about the quality of treatment and care received bypatients/clients, families, and communities. They also raise significant values-based questions about themoral well-being of nurses and other health care providers, as well as the moral well-being ofmanagers/administrators. There has been erosion in the moral climate for nursing and interdisciplinarypractice. And when nurses and other health care providers are unable to practice according to their ethicalstandards, 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 actionresearch 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 ofHealth Care Delivery). This is a three year study funded by the Social Sciences and Health ResearchCouncil of Canada, and is taking place in an acute medical/oncology unit and a busy suburban emergencydepartment. The author and the team of investigators, graduate students, and clinical researchers she isworking 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 specificmethods the research team has used. She will also outline the research team's major insights andachievements. This will include highlighting the policy implications of the research findings. Audiencemembers will have the opportunity to engage in discussion about the implications of the research.

295.6. Workplace Empowerment as a Predictor of Nurse Burnout and Mental Health inCanadian Health Care SettingsHeather K. Spence Laschinger , University of Western Ontario (hkl@uwo.ca)Joan Finegan, University of Western OntarioJudity Shamian, University of Western OntarioPiotr Wilk, University of Western OntarioNurses have been hit hard by health care restructuring initiatives in Canada. There is evidence to suggestthat 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 helpnurses do their work more effectively to avoid endangering patient care. Employee empowerment has beensuggested as a strategy to foster improved performance and lower job stress. Kanter’s (1993) Theory ofOrganizational Empowerment provides a framework for investigating the role of empowering workconditions on nurses’ mental health. This study tested a model linking the effects of empowerment at onepoint 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 arandom sample of registered nurses (Conditions of Work Effectiveness Questionnaire-II: PsychologicalEmpowerment 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 fitof 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 atTime 1 (.435), which in turn, had a significant effect (-.283) on perceptions of emotional exhaustion atTime 2 (3 years later).Nurses’ perceived access to workplace empowerment structures resulted in increased psychologicalempowerment at Time 1 and these feelings of empowerment were predictive of lower burnout levels atTime 2. These results strengthen those of previous cross-sectional research linking empowerment toburnout among nurses and suggest that fostering environments that enhance perceptions of empowermentcan be an effective way of preventing burnout and improve mental health among nurses. The resultsprovide insight for managers, nurses and policy makers regarding the applicability of Kanter’s workempowerment theory in creating work environments that reduce the likelihood of job stress and poormental health among nurses.

306. Assessment and Treatment of Sex Offenders in Switzerland6.1. Present and Past Practices of the Biological Treatment of Sex Offenders inSwitzerland: A ReviewAndreas Frei, Psychiatrische Klinik, Lucerne, Switzerland (andreas.frei@ksl.ch)The biological or pharmacological treatment of sexual offenders in Switzerland has—in spite ofunquestionable success concerning recidivism—been challenged in the last decades, and hardly everapplied, mostly due to an uncritical application of this treatment charged with heavy side effects. Since theconceptualisation of some of the paraphilias as disorders of the OTC-spectrum, the application of SSRI'shas been recommended. For some time, anti-testosterone treatment with so-called LDHD-Agonists hasbeen said to be both successful and better tolerated than the one with Androcur® (Cyproterone-Acetat), aperpherically acting substance. Due to some very encouraging studies, the application of drug-treatment fordangerous and/or reoffending perpetrators in Switzerland should be reconsidered.6.2.Release From Preventive Criminal Detention of High-Risk Offenders. MethodicalConsiderations Based Upon a Catamnestic Study About the Results of a SwissExpert CommissionMarc Graf, Universitäre Psychiatrische Kliniken, Basel, Switzerland (marc.graf@upkbs.ch)N. Händel, Universitäre Psychiatrische Kliniken, Basel, SwitzerlandVolker Dittmann, Universitäre Psychiatrische Kliniken, Basel, SwitzerlandIn Switzerland every year about 15 high risk offenders are sentenced to preventive detention whereas oneoffender per year is released. Since the introduction of the interprofessional expert commission in thecanton of berne in 1995, none of the 18 released cases led to relevant relapse. The expert commissions dutyis to perform risk assessment and to advice the responsible authorities .We will present the data of ourcatamnestic 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.

316.3.Criminal Career and Relapse of Sex Offenders – Results From a Swiss CohortStudy on Forensic-Psychiatric Risk AassessmentK.D. Römer, Universitäre Psychiatrische Kliniken, Basel, Switzerland (Konstanze.roemer@upkbs.ch)Marc Graf, Universitäre Psychiatrische Kliniken, Basel, SwitzerlandC. Kiss, Universitäre Psychiatrische Kliniken, Basel, SwitzerlandVolker Dittmann, Universitäre Psychiatrische Kliniken, Basel, SwitzerlandAs part of the Basel cohort study on forensic-psychiatric risk assessment, we examined the sub-populationof 63 sex offenders. Mean observation time was 90 months and the group consisted of an almost equalnumber 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 evaluationof risk prognosis. The latter being accomplished by means of a structured criteria based method, betterknown lately as “structured professional judgement”.6.4.Is There a Difference Between Consumers of Child Pornography and ChildMolesters?Marc Graf, Universitäre Psychiatrische Kliniken, Basel, Switzerland (marc.graf@upkbs.ch)Volker Dittmann, Universitäre Psychiatrische Kliniken, Basel, SwitzerlandPedophile paraphilia is considered to be a strong predictor for child abuse. At a first glance, the largenumber of persons convicted lately for consuming pedophile internet pornography and the data onprevalence of pedophile sex interest in the general population questions whether this thesis can be held. Onthe other hand, this might explain the high prevalence of child abuse. The above mentioned questionbecomes crucial, when it is used to decide, for example, whether a school teacher convicted for theconsumption of pedophile internet pornography, is at risk to commit sex offences against children andtherefore to disqualify him from his profession.The forensic psychiatric department at the univeristy of Basel, switzerland, is therefore running acomparative study with different group therapies for consumers of pedophile pornography and childmolesters. Both, methods and results of psychiatric, forensic and biological assessment will be presentedand considerations for therapy and risk assessment will be outlined.

327. Capacity and Consent I7.1. Review of the Office of the Protective Commissioner in New South WalesAndrew Constance, Parliament of New South Wales (catherine.watson@parliament.nsw.gov.au)The New South Wales Parliamentary Public Bodies Review Committee is currently reviewing the NewSouth Wales Office of the Public Trustee. The Office acts as an independent and impartial administratorand trustee for the people of New South Wales. It has four core functions: will making, estateadministration, trusts, and power of attorney services. The Public Trustee is currently a financially selfsupporting government trading enterprise with a revenue stream derived from both commissions and feeslevied against individual estates, trusts and agency matters. The Office only makes wills for people whoappoint the Public Trustee as Executor, Co-executor or Substitute Executor. Will making is free and thus aloss leader for the Office. The Public Trustee also acts as trustee, manager or receiver of funds for infantsor 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 futureof the Office. Recent radical reforms to tort law in New South Wales have seen a significant drop in theamount of compensation payouts being awarded for injuries and thus subsequent trusts being handled bythe Office.7.2. Communicating with Carers; A Key to Consent, Care and TreatmentPauline Gill, Central Mental Hospital, Dundrum, Ireland (Pauline.gill@ecahb.ie)Working with carers is more than adhering to a political correct philosophy. In 2003 a programme ofpositive engagement with carers was established within the National Forensic Mental Health Service. Acentral principle of the programme was to improve the standard of care for the patient. The aim of theprogramme was to develop a partnership with carers and empower them to participate and contribute to thetreatment and care plan of their relatives. It was also to recognise the positive contribution that carers maketo assessment, treatment and compliance with treatment and care plansFrom the questionnaire carers identified the main issues as:• Recognition that carers have an expertise that when accessed, enables professionals toformulate accurate assessment and treatment plans• Carers’ ability to support their relatives within the service in decision making regarding theirtreatment and care• The more informed carers are, the greater their ability to provide accurate information andengage in discussion with their relatives (informed consent)• The ability of carers to become powerful advocates on behalf of the service. communicatingthe needs of the service in a unique way• Recognition of the protective factors that family support provides for patients on dischargefrom hospital• The need to feel valued and supported as carers• A lack of easily accessible information regarding mental illness and current treatment.

33• 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 mayhave offendedThis presentation reviews the outcomes the carers program within a National Forensic Mental HealthService.7.3. Are Measures of Psychopathology Reflective of Functional Mental Capacity?Emer Rutledge, Glenroyd Day Hospital, Nenagh, Ireland (erutledge@oceanfree.net)Helen O’Neill, Central Mental Hospital, Dundrum, IrelandHarry Kennedy, Central Medical Hospital, Dublin, IrelandWe hypothesized that in schizophrenia and schizophreniform psychoses (1) tests of functional mentalcapacity should be independent of general measures of mental state if these capacities can really bepreserved in the presence of psychosis (2) tests of functional mental capacity should be independent of eachother if they are truly function-specific (3) tests of functional mental capacity should differentiate patientsaccording to independent criteria.For legal purposes, functional capacities are held to be specific to the task in hand, and it is assumed thatsome functional capacities can be intact even while others are impaired. The most extensively researchedinstruments for the measurement of functional capacities, e.g. the capacity to stand trial, to consent totreatment, to make a will; emphasize the capacities to understand relevant information, to reason about thetask 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 AssessmentTool – 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 ofFunctioning 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 correlationonly accounts for 30% to 40% of the variance. The elements of functional capacity correlate with eachother and are not function-specific. Using the criteria of fitness to plead and the capacity to make atreatment choice the MacCAT-FP performs better than the MacCAT-T in differentiating between thosewho can make valid treatment choices and those who cannot. The PANSS-positive, PANSS-total and GAFalso differentiate between these groups.Measures of mental state and functional capacity are only partly independent. 64% of the variance infunctional capacity measures is not accounted for by variation in mental state as measured by the PANSS.

368. Capacity and Consent II8.1. Contrasting Contractual with Testamentary CapacityLawrence A. Frolik, University of Pittsburgh, (frolik@law.pitt.edu)Anglo-American law has long of enforced a higher level of mental capacity for an individual to enter into avalid contract than to execute a valid will, the latter being known as testamentary capacity. There areseveral 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 lawof wills was created by the English courts of equity. The courts of law enforced the principal of contractlaw that mandated a “meeting of the minds” before there could be a valid contract. If, because of a lack ofmental capacity, either party to the contract could not understand the essence of the agreement, no contractcould result. The result of judicial invalidation of a contract placed the parties back in the position that theyoccupied 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 mentalcapacity because they had a strong bias towards validating wills and avoiding having the estate of thedecedent 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 oftestamentary capacity in order to ensure that they could validate wills even if executed by decedents whohad 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 definedby its context. Legal mental capacity is a creation of the Anglo- American common law tradition thatpermits 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 asan adaptive, flexible response to larger societal concerns.8.2. Determination of Capacity and Judicial Commitment to Safety and Order in WillContests and GuardianshipAlison Barnes, Marquette University (alison.barnes@marquette.edu)Legal mental capacity proves to be an elusive standard to define for all cases. The capacity fortestamentary decision, while one of the lowest requirements for capacity, is sharply criticized forcontradictions in similar cases. Once removed from the objective and professional realm of decisionmaking, 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 conclusionof incapacity is related as much to the abilities and efforts of family and professionals providing care, as itis 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 withsimilar disabilities are sometimes deprived of their testamentary freedom in the context of a will contest by

37means of judgments of incapacity. This presentation discusses the connection between the elusivestandards for determination of incapacity in life and in will contest decisions.8.3. Testamentary CapacityMary F. Radford, Georgia State University (mradford@gsu.edu)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 adisposition of one’s property at death. The court will not enforce the provisions of a will if the testatorlacked that capacity. When a testator’s will is submitted for probate, those submitting it must prove thatthe testator did in fact have testamentary capacity at the time the will was signed. The law favors atestator’s right to dispose of his or her property at death, and, consequently, the required level of capacityfor doing so has historically been quite low. Generally, a testator must have only a basic comprehension ofthe extent of her estate and the general nature of the disposition she is making. These two components ofthe test for testamentary capacity resemble somewhat the test used to determine whether an individualneeds 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 havehad testamentary capacity. This session will explore how these two definitions of capacity differ and yetmutually co-exist. An additional element of testamentary capacity that will be discussed is the requirementthat a testator recognize those persons whom the law deems to be the “natural objects of her bounty.” Thelaw considers a testator’s immediate family to be the “natural objects of her bounty.” Sometimes testatorsmake dispositions that are considered “unnatural” in that the testator gives the property to people other thanfamily 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 becomesthe focus of will contests. This session will explore traditional definitions of testamentary capacity as wellas cases in which decision-makers confuse the question by infusing their own values into the determinationof whether a testator had the requisite capacity.8.4.Assessment of Mental Capacity in Medical and Psychiatric In-PatientsMatthew Hotopf, Weston Education Centre, London, England (m.hotopf@iop.kcl.ac.uk)In England and Wales, two draft bills - the Mental Capacity Bill and the Mental Health Bill - will have aconsiderable impact on how mentally incapacitated adults are treated. There have been calls for the MentalHealth 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 tomake a specific treatment decision. There has also been concern over the potential gaps in legislationbetween the two Bills.In this presentation, I will describe three studies supported by the Wellcome Trust. First, I will present datawhich suggest that mental capacity can be assessed with excellent inter-rater reliability when using theMacArthur Competence Assessment Tool – Treatment (MacCAT-T). Second, I will describe our generalhospital study in which 159 consecutive patients admitted to medical wards were interviewed, usingMacCAT-T. 31% of the interviewed sample lacked capacity; this figure rose when taking into accountnon-participants who did not complete the interview because of severe cognitive impairment orunconsciousness. Mental incapacity was strongly associated with cognitive impairment and advancing age,

38but not with ethnic group, education or social class. Third, I will describe a similar study involving 112psychiatric inpatients interviewed within one week of admission. In this sample, 43% lacked mentalcapacity; 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 werejudged to have mental capacity, 10% had been admitted under the Mental Health Act; this group perceivedtheir treatment to be more coercive than the remainder of the sample. Of the 49 patients who were judgedto lack mental capacity, 39% were not admitted under the Mental Health Act, and would therefore fall inthe “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 hasmajor implications for services, patients and carers. Finally, I will discuss the implications and potentialimpacts of these findings in terms of proposed legislation.8.5. An Instrument for Assessing Informed Consent in Inpatient Populations withPsychosisGeoffrey Rees, Coronation Place Specialist Centre, Brisbane, Australia(catherine@impressionbay.com.au)It is widely assumed that long-term inpatients with chronic psychosis often have impaired ability to giveinformed 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. Wehave devised an instrument in the form of a 10 minute questionnaire that is easily administered to inpatientswith chronic psychosis. Its aim is to measure and improve levels of informed consent in all patientsconsidering treatment, with particular use in those with psychosis. Issues covered include patients’experiences of illness / health on current, alternative and previous medication and contrast this with pastexperience of mental status when medication free (including periods of non compliance or voluntaryabstention). Assessment of any acknowledgement of risk to self / others when taking or ceasing treatmentis attempted. We will also assess patient preparedness and understanding of known risks should they ceasetreatment.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 risksResults of a comparative application of this instrument with 2 populations will be presented---• Inpatients with a diagnosis of Chronic Schizophrenia• Outpatients with non-psychotic Axis 1 (DSM – IV) disorders

399. Capacity, Consent and Advance Directives9.1. Psychiatric Advance Directives and the Right to Refuse Treatment in CanadaDaniele L. Ambrosini, McGill University (daniele.ambrosini@mail.mcgill.ca)Throughout the 1990s Canadian courts began to abandon traditional and paternalistic views that patientsmust simply conform to treatment by doctors, irrespective of their individual personal rights. The parenspatriae power, traditionally the power of the State to act in the best interests of those unable to provide fortheir own welfare, must be balanced with a patient’s prior wishes, bests interests, and what constitutes theleast intrusive manner of treatment. Legal scholars, psychologists, and psychiatrists have recommendedadvance directives for mental health treatment decisions as a legal method of treatment pre-planning, and toensure that competent persons will have their capable decision-making abilities respected in the event theybecome incapacitated. A Psychiatric Advance Directive (PAD) is an extension of an advance directive, thatapplies to individuals with mental health problems.The article provides a review of jurisprudence, with its development in the right to refusal of medicaltreatment, followed by a discussion of provincial legislative models, and an overview of potentialarguments based on the Charter of Rights and Freedoms and relevant sections of the Criminal Code. Inaddition, issues regarding patient’s psychological perceptions of PADs, their benefits and potentialobstacles in securing psychiatric patient’s rights will be addressed.9.2.Mental Capacity in Psychiatric and Medical In-PatientsMatthew Hotopf, King’s College (m.hotopf@iop.kcl.ac.uk)In this presentation, I will describe three studies supported by the Wellcome Trust Biomedical EthicsProgramme. First, I will present data which suggest that mental capacity can be assessed with excellentinter-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 medicalwards were interviewed, using MacCAT-T. 31% of the interviewed sample lacked capacity; this figurerose when taking into account non-participants who did not complete the interview because of severecognitive impairment or unconsciousness. Mental incapacity was strongly associated with cognitiveimpairment and advancing age, but not with ethnic group, education, or social class. Third, I will describea similar study involving 112 psychiatric inpatients interviewed within one week of admission. In thissample, 43% lacked mental capacity; incapacity in this group was strongly associated with psychotic illnessand with country of birth - those born outside the UK were more likely to be rated as lacking capacity. Ofthe 63 patients who were judge to have mental capacity, 10% had been admitted under the Mental HealthAct; this group perceived their treatment to be more coercive than the remainder of the sample. Of the 49patients who were judged to lack mental capacity, 39% were not admitted under the Mental Health Act, andwould therefore fall in the “Bournewood gap”. This “gap” refers to incapacitated patients who are treatedinformally – that is, without being sectioned under the Mental Health Act, because they accepthospitalisation and treatment "compliantly". The European Court has ruled that such patients should betreated formally, which has major implications for services, patients, and carers.

409.3.Capacity - the Parallel Tracks of Law and MedicineSue Field, University of Western Sydney (s.field@uws.edu.au)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 themost 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 onthe evidence submitted - will be that of the courts. It will be argued that, often, the evidence submitted isinconclusive, and demonstrates a lack of understanding of the processes engaged in to determine the mentalstate 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.9.4. Psychiatric Advance Directives: A Qualitative Study of Informed ConsumersDeliberatingMichaela Amering, University of Vienna (michaela.amering@univie.ac.at)Established legal mandates and high expectations for Psychiatric Advance Directives (PADs) are notmatched by empirical evidence documenting their actual implementation. The aim of this paper is toexplore the interests, concerns, and planning activities of informed consumers contemplating PADs.Standard qualitative research techniques were used: field observations, interviews, focus groups, archivalresearch, and key informant interviews. 33 persons participated. Transcripts were coded, analyzed forthematic content, and results were member-checked. The results were that training set in motion laborintensiveprojects that involved conceptualizing how a PAD would work in one’s own life, mobilizingresources, reviewing past experiences, and assessing risks. Especially meaningful was the prospect of beingtreated as a responsible agent in future interactions with the mental health system. PADs are best thought ofas complex planning tools for future crisis management, rather than focal interventions to enhancecompliance. Research is needed to explore the institutional response to this prospective decision-sharinginitiative.

419.5.The True Interest of the Client: Dilemmas for Attorneys in Therapeutic LawStefan Sjöström, Umeå University (Stefan.sjostrom@socw.umu.se)Maritha Jacobsson , Umeå UniversityAnna Hollander, Umeå UniversityIn therapeutic law, courts decide whether coercive intervention from authorities such as a psychiatric clinicor social welfare office is warranted. The persons who are subjected to coercive interventions are typicallyin 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 itmeans to “represent” under such circumstances. Representing the client’s interest can be conceived in threemajor ways: 1) to “win” the case (“defender”) 2) to give voice to the client (“mouthpiece”) 3) toaccomplish the best solution for the client (“therapist”). In the paper, we analyse the role of attorneys inSwedish 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 socialauthorities question parents’ ability to care for their children. The analysis is based on 45 court hearings andinterviews with 31 participants. Findings indicate that the dominating roles for attorneys are as“mouthpiece” and “therapist”, rather than “defender”.10. Children and Mental Health Treatment10.1. Have We Gone too Far in Labeling Children ADD/ADHD?David R. Friedman, Attorney-at-law, Madison, USA (friedlaw@chorus.net)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 isto 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 ofthese services and the amount a time a student will be placed in either a special education program oreducated with the student’s non-disabled 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 wherethe student’s behavior is a manifestation of the disability. When discipline is going to be imposed, parentsand students who were not previously classified as disabled, often seek to have the student classified asdisabled to avoid the disciplinary action.The most common disability associated with behavioral problems is either ADD or ADHD. Many of thedisease’s symptoms are the same as those associated with bad or inappropriate behavior.

42There is a myriad of sources of information on ADD and ADHD. Books have been written on the subject,Internet cites abound, and advertisements are even placed in newspapers listing common childhoodbehavior such as losing things, interrupting others, talking excessively and having trouble waiting for his orher turn as possible symptoms of ADHD.In the course of representing the school district in there efforts to discipline students, I have becomeconcerned that there is a drive by parents to label their child ADD or ADHD as a means of avoiding schoolimposed disciplinary actions. Social and emotional factors as well as neurological factors can contribute tothis disease. It is my contention the parents are pressuring doctors to assist in this endeavor just as patientspressure doctors to prescribed the latest medicines advertised on television.I have heard comments from school board members and administrators indicating a belief that parents andstudents are using this diagnosis as a means of avoiding discipline. This belief is in part due to theawareness of school officials for the potential of over diagnosis. This perception hurts the students that thelaw was designed to protect.Over diagnosis of the disease for those who are not ADD or ADHD devalues the disease for those whotruly need the diagnosis. This over diagnosis also causes those who have to make decisions to viewstudents using their disability as a means of scamming or playing the system. This view also leads to theperception, which does have some validity, that there are two discipline systems - - one for disabledstudents and one for non-disabled students. Another concern is that over diagnosis causes a misapplicationof scare resource.The law was intended to make sure that children with a disability receive an appropriate education. Theunintended consequence of over diagnosis creates the perception that the disease is not real but merely ameans by which students and parents can avoid the consequence of the student’s actions.10.2. Is it Time to Develop Protocols for Non-drug Treatment of ADD/ADHD inSchools?Debra K. Friedman, Bioenergy Clinic Inc., Madison, USA (info@bioenergyclinic.com)There are questions and concerns about prolonged use of Ritalin in ADD/ADHD childrensuch as physiological damage and addiction. What alternative non-drug approaches havebeen tried and what are their success rates? Schools have developed protocols foradministering drugs. Do schools have or need to develop protocols for non-drugtherapies? Discussion will follow of the costs and feasibility of non-drug treatments.10.3. The Right to Mental Health Rehabilitation Under Article 39 ‘The Convention OnThe Rights Of The Child’: The Case of Palestinian ChildrenReem Bahdi, University of Windsor (rbahdi@uwindsor.ca)This paper will examine Palestinian children’s rights to mental health rehabilitation under article 39 of theConvention on the Rights of the Child.

43Article 39 requires States Parties to take all appropriate measures to promote the psychological recoveryand social reintegration of a child victim of armed conflicts. Both Israel and the Palestinian Authority owea 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 todetermine how armed conflict and occupation has affected their mental health. The analysis will start withthe first Intifada, which began in December 1987 and extend to the present crises in both the Gaza Strip andthe West Bank. Part II will explore the extent to which the Children’s Convention binds Israel, as anOccupying Power, and the Palestinian Authority, as a non-state actor, in relation to Palestinian children; itwill critically examine the claim that international human rights treaties do not apply to Israeli actions inthe 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 thepurposes of determining to what extent Israel and the Palestinian Authority owe a duty under internationallaw to promote the psychological recovery and social reintegration of Palestinian children. Finally, Part Vwill explain why it is important to turn to international law in general, and the Convention on the Rights ofthe Child in particular, in order to measure the conduct of Israel and the Palestinian Authority at this criticaljuncture of the Israeli-Palestinian conflict and in light of the difficult history of negotiations between theparties.If there is sufficient time, the paper will also identify and assess the mechanisms available underinternational law to secure compliance with the obligations recognized under article 39 of the Convention.10.4. Traumatic Presentations and Behaviors in Youth Exposed to Family MemberHomicidePaul T. Clements, University of New Mexico (pclements@salud.unm.edu)Homicide of a family member leaves more than just bodies behind and leaves survivors to struggle andcope with sudden and violent loss of life, crossing all cultures, races, and both genders. For youth, homicideof a family member may result in more negative post-trauma reactions than loss to natural causes sincedeaths 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 memberhomicide provided insight into themes of bereavement and traumatic stress. A major finding in the studieswas that witnessing or hearing the news of a family member homicide was a powerful associative factor forchildhood posttraumatic stress disorder and for complicated bereavement. Many issues for bereaved youthafter family member homicide are unique in scope. Serious consequences can occur surrounding a youth’sevolving moral reasoning, understanding of the consequences of a person’s actions, and the significant needfor family permanence. Family member homicide can confound all of these developmental taskssimultaneously. A primary issue is the helplessness of youth at having to watch or listen to the sights andsounds surrounding a violent act and being unprotected from the full emotional impact of the violence.

4410.5. Effects of Abusive Intimate Relationships on Mental Health Status of PortugueseYoung AdultsCarla Alexandra Paiva, University of Minho (cpaiva@iep.uminho.pt)Bárbara Figueiredo, University of MinhoIntroduction: Quality of intimate relationships has a major role on mental health. However, when abuse ispart of the relationship, negative consequences in health can emerge, pending on the type and severity ofabusive behaviour.Aims: To determine the prevalence and severity of abuse, and its implications on mental health status ofPortuguese young adults.Methods - Sample: 500 university students, 64.6% females, mean age 23 years old, 84.8% in a datingrelationship, 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 predictorof psychopathological symptoms is the victimization of assault and both the perpetration and thevictimization 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: psychologicalaggression (53.2-50%), sexual coercion (25-24.8%), assault (18.8-15.5%) and injury (4.6-4.3%). Comparedwith non-abused individuals, the victims of assault (t(388)=3.0, p=.003) and the perpetrators ofpsychological aggression (t(302)= 2.4, p=.016) reported significantly more psychological symptoms.Conclusion: The experience of abuse in early adulthood close premarital relationships is frequent and isconsidered a major determinant factor for psychological distress. This study provides insight into theimportance of having healthy significant relationships, and warns against the negative effects of violenceon mental health status. The need for implementation of social, legal and mental health strategic policies inearly adulthood premarital relationships are essential as a means of preventing violence, promoting thequality of close relationships, and potentially reducing future dysfunctional marital relationships (e,g.,divorce, domestic violence, mental and physical illness).10.6. Psychiatric Nursing Staff’s Views of Aggression Management in the Treatment ofMinor Patients with Aggression and Impulse Control ProblemsJohanna Berg, University of Tampere (johanna.berg@turkuamk.fi)A qualitative study on nurses’ understanding and beliefs of, and attitudes to adolescent aggressivebehaviour in psychiatric inpatient units specialising in treatment of adolescents with forensic backgroundand/or violent and noncompliant behaviour is presented. Nursing staff are interviewed using semistructuredtheme interviews about their views on reasons of adolescent aggression, optimal ways ofmanaging aggressive behaviour in safe way, and preferences for improving aggression management inpsychiatric care. The presented analysis is a part of a cross-cultural comparative study to be carried out infive adolescent forensic units in four European countries. The first part, carried out in Finland, will serve asreference for the cross-cultural analyses. In the pilot interviews, nursing staff members in one Finnish and

45one Dutch unit emphasized, for example, the importance of being able to trust the team as an essential partof aggression management.11. Children and Mental Health: Forensic Care in Youth Prisons11.1. The Concept of Severe Mental Disorder as the Basic Commitment Criterion forMinorsRiittakerttu Kalatiaia-Heino, Tampere University Hospital, Pitkäniemi, Finland (riittakerttu.kaltialaheino@pshp.fi)In Finland, commitment to psychiatric care is allowed for adults in case of mental illness, and for minors incase of severe mental disorder, when certain specific commitment criteria are fulfilled. Since the MentalHealth Act allowing for commitment in broader spectrum of diagnoses was passed in 1991, the number ofinvoluntary commitments of minor patients has doubled as proportion of all admissions, and increasedalmost fourfold in absolute numbers. This study set out to evaluate how psychiatrists working with childrenand adolescents understand the concept of "severe mental disorder". The study was requested by theMinistry of Health and Welfare that sought to produce guidelines for interpreting the Mental Health Act inthis sense. 44 psychiatrists in different positions within C&A psychiatric services were interviewed with thehelp 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 severemental disorder, and what they think should be considered as severe enough to allow commitment of minorpatients 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'ssituation beyond descriptive diagnosis. In the child and adolescent psychiatrists' opinion, severity of aminor's disorder is related to progression / regression of childhood / adolescent development presented infunctioning in family and peer relations and ability to schoolwork / play. These factors are salient indescriptive diagnoses.11.2. A Qualitative Survey of the Views of Young People in Secure Care on Physicaland Mental Health NeedsNathan Whittle, Salford & Trafford Mental Health NHS Trust, Bolton, England(njwhittle@gardener.bstmht.nhs.uk)The aim of this project was to conduct a systematic qualitative survey of the views of current service usersand providers of services of physical health, mental health and substance abuse services to adolescents inthe 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 ofinteragency working. A sample of young people will be interviewed to examine their views about currentservices, what treatments they have already been offered, those they thought were most appropriate and

46those they considered to be most effective. Specific enquiry will be made about the continuity of careacross agencies and over time. This study is currently ongoing and some preliminary results will bepresented. While there is growing evidence that adolescents in secure care have a high level of physicalhealth, mental health and substance abuse problems, they often fall through the gaps of conventionalservices. There is a strong argument for the integration of these services, but before contemplating this, it isnecessary to survey the views of adolescents in the secure estate. This data will contribute to thedevelopment of a CD-ROM, which will provide information to young people in the secure estate onrelevant physical, mental and sexual health issues.11.3. Policy, Rights and the Ethics of Secure Detention for Young OffendersInti Qurashi, Ashworth Hospital, Liverpool, England (intiqurashi@hotmail.com)There are an increasing number of children and adolescents in secure detention in the United Kingdom andthe debate surrounding punishment versus welfare continues. Up to one in five of these individuals willsuffer from a mental disorder and previous research shows that their needs are not being met. There areconsiderable challenges facing statutory agencies and service providers in how to maintain an ethicalunderpinning to service delivery to these individuals.The aim is to describe, from a United Kingdom perspective, the place of children in society and presentpolicy across health, social care and justice as it applies to children and adolescents with mental healthdifficulties; furthermore, the goal is also to increase the knowledge and understanding of a safe and ethicalbase for service delivery to 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 betweencountries in the Council of Europe and the United Kingdom.• The variation in legal sanctions and punishment for children between United Kingdom andEuropean countries.• The balance between punishment versus welfare for children and young adults in contact withthe criminal justice. This will review overarching European legislation, United NationsConventions and domestic legislation and present these in the context of liberal andconservative arguments.Children and young adults with mental health difficulties are increasingly being diverted to the criminaljustice system rather than social and healthcare pathways. There are a number of contributory factors to thisincluding domestic legal policy, lack of appropriate resources and service provider inexperience. The ethicsof United Kingdom policies will be discussed, both at individual and organisation levels, in the context ofrights of service users and obligations on service providers. The minimum requirements of a safe andethical service for children with mental health difficulties will be discussed.

4711.4. An International Comparison of Juvenile Facilities in the Netherlands andBelgiumRobert Vermeiren, University of Leiden (robert@vermeiren.name)The aim is to compare the judicial handling of juveniles and the population characteristics of juveniles inforensic institutions between Belgium and the Netherlands.Belgium and the Netherlands will be compared with respect to legislation of handling juvenile offendersand with respect to the available facilities for forensic interventions with juveniles. Also, results from astudy in juvenile (justice) institutions by means of a self-report instrument, the SAHA (Social and HealthAssessment), will be presented.Noteworthy differences between both countries will be reported. The main difference is undoubtedly thatBelgium has adopted ‘protection legislation’ for juvenile delinquents (below 18), whereas the Netherlandshas a penal law system for minors between 12 and 18. Other differences that will be reported on are: theorganization and capacity of residential (judicial) institutions and the characteristics of the juveniles inthose institutions. It will be shown that differences in legislation may exert major influences on theorganization 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 onthe necessity of protection or punishment.12. Children and Mental Health: The Elusive ‘Best Interests’Principle?12.1. The Best Interest of the ChildBarbara Willenbacher, University of Hannover (Willenbacher@rsoz.uni-hannover.de)Nearly all western countries instituted joint custody in the recent decades. The aim of the legislation was toinfluence the behaviour of parents. Parental responsibility rests automatically on both parents; it is anenduring status that is not lost on separation or divorce. The legislation aims to reduce legal involvement inparents’ care of their children past separation. Many statutes established a preference for joint custody oversole custody. They have established presumptions that shared parenting is in the best interest of the childnot limiting the application to cases where parents are in agreement. In deciding any question relating to theupbringing of the children the court has to make the welfare of the child its paramount consideration. Courtsubstantiates the best interest of the child in the following arenas:1. Custody OrdersCourts have the option to make joint awards despite a parent’s objections.2. Residence, Specific Issues and Prohibiting Step Orders

48Courts have to adjudicate when parents disagree in relevant joint parental decisions. In some aspectsresidence, specific issues and prohibiting step orders replace custody orders.They are designed to restore concrete, practical issues relating to the care and upbringing of children. Thecourt must choose the most appropriate order in the particular case and can specify where the child willlive, disallow certain aspects of parental responsibility or suggest how specific areas of parentalresponsibility should be carried out.3. Contact OrdersThe strong presumption in favour of contact between the child and the non-resident parent in consequenceof the UN Convention on the Rights of the Child everybody shall respect the right of the child who isseparated from one or both parents to maintain personal relations and direct contact with both parents on aregular basis. Cases involving violence are not treated as a separate category in Germany andEngland/Wales, although violence may well be a circumstance justifying the denial of contact. But contactis very rarely denied altogether.My material is based on an analysis of published German jurisdiction 1998-2004. My aim is to discernsome of the principles that underlie decisions of the court and to deduct a welfare checklist of variousfactors, which determine what outcome, is in the child’s best interest.12.2. The Best Interest of the Child from the Perspective of Democratic PolandAlicja Czerederecka, Institute of Forensic Research, Krakow, Poland (aczere@ies.krakow.pl)Jozef K. Gierowski, Institute of Forensic Research, Krakow, Poland (kgierowski@poczta.onet.pl)The paper presents the consequences of the changes in the legal situation of children rights in Poland,between 1989 and 2003. Most of the reforms are ratification of European conventions and internationalpacts, focused on the best interest of a child, specifically: children’s rights, adoption of children, legal statusof children outside marriage, and protection of a child. Regulations of the act on legal proceedings withjuveniles, as well as a new article in the code of penal proceedings protecting a child as a witness, factorinto the changes which have occurred in child protection legalities. Many organisations and associationsserving to protect and help abused and neglected children have arisen and developed in democratic Poland.Also, current media focusses on the protection of children’s rights. This paper discusses the consequencesof such changes in terms of both advantages and disadvantages to the children. The main positive changesin the adults’ attitudes towards these cases include taking into account the subjectivity, the dignity of achild and willingness to listen to the child. Also children are becoming increasingly prone to seeking helpwhen their personal rights have been disturbed. On the other hand, it sometimes happens that parentsmanipulate their children’s feelings by preparing false accusations against their partners in marital conflictsaccusing them of emotional, physical or even sexual violence towards their children

4912.3. The Best Interest of the Child: The Russian ViewElena G. Dozortseva, Serbsky National Center for Social and Forensic Psychiatry, Moscow, Russia(edozortseva@rambler.ru)Recently in Russia, demographic problems, decrease of population, and therefore problems of family andchildren have become an issue of national security. Every year about 470 000 children are left with oneparent as a result of divorce.The Russian Family Code adopted in 1995 regulates issues of children’s rights, parents’ rights and duties,custody in cases of divorce, deprivation and limitation of parental rights, adoption etc. The central notionof this regulation is focused on the best interests of the child. According to the law “interests of the childmust be the essential subject of parental care” (Art. 65, 1). Whereas the Code defines the child’s rights,there is no clear legislative definition for the category titled “interests of the child”. Articles characterize achild’s best interest as inclusive of education, care for health, physicality, psychological well being, as wellas a responsibility for spiritual and moral development (article 63, 1).Theoretically, in cases of divorce, parents have equal rights for custody of the child, and therefore issues ofconflict can be discussed in terms of the child’s primary residence. Both parents have equal opportunity toexert their rights regardless of which parent the child lives with. In deciding issues of custodial control, thecourt first takes into consideration “the child’s attachment to each of the parents and to the siblings, thechild’s age, moral and other personal quality of the parents, the relationships between each of the parentsand the child, conditions for the child’s education and development…” (article 65, 3). The rights of theparent who resides separately from the child on issues of child rearing and education can be contested bythe former spouse when contacts with the parent damage the child’s “physical and psychical health andmoral development” (article 66, 1). The court can demand expert opinion in such cases, in considering thebest interest of the child.The development of expert assessment in the framework of family law in Russia is now in its initial stagedemanding a clearer definition of what is included in the best interests of the child.12.4. Investigative Methods and Standards for Psychological Expertise Concerning theBest Interest of the ChildMarianne Kalinowsky-Czech, Practicing Psychologist, Buchholz/Nordheide, Germany (M.Kalinowsky@tonline.de)Since 1998, when the Child Reform Act came into effect in Germany, joint custody has been obligatory; incontested cases however, parents can ask for sole custody to be awarded. This process entails psychologicalexpertise in answering the question of the child’s best interest. This paper will demonstrate through aconcrete case, the plan of the investigation, the hypothesis, and the guideline for exploration with theparents, the child and other related persons, the process of determining best interest.The position of the law court depends on stereotypes of the judges (e.g. preferring a rapid decision) inawarding custody to the mother (with whom in most cases, the child lives), determining damages ordisadvantages of the best interest of the child living in joint custody, or to suggest communication and cooperationbetween the parents as a base for the decision. Important points to explore are: the educationalpositions and opinions of the parents concerning physical custody, every day life problems and importantconcerns like schooling, religious denomination, or basic conception about medical treatments.

50Psychological expert experience shows that most parents agree about the important concerns for theirchildren, if they are both asked in a concrete and understandable way. The exploration must be carried outcarefully to avoid a rapid decision for sole custody. In these cases one parent loses responsibility for, andcontact with, the child; the consequence of such court decisions lead to more disadvantages of the wellbeingand best interest of the child. Psychological expertises can improve better legal decisions andenforce the best interest of the child.12.5. Joint Custody – Psychological Aspects of the Best Interest of the ChildAdelheid Kühne, Univeristy of Hannover (Kuehne@erz.uni-hannover.de)Family law in Continental Europe and also in Germany prefer joint custody for children of married andunmarried parents. In Germany the Child Reform Act came into force on July 1, 1998. Following itsimplementation, unmarried parents can agree to joint custody and can now share equal rights like marriedparents.This means parents may continue to practice joint custody after divorce and/or separation. Regardless ofwhether the child is living with a single parent or cohabitating, the capital motive of the legislator is tomaintain the best interest of the child. Parents cannot give up the claim of responsibility.Best interest of the child includes caring for all issues of everyday life maintenance, as well as health care,pedagogical decisions of school development, and job education etc. Only a judge’s decision can changethe joint custody and award custody to a single parent after request. In those specific cases, the judgerequests psychological expertise.One of the main topics of this report is the redefinition of the parental custody under the new ChildReform Act. Forensic research points out the necessity of new abilities for parents, like consensus andcompromise, tolerance of attachment and the readiness for continuity concerning emotional, social andenvironmental relations. These factors are increasingly significant constructs of successful childdevelopment. The protection of children against maltreatment and abuse remains an important topic infamily law; psychological experts have to deal with these severe problems.12.6. Best Interest of the Child: the Interface of Family Law and Mental IllnessJennifer Boland, Family Court of Australia (Appeal Division), Sydney, Australia(justice.boland@familycourt.gov.au)The Family Court of Australia regularly deals with applications by parents of both nuptial and ex-nuptialchildren about where they should live, and the contact they should have with their non-residential parent. Inmany 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 expertevidence, appointment of a representative for the child, supervised contact orders and imposing conditionsincluding treatment for a parent as a condition of an order. Also examined are difficulties in conductingsuch hearings particularly when parties are self represented, require the appointment of a “next friend” orguardian for the litigation, and repeat litigation. It also studies the Court’s recent pilot of dealing with allchildren’s cases in a less adversarial manner in order to achieve the best outcomes for children before theCourt.

5113. Children and Sexual Abuse13.1. Determining the Verite of Childhood Sexual Abuse: the Problems for Courts,Clinicians and Law EnforcementMark J. Mills, Columbia University (mjmills@forensicsciences.com)As allegations of child sexual abuse/exploitation have become more frequent (and to some extent morecredible), 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 whatoccurred and may complicate psychological recovery. This presentation examines a variety of troublesomeissues 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 lessinterested in the verity of what occurred. Law enforcement typically takes the opposite tact: mostinterested in what actually occurred to bring perpetrators to justice and less interested in the clinical impactof what is assumed to be reasonable inquiry. Courts try to balance these two interests—bringingabusers/exploiters to justice while wanting to ensure that child testimony, if it occurs, is brief and notharmful to the child. In the “real world”, of course, the lines blur. What is difficult in the U.S. judicialsystem 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 thepsychological sequelae of the original event. These issues are made more complex by parents whooverreact to routine physical and sex play between children. More difficult still are the differences ininternational law that attempt to regulate such matters across international borders. These matters and morewill be discussed by the panel and the audience.13.2. Borders, Boundaries, & Barriers: Cross-Cultural Legal Issues in InternationalCases of Child Sexual AbuseDelissa A. Ridgway, U.S. Court of International Trade, New York, USA(delissa_ridgway@cit.uscourts.gov)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 ofinvestigating and prosecuting cases that span more than one country. This presentation will survey some ofthe complex cross-cultural issues that may be raised in such cases – ranging from linguistic barriers anddiffering psycho-social mores and taboos, to wide variations in legal standards and procedures on matterssuch as the rights of all interested parties, proper investigative and interrogation techniques, the requisiteburden and quantum of proof, admissibility of testimony and other evidence, the role of mental healthprofessionals, statutes of limitations, and disparate approaches to punishment and/or treatment of offenders,as well as issues of international judicial cooperation.

5213.3. Assessing Children’s Allegations of Sexual Abuse – DiscussantLeonard D.Goodstein, Forensic Sciences Medical Group, Inc., Washington, USA (LenDG@AOL.com)13.4. Evaluation of Sexual AbuseRoy Lubit, Mount Sinai School of Medicine (Roylubit@rcn.com)The evaluation of alleged sexual abuse is difficult and complex. Both children and adults frequently denythat they had been sexually abused when they had been. Others assert that they have been sexually abusedwhen they had not. To assess whether sexual abuse had in fact occurred, it is necessary to understandchildren’s memory and children’s response to pressure. The propagation and use of appropriateinterviewing techniques of allegedly sexually abused individuals is crucial since once someone has beensubject 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.13.5. Assessment of Post-Traumatic Stress Disorder in Children and Adolescents:Methods and PittfallsWilfred G. van Gorp, Columbia University College of Physicians and Surgeons (wvangorp@aol.com)Children who are the victims of child sexual abuse often experience, or are thought to experience, posttraumaticstress reactions secondary to the abuse. Additionally, questions of credibility of the child’s reportoften come into question. This presentation will focus upon assessment of validity of self-report, as well asassessment 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 methodsto assess for PTSD in children and adolescents, with a critique of the most commonly used methods. Issuesin deciding which, if any of these formal instruments to use will be discussed with the audience. Also, wewill review the differences between standard clinical measures and newer research-based instruments, witha review of pro’s and con’s between these two approaches for use in the non-research setting. We will endwith audience discussion of the utility of these various methods of assessment for the child who issuspected of being the victim of sexual abuse.

5314. Children and Trauma I: Assessment and Intervention14.1. Conducting Forensic Interviews with Traumatized ChildrenKathryn Kuehnle, University of South Florida (kkuehnle@aol.com)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 eventsare of human design, such as the various forms of family violence, the effects on the child may beespecially severe. Furthermore, co-occurring exposure to multiple forms of family violence, compared tosingle form exposure, is associated with heightened trauma for the child. Studies on the psychobiologicalconsequences of family violence and longitudinal studies of abused children’s functioning indicate thatfamily 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 maypersistently avoid stimuli associated with the trauma and make deliberate efforts to avoid thoughts orconversations about the traumatic event or people who arouse recollections of it, the child’s effectiveprovision 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 notprovide false information or become cognitively contaminated, only one element of the disclosure dilemmahas been resolved. The part that has not been resolved is how to identify the chronically abused andtraumatized children who make deliberate efforts to avoid thoughts or conversations about their traumaticexperiences or who disclose bizarre, improbable, or seemingly impossible statements during the forensicinterview. This presentation will explore how trauma may impact the child’s perceptions, memory, and/ordisclosure of family violence. A decision tree will be offered to assist in the identification of thesechronically abused and traumatized children.14.2. Nature vs. Nurture: Are They More Than Complementary?George B. Palermo, Marquette University (Palermogb@juno.com)Present-day genetic and biological research seems to be complementary to the long-standing observationsof behavioural psychology. Traumatic experiences in childhood and adolescence and their behaviouralconsequences, at times antisocial, have been well-documented by Sigmund Freud and Anna Freud and bynumerous criminologists thereafter. The consequences of abuse may be explained not only on the basis ofan interactional relationship between the offender and his or her usually young victims, but also on the poormyelinization of neurons in the young person’s brain; a dysfunctional interplay of neurotramsmitters, suchas 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 morethorough 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 puzzlingobservation for socio-behavioral psychologists and criminologists. Recent new genetic research may shedlight on the observation that some abused children go through periods of physical and sexual maltreatmentwithout showing later the antisocial behavioural consequences seen in other persons who had been abused

54as children. This recent research may further contribute to overcoming the perennial dichotomy of naturevs. nurture.14.3. Innovative Mental Health Programs for Treatment of Trauma With IncarceratedJuvenile Habitual Serious Offenders and Juvenile Sex OffendersRoy W. Persons, Beaumont Correctional Facility, Beaumont, Canada (personrw@djj.state.va.us)Natasha Persons, Bon Air Juvenile Correctional Center, Richmond, Canada (discoveryroy.@aol.com)This presentation will review innovative treatment programs used at our facilities that are designed to avoidthe typical defense mechanisms and resistences that serious habitual and sexual offenders utilize to avoidpsychological engagement in the treatment process. A specific focus of the use of these procedures withtrauma cases in juvenile offenders is presented. Art therapy, journaling, bibliotherapy, and gestalt therapyare combined with cognitive-behavioral therapy into a uniquely integrated approach. The programcombines individual psychotherapy, organic group therapy, and milieu programs with the above listedapproaches. A slide presentation of the art work of the trauma cases will be presented to illustrate thedynamics and the therapeutic process. Participants will be able to chart and follow the method and processof the treatment procedures. Both qualitative and quantitative research will be presented. The presentationwill end with a voluntary experiential procedure that is utilized in our treatment program with juvenileswith trauma. Research and treatment method papers will be distributed.14.4. The Biology of Childhood Trauma: Is it time to Rethink Our Concepts ofAccountability and Justice?Kathleen M. Heide, University of South Florida (kheide@cas.usf.edu)Eldra P. Solomon, Center for Mental Health Education, Tampa, USA (epbsolomon@aol.com)This paper will review recent findings in the developmental neurophysiology of children subjected to TypeIII (extreme, multiple event) trauma. Studies link psychological trauma with long term changes in the brainand endocrine system that affect development and lead to problems in cognitive, affective, social, andphysiological function. These children have difficulty regulating affect and, without intervention, may notdevelop empathy. When confronted with stressful situations, survivors of extreme childhood neglect orabuse have difficulty accessing higher cortical centers, the areas of the brain essential for formulatingsocially appropriate decisions. Instead, they are driven by limbic system activity leading to emotionallydriven responses.The authors discuss the implications of these findings for forensic evaluations, including competencyevaluations, mental status at the time of the offense, and factors in mitigation. Knowing that childhoodmaltreatment compromises brain development and affects future ability to make decisions, the authors askwhether it is just and fair to hold Type III trauma survivors to the same standards of accountability as otherswho do not have the same history and risk factors? Based on new understanding of the effects of childmaltreatment, the authors invite law and mental health professionals to rethink their notions of justice andoffender accountability.

5514.5. Psychological Impact on Children of the Death of a Parent or Close Relative bythe PoliceJohn Burris, Attorney-at-law, Oakland, USA (Burris@lmi.net, burris@pacbell.net)In police abuse cases involving the death of a parent or loved one at the hands of the police, children areoften the neglected victim(s). It is well established that children suffer terribly when they are the victims ofdirect physical and psychological abuse whatever the source. This presentation will focus on the childrenof the victims of police abuse in death cases where the child has lost a parent or a close relative. In a deathcase much attention is given to the adult members of the families particularly the spouse and the victim’sparent. But often the child of the decedent suffers terribly and little if any attention is given to his/heremotional and psychological needs. Many children suffer long-term effects of Post Traumatic StressDisorders 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. Iwill discuss the short and long terms affects of the death on the children, and what efforts if any were madeto meet their needs. Also I will explore what effects this type of death had upon the child’s developmentfrom childhood through adolescence and in some cases adulthood (school, social behavior, relationshipswith families, friends and the police). As a reference, we will use my cases accumulated through 25 yearsof practice working with families suffering the shock, despair and frustration of losing a loved one at thehands of the police causing the children as innocent bystanders suffering in silence. I will also explore theavailable options for these child victims.I will also look at other cases in the United States and Western Europe to compare and contrast whethervictims of police abuse manifest similar mental health distress when confronted with outrageous policeabuse such as that reflected in the case study. Also, I will examine mental health treatment optionsavailable for these types of child victims in other countries.14.6. The Role of the Youth Court Judge in Cases Involving Mental Health Problems:A Canadian PerspectiveBrian Weagant, Ontario Court of Justice, Toronto, Canada (Brian.Weagant@jus.gov.on.ca)Marion L. Cohen, Ontario Court of Justice, Toronto, CanadaTwo Youth Court Judges from Canada’s largest jurisdiction will discuss the new and emerging role of theYouth Court in cases involving mental disordered young offenders. In addition to outlining the spectrum ofinterventions available to the Court under Canada’s new Youth Criminal Justice Act , the presenters willcanvass the various models enabled by the legislation with an emphasis on possible legal, ethical andpractical considerations.

5615. Civil Liability and Mental Health I15.1. The Four Dimensions of the “Accountability” Motive: Sanction, Correction,Restoration and CommunicationEdward A. Dauer, University of Denver (edauer@law.du.edu)People who are injured by what they see as the fault of another – for example, patients who sufferunexpected adverse outcomes as the result of medical care – often describe their motivation to bring a legalclaim as the desire to achieve “accountability”. The notion of accountability, however, is surprisinglyinchoate, particularly in the immediate aftermath of the event; and the same reported motivation is invokedto explain any of a number of very different post-injury behaviors. From both psychological andphilosophical perspectives, “accountability” seems to include four distinct dimensions: Sanction (thewrongdoer should be punished); Correction (this injury should not be allowed to happen again);Restoration (the wrongdoer must make the injured person whole); and Communication (the wrongdoermust personally confront those whom they injured and at a minimum explain or “account for” theiractions.)How an injured patient will act – by claiming, exiting, suing, or some other response – is determined asmuch or more by the psychological and social environment of the incident than it is by the nature of theinjury or other objective facts. This suggests that the four dimensions of accountability are not just fourdifferent motivations accidentally captured within a single word; but rather that they may, as a matter ofhuman psychology, be commensurable – that is to say, that under the proper circumstances, satisfaction ofany of the four dimensions can effect a satisfaction of the whole.The practical problem is that the civil justice system tends not to serve either Correction or Communicationvery well, when it does so at all; and in that narrowness it fails to offer what may be more satisfying andtherapeutic alternatives to people motivated to achieve “accountability.”This paper will explore and integrate recent empirical findings about claiming behavior, apology, and thesuccesses of mediation, “early intervention” and “voluntary disclosure” practices, to describe theaccountability phenomenon more fully (and, as a sidelight, to suggest what may have been its evolutionaryorigins.) From that elaboration, we should be able to derive practical implications for how the civil justicesystem could do better.15.2. Dealing with Vexatious Complainants and LitigantsIan Freckelton, Monash University (I.Freckelton@latrobe.edu.au)The making of unmeritorious complaints and the bringing of baseless litigation are well-recognized clinicalphenomena. They have given birth to terms such as “vexatious litigants” and “querulous litigiousness”.Modern administrative law systems and the role of complaints bodies and ombudsmen provide previouslyunavailable forums for persons with personality disorders, delusional disorders, and even schizophrenia toact out their illnesses to the detriment of their victims. Such persons are also very difficult for suchagencies to deal with. They can tie up scarce resources and intimidate inexperienced investigators andjudges; this may result in unfairness.

57The paper reviews clinical insights into the phenomenon of the pathologically-driven utilization ofcomplaints agencies and litigation forums. It warns of the risk in being too ready resort to dismissiveclinical labels and analyses, and practical ways in which there can be constructive and informed responsesto those who are suspected of being “vexatious” complainants and litigants.15.3. An Evaluation of Tort Law’s Treatment of Problems Relating to Mental DisabilityAllen Linden, Federal Court of Appeal of Canada (allen.linden@fca-caf.gc.ca)Tort law is ambivalent about holding people with mental disabilities liable. We should evaluate thedifferent types of situations where these questions arise and consider the best solutions, taking into accountboth the interest of the injured person as well as that of the mentally disabled. Vicarious and othersecondary liability is also a problem for tort law. Reassessments of the principles involved are required tobetter fashion an approach to civil liability of the mentally disabled and their caregivers.15.4. Liability for Negligently Occasioned Pure Psychiatric Injury in Australia: ThePost-Reform LandscapeDanuta Mendelson, Deakin University (danuta.mendelson@deakin.edu.au)Two important developments in the field of liability for pure psychiatric injury (traditionally known as“nervous shock”, also referred to as “mental harm”) took place in 2002. The High Court of Australia (inTame v New South Wales (2002) 211 CLR 317) determined that reasonable foresight of pure mental harmshould be the only precondition of the existence of a duty of care. This supposes it was foreseeable thatunless care was taken, a person of ‘normal fortitude’ would suffer mental harm in the circumstances of thecase.In the same year, as part of a wider Torts Law Reform, the Review of the Law of Negligence Report (the IppReport) recommended codification of stricter principles that should govern recovery for pure mental harm.Subsequently, most Australian legislatures implemented the Ipp Report’s recommendations. However,despite the commonality of features, there are jurisdictional variations in the way in which the law ofliability for pure psychiatric injury has been codified. This means that the law in this area, which in 2002was relatively uniform throughout Australia, has fragmented into eight discrete systems. Moreover,statutory exceptions have created a situation whereby the common law as enunciated in Tame will continueto apply to many claimants.15.5. Litigating and Regulating Antidepressants: Changing PerspectivesPatricia Peppin, Queen’s University (peppinp@post.queensu.ca)Advertising has contributed to the creation of a vast market for antidepressants. As the products reachedthe end of their patent protection, marketing expanded to include adolescents, children, and conditions such

58as panic disorder and social anxiety disorder. Advertising became more pervasive, with the relaxation ofthe limits on direct-to-consumer advertising in the U.S. and elsewhere.Litigation commenced against manufacturers of SSRIs in the first decade of use, which focused on seriousadverse effects allegedly created by these products, was largely unsuccessful. At the beginning of thesecond decade, however, widespread efforts to evaluate the full impact of these products and to controlpromotional excesses began to achieve some success. These broader efforts have included investigativejournalism, government review, academic research, and novel litigation strategies, such as seeking aninjunction against direct-to-consumer ads in California Paxil litigation and fraud litigation launched by theNew York State Attorney General over alleged concealment of negative information. This paper willanalyze these efforts to improve disclosure of information about these widely used products and to controlmisleading and biased promotional activities. The merits of litigation will be evaluated in relation toothers, such as state regulation and advertising board evaluation.16. Civil Liability and Mental Health I: Issues in ServicingProblematic Groups16.1. The Risk of Proceedings for False Imprisonment or Negligence in SituationsWhere Patients Who Appear to Be Dangerous are CommittedAndrew Alston, Flinders University (andrew.alston@flinders.edu.au)Health professionals who commit patients in situations of perceived emergency are at risk of being liablefor false imprisonment or negligence. The action of false imprisonment occurs “when the liberty of aperson has been restrained against his will without the authority of the law”: Washburn v Robertson (1912)8 DLR 183 at 185. In cases of emergency, there may be a defence where the patient is not competent or thehealth professional is protecting the patient from harm, or acting in self defence or in defence of another, orin defence of property. The circumstances of the committal, including the conduct of the plaintiff, will betaken into account in awarding damages. Damages can vary enormously, depending on the circumstances.Courts may award damages under three headings: pain and suffering; aggravated damages; and exemplary(punitive damages). Negligence is an alternative cause of action, although there may be little prospect ofsuccess in cases of perceived emergency. Many jurisdictions have legislation that protects the personresponsible for the committal. The extent of protection provided for varies considerably. In Canada, at oneextreme, a number of Provinces give protection if the person acted in good faith and in performance of astatutory duty: British Columbia; Manitoba, Northwest Territories, Saskatchewan. At the other extreme,other Provinces offer no protection at all: Alberta; Nova Scotia; Quebec, Yukon. In Australia, there is asimilar divergence amongst the States.

5916.2. S.O.S.? Not My Problem!Michele Slatter, Flinders University (Michele.Slatter@flinders.edu.au)Traditionally, the common law of negligence has been unwilling to recognise positive duties to act. It hasalso been reluctant to impose liability for an omission. To commentators, distinctions in such situationsbetween legal liability and ‘the moral sentiment of mankind’, Donoghue v Stevenson’s touchstone ofnegligence, can seem intolerably provocative. This has been especially true in discussions of physiciansconfronted by emergencies. Where the emergency is not of their making and affects strangers, are theyobliged to become involved? If so, what is the measure of their performance? It is an area of extremetension between competing expectations and apparently divergent imperatives. Personal, professional, andpurely legal concerns come into play. The resulting confusion is largely unreconciled.The well-known Wood v Lowns litigation in New South Wales in 1995 and 1996 re-energised these issues,both in Australia and internationally. It appeared to introduce new direction into the law, challenging thetraditional respect for non-intervention but leaving the precise parameters of change for further definition.It prompted intense debate, but was not followed by further defining litigation. In the ensuing period, twomajor changes have occurred. First, the High Court of Australia has re-cast the law relating to duty of carein negligence. It has extensively reconsidered ‘proximity’ and reformulated the approach to imposing aduty in novel circumstances. Secondly, the ‘liability crisis’ identified by insurers has resulted in legislativechanges in all States and Territories of Australia directed to a wholesale restriction of negligence liability,either in incidence or quantum. Situations of duty have been curtailed; standards of care have been‘clarified’ and awards of damages have been capped.This paper considers the standing of Wood v Lowns in the light of these changes, and reviews its currentstatus as either a beacon of light on the horizon or, alternatively, the harbinger of unsustainable liability. Itidentifies related international developments and outlines the professional implications of this interesting, ifuncertain, area of potential liability.16.3. Structured Mental Health Awareness Training for Specialist Police OfficersShaun Parsons, University of Newcastle Upon Tyne (s.parsons@ncl.ac.uk)In the United Kingdom, structured mental health awareness (MHA) training is not routinely delivered tooperational police officers. A research project, evaluating the use of MHA Training in the United States,demonstrated that training could be used in Police Office training in the United Kingdom (Dowd andParsons 2004). Despite a number of calls for this to be addressed due to the increasing number of contactsbetween such officers and mental health service users, structured MHA training for police officers has notbeen developed.Drawing on the results of a pilot initiative in 2003 by the University of Newcastle and NorthumbriaPolice—structured MHA training was administered to all firearms and hostage negotiators officers in theNorthumbria Police area (n=110). This training has been evaluated by assessing police officer attitudestowards individuals experiencing mental health problems, immediately before training, and immediatelyafter training. These data have also been compared with police officers preferred learning styles and theofficers personality structure. The results will show firearms and hostage negotiator attitudes towardsmental health issues, and how they relate to officers individual differences.The results of this research will demonstrate the effects of such training on the interactions of specialisttrained police officers with individuals with mental health problems, and may enable the police service of

60the UK to improve the front line response and service delivery at ‘Point of contact’ incidents where thepotential for violence is increased.This research is funded by a Queen Elizabeth II Award for Police Training and Innovation, having beenidentified as ‘Best Practice’ by the British Home Office. It is the subject of a PhD thesis by one of theauthors (JD). This initiative has important implications for the policing of people with mental healthproblems involved in critical incidents across the world.16.4. Rendering Assistance in an Emergency: The Legal Obligations and Implicationsof a RescueKim Forrester, Griffith University (K.Forrester@griffith.edu.au)The public expectation that members of the community, particularly health professionals, intervene andrender assistance at the scene of an accident is a common one. Anecdotal evidence suggests thisexpectation is, however, often not matched with an equal enthusiasm from health professionals who areconcerned about their legal responsibilities in such situations. The real or perceived obligation, to renderemergency assistance, is frequently raised by health professionals both formally and informally as an issuethat generates a considerable amount of confusion. What are the legal obligations and responsibilities ofhealth professionals when they come across the scene of an accident, or are called upon to render assistancein such a situation? To what extent are health professionals obliged to provide emergency assistance and,having done so, are they vulnerable to future litigation? One of the causes for concern, expressed by healthprofessionals, appears to be directly attributable to the possibility that the victim may have sustainedinjuries that require intervention beyond that of the rescuer’s level of skill and knowledge. In addition tothis, there is the practical reality of attempting to deliver emergency care in an environment where there islittle or no suitable equipment or assistance. This paper will discuss the legislation and common lawrelevant to providing emergency care and treatment16.5. Resource Rationing and Potential Medicolegal Liability for Practitioners andOrganisationsAndrew Alston, Flinders University (andrew.alston@flinders.edu.au)Mental Health practitioners may be called upon to provide professional care for unwell patients, whenoptimal facilities do not exist. For example, patients may require ongoing treatment while awaitinginpatient care in their homes (with community mental health assistance) or in emergency departments orgeneral wards (with consultation-liaison psychiatry assistance). This raises the issue, should something gowrong, what is negligence and who is liable—the practitioner or the organisation which was unable toprovide a needed resource.Similar issues arise in the non-provision of best practice treatment, whether it is a psychotherapy thatcannot be provided because it is resource intensive and costly to train staff, or a new drug (such as newatypical antipsychotic treatments) that may be expensive to purchase and be rationed within a service. Forexample, a new depot atypical medication may improve patients' compliance and prevent both relapse andforeseeable complications including self harm, but are not routinely provided in Australian mental healthservices due to cost.

61A particular dilemma is the rationing of treatment to patients receiving involuntary care—either as detainedinpatients, or as community patients taking medications against their will.In this context, practitioners working in such a system may be at increased risk of negligence actions andcoronial criticism. However given a defined health budget, health rationing is inevitable. Clinicians needto be clear about which management decisions reflect their own professional judgement, and which areimposed due to resource limitations or rationing. Consumers also need to be informed if an alternativetreatment is not offered due to cost.17. Civil Liability and Mental Health II17.1. The Effects of Litigation Strategies on Decision-Making in Sexual HarassmentCases: Theory and PracticeSarah Greathouse, John Jay College of Criminal Justice (sgrea001@fiu.edu)Margaret Bull Kovera, John Jay College of Criminal Justice (mkovera@jjay.cuny.edu)Courts in the United States have ruled that plaintiffs in sexual harassment cases claiming specific harm totheir mental health (e.g., clinical depression) have opened themselves to mental examinations. If theseexaminations uncover past sexual abuse, defense experts may testify that victims of past abuse provokesexual harassment and overreact to sexual advances (Feldman-Schorrig, 1995). In response to thesedefense strategies, some psychologists suggest that women claim garden-variety damages (e.g.,embarrassment or humiliation) to avoid the negative effects of compelled mental examinations (Fitzgeraldet al., 1999). The present research examined how testimony by a defense expert testifying about theplaintiff’s previous sexual abuse affected jurors’ judgments of welcomeness, reasonableness, and liabilityin a sexual harassment case. This study also examined the effects of claiming specific vs. garden-varietydamages on liability decisions and damage awards. Finally, this study examined the influence of thesevariables in the context of a model that explains gender differences in sexual harassment decisions(O’Connor, Gutek, Stockdale, Geer, & Melancon, in press). This model purports that self-referencingmediates the effects of gender on sexual harassment judgments and that complainant credibility partiallymediates the effects of self-referencing on harassment judgments. One hundred and sixty jury eligibleparticipants read a sexual harassment trial transcript that varied the type of damages the plaintiff claimed(specific vs. garden variety), whether a defense expert testified, and whether the plaintiff had a history ofchildhood sexual abuse. After reading the transcript, participants decided liability in the case, awardeddamages (if they found the defendant liable), and completed a post-verdict questionnaire. Specifically,participants rated their perceptions of the welcomeness, severity, and pervasiveness of the sexual behavior,their perceptions of plaintiff credibility, and the extent to which they engaged in self-referencing whendeciding the case. Results support a model, in which defense strategy influences self-referencing, which inturn influences perceptions of plaintiff credibility and judgments of liability.

6217.2. The Right to Privacy and Its Application to Psychiatry in SpainJesús Sánchez-Caro, Consultant, Madrid, Spain (jesus.sanchezc@salud.madrid.org)The right to privacy is established in the Constitution of Spain, (art. 18.1), and has been developed in somesubsequent laws, but not completely. In our opinion professional confidentiality is not well defined in theselaws. Various psychiatric cases will be reviewed to highlight the ethical problems posed by the applicationof the right to privacy in legal psychiatric practice. One of the most important dilemmas faced bypractitioners is the obligation to testify before the court when the so ordered–violating the privacy rights ofthe patient and at the same time safeguarding the right to privacy according to constitutional law.17.3. Considering Sexual Orientation in the Context of Custody and Adoption—Intersection of Law and Mental HealthCheryl Amana, North Carolina Central University (Burris@LMI.net)This paper will address the issue of sexual orientation in the context of custody disputes and fitness toadopt. It will examine existing literature and case law in considering what factors courts and legislaturesuse in addressing this issue and in particular, what role sexual orientation plays in a court’s determinationof a child’s best interest. It will incorporate the concept of psychological parenthood as well as that of a“functional” parent.This paper will review available studies on child development for children raised in same-gender familystructures to see if they provide any guidance and clarity. It will also consider whether the approach takenin the United States is similar to that taken in other countries.From the ongoing debate about same-gender marriages and the increasing availability of reproductivetechnologies to persons of all sexual orientations, it appears that determining the status of children born orraised in such unions will continue presenting questions for the courts and legislatures to answer. I hopethat this paper can lend some direction and structure to those charged with addressing this evolving andsometimes volatile issue.17.4. Forensic Aspects of Psychiatric Practice in the Electronic AgePatricia Ryan Recupero, Brown University (Patricia_Recupero@Brown.edu)Since the advent of the Internet, interest in the use of electronic communication technologies to providemedical services has surged throughout the United States and the world. As mental health professionalsbegin to explore the possibilities offered by cyber medicine, the potential risks and benefits associated withonline therapeutic interventions will require increasing examination.Four general sets of legal issues are affected by the growth of e-therapy: regulation; the therapist-patientrelationship; quality of care; security and privacy. Within the United States, in the absence of nationallicensure, state-specific licensing and disciplinary statutes variously regulate the practice of e-therapy andhinder the development of telemedicine across state lines. In Europe, however, the potential to improve

63access to care inspired the European Commission to permit the exchange of telemedical services acrossnational boundaries within the European Union. The Internet has the potential to improve patient care andhealth outcomes; however, physicians must first address concerns about patient care that are specific to thepractice of telepsychiatry. These concerns include the establishment of a doctor-patient relationship online,prescribing medication over the Internet, the importance of informed consent, and issues of privacy andsecurity on the Internet.This presentation will review e-therapy and the use of electronic communication in psychiatric practice.Relevant legal issues will be discussed, with special emphasis given to licensure, confidentiality andconsent, and the impact of technology on traditional mental health care delivery.18. Clinical Criminology in the Italian Context I18.1. Preliminary Study Carried out in J.P.H. (Judicial Psychiatric Hospital) on 20Cases of Filicide Mother-Standardization of the Operating Criteria and PrematureLocation of Risk Factors (« Paleopatterns ») in the Primary Prevention of FamiliarMurdersVincenzo Mastronardi, University of Rome (iissrcm@uniroma1.it)Matteo Villanova, University of RomeAlberto Mendini, Medico Sezione Femminile Ospedale Psichiatrico Giudiziario Castiglione delle Stiviere,ItalyIn terms of predicting intra-familiar murders where the victim is a minor, in an optics of ethologicalcomparativeunderstanding 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 beenprepared (items A, B, C, D, E) for the analysis of personality of 20 cases of filicide mothers. Themethodology of data collection comprises the direct observation of the perpetrator of crime in an intrabuildingcondition (Judicial Psychiatric Hospital of Castiglione of Stiviere - Mantua) and through clinicalanamnesteticdossier, diaries and judicial procedures. Therefore, statistical analysis andcorrelation/comparison with confrontation groups could be later used in forming predictive methods. Itemsincluded in the data: A) Dossier; B) “Predisposing” factors (specific patterns such as behaviour/symptoms);C) “Precipitating” factors (“quid novi, quid plus” in determining the event/crime); D) Systematicdestruction of the Himself of the adult on the child at the future risk of infanticide; E) Sacrifice of childrenfor the maintenance of psychic homeostasis of the parent.

6418.2. Aggressiveness: Pointers of Risk, Paleopatterns and Primary ProphylaxisMatteo Villanova, University of Rome (matteo.villanova@uniroma3.it)Antonino Calogero, Ospedale Psichiatrico Giudiziario di Castiglione delle Stiviere, Italy“Primary prophylaxis” need to contain social coasts, aimed at strategic operations which can be appliedbefore the disturbing behavioural symptomatology manifests itself. In line with the philosophy ofintervention already adopted by culturally advanced Countries and in agreement with the necessary politicsof observation, control, prevention, deal of phenomena joined in social aggressiveness, and above all by thepossibilities of massive retrenchment of Judicial System, the permanent formation of future Operators andof those already present on the territory should tend towards the maturation of contents relating to isolatingpredictive factors (paleo-patterns) of behavioural dysfunctions. Clinical reality and improvement ofprognoses in the judicial and the medical-legal field are would benefit the individual, by creating a systemwhereby individualization of elements considered “quid-novi” or “quid pluris” (thus incident on the sociorelationalcontinuum of a context in observation), and emergent "patterns" of relative and absolute riskcould be discovered and isolated before manifesting themselves as “running wild-factors” of a possible“event-crime”, and thus spare the individual of a future enormous judicial cost. At the moment results defacto unsatisfied the continuous request of Operators and institutions, for an active service demandingterritorial preventive-treatment intervention in situations of social alarm and territorial defense(aggressiveness and sexual abuse, murders and serial killers syndromes, psychosis of post-pregnancy andinfanticide, family mass murders etc.). Some studies conducted on 1.500 students of middle school of theroman district and on 20 cases of homicide mothers are related too.18.3. European Data Base on Serial Killers Updated to 2004Ruben De Luca, University of Rome (ruby007@vodafone.it)Vincenzo Mastronardi, University of RomeThe 2004 Data Base survey of well- known and ambiguous serial killers in the European–Italian frameworkhas been updated to include information regarding nationality, date of birth and death, murder locations,victim typology, and crime timespan. For each serial killer, the Data Base continues to provide allavailable information pertaining to biography, personality, sexual behabiour, modus operandi, and previousoffenses. The survey begins with the English serial killer Margaret Davey (1542). Research has beenconducted in order to provide technical and investigative background information for future criminologicalprofiling.

6518.4. Post Critical Incident SeminarBarbara Nardi, Ministry of the Interior, Rome, Italy (barbara._nardi@libero.it)Emanuela Tizzani, SMART, Rome, ItalyThe aim of this article is to describe a workshop that the South Carolina Law Enforcement AssistanceProgramme oranizes annually in order to reduce the impact of critical incident stress amongst policemen.The workshop, called Post Critical Incident Seminar (PCIS) takes place over three days and involves manytherapeutic elements directed at achieving an overall decrease in traumatic stress. These techniques includepeer debriefing exercises, education and information regarding coping mechanisms, and the addition ofEMDR. The three day format allows the participants time to open up, process and discuss their experiences.The group dynamic, granting participants the opportunity to interact with others who have experiencedsimilar traumatic incidents facilitates dialogue and a sharing of experiences; the process encouragesnormalization, and validation of traumatic experiences. Research shows that the addition of EMDRappears to have resulted in significantly lower levels of distress. It is important that the workshop processbe professionally guided and adequately staffed in order to most appropriately deal with emotional materialthat may surface.18.5. Post Critical Incident SeminarBarbara Nardi, Ministry of the Interior, Rome, Italy (barbara.nardi@libero.it)Emanuela Tizzani, SMART, Rome, ItalyBeing involved in a violent crime, whether as victim or witness, often entails exposure to a traumatic event.Right after the event itself, victims or witnesses have to face the subjective consequences of such anexposure, while simultaneously accounting to the police the objective evidence of the event, through theirpolice statements. This statement is often crucial in order to allow police forces to reach success in theinvestigation, but at the same time repeating the memory of such an event places the victims or witnesses inan “at risk” situation, namely being exposed to secondary trauma. In addition, the evidence itself becomessubject to bias and the influence of perspective distortion. After the event, a common initial response totrauma is to isolate and disconnect memories rich in sensory details and lacking in communicatoryelements. Such memories are likely to not be integrated into the spatial and temporal context. Directlyfollowing the exposure to a traumatic event, the subject may be shocked, can be dissociated, and is likely tofeel very weak and fragile. The recall of trauma can lead him back to the same emotional feelingsexperienced during the event. In order to prevent secondary traumatization during police statements and toobtain more detailed and factual evidence, a structure for victim and witness recall is necessary. Concreteprocedures, created according to what the scientific community has discovered about trauma and memory,could be very helpful in the implementation of a systematized means of obtaining factual evidence. Theaim of this presentation is to describe how trauma can impact memory and memory recall, and to providepractical recommendations as to how to proceed with preparing traumatized subjects for giving statementsand for conducting interviews.

6619. Clinical Criminology in the Italian Context II19.1. Psychological Profiles and Forensic Animation Through PC GraphicReconstructionVincenzo Mastronardi, University of Rome, Italy (iissrcm@uniroma1.it)Antonella Conticelli, University of RomeMariano Fischetti, University of RomeAfter a brief analysis of judicial issues on the theme of Forensic Animation in recent years, Prof.Mastronardi and the authors, inspect certain classical typologies that emerge in the modality of behaviourprofiles, as those deduced from the scene of the crime. Various graphical reconstructions have been carriedout through computer animations, to connect crime scene with corresponding scenarios, such as scene ofthe crime and drug addiction, scene of the crime and satanic rituals, scene of the crime and rape, and so on.Implications of such animations will be assessed and discussed.19.2. Guidelines for the Reduction of Illegal Behaviours and the Relapse through theIntegration of Several Operators of the Social Security on the TerritoryMichele Di Nunzio, University of Rome (matteo.villanova@uniroma3.it)Matteo Villanova, University of RomeIn relation to the popular perception of psychiatric patient dangerousness, proposed guidelines forpreventive-treatment interventions achievable in a Diurnal Centre for Psychosocial Rehabilitation havebeen brought into effect. Such institutional interventions can accomplish both successful patient behviouralmodification, and citizenship protection. An examination of 10 years integration data relating to the 5 mainactivated sectors studied included: artisanship, artistic expressiveness, professional pre-formation, tourismand culture, and sport. These wide alternative of activities allow each patient, a Personalized Therapeutic-Rehabilitative Project (P.T.-R.P.) ensuring personalized psycho-educational courses. The neighbourhoodcommunity’s involvement improved the therapeutic interventions quality, favouring a different and betterperception of the psychiatric patient. The neighbourhood community has been involved in literary andpopular-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, proposedthemselves as volunteers in order to further collaborate with patients. The study, even though aimedtowards tertiary prevention (damage consequences reduction), confirmed that the insertion of the patient incure plans which involve him/her in everyday life, detracting him/her from social alienation, reduces themotivation and/or possibility to carry out illegal acts; noticeable advantages even on the primary prevention(risk reduction) and the secondary stage (damage reduction), and on the expenses of the future judiciaryintervention suggests that this is a successful method of intervening.

6719.3. Guidelines Aimed at the Monitoring and the Forecast of Typologies of Crime,Perpetrator of Crime, Victim and Preventive Intervention in the E.U. StatesMarica Villanova, University of Rome (matteo.villanova@uniroma3.it)Matteo Villanova, University of RomeEmerging typologies of crime, perpetrators of crimes, and possible victims are analysed with historicallegalexamination and inquiry of demands, developed from the prevention system and the Social Defensecontrol (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 the13\07\02 and finally the Treaty for the European Constitution in order to make Europe a space of“Freedom – Security – Justice”), offering an operative profiling of identification for the use of theTerritorial Operators. Protocol aimed at various typologies of intervention are proposed, providingexecution guidelines according to standardized events from primary prevention (risk reduction) tosecondary (damage reduction) and then to tertiary (damage consequences reduction) stages; the resultingpossibility would be a systematization of monitoring, filing and comparison of data for intervention. Thiscould be shared by Operators from different countries of the European Union.From the projection and extrapolation of the data derived from a statistic analysis, the crime typologies bestpredicted 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 relatedto informatics against the property, counterfeiting and piracy against the property, traffic of drugs andproduction of new psychotropic substances, abetting of illegal immigration, kidnapping of person forsexual or extorsive purposes, terroristc organisation with the “honour killing”, new sexual crimes joined tominors and new pervertions or emerging paraphilium of destructivity nature, included snuff sex andperpetrate rape by both the sexes.Emerging typologies of perpetrator of crime coincide with the following profiling: subjects of upper-middleculture with strong entrepreneurial incentive and insufficient formation, subjects of lower-middle culture(often with mental troubles), subjects in second generation of permanence in a country (coming from acountry with a poor economy), and subjects affected with serious mental troubles.Emerging typologies of crime victims are: subjects of upper-middle social-economic level (freelance,manager, entrepreneur), subjects of low social-economic level (labourer and irregular worker), and subjectsof the lowest social-economic level (unemployed, tramp included). The intervention typologies aim tocreate a “space of Freedom, Security and Justice”, according to the Treaty of European. The greatinvestment of the future concern the permanent formation of various Operator figures and the facilitatingaction of the connecting capacities intra- and inter- territorially, in order to operate an effective controlregarding the Social Defence on the Territory.19.4. International Outline of Most Wanted Terrorists in the WorldSilvia Leo, Consultant, Milan, Italy (slsawuk@infinito.it)Vincenzo Mastronardi, University of RomeThe research, already published in a monographic study with the Newton & Compton (2005), signed byMastronardi V. – Leo S., starts from the definition of terrorism in dealing with the whole internationaloutline of most wanted terrorists in the world. It takes into account the Basque terror, the IRA’s terrorists

68and the Italian Red Brigades (Brigate Rosse), displaying the different sub or related groups, of the latterlisted terrorist group, such as:• BR-PCC = Brigate Rosse – Partito Comunista combattente (Red Brigades – CommunistFighting Party)• CARC = Comitati di Appoggio Resistenza per il Comunismo (Supporting and ResistanceCommitee for Communism)• SI = Solidarietà Internazionale (International Solidarity)• NTA = Nuclei territoriali Antimperialisti (Territorial Anti-imperialist Nuclei)• NTPR = Nucleo di Iniziativa Proletaria Rivoluzionaria (Nucleus of Proletarian RevolutionaryInitiative)• NPC = Nuclei Proletari per il Comunismo (Proletarian Nuclei for Communism)This research combines lists of fugitive terrorists with an outline of BR-PCC structural and organizationalinformation found in “The handbook of perfect Brigade member”. In addition, this research highlights theTurkish terrorists, the PKK, terrorism in Bosnia and Kosovo, and Cecenia’s terrorists.Moreover, considering the topical relevance of Islamic terrorism, particular attention has been devoted tothe 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 September 11 th2001 attacks and the relevant planned strategies. After the illustration of the flow-chart of Bin Laden’sdynasty,research focusses on the recruitment and training modes of Jihadists, the seven specializationcourses and advanced Masters of 15-45 and 60 days, as well as a summary of the Handbook of trainingtheory, organized in 11 Volumes and CD, which also describes the 11 qualifications required to be an AllahAgent.The work concludes with a description of the tools and strategies used in the armed and IT activities,including Cyberterrorism, and details information about the financing of activities.19.5. Hypnosis and Brainwashing Strategies Used in Terrorist TrainingErmanno Gioacchini, University of Rome (ermanno.gioacchini@fastwebnet.it)Vincenzo Mastronardi, University of RomeAntonella Pomilla, University of PalermoMethods of persuasion used in mass suicides and mechanisms of moral disengagement employed inchanges of faith and religion, from Christianity to Satanism, the Stockholm Syndrome, and techniques ofpsychological manipulation used by several religious sects, physiologically resemble the construction ofbrainwashing strategies used in the psychodynamics of terrorist training as mentioned by Bandura and reelaboratedin its 12 fundamental steps by Mastronardi (2005). The report aims to use the latest research toreview, in light of the most recent developments in international terrorism, the most peculiar aspects thatare also mentioned in the book “Manuale del perfetto terrorista” [The Perfect Terrorist Manual].

6920. Clinical Criminology in the Italian Context III20.1. The Development of the CIRP (Child Internet Risk Perception) Research Project.Its Contribution to the Development of New Undercover Investigative Techniquesin Chat Rooms.Roberta Bruzzone, International Crime Analysis Association, Rome, Italy (bruzzone@icaa-italia.org)G. S. Manzi, International Crime Analysis Association, Rome, ItalyThis lecture offers information about the real behaviour of children in chat rooms during some meetingswith adult pedophiles. The result of the preliminary phases of the CIRP research project have quantified thephenomenon of enticement attempts by pedophiles within the chat sessions and have shown a considerablereluctance on the part of children to tell their parents (or teachers) of these attempts. The ICAA(International Crime Analysis Association) has analyzed the motives behind this lack of communicationabout the abuse and the personality profiles of the children, who are at a higher risk from this perspective.The information obtained with this research activity has allowed for the realization of guidelines forundercover activities (simulation of children in chat) that are carried out by the specialized LawEnforcement Operators of some European Countries. Moreover, the information obtained through thisresearch project represents an important knowledge basis to build an awareness route on pedophilia online,destined first of all to children and to fundamental socialization and control systems (family and school) inorder to make internet surfing safer.Certain companies that work in this sector are receiving scientific information from the ICAA about theinternet dynamics that represent an objective danger for children in order to help in the design of effectivetechnological tools. In particular, the companies that develop software (specialized in ICT security) haveobtained some useful tools for the realization of more effective products that are able to consider even thepsychological dimension of children and the level of computer knowledge of the users (parents) of thesetechnologies.20.2. Juvenile Hacking: A Criminological AnalysisMarco Strano, International Crime Analysis Association, Rome, Italy (bruzzone@icaa-italia.org )The lecture presents the data collected by the ICAA (International Crime Analysis Association) through aresearch project that has the aim of scientifically evaluating the criminological dimension of young hackers.This study uses a criminological assessment that has been administered to a sample of young hackers(clandestinely). The assessment includes 5 research tools that measure the socialization, the perception ofcrime, the techno-criminal expertise, moral disengagement and the criminal motivation. The administrationof these tools has happened within a period of 2 years of activity and this research is still going on. Theresults of this study offer some scientifically reliable profiles and integrate the ICAA’s research that usesthe honeynet (HAIPA research project).

7020.3. The H.A.I.P.A. Honeynet: Hacker Criminal ProfilingMarco Strano, International Crime Analysis Association, Rome, Italy (bruzzone@icaa-italia.org)F. Battelli, International Crime Analysis Association, Rome, ItalyThis lecture will consider the role that criminal profiling should play in the computer forensics process. Itwill be presented as a research project centered on criminological and psychological profiles within adigital ambit. The primary use of criminal profiling in computer forensics investigations takes place whenan attack has happened (outside or inside attack) but the identity of the offender is unknown. As intraditional investigations, profiling is used to develop the investigative strategy, to narrow the list ofsuspects and develop a plan for the suspect interview. Our research, which uses a honeynet designed by theICAA (International Crime Analysis Association), has realized a web scenario that simulates an onlinecompany. The system emulates operating environments and different applications that propose to theattacker an interesting target and, at the same time, allow a precise monitoring of the offender’s actions. Acentral system collects data of traffic coming from a single host (honeypot). The operators analysetechniques and the level of attack in terms of depth and interact in real time with the target. The HAIPAhoneynet has been designed to develop two fundamental functions: first, to try to outline criminologicalprofiles of hackers (criminal profiling) by observing their behaviour during the attack; second, the systemprovides useful indications for computer forensics by outlining a series of electronic crime scenes (ECS)correlated to specific modalities of attack. The analysis and recording of ECS by the ICAA researchersallows them to develop lab experiences that can be effectively transferred to a real investigation scenario.20.4. The Human Factor and Computer Inside CrimeRoberta Bruzzone, International Crime Analysis Association, Rome, Italy (bruzzone@icaa-italia.org )Marco Strano, International Crime Analysis Association, Rome, ItalyThe research focus is the new frontier of applied criminology within companies. This lecture presents thedata collected during research on cybercriminology developed by the ICAA (International Crime AnalysisAssociation) on the social perception of computer crime among employees in a sample of Italiancompanies.This study has been focused on the perception of crime within each company, starting from the basicassumption that some choices of illegality are connected to certain cognitive distortions (e.g., lack ofawareness of the damages caused by their behaviour; lack of knowledge of laws and relative sanctions;underestimation of the possibility that a given crime can be discovered and reported, etc.). The researchtools used are two questionnaires developed by the ICAA: WCPQ (Workplace Computer crime PsychologyQuestionnaire) and CRPQ (Computer crime Risk Perception Questionnaire). The aim of the criminologicalresearch developed by ICAA in the Italian companies is to create new techniques for psychological crimeprevention.

7121. Clinical Criminology in the Italian Context IV21.1. NNPCP (Neural Network for Psychological Criminal Profiling): DecisionalInvestigative Analysis Support SystemMarco Strano, International Crime Analysis Association, Rome, Italy (bruzzone@icaa-italia.org )Roberta Bruzzone, International Crime Analysis Association, Rome, ItalyS. Alvares, International Crime Analysis Association, Rome, ItalyThe neural network, NNPCP, unlike the traditional database, is closer to the way of working typical of thehuman mind with its capability of making emerge non-evident correlations (process known as knowledgediscovery) and to learn, in a simplified manner, from experience. The functionalities of the NNPCP systemverify the reliability of inductive and deductive profiling methods; they offer to investigators a decisionalsupport for analysis and investigation; they drive and standardize the investigative analysis; they reduce theerror margins based on probability by the hint of analysis of various tracks and provide a data-orientedevaluation of the different opportunities; they reduce emotion/irrationality based investigative choices. The“typical” approach of the neural network is represented by the most likely trend but also considers otherpossibilities of choice. The insertion of real case data inside the neural network that is carried out in thisperiod, then correlated to bio-social, motivation, psychological and psychopathological profile of theoffender that has been identified by investigators (and interviewed in jail) slowly modifies the “certainties”of the starting statement (on statistic basis) and takes the system towards the production of outputs that aremore accurate and reliable.21.2. The Development of the “Spider”: Investigative Software for On-lineInvestigationF. Di Marco, International Crime Analysis Association, Rome, Italy (bruzzone@icaa-italia.org )Marco Strano, International Crime Analysis Association, Rome, ItalyThis lecture presents the preliminary results of some experiments conducted with some investigativesoftware (spider) developed by the ICAA (International Crime Analysis Association) for investigation andintelligence activity on cultural pedophilia websites and cultural hate-oriented websites. The “spider”, inthe testing phase, allows the localization on the world wide web of texts that instigate racial hatred or thatjustify pedophilia and, at the same time, can carry out a link-analysis. These tools have been trainedthrough specific textual contents and are destined to evaluate different signs of dangerousness of thewebsites localized on the WWW. The use of this kind of system is aimed at investigators only but offersinteresting scenarios of criminological research.

7221.3. The Italian ‘Unabomber’: Innovative Criminal Profiling TechniquesMarco Strano, International Crime Analysis Association, Rome, Italy (bruzzone@icaa-italia.org )Roberta Bruzzone, International Crime Analysis Association, Rome, ItalyThe aim of this lecture is to propose a new and innovative methodological approach to criminal profilingtechniques that consider primarily the activity of a multidisciplinary team (and not just a single profiler)and the use of software to support the psychological analysis and the elaboration of the geographic profile.The study shows the psychological and geographic profiling technique applied to a real case by the ICAA(International Crime Analysis Association) equipe in collaboration with the Criminological Analysis Unitof the Carabinieri and already consigned to the investigators that work on the case. The ICAA researchershave been on the various crime scenes of the “Unabomber case” and have carried out special analyses. Theoutcome of this analysis work will be presented during the session.21.4. Criminological Implications of Compulsive GamblingC. Guerreschi. International Crime Analysis Association, Rome, Italy (bruzzone@icaa-italia.org)Marco Strano, International Crime Analysis Association, Rome, ItalyThis lecture suggests the hypothesis that some criminal behaviours by people apparently very distant fromprofessional/habitual crime can be correlated to diversified forms of compulsive gambling. The study ofsome exemplary cases from both clinical and criminological perspectives outlines the fact that themotivational dynamics of some appropriation crimes or violent crimes can be found within the state ofeconomic difficulty that some of these subjects—compulsive gamblers (who commit the crime)—cansuddenly experience. From this perspective, an analytical approach acquires a significant importance of theinterdisciplinary type for the evaluation of probable recidivism.22. Clinical Criminology in the Italian Context V22.1. Criminological Evaluation of Crime Scenes in Satanic CrimeRoberta Bruzzone, International Crime Analysis Association, Rome, Italy (bruzzone@icaa-italia.org )This lecture describes the results of an ICAA (International Crime Analysis Association) research onsymbology and typical ritual objects that are connected to the world of Satanism. Some ICAA researchers,together with a deep bibliographic research, have taken pictures and analysed, in collaboration with someItalian Police offices, the evidence and the remains of Satanic rituals in order to provide investigators withguidelines for intervention in cases of suspected ritual crime.

7322.2. Exploratory Analysis of Violent Protest Groups on InternetRoberta Bruzzone, International Crime Analysis Association, Rome, Italy (bruzzone@icaa-italia.org )The research is focused on the detailed monitoring and analysis activity of websites, chat rooms,newsgroups and other online resources of over 1500 violent protest groups, which are groups andorganizations that pursue their own political, social and religious agendas through the direct appeal, thesupport or the invitation to violence. The term Violent Protest Groups, therefore, includes a wide range ofrealities that includes different kinds of organizations, from the ones with strongly anti-social targets tosuch terrorist organizations as Al Qaeda, Hamas, POJ, Hizbollah, etc. The study examines the use thatthese Violent Protest Groups make of the telematic medium and tries to illustrate the possible futuredevelopments and the implications in terms of security, privacy and the right of freedom of expression.Moreover, the modus operandi on the Internet of this kind of group has been described in detail with aspecial focus even on the support that the Information and Communication Technology offers to thesegroups in terms of propaganda, proselytism and motivation.22.3. Sects, Brainwashing and Crime: A Case StudyRoberta Bruzzone, International Crime Analysis Association, Rome, Italy (bruzzone@icaa-italia.org )The lecture presents the data obtained by the ICAA (International Crime Analysis Association) throughmeeting/talking with family members of subjects that have entered some dangerous sects that operate inItaly. The information has been collected by a multidisciplinary team made of ICAA members that work asvolunteers for a public office activated by the ICAA from October 2004. The study proposes the principaltechniques used by sects to approach and involve the victims and the personality profiles that are at riskfrom this perspective. The aim of this research is to design investigative techniques and exit counsellingsystems.22.4. Satanism: An Analysis of the Enchantment Experienced by Adolescents from aCriminological PerspectiveRoberta Bruzzone, International Crime Analysis Association, Rome, Italy (bruzzone@icaa-italia.org )This lecture presents the data collected by the ICAA (International Crime Analysis Association) through aresearch project. The aim of this study is represented by the scientific evaluation of the diffusion of Satanicculture among young people and the correlation of this culture with the situation of social or psychologicaldiscomfort, and with criminal behaviours. The research has administered an anonymous questionnaire to agroup of adolescents in various schools. The questionnaire has been developed by the ICAA and has beenadministered to a sample of 5000 Italian adolescents who attend various schools in different Italian cities:Torino, Padova, Firenze, Bologna, Genova, Terni, Roma, Napoli, Reggio Calabria and Palermo. The aim ofthe study is focused on the realization of a campaign of prevention and sensitization that the ICAA hasstarted up by using the outcomes of this research.

7423. Competency Issues in Law and Psychiatry23.1. The Continuing Conundrums of CompetencyJohn A. Devereux, University of Queensland (j.devereux@law.uq.edu.au)Competency operates as a “gatekeeper”. Those patients who are competent must have their wishes as toconsent or refusal of treatment respected. Those who are not competent may have their treatment decisionsoverruled (Faden and Beauchamp 1986). Competency functions both as a legal construct and as anacknowledgement 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 asufficiently 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 andBiomedical and Behavioural Research 1982).This paper will argue that the continuing conundrums of consent are sourced not so much in differing viewsof 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 inthe legal literature to use the terms “inform” and “understand” interchangeably. Schwartz and Roth argueconvincingly 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 tounclear outcomes. The term “nature of the treatment” is also not clearly understood. Exploring what isencompassed 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. Muchof the recent literature, however, suggests the concept of competency continues to be a difficult one whichneeds further thought and definition. (Stewart 2004, Parker 2004).23.2. Fitness to be Sentenced: An Historical, Comparative and Practical ReviewAllan Manson, Queen's University (mansona@post.queensu.ca)A Canadian Court, in a decision called R. v. Balliram recently held that a person convicted of a criminaloffence who suffered a substantial deterioration in mental condition since the trial could be found unfit tobe sentenced. The court based its conclusion on both historical arguments and the Canadian Charter ofRights and Freedoms. While the reasons themselves may be open to question, there are compellingjustifications for recognizing this concept. The paper examines the Balliram decision and then looks at thehistory of fitness and how the sentencing phase became disconnected from claims of unfitness in the late19 th century. It then considers theoretical justifications based on fairness and the need for sentencing to bea moral discourse before looking closely at a variety of issues arising from the Canadian Charter of Rightsand Freedoms. Recognizing the number of practical questions that need to be addressed beforeimplementing a concept of unfitness at the sentencing stage, the paper looks at some common lawjurisdictions 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, therecognition of unfitness at the sentencing stage should be followed by a form of sentencing that takes intoaccount the gravity of the offence, the prosecutor’s position, any relevant aggravating or mitigating factorsthat can be adduced, and then results in a “provisional” sentence, whether custodial or community-based,

75which stays in effect until the offender becomes fit. The paper ends with a model that incorporates thisapproach 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 oneroussanctions are imposed.23.3. The Rating of Psychiatric Impairment for Legal Purposes: Issues of Validity andReliabilityGeorge Mendelson, Monash University (george.mendelson@med.monash.edu.au)Workers’ compensation jurisdictions utilise medical ratings of permanent impairment to determine thequantum of compensation payable to injured workers. In Australia, similar provisions have been enactedin 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 arefrequently prescribed by legislation as the method for the medical assessment of impairment, the recenteditions of the Guides do not provide for the percentage rating of psychiatric impairment. The ratingmethod for psychiatric impairment in the 4 th and 5 th editions of the Guides deals with the assessment ofdisability 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 aspectsof mental functioning that are assessed during a psychiatric interview as part of the mental stateexamination. Descriptors indicative of the severity of impairment have been provided for each of the sixcategories, and the median method is utilised to determine the whole person psychiatric impairment.23.4. Supreme Court of Canada on Consent to Treatment: Findings and FalloutJohn E.Gray, University of Western Ontario (jegray@shaw.ca)Richard L. O'Reilly, University of Western OntarioFew mental health cases reach the Supreme Court of Canada. There was therefore considerable interestwhen the case of an involuntary patient, described as "Canada's beautiful mind," who had been found to becapable of refusing treatment by lower Ontario courts, was appealed to the Supreme Court of Canada. Thisdecision was of considerable interest because in addition to guidance on how judgements of incapability inOntario should be made by physicians, review tribunals and courts, it appeared to some to address the issueof the right of an involuntary patient to refuse the treatment required to become well enough to be releasedfrom detention.This paper will briefly describe the Ontario law concerning capability and substitute decision maker rulesand the facts of the case. This will include the intellectual abilities of the patient Scott Starson, who was abrilliant amateur physicist with 17 previous psychiatric admissions and an active delusional system. Thedifferences between the minority on the Supreme Court of Canada, which included the chief justice, and themajority will be identified. Implications for Ontario and provincial mental health acts that do not allowrefusal of the treatment required to enable the person to be discharged will be addressed. Finally, the effects

76of the Court decision on Scott Starson, who has now spent 6 years hospitalized without treatment, and hisfamily and those in similar situations will be discussed.23.5. Voluntary Intoxication and Guilt in Criminal Cases: A Comparative PerspectiveSteve Thaman, Saint Louis University (thamansc@slu.edu)The Criminal Law has struggled with how to take account of voluntary intoxication when assessing aperpetrator’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 disproveguilty mens rea in criminal cases. In the 19 th Century, however, most U.S. jurisdictions began to admitevidence of voluntary intoxication to negate guilty mental states, and a specific doctrine developed, that ofgeneral and specific intents, to deal with the complexities of evidence of intoxication. As the trends inaccepting insanity and diminished mental capacity became more liberal, so did those relating tointoxication evidence, and thus implicitly recognized the fact that intoxication has the capacity tosubstantially 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 theAmerican Common Law in this area in the 19 th Century and my paper will compare the current USapproaches 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 substantiveoffence of “complete intoxication” under which a drunken person may be condemned, even if the elementsof the crime originally charged cannot be proved due to the defendant’s intoxication. At least 10 Americanjurisdictions have returned to the original Common Law approach and made evidence of intoxicationinadmissible, thereby raising serious doubts as to whether a defendant in such cases can receive due processand a fair trial. The paper will try to place this issue in its social, criminal and mental health context as well.23.6. At the Fringe of the Law: Interpretive Oscillations in Assessing Fitness to StandTrialMichael Feindel, Ministry of the Ontario Attorney General, Toronto, Canada(Michael.Feindel@jus.gov.on.ca)This paper closely examines the test employed by Canadian courts, psychiatrists and Review Boards indetermining whether an accused is unfit to stand trial. The case of R. v. Taylor decided by the Court ofAppeal in Ontario (1992) adopted what the court referred to as the “limited cognitive capacity” test forfitness: if an accused person suffering from a mental disorder demonstrates a rudimentary understanding ofthe legal process and has the capacity to communicate with counsel, she is “fit to stand trial.” The fact thatthe accused was not capable of making rational decisions beneficial to her did not merit a finding ofunfitness. Such is the basic law for Canada. The low threshold of the test has attracted some criticism overthe years. The test has also been the source of inconsistent application, where the same evidence has givenrise to different assessments, as happened in the recent case of R. v. Balliram—a case primarily noteworthyfor 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 oscillationsparticularly in cases involving the accused’s embracing delusions or suffering delusional disorders. Shouldthe accused demonstrate a personal understanding of the trial process or is it sufficient that he have a

77hypothetical appreciation of what a trial involves? What constitutes a sufficient capacity to instructcounsel? What merits “an instruction”? These and other questions are no less troubling for the forensicpsychiatrist expected to give expert evidence on fitness. Other jurisdictions are examined for applying anexplicitly higher standard of cognitive capacity in determining fitness.Finally, the paper examines the consequences of a “higher” or “lower” threshold being applied to determinethis question. Each, it is argued, has “complex” (i.e. positive and negative) consequences for the accusedperson. 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 thepublic and for the liberty interests of the accused.24. Compulsory Community Treatment Orders I24.1. Social and Structural Dimensions in the Implementation of Community TreatmentOrdersLisa Brophy, University of Melbourne (Lisa.Brophy@mh.org.au)This paper will explore the demographic characteristics of approximately 170 people on CommunityTreatment Orders (CTOs) in one area mental health service in Victoria, Australia. The results of a clusteranalysis will be presented and discussed in relation to whether this analysis can inform the question ofwhether there are particular ‘types’ of people who are most likely to be subject to a community treatmentorder. The data will be compared and contrasted with the author’s qualitative research that is exploring keystakeholder perspectives on the current use and purpose of CTOs. Preliminary identification of themessuggests that resource management, along with risk management, form significant foundations for decisionmaking. These findings are important in the context of policy and practice in Victoria, where the use ofCTOs is common practice and orders are generally made for a 12 month period (it is estimated that at anyone time at least 3,000 people are on community treatment orders). There is a significant challenge toensure that those subject to CTOs are not subsequently ‘languishing’ on them due to resource restrictionsthat inhibit the development of less coercive treatment options. The potential of recent law reform to beable to meet this challenge will be considered, including the introduction of treatment plans as anattachment to CTOs.

7824.2. Involuntary Care and Treatment in the Community: Policy and Practice AcrossThree JurisdictionsJim Campbell, Queens University at Belfast (jim.campbell@qub.ac.uk)Lisa Brophy, University of Melbourne (Lisa.Brophy@mh.org.au)Bill Healy, Queens University at BelfastAnn-Marie O’Brien, Royal Ottawa Hospital, Ottawa, CanadaAs we move into the twenty first century, many nation states are increasingly using laws to treat mentalhealth service users compulsorily in the community. In some ways, this is an understandable trend, giventhe consensus that institutional care be used only 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 towardscontrol, however, has profound implications for the role of social workers and other professionals; webelieve that there is a need to examine such developments in the context of national and internationalcontexts and standards of professional practice and human rights law.The paper will begin by briefly reviewing the literature on the subject, including arguments around theefficacy 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: A jurisdiction that has experienced rapid deinstitutionalization, coincidingwith expanded use of CTOs over the last decade. It has been argued that client rights have not always beenbest protected because of a tendency to retreat to a medication only regime and failures in care planningprocesses. Recent reforms in Victorian legislation around mandatory treatment plans may help to addresssome 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 issome evidence to suggest that the strategic use of hospital beds and the care/treatment planning process canenhance patient autonomy.The United Kingdom: Only one jurisdiction – Scotland – will have introduced CTOs by 2005. In thissection a discussion will take place about the relative merits of Scottish mental health law and proposals forchange to English and Welsh and Northern Irish legislation, when compared to other internationalexperiences.The paper will conclude with a proposed typology which highlights areas of convergence and divergencebetween systems.

7924.3. An International Comparison of Health Service Use in Two Jurisdictions Withand Without Outpatient CommitmentStephen Kisely, Dalhousie University (Stephen.Kisely@cdha.nshealth.ca)Neil Preston, Fremantle Hospital and Health Service, Perth, AustraliaJianguo Xiao, Health Department of Western Australia, Perth, AustraliaMark Smith, Dalhousie UniversityWe examined whether outpatient commitment (OPC) reduces in-patient health service use for patients fromWestern Australia in comparison with control patients from a jurisdiction without this legislation (NovaScotia). We used a population-based record linkage analysis of an inception cohort using a two-stagedesign of matching and multivariate analyses to control for socio-demographics, clinical features andpsychiatric history. All discharges from inpatient psychiatric services in Western Australia and Nova Scotiawere included covering a population of 2.6 million people. Patients on OPC in the first year ofimplementation in Western Australia were compared with controls from Nova Scotia matched on date ofdischarge from in-patient care, demographics, diagnosis, and past inpatient psychiatric history. Weanalysed time to admission using Cox-regression analyses and number of bed-days using logisticregression. We matched 196 OPC cases with an equal number of controls. On survival analyses, OPCcases had a significantly greater risk of readmission. Co-morbid personality disorder and previouspsychiatric history were also associated with readmission. However, on logistic regression, patients onOPC spent less time in hospital in the following year, with a reduced risk of inpatient stays exceeding 100days. Although outpatient commitment does not reduce hospital admission rates, increased surveillance ofpatients 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.24.4. Community Treatment Orders: Profile of a Canadian Population Project UpdateAnn-Marie O’Brien, Royal Ottawa Hospital, Ottawa, Canada (aobrien@rohcg.on.ca)Susan Farrell, University of OttawaSylvie Faulkner, Montfort Hospital, Ottawa, CanadaCommunity Treatment Orders: Profile of a Canadian Experience (project update) is a continuation of astudy published in the Canadian Journal of Psychiatry (O’Brien and Farrell, December 2004). Our studyrepresents 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 arebased on a comprehensive plan of community based treatment or care. This plan must be developed andagreed to by all parties involved prior to the CTO being issued. CTOs in Ontario are consent based. Thepatients 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 tocontest the order before the Consent and Capacity Board, prior to the CTO being issued. Physicians, notcourts, issue CTOs. CTOs in Ontario are in effect for 6 months, and there is a mandatory review of theCTO every year.

80Our study reports on the first 50 patients of the Royal Ottawa Hospital issued CTOs. Using a mirror imagedesign this study reports on hospital utilization patterns, involvement with community resources, andhousing one year prior to first issuance of the CTO and 1-year post 1 st issuance of the CTO. A standardizedinformation collection tool was developed based on the data requirements of the ministry of health andlong-term care in the province of Ontario. This tool was completed at the time the first CTO was issuedand then updated to reflect the patient’s ongoing involvement with the legislation as well as related clinicaloutcomes. This study found a statistically significant reduction in both the number of hospital admissionsand the length of admissions following issuance of a CTO. Issuance of a CTO was also associated withincreased involvement with community-based resources such as ACT teams and case-management. 82CTOs were issued for these 50 patients and only two were contested before the consent and capacity board.Four 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. AlthoughCTOs in Ontario are unique, our data is consistent with findings of other international studies of a similardesign. CTO legislation in Ontario has been described as “showing an admirable degree of respect forpatients’ autonomy” (Dawson et al International Journal of Law and Psychiatry, 2003). Respectingpatients’ autonomy will be discussed in light of findings of our study. Future directions on examiningcoordinated collaboration between mental health and judicial systems connected to CTO legislation will bereviewed.24.5. The Utility of Early Intervention Community Treatment OrdersSteven P. Segal, University of California at Berkeley (spsegal@uclink4.berkeley.edu)Outpatient commitment has become a controversial procedure, some viewing it as an infringement onindividual 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 tohow it has been used, for what clinical purposes, and to what clinical ends. Further, no one has looked atits use in the context of the patient’s total treatment experience. This study considers early-interventionoutpatient commitment—i.e. orders issued following the patients’ first hospitalization and/or within ninetydays of entry into the mental health system as a possible reasonable scheme for pre-emptive use ofoutpatient commitment orders. Such a procedure may be considered pre-emptive in that it represents aneffort to establish a structured treatment relationship with the patient early on in their treatment careerrather 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 usesthe data from the Victorian Psychiatric Case Register to consider nine years of early interventionexperience with outpatient commitment among patients placed on orders (N=8979) and a matched controlsample (N=8979). Descriptivism on the frequency of the use of this intervention is presented and the utilityof 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.

8125. Compulsory Community Treatment Orders II25.1. What Determines Compulsory Community Treatment? – A Logistic RegressionAnalysis Using Linked Mental Health and Offender DatabasesNeil Preston, Fremantle Hospital and Health Service, Perth, AustraliaStephen Kisely, Dalhousie University (Stephen.Kisely@cdha.nshealth.ca)Jianguo Xiao, Health Department of Western Australia, Perth, AustraliaWestern Australia has one of the highest published rates of the use of compulsory treatment orders in theEnglish-speaking world. Differences in patient characteristics, legislation, and service setting may explainvariations in the reported efficacy of compulsory community treatment. The objective was to investigatepredictors of Community Treatment Order (CTO) placement in the first year of implementation in WesternAustralia and see if there were any differences in the type of patients placed on these orders compared toother studies.A population–based record linkage study of Mental Health and Offender Databases comparing 265 patientson a CTO with a consecutive control group (CCG) of equal number matched on date of discharge from inpatientcare 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 significantpredictors of CTO placement.Studies of compulsory community treatment appear to be of similar populations. In spite of thecomparatively high rate of use, psychiatrists in Western Australia do not appear to be applying communitytreatment orders to different types of patients compared to elsewhere. We need further research to establishthe relative contribution of patient characteristics, legislation, and service setting towards the use andoutcome of compulsory community treatment.25.2. The Use of Involuntary (Surreptitious) Psychiatric Medications in LawEnforcement Emergencies—Yes, No or Maybe?Victoria Dreisbach, Yale University (Victoria.Dreisbach@yale.edu)Involuntary psychotropic medications have been used in psychiatric emergencies when a person has beenassessed to be imminently dangerous to themselves or others. However, the use of psychotropicmedications in law enforcement emergencies has received little attention. Surreptitious drug use in lawenforcement 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 aboutthe risks and benefits of medication use in such circumstances versus individual rights and communitysafety.This presentation will examine a case in which a psychotropic medication was surreptitiously administeredby police to a violent person with a known psychiatric history during a life-threatening law enforcementemergency that threatened the life of the alleged perpetrator, the police, and innocent bystanders. A review

82of the community legal standards regarding psychotropic medications and informed consent, medicalstandards regarding medical involvement with police interventions, and the ethics about the use ofpsychotropic 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, thepolice emergency was resolved without loss of life to both the alleged perpetrator and the police.Nevertheless, it does raise questions about whether the use of surreptitious medications is justified incertain situations.25.3. A Question of Numbers: Introducing Community-Based Treatment Orders inEngland and WalesSimon Lawton-Smith, The King’s Fund, London, England (s.lawton-smith@kingsfund.org.uk)The UK Government intends to introduce compulsory community-based treatment orders in England andWales through new mental health legislation. This is primarily driven by concerns about public safety and adesire 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 tocompulsory powers. There are many opponents of the legislation, including professional bodies, legalorganisations, 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 citedspecific evidence to support their position.The King’s Fund is undertaking a piece of research that aims to estimate the likely number of people whowould be subject to compulsion in the community should the new legislation be passed by Parliament. Thiswill enable policy-makers and service providers to plan for the introduction of community-based treatmentorders 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 literaturereview, distributed a questionnaire to a number of individuals in those countries, and undertaken interviewswith individual policy-makers, academics and service providers in England and Wales.The findings from the research are expected to be made public in July 2005.25.4. The Voice of the Community: The Role of Citizens’ Advisory CommitteesSean Taylor, Correctional Service of Canada, Saskatoon (sean.taylor@sasktel.net)Citizens’ Advisory Committees (CACs), through voluntary participation in the Canadian federalcorrectional process, contribute to the protection of society by actively interacting with staff of theCorrectional Service of Canada (CSC), the public, and offenders. Since their inception in 1965, CACs havecontributed to the overall integrity of correctional services and programs in Canada by providing impartialadvice, 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

83communities for all concerned. Currently, more than 600 volunteers are members of the 106 CACs acrossCanada. Members represent various social, cultural, and demographic backgrounds and occupations.Contemporary contributions made by CACs to correctional systems in Canada will conclude thepresentation. CACs, as representatives of their communities, have important roles to play in facilitating thesuccessful reintegration of offenders into society.Objectives:• Examine issues that affect the creation and maintenance of successful CACs.• Discuss the impact of CACs on offenders, correctional staff, and the community.• Review strategies for recruitment and retention of volunteers for CACs.25.5. Compulsion in New Zealand Mental Health CareAnthony J O’Brien, University of Auckland (a.obrien@auckland.ac.nz)Mental health care in New Zealand moved from an institutional to community focus between the 1970s and1990s. In 1992, mental health legislation changed significantly with the introduction of the Mental Health(Compulsory Assessment and Treatment) Act. This Act introduced Community Treatment Orders, a formof involuntary outpatient treatment, further reinforcing the notion that mental health care should beprovided in the least restrictive environment, ideally in the community. Since the changes over the latterperiod of the 20 th century, there has been no systematic study of the rate of use of compulsion in mentalhealth care, or of trends in the use of compulsion. This presentation will outline a study aimed at providinga quantitative description of the use of compulsion in New Zealand, and will present initial data mappingthe use of compulsion. Data presented will describe compulsion in relation to region, demographiccharacteristics of patients, and clinical presentation. The data are part of a PhD study aimed at modellingthe use of compulsion in terms of geographical, service, clinician, and patient characteristics. Thepresentation will include an outline of the latter part of the study.26. Compulsory Community Treatment Orders III26.1. Mandatory Outpatient Treatment in AustraliaIan Freckelton, Monash University (I.Freckelton@latrobe.edu.au)Mandatory outpatient treatment orders have become an orthodox part of the clinical and legal landscape inAustralia. They constitute the principal mechanism by which deinstitutionalisation has been accomplishedand by virtue of which treatment is provided in the community to persons who are adjudged likely, withouta 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 suchorders. Nor is there much by way of guidance for clinicians or mental health review tribunal members as to

84when coercion has become counter-therapeutic or when a patient should be extended the opportunity toresume autonomy in relation to their mental health.From the perspective of a review tribunal member, the paper will review the various statutory tests formandated outpatient treatment in Australia, and will scrutinize a cross-section of cases coming before theVictorian Mental Health Review Board in order to assess the criteria in practice for the issuing and reissuingof such orders. It will suggest that looseness too often attaches to the making of such orders, on thebasis of a fallacious contrast with the alternative – the making of an inpatient detention order. Havingregard to the realities of limited resources for provision of care to persons with mental illnesses in thecommunity, it will analyse the real-world impact of mandated outpatient orders in Australia.26.2. Involuntary Outpatient Treatment in the USA: Conundrum to QuagmireJeffrey Geller, University of Massachusetts (jeffrey.geller@umassmed.edu)In the U.S.A. the actual beneficiaries or victims of involuntary outpatient treatment (IOT) (depending uponone’s point of view) have expressed a wide range of opinions about these interventions. IOT has beencharacterized by considerably more opinion than fact: “involuntary outpatient commitment is acontemporary lightning-rod issue in American psychiatry. Its assets and liabilities are all too often lostsight 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 isused extensively.IOT can be conceived as having been researched through three generations of studies. First generationstudies are cases and represent the rare instances where the person conducting the treatment actually writesabout it. Second generation studies are best characterized as quasi-experiments and surveys. Thirdgeneration studies, to be discussed in detail, involve three states’ efforts that have or will include controlledstudies 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 andwas better coordinated, involuntariness in community treatment would not be necessary. This opinion iswithout foundation. It is time that IOT in the U.S.A. move toward an evidence-based practice, in the samemanner that we are trying to move all psychiatric interventions.26.3. Canadian Approaches to Mandatory Community TreatmentJohn E. Gray, University of Western Ontario (jegray@shaw.ca)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 inpatientcriteria are based on physical dangerousness very few people are placed on leave. Where the criteriainclude the likelihood of significant mental or physical "deterioration" conditional leave is used morefrequently. In the two jurisdictions with community treatment orders, the "deterioration" rather than a"dangerousness" criterion is used.

85Unlike New Zealand and some other jurisdictions Canadian community treatment provisions cannot beused to avoid in-patient hospitalization altogether. Avoiding or shortening hospitalization can be helpful forpeople with a first psychotic break, who require mandatory medication but can be managed safely in thecommunity. 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 competentpatient or substitute decision maker. In all jurisdictions, the services the patient is ordered to use must beavailable. In formulating and signing off the treatment plan the involvement of people varies. Methods fortriggering an assessment if the conditions are breached and the consequences are discussed. Rightprotection mechanisms are discussed. The extent of the use of mandatory community treatment in Canadais estimated.26.4. Involuntary Outpatient Psychiatric Treatment in Israel – Its Evolution andEvaluationRoberto Mester, Tel Aviv University (rmester@netvision.net.il)Yair Barel, Israel Ministry of Health, Jerusalem, IsraelInvoluntary outpatient psychiatric treatment (IOT) was introduced in Israel in 1991, through theimplementation of the 1991 Mental Health Act. Since then, it has been used extensively all over thecountry. The law differentiates two different types of involuntary psychiatric treatment: the civil outpatientcommitment 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 enforcedcommitment 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 aspectswill be discussed. Several follow up studies have been carried out through the years. These will beanalysed.One of the Israeli associations of families of schizophrenic patients has been lobbying for modification inthe Mental Health Act, to increase the legal power of the law to allow preventive interventions to enforcetreatment in uncooperative patients at the very inception of psychotic decompensation. The controversialissues in this proposal will also be discussed. The supervision of the IOT is carried out by regionalpsychiatric boards. This raises interesting issues which will also be presented in this paper.26.5. Statutory Roles as a Vehicle for Advanced Nursing Practice in New Zealand:Progress or Problem?Brian McKenna, University of Auckland (b.mckenna@auckland.ac.nz)In New Zealand, patients subject to compulsory processes under the Mental Health (CompulsoryAssessment and Treatment) Act (1992) (the Act) are assigned a Responsible Clinician, defined as ‘theclinician in charge of the treatment of that patient’. Responsible Clinicians must be:a psychiatrist approved by the Director of Area Mental Health Services; or

86some other registered health professional who, in the opinion of the Director of Area Mental HealthServices, has undergone training in, and is competent in, the assessment, treatment and care, of personswith mental disorder.While the Responsible Clinician is clearly defined in generic terms, the role has been assumed exclusivelyby medical practitioners. The 1998 Ministerial Taskforce on Nursing noted that this role could potentiallybe assumed by nurses. However, at that time there was no clear pathway for nurses wishing to take the roleof Responsible Clinician. The Ministry of Health has recently defined the competencies of ResponsibleClinicians, and it is clear that those competencies are within the scope of advanced mental health nursingpractice.Despite this potential, there are only a few mental health nurses in general mental health services who haveendorsed the role. In the past, nurses have been ambivalent about acting in statutory roles under mentalhealth legislation. Statutory roles have been perceived as inherently coercive and supporting a custodialmodel of care. Furthermore, statutory roles have been considered threatening to the therapeutic relationship,which is the foundation of mental health nursing practice. However, mental health legislation, with itspower to intervene coercively in the lives of patients, is a reality in mental health nursing practice. Ratherthan protest the assumption of statutory roles, nurses might do better to explore ways in which these rolescan be enacted in the interests of consumers. This would involve considering how the power of mentalhealth legislation could be used for therapeutic advantage, rather than as a tool of coercion. The alternativeto assuming generic roles, such as Responsible Clinician, is to accept a position of decision-makingdependent on medical authority.A strong case will be put forth, in this presentation, for advanced mental health nurses to actively pursuethe potential for adopting the role of the Responsible Clinician. The current need is for the development ofa planned process of implementation, to give practical weight to the Ministry guidelines that determinecompetency.27. Compulsory Community Treatment Orders IV: ‘TheOntario Experience’27.1. The First Four Years of Community Treatment Orders - The Experience ofPhysicians' CounselPatrick J. Hawkins, Barrister and Solicitor, Toronto, Canada (phawkins@blgcanada.com)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 nowbeen in use for four years and a body of jurisprudence is being developed that considers the enablinglegislation. The paper will analyse that jurisprudence. I will test the jurisprudence against the purposes ofthe 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 thantreatment in a psychiatric facility, and a way to maintain treatment in the community for that group ofpatients that is often lost to follow-up. They are designed to assist the "revolving door" patient, who istreated in hospital, stabilised and discharged, only to be lost to follow-up care, deteriorate and require readmission.I question whether the needs of patients and the goals of the legislation are being met at this

87time by the legal process—is it becoming unduly complicated and technical? And, are the purposes of thelegislation being forgotten? After considering the existing jurisprudence against these questions, I willoffer some suggestions for the future and what I believe should happen with CTOs in the coming years.27.2. CTO Case Management Services in Toronto: The Hard Data—First Returns onthe Efficacy of the Ontario ExperimentSteve Lurie, Centre for Mental Health & Addiction (CMHA), Toronto, Canada (slurie@cmha-toronto.net)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 implementthe community treatment plan outlined in the order. Clients are seen one to three times per week andassisted 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 acomparison group of hard to serve clients. CMHA has provided case management services to over 200people and achieved a 94-96% reduction in hospital days after a year. 80% of clients stay engaged with thecase management service following the expiry of the CTO.The results of a research project comparing perceived coercion and service satisfaction between the twogroups will also be presented.27.3. Legal Oversight of Community Treatment Orders in OntarioTheodore Nemetz, Consent and Capacity Board of Ontario, Toronto, Canada (nemetz@inforamp.net)The purpose of a Community Treatment Order (CTO) is to provide community based treatment to thosepeople who have a history of repeated hospitalizations followed first by improvement and then bydeterioration. 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 allof the statutory criteria have been met. It additionally mandates a review upon the second renewal of theCTO and thereafter upon each 2 nd renewal.The purpose of this paper is to examine how the review process takes place—the effectiveness of thisreview process, and a consideration of possible alternatives.

8827.4. Ethical Concerns Arising from the Ontario Experience with CommunityTreatment OrdersMark Handelman, University of Toronto (m.handelman@sympatico.ca)Community Treatment Order legislation seeks to balance the right of a person suffering serious mentaldisorder to treatment with the right to make his or her own treatment decisions. A stated principle of thelegislation 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 compromisesmade and the effect upon the dignity and autonomy of the individuals placed on community treatmentorders. It also examines the ethical conflicts faced by physicians who place patients on treatment ordersand the societal interest in the allocation of the resources available for treatment of mental disorder in thecommunity.27.5. The Impact of Community Treatment Orders on Patients with AssertiveCommunity Treatment and WithoutAlison Freeland, University of Ottawa (afreelan@rohcg.on.ca)Ann-Marie O’Brien, Royal Ottawa Hospital, Ottawa, CanadaSusan Farrell, University of OttawaDespite the paucity of research on Community Treatment Orders (CTOs) in Canada there is growinginterest in their use clinically. Those concerned with the use of CTOs in the context of unclear researchoutcomes, recommend less coercive forms of community based treatment, such as Assertive CommunityTreatment (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 improvedadherence to treatment and follow-up.The purpose of this study is to examine the socio-demographic, psychiatric, and service utilization profilesof patients with ongoing ACT involvement who are placed on a CTO, compared to those on a CTO withoutACT. Preliminary findings at 6 months indicate no statistical difference between groups with respect todiagnosis, concurrent substance abuse disorder and legal involvement. However, ACT patients did notexperience 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 post1 st issuance of a CTO, if outcome is measured by hospital days. It has been suggested in the literature thatthe efficacy of CTOs lies in the provision of community based resources that accompany the CTO. Ourstudy focuses on a group of patients who have the highest intensity of community based service availableprior to a CTO being considered. Our findings will be discussed with respect to these issues.

8927.6. Importance and Methodology for Changing Public Perception about CommunityTreatment OrdersCathy Plyley, Regional Mental Health Care London, Canada (Cathy.plyley@sjhc.london.on.ca)Joe Skufca, Regional Mental Health Care London, Canada (Joe.skufca@sjhc.london.on.ca)This presentation will look at challenges and successes for Community Treatment Consultants in LondonOntario. London is an urban area with a large population of individuals with a serious mental illness. Thenegative connotations for Community Treatment Orders in Ontario has acted as a barrier, preventing anincreased utilization of this tool for treatment of the seriously mentally ill. This presentation will reviewmethods used to change the perception of Community Treatment Orders to make them a more acceptabletreatment option for treatment teams, community supports and Substitute Decision Makers. Whenlegislative changes were brought to Ontario in 2000, Community Treatment Orders were called Brian’sLaw 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 patientsby utilizing the Treatment Plan associated with CTOs in a creative and client friendly manner. We will alsoreview the use of CTOs with populations such as geriatrics, early psychosis, adolescents and adultpopulations. We will review the feedback from clients, families and treatment teams regarding enhancedopportunities for relationship building, which allows for more positive re-integration into the community ofchoice while maintaining well being. In our area over 90 percent of the clients on Community TreatmentOrders are considered incapable to consent to treat. Potential reasons for such a high ratio of incapableclients will be explored.28. Compulsory Community Treatment Orders V: ‘The OntarioExperience’28.1. Community Treatment Orders (CTOs) and Forensics: The Sudbury ExperienceDianne Stewart, Northeast Mental Health Centre, Sudbury, Canada (Canadadstewart@nemhc.on.ca)Community treatment orders (CTOs) were introduced as an amendment to the Mental Health Act inOntario, 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 hasbeen quite innovative. The blending of CTOs with forensics is one of the areas that has been very uniqueand successful. As is well known, many individuals with SMIs do not receive adequate psychiatric care inthe correctional system. Through the implementation of a Mental Health Court in Sudbury, along with theneed to treat these unique individuals in the mental health system, the idea of the collaboration between theCTO program and the forensic mental health system arose. This partnership has helped build a strongconnection for these individuals within the mental health system. The goal of this presentation is tointroduce the successful outcomes of the marriage of these two distinctive areas. Also, to demonstrate howthis alliance has led to prompt integration of the individual into the community mental health system, with a

90reduction in the continuing need for incarceration. In other words, these exclusive individuals havesuccessfully been “taken out of the criminal system and solidly planted into the mental health system”.28.2. A Critical Analysis of Community Treatment Orders in Ontario, Canada: Clinical,Social, Legal and Moral ImplicationsTy Turner, St. Joseph’s Health Centre, Toronto, Canada (turnet@stjoe.on.ca)Achieving the right balance of autonomy and beneficence is a never-ending challenge for free anddemocratic societies.Complicating this, the fulcrum continues to move, sometimes at an accelerated pace. This can reflectcultural change, law reform, or political dynamics. In Canada, all of these factors converged when theconstitution was patriated from the United Kingdom. A major elaboration of civil and political rights wasenshrined in a new constitution, which contained the Charter of Rights and Freedoms. First introduced in1982, the Charter extended its protections to mentally ill persons in 1985. The Charter has contributed to amajor shift towards the ascendancy of personal autonomy and civil liberty. Nevertheless, the beneficentimpulse remains and post Charter attempts to reconcile beneficence with freedom can generate a confusedatmosphere for all stakeholders. In Canada, this shift has most dramatically affected Ontario, its mostpopulous province, where significant changes in mental health legislation have taken place. Passingthrough 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 ofthe mentally ill, aversion to state intrusion, and the government’s need to fulfill election promises bydownsizing itself, reducing spending, and cutting taxes. From this, Ontario brought forth its first legislatedattempt 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 attemptsto strike the ethical balance.28.3. Use of Community Treatment Orders within a Context of Community Care:Experiences in OntarioPamela Khan, University of Toronto (pamela.khan@utoronto.ca)Community mental health care in Ontario, Canada, has continued to evolve over the last few decades. Oflate, even more emphasis is given to maintaining individuals with serious mental illness in the community,while avoiding hospitalization whenever possible. Various configurations of community support teamsexist, as do programs providing hospitalization for acute episodes of illness, when required. One legislativeeffort to ensure continuing care to those with persistent mental illness is the passing of Brian’s Law, whichintroduced Community Treatment Orders in Ontario in 2000; this legislation has met with mixed reviewsfrom 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 communitysupport services. In an effort to provide care to some of these clients. Community Treatment Orders have

91been used. This paper will discuss various perspectives on the use of this approach to care. The experienceof clients and health professionals, in the First Episode Psychosis Program, with Community supportservices and Community Treatment Orders will be a focus of the discussion.28.4. Community Treatment Order: A Legal Tool to Recovery and Wellness in theCommunityO. J Oluboka, University of Western Ontario (oloruntoba.oluboka@nbph.moh.gov.on.ca)Providing consistent and effective treatment for patients with severe and persistent Mental illness in thecommunity, has been one of the most difficult challenges for the mental health care providers. The patientsusually respond to management interventions while in hospital but soon default follow up appointments inthe community. Subsequently, recurrence of their illness is the rule rather than the exception. Frequentrecurrences/relapses of a psychotic illness have been shown to predict poor outcome and progressivedeterioration of the illness. Hence the patients deteriorate mentally, physically, and functionally withinevitable poor quality of life.Following an extensive province-wide consultation, Brian’s Law (Mental Health Legislative Reform) wasintroduced in Ontario, Canada in December 2000. This amends the Mental Health Act and Health CareConsent Act to enable community treatment orders (CTOs) for persons with severe and persistent mentalillness.In this presentation, we review the unique approach used by the “CTO Team” from the North BayPsychiatric 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 processthat helps the patient embrace wellness in the community. Not only has the CTO, in our experience,assisted some patients to follow a treatment regimen in the community, it has empowered them to remainwell long enough in the community to enjoy a better quality of life within the context of their illness.28.5. The Case Against Community Treatment OrdersGary Chaimowitz, McMaster University (chaimow@mcmaster.ca)Community Treatment Orders (CTO) or their variants are now available in many parts of the world, yettheir use remains controversial especially outside the psychiatric profession. However wheneverpsychiatry claims to speak for the rights of others, it is perhaps time to step back and re-evaluate thelandscape that altruism has had, at times, a dark heart. This presentation will outline the case against the useof CTOs. Several clear cautions seem to have been ignored as a beleaguered profession resorts to whatmay be considered tools associated with being agents of state control. Psychiatry is no stranger to coerciveinterventions – a utilitarian model attenuating the discomfort of forced detention or treatment. Althoughmaking for odd bedfellows, the debate about the use of CTOs has also highlighted the arguments of thosewho 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 arguablydeprives them of choice. Various principles have operated in civil commitment, including the ‘leastrestrictive alternative’. In fact, it is in the area of civil commitment, that psychiatrists are perhaps mostoften cast as agents for state control. Moving from inpatient to ‘outpatient committal’ may often appear tobe a less restrictive alternative although the implicit expectation for medication adherence to maintain

92outpatient status – is a feature that attracts the label of ‘coercion’. The view that CTOs representpaternalism, benevolent coercion respectful of autonomy and liberty has been used to excuse the loss ofliberty associated with this process. Ignoring the principles of justice and fairness is the beginning of aslippery slope. The challenge to society is how to engage a marginalized group in a treatment processwithout resorting to coercive measures.29. Contemporary Challenges in Law and Psychiatry29.1. Killing for the State: The Darkest Side of American NursingDave Holmes, University of Ottawa (dholmes@uottawa.ca)Amelie PerronThe aim of this presentation is to bring to the attention of the international nursing community thediscrepancy between a pervasive ‘caring’ nursing discourse and a most unethical nursing practice in theUnited States. In this presentation, the author will present a duality: the conflict in American prisonsbetween nursing ethics and the killing machinery. The US penal system is a setting in which trainedhealthcare personnel practice the extermination of life. The author looks upon the sanitization of deathworkas an application of healthcare professionals’ skills and knowledge and their appropriation by the state toserve its ends. A review of the states’ death penalty statutes shows that healthcare workers are involved inthe capital punishment process and shielded by American laws (and to a certain extent by professionalboards through their inaction). In considering the important role healthcare providers, namely nurses andphysicians, play in administering death to the condemned, the author asserts that nurses and physicians arepart 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 whotake part in execution protocols are state functionaries who approach the condemned body as angels ofdeath: they constitute an extension of the state which exercises its sovereign power over captive prisoners.29.2. On The Road Again: Insights into Predators on the Information SuperhighwayEileen M. Alexy, The College of New Jersey (emalexy@nursing.upenn.edu)While the Internet opens a vast array of communication, entertainment, and educational resources forchildren and adolescents, it also opens a gateway to home and school for predators. The anecdotal termsused by law enforcement to describe Internet predators are “traders” and “travelers.” This descriptive studyintroduces 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 “combinationtrader/traveler.” To date, few studies in the psychiatric, criminology, and sociological literature haveexamined cases of Internet predators. This investigation points toward understanding and identifyingassessment and prevention strategies for predators and suggests future areas of research surrounding thisphenomenon.

9329.3. Polygraphy as a Treatment Strategy for Sex Offenders: Policy Development,Process & OutcomesRochelle A. Scheela, Bemidji State University (rscheela@bemidjistate.edu)This research study explored the outcomes of instituting polygraphy as a treatment strategy in an outpatientsex offender treatment program. Data collection involved polygraphy, focus group interviews of sexoffenders and treatment providers, direct observations during group treatment, a survey of offenders, asurvey of therapists and probation agents, and record analysis. The subjects were 189 adult male sexualoffenders currently in a rural community sexual abuse treatment program, and the therapists and probationagents 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 increasedcosts.In this presentation, the treatment program will be explained and the process of instituting polygraphy willbe discussed including the use of a community collaborative representing treatment providers, lawenforcement 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 researchand practice implications and recommendations.29.4. Assisting Families of Sudden Traumatic Death After Interpersonal Violence andCrime: An Evolving Role for Forensic NursingJoseph T. DeRanieri, Thomas Jefferson University (drjoed2@comcast.net)This presentation will explore the role of forensic nursing management, in the EmergencyDepartment/Urgent Care Environment (ED), in assisting the family members with death resulting frominterpersonal violence and crime.The sudden and violent nature of murder can leave surviving family members with an immense burden ofunresolved issues. Understanding the unique facets of medico-legal procedures in the ED can provide aplatform for ED nurses to educate surviving family members and promote the important beginning stagesof 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 specialconsiderations for the ED nurse. It automatically triggers a medico-legal investigation. In such aninvestigation, the body, clothing and personal effects are all considered evidence. This presentation willdiscuss the role that the nurse plays in preserving evidence on the body and clothing, preserving physicalevidence removed from the body, and preserving personal effects, while working with the family who maybe asking for the personal effects.In addition, this presentation will discuss methods to promote the beginning stages of adaptive grief andbereavement when faced with murder, how to prepare the family for viewing the decedent and how toapproach the family while providing a supportive environment for family to allow the grieving process tobegin.

94Given the complexity of murder and the impact it has on families, complicating factors, typical and atypicalresponses will also be discussed, ending with a listing of basic interventions nurses can perform in thissetting.The presentation is drawn from clinical and research experiences from a large urban area.29.5. Dating Violence: Comparing Victims Who Are Also Perpetrators with VictimsWho Are NotAngela Frederick Amar, Georgetown University (acf25@georgetown.edu)In adolescent populations, dating violence is regarded as bi-directional. While many researchers havestudied the associated effects of victimization and perpetration, limited research has explored differences invictims who are both victims and perpetrators and victims who do not report perpetration of violence. Thepurpose of this study was to compare injury and mental health symptoms of victims who reportedperpetration with victims who did not.A sample of 411 young women was recruited from a historically black college in the south and a privatecollege in the Mid-Atlantic. Participants completed the Abuse Assessment Screen and the SymptomChecklist-90-Revised.While all of the participants reported dating violence victimization, 35% (n=144) of the women alsoreported perpetration of dating violence. As compared to non-perpetrating victims, victims who reportedperpetration were more likely to report injury, had significantly higher scores on depression, hostility, andgeneral psychological distress, and were at greater risk of psychiatric diagnosis.Findings suggest the importance of further research on the effects of perpetration. Clinical implicationsinclude the importance of assessing all young women for victimization and perpetration of violence and theinclusion of perpetration in health teaching.30. Corrections and Mental Health I30.1. Treatment of Mentally Disordered Youth Offenders in GermanyFrank Haessler, University of Rostock (frank.haessler@med.uni-rostock.de)Despite being part of the psychiatric classification system, mental retardation as it is described in ICD-10and DSM IV is not a psychiatric illness. The prevalence of psychiatric illness among adults withintellectual disability varies widely, between 10 and 60%. For example, disruptive behaviour as well asself-injurious behaviour occurs in 12 to 36% of individuals with mental retardation, who reside ininstitutional settings.Impulsivity also constitutes a core symptom of attention deficit hyperactivity disorder reaching intoadulthood. Aside from this, a lot of other psychiatric disorders contain symptoms of impulsivity and

95disruptive behaviour. Additionally, lack of impulse control is also prevalent among sexual offenders,arsonists, and young murderers. Given the aggravating laws for criminal prosecution of violent and sexualoffenders, questions of the effectiveness of therapies using psychopharmacological drugs are becomingmore salient, as such offenders are taken into custody more often and for longer times.Our presentation explores opportunities for treating offenders, taken into custody for disruptive behaviour,with psychopharmacological drugs. There is some evidence that conventional antipsychotic zuclopenthixolhas a positive effect on destructive behaviour. A few studies have described the successful use of atypicalantipsychotic risperidone to control severe self-injurious behaviour and other behaviour problems in avariety of diagnoses. Anticonvulsants, antidepressants, and anxiolytic medications may also find animportant place in the treatment of some individuals with disruptive behaviour. Furthermore, stimulants inmonotherapy or in combination with atypical neuroleptics are also effective for aggression relatedbehaviour. Taking the example of the Rostock youth forensic clinic, our paper also discusses variouspsychopharmacological therapies and lists different options of psychopharmacological therapy for sexualoffenders.The principles of treatment in people with mental retardation are the same as for persons without mentalretardation, but modification of techniques may be necessary according to the individual patient’sdevelopmental level, and especially communication skills. Psychopharmacological, psychotherapeutic, andeducational interventions should be coordinated within an overall treatment.30.2. Prison PsychosesNorbert Konrad, Free University of Berlin (norbert.konrad@medizin.fu-berlin.de)With reference to mental illnesses with psychotic symptoms, a substantial proportion of Germanpsychiatrists 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 ofschizophrenic illnesses, with psychopathology, which may be coloured by prison conditions in aspects suchas the contents of delusions, whereas “prison psychoses” are specific reactions to imprisonment. “Prisonpsychoses” have not entered international classification systems (ICD 10, DSM IV) as a distinct clinicalentity. 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 animportant 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 fellowprisoners (Nitsche and Wilmanns 1911). Another differentiating factor, identified as crucial, is thetermination of prison psychotic phenomena with the interruption or ending of imprisonment, even thoughthere may be “remnants” of psychoses in the form of “now affect-free remains of delusions ” or querulantor 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 specialfeatures are demonstrated by prisoners with the diagnostic label prison psychosis with regard tosociodemographic, clinical-psychopathological, and forensic factors.

9630.3. Patient Safety in Secure Settings: The Critical Relationship Between thePerceptions of Forensic Patients Regarding their Personal Safety and theLikelihood of Successful Treatment and Rehabilitation OutcomesShirley Pullan, Centre for Addiction & Mental Health, Toronto, Canada (Shirley_pullan@camh.net)This paper will address a critical factor in the successful treatment and rehabilitation of patients in mediumsecure forensic settings. The degree to which forensic patients feel safe in their environment has asignificant impact on their willingness to participate in clinical programs, their therapeutic relationshipswith staff, the extent of interactions with co-patients/interdisciplinary team members and their overall levelof trust of the detaining facility. Patients experiencing fear or uncertainty in a secure setting as a result ofperceived/actual threats of harm from co-patients may become withdrawn, isolated, reluctant to participatein clinical programs, and limited in their interactions with both staff and co-patients. These copingstrategies from the patient who is feeling unsafe present challenges for the interdisciplinary team, whichimpede the ability to assess mental status and level of risk. Sub-optimal interactions with the patient, thepatient’s absence from clinical/recreational/vocational programs and the impaired ability to evaluate thepatient’s relationships with co-patients may result in suspending decisions relative to the granting of offunitprivileges, access to approved persons and considerations of increased freedom due to the lack ofcurrent clinical and risk information. In this paper, the author will describe an evaluation system developedto obtain feedback from patients in a medium secure setting regarding their personal perceptions of “howsafe do you feel” within their environment. This system addresses a range of dimensions relative tosafety/security and includes 1:1 sessions with patients, focus groups and a written survey. The purpose ofthe system is to elicit information from patients that will assist in identifying possible offenders, ensure thatall patients feel safe, provide a venue for evaluating the unit’s milieu and protocols and to reinforce theprocedures for reporting situations that are unsafe or threatening.30.4. Psychotherapy Within the Prison System and the Role of Professional SecrecyVera Schneider, Institute for Forensic Psychiatry, Berlin, Germany (vera.schneider@charite.de)Treating prisoners in the German prison system, especially in so-called "social-therapeutic facilities", iscarried out in an institutionalized form. The aim of therapy is to resocialize the prisoner. In theseinstitutions, treating sexual offenders—with the corresponding indication—is mandatory, but therapy isvoluntary for all other offender groups. In addition to social-therapeutic facilities, treatment can beobtained externally, from psychologists and the corresponding projects in prison as well as in psychiatricdepartments 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) ofTegel prison in Berlin, the largest in Germany. Three certified psychologists offer outpatientpsychotherapy and counseling on a voluntary basis there. An important feature of the institution is theguarantee of professional secrecy. Therapy focuses on working out personal problems. Resocialization isanother, but not primary, goal of treatment. Using a quasi-experimental design, the treatment effects of thisinstitution were evaluated for the first time 13 years after the programs inception, based on the probation offormer clients. We also examined the differential treatment effects in a control group from the regularprison population, and in two groups of former clients from the social-therapeutic facilities. The followingbrief discourse discusses the findings of this study.

9730.5. Inmates’ Reactions to Telepsychiatry Consultations: Legal ImplicationsWilliam Tucker, Columbia College of Physicians & Surgeons (tuckerb@pi.cpmc.columbia.edu)In 2001, the New York State Psychiatric Institute and Columbia College of Physicians & Surgeons beganproviding consultations to mentally ill inmates of the state’s 12 maximum-security prisons. Using highbandwidthvideoconferencing equipment, Columbia faculty responded to requests from prison mentalhealth staff regarding particular clinical challenges. Consultations were real-time and interactive, includingboth case-presentation and inmate interview. Inmates themselves appeared to respond so favorably to thismedium that a follow-up research study was undertaken, to assess which mental health services theypreferred to have delivered in this way, rather than by their on-site mental health team. Preliminary resultsof 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.30.6. International Standards and the Treatment of Mentally Disordered OffendersRosemary Wool, Council of Europe (rjwool@wicken.nildram.co.uk)The mandate governing the treatment of prisoners, including their physical and mental health care, isincluded 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 itsinception, when the First UN Congress in 1955 adopted the Standard Minimum Rules for the Treatment ofPrisoners. These rules have stood the test of time, and specifically comment on the treatment of ‘insane andmentally abnormal’ prisoners. Sadly, fifty years later, there are numerous examples worldwide where thestandards of mental health care fall well below these recommendations, and indeed, in some instances, donot conform even to the UN conventions.The paper will explore where deficiencies are found with examples given from personal knowledge ofEuropean countries.30.7. Conceptualizing Nursing Research with Offenders: Another Look at VulnerabilityCindy Peternelj-Taylor, University of Saskatchewan (peternel@duke.usask.ca)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 provideoffenders with quality nursing care. And although correctional nursing has undergone significanttransformations in role development in recent years, correctional environments have attracted very fewnurse researchers, even though a gold mine of opportunities exists for nurses to make a significantcontribution to the health care of the offender.Embracing a research agenda that focuses on offenders as a vulnerable population is fraught withambiguities not generally encountered in other settings. The dilemmas surrounding research with offenders

98as a vulnerable population reflect a contemporary research problem that requires further exploration withinnursing 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 specialpopulations; 2) discuss existing safeguards that are in place to guide nursing research with vulnerablepopulations; and 3) review the idiosyncratic dilemmas encountered when conducting research withoffenders in correctional environments. Ultimately, it is hoped that nurses will develop innovation andcreativity in the conduct of ethical research with offenders. In doing so, nursing science will be informed.31. Corrections and Mental Health II31.1. Psychoimmunological Aspects of ImprisonmentN. Brandstätter, University Clinic for Psychiatry, Vienna, AustriaB. Saletu, University Clinic for Psychiatry, Vienna, AustriaE. Wienerroither, University Clinic for Psychiatry, Vienna, AustriaS. Strnad, University Clinic for Psychiatry, Vienna, AustriaT. Wenzel, University Clinic for Psychiatry, Vienna, Austria (drthomaswenzel@web.de)Imprisonment must be assumed to be a live event impacting on the complex biopsychological system in ayet to be understood way. To evaluate the effect of imprisonment 55 male prisoners, from whom voluntaryconsent had been obtained, were compared to 55 age and sex matched healthy volunteers in regard to keyimmune and neuroendocrinological parameters, including Lymphocyte typing, Natural Killer Cell Activity,Zell-Aktivität, PHA stimulation, Cytokins after PHA stimulation at baseline shortly after imprisonment and2 months later (prisoners, control group at baseline), parallel to questionnaires evaluating coping andcoping strategies, including the German language Streßverarbeitungsfragebogen (Stress CopingQuestionnaire, SVF (Janke, Erdmann & Kallus 1984). Results indicate that in prisoners, natural killer cellactivity was reduced both at baseline, shortly after imprisonment and after two months; Heightened cortisollevels were accompanied by low natural killer cell activity, while dysfunctional coping strategies in theSVF were accompanied by lower natural killer cell activity.

9931.2. Trauma, Dissociation and Post-traumatic Stress Disorder in Forensic InpatientsCarsten Spitzer, Ernst-Moritz-Arndt-University (spitzer@uni-greifswald.de)Manuela Dudeck, Ernst-Moritz-Arndt-UniversityHeike Liss, Ernst-Moritz-Arndt-UniversityMichael Gillner, Ernst-Moritz-Arndt-UniversityHarald J. Freyberger, Ernst-Moritz-Arndt-UniversityGiven the high prevalence of trauma, dissociation, and posttraumatic stress disorder (PTSD) in the generalpopulation, psychiatric patients and criminal offenders, this study investigated the frequency of traumaticevents, 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 astructured 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 anddissociative 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 thesemet lifetime criteria for PTSD. At the time of assessment, 9 patients (17%) suffered from PTSD, which hadnot 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 asubstantial overlap between PTSD and dissociative disorders with 20% of all participants suffering fromboth conditions. The findings from the expert ratings were confirmed by the results of the self-reportmeasures. Patients with PTSD and/ or dissociative disorders exhibited significantly higher degrees ofpsychopathological 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 comorbiddisorders such as PTSD or dissociative disorders, which are frequently overlooked in the diagnosticprocess. However, these conditions play a very important role for the therapy. For example, dissociativesymptoms such as amnesia, absorption, derealization, and depersonalization, as well as misperceptions ofthe environment might cause difficulties in adequately understanding and responding to therapeuticinterventions. Consequently, the therapist must be aware that these patients tend to dissociate whenconfronted with trauma-associated cues which is likely to result in a reduced responsiveness to therapeuticinterventions. This, in turn, may result in a poorer medical and legal prognosis.31.3. Taking the Mystery out of Designing Medium Secure Forensic Units: A Model ofCollaboration between a Clinical Program Administrator and an ArchitectShirley Pullan, Centre for Addiction and Mental Health, Toronto, Canada (Shirley_pullan@camh.net)Roman Mychajlowycz, Kleinfeldt Mychajlowycz Architects Inc., Toronto, Canada (roman@kma.to)The planning and design of medium secure forensic units, poses challenges for Clinical ProgramAdministrators and Architects. Medium secure forensic units are complex in terms of the security featuresrequired to manage risk and public safety, the needs of the target population, and the additional componentsspecific to clinical programming. The ideal unit balances a therapeutic environment that is conducive to

100treatment and rehabilitation, while ensuring the secure detention of assigned patients. The combinedexpertise of the Clinical Program Administrator and the Architect is essential to the successful design of asecure setting; however, initially obstacles may be inherent when these professionals with such diversebackgrounds undertake to plan for these units. The optimal design and planning process is dependent onthe effective relationship between these individuals, and is enhanced when a reciprocal appreciation andunderstanding 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 forover 10 years. They have developed an effective system that has resulted in the design of units thatsuccessfully incorporate clinical program requirements with architectural concepts. The model adopted bythe authors is based on the premise that all security requirements for medium secure settings can beachieved without being unnecessarily obstructive or inhibiting the needs of both patients and staff. Thecritical design features of a medium secure forensic unit accommodate the effective monitoring of patientmovement, the need for patient privacy, a secure perimeter, the ability to segregate individual patients fromthe 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 productsthat minimize the risk of self-harm by patients and the ability to conceal or create potential weaponsdirected towards violence against others. The authors will outline a process for the translation of clinicaland risk management needs associated with medium secure settings, into the design of an environment thatincorporates all of these elements.31.4. Continuity of Care Models for Soon to be Released OffendersNancy A. Flanagan, University of Buffalo (nf7@buffalo.edu)In the last five years, there has been an increased focus on transitional planning in U.S. prisons for soon tobe released offenders. This interest in transitional planning is a result of increased numbers of offendersbeing released from correctional facilities. Offenders have a higher incidence of mental health problems,substance abuse, and concomitant communicable disease, that occur as a result of poor health promotionand disease prevention practices before incarceration. Pre-release managed health care may increase exoffenderaccess to community health services, ensure continuity of care, decrease the incidence of acuteexacerbations, control the spread of communicable disease, and reduce public health care costs. Outreach,discharge planning, entitlement applications, and case management have been suggested pre-releasemanaged 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 ofthese new programs, a field study of transitional health care models was undertaken. The results of aNational Institute of Justice funded study of models of transitional health care planning within state prisonsin the United States will be reported. Study subjects included chief medical officers in state correctionaldepartments, coordinators of transitional health care programs, and interdepartmental liaisons. The studydesign utilized field research observations and interviews to assess current U.S. state prison models thatprovide 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 currenttransitional health care programs for soon to be released offenders with mental illness; 2. describe currentactivities that provide continuity of care for soon to be released offenders with mental illness; 3. explainevaluation strategies for transitional health care programs for offenders with mental illness; 4. identifyservice provider recommendations for transitional health care of the mentally ill offender; 5. provide datathat will assist correctional departments and community public health care providers develop managed reentryhealth care for soon to be released offenders with mental illness.

10131.5. Group Psychotherapy with Bipolar Mood Disordered Forensic PatientsSergio Santana, University of Alberta (sergio.santana@amhb.ab.ca)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 25-50% of people with bipolar disorder against further episodes. In light of these findings, itis imperative that clinicians explore other therapeutic avenues. Moreover, many authors have emphasizedthe benefits of using different psychological interventions as adjunctive therapy. In the demanding field offorensic psychiatry, there are only so many hours in the day with so many patients to see to develop andprovide adjunctive psychotherapy. This presentation will offer a relatively new approach to treatingoutpatients in forensic psychiatry that could potentially alleviate acute symptoms, restore psychosocialfunctioning, identify early signs of relapse, and economically use clinician’s time. A bipolar mooddisorders group was established for forensic patients found not criminally responsible for their crimes dueto a mental disorder. Psycho-educative, psychodynamic, and narrative approaches were the mainstay of thegroup. It appears that a psychotherapeutic group program for patients with bipolar disorder may beestablished quite readily with the forensic population, with positive implications for patient treatmentprognosis. The presentation will discuss the dynamics of establishing such a group and the implications forthe patient and for the treatment team, such as increased adherence to medication, greater acceptance oftheir illness, treatment engagement, fewer hospitalizations, and improved efficacy of the treatment team.32. Criminal Responsibility I32.1. Another Look at People v. Garabedian: Means, Motive, and the MolecularBiology of IntentJanet K. Brewer, The Center for Molecular and Behavioral Medicine, Chicago, Illinois(JanetKBrewer@cs.com)On a March afternoon in 1983, David Garabedian, an employee of the Old Fox Lawn Care Company inMassachusetts, arrived at the home of Eileen Muldoon to spray her lawn with insecticides. He knocked onthe door and received no response, so he surveyed the front lawn and calculated a cost estimate. Next,according to Garabedian, he felt the strong urge to urinate, and, under the impression that no one was home,walked around the back of the house and proceeded to urinate on the lawn. Mrs. Muldoon emerged fromher home unexpectedly and berated Garabedian. Garabedian, a model citizen who had never shown violenttendencies, suddenly dislodged nearby stones and bludgeoned Mrs. Muldoon to death. As Garabedianformulated his unique defense based on prolonged exposure to allegedly mind-altering chemical agents, thetrial that ensued called into question what role neurobiology plays in the intent to commit murder.David Garabedian, convicted of first degree murder, is currently serving a life sentence. In contrast to thevast majority of prisoners, he still has hope that he will receive a new trial. His hope is grounded in theconviction that scientists will unravel the mysteries of the human mind. Indeed, the scientific communitywas bent on doing just that when it universally proclaimed 1990-2000 to be the “Decade of the Brain.” As

102the newfound study of neurobiology flourishes, evidence is multiplying that important aspects ofphysiology and even behavior can be affected via involuntary exposure to sublethal doses of neurotoxins--with results ranging from mild gastrointestinal discomfort to severe psychiatric disturbances, even a violentmind. Since the onset of the medical community’s “Decade of the Brain” in 1990, a new body of scientificliterature has emerged with regard to the workings of the brain at the molecular biological level.This paper explores in what way these scientific findings may impact criminal non-responsibility, theGarabedian case specifically. Part I explains how molecular neurobiology first came to converge with lawto become the involuntary neurotoxic damage defense. Part II explores the precise mechanism of action ofacetylcholinesterase, including its discovery and current problems associated with its pharmacologicalutility. Part III examines the influence of molecular neurobiology on different aspects of the insanitydefense. Ultimately, the paper concludes that Garabedian is entitled to post-conviction relief based on thegreater understanding of the molecular mechanism of aggression.32.2. Affective Disorders and Criminal ResponsibilityAndrew Carroll, Monash University (Andrew.Carroll@forensicare.vic.gov.au)Evaluating criminal responsibility in the setting of affective disorders poses particular challenges for mentalhealth professionals. The ‘McNaghten Rules’, which form the basis for determining legal insanity in manyjurisdictions, have often been criticized as being too ‘cognitive’ in nature. In practice, they (or theirmodified forms) can in fact apply to cases where the primary problem is affective rather than cognitive, buttheir use in this context does raise certain problems. One such problem is maintaining appropriateboundaries around the concept of insanity. It will be argued for example that the ‘irresistible impulse’ test,which is still operational in some Australian states, fails to do this. It will also be argued that reliance on thepresence or absence of ‘psychosis’ is an inadequate guide. The value of the ‘evaluative’ concept ofemotion, which incorporates cognitive aspects of emotional states, as opposed to ‘mechanistic’ models,which view such states as essentially impervious to reason, will also be discussed.The challenges involved will be illustrated by a recent Australian case. A tentative model for appropriateanalysis of affective disorders in the context of insanity evaluations will be proposed.32.3. Forensic Psychiatry: A Pathological EnterpriseJohn Douard, Rutgers University (douard@rci.rutgers.edu)Richard Friedman, Office of the Public Defender, Newark, New Jersey, (Rif1@aol.com)Daniel P. Greenfield, Seton Hall University (dpgfldmd@msn.com)A presupposition of criminal law is that a person is legally responsible for what s/he has done only if hecould have done otherwise. This is a presupposition grounded in respect: we can properly punish peopleonly for acts they could have chosen not to perform. Sexually violent predator acts rest on the notion that asex offender can be civilly committed, but not punished, if his sex offending behavior is the result of acausal process over which he has little or no control. Such people generally know right from wrong, andthey may even want to do what is right, but they cannot execute that moral knowledge or those moraldesires. How can a person know that his sexual conduct is wrong and desire to refrain from engaging inthat conduct, yet be unable to control his behavior? Forensic psychiatrists often utilize categories of mentaldisorder set forth in the DSM-IV-TR to explain why a person accused of being a sexual predator is, or is

103not, capable of volitional control. We shall argue that the use of the DSM in a forensic context ispretextual, in a way that mimics the pretextuality of sexually violent predator laws themselves, and istherefore morally indefensible.32.4. The Implications of Behavioural Genetics for Notions of Free Will in theCriminal LawAllan McCay, University of Sydney Foundation Program (amccay@pacific.net.au)Hart has described the criminal law as a choosing system (1995). However recent in advances inbehavioural genetics can be seen as calling into question the choices of those who come before the criminalcourts. This is not merely a theoretical argument but has been one that the courts have been asked toanswer. This presentation will briefly discuss what behavioural genetics are and how they are seen bysome to relate to the criminal law. It will be briefly argued that the science has some significant issues thatdetract from its reliability for legal purposes. The main focus of the paper will be based on the hypothesisthat some of the issues of reliability are overcome and this leads to an increased ability to predict who willoffend. With this hypothesis in mind some philosophical views of free will will be discussed in the light ofbehavioural genetics. In conclusion, it will be argued that notions of free will in the criminal law maybecome increasingly hard to defend.32.5. Capital Litigation, Culture, and Mental HealthKaren B. Froming, University of California at San Francisco and Pacific Graduate School of Psychology(Karen@Froming.net)Capital Litigation, when an individual’s life is at stake, requires the most extensive legal work andmitigation or investigation. That investigation should, but does not always include, the analysis of cultureor the milieu in which the individual grows up. In the United States, where the death penalty is still legal,the Supreme Court has held that mitigation and the generation of a complex, comprehensive Social Hisotryis required for responsible presentation of the case.This presentation will focus on the complexities inherent in the mitigation of capital crimes and thedevelopment of a Social History when the defendant is of another culture. The case involves a Rwandesenational who was a refugee, post-genocide, in that country. I will discuss the levels at which theinvestigation was enhanced by knowledge of the culture and hindered by the lack of appreciation of thatsame culture. Mental health and legal issues will be highlighted.

10432.6. Factor Analysis of Responsibility in Schizophrenic PatientsShaoai Jiang, The 2nd Xiangya Hospital Central South University (shaoaij@hotmail.com)Objective: To explore and understand the relative factors of responsibility in schizophrenic patients.Method: A self-developed responsibility rating scale for mental illness was used to assess 286schizophrenic offenders who were divided into three groups according to the different responsibility levels.Results: No realistic motivation, impairment of life ability and impairment of reality testing are the mainrelative factors of responsibility assessment for schizophrenic offenders. Conclusion: This studyconcluded that the responsibility rating scale is more effective than experimental evaluation in theassessment of responsibility for schizophrenic offenders.33. Criminal Responsibility II33.1. Methodology of a Psychiatric Judgment in Cases of Simulation and/orDissimulation of Mental DiseaseMaria Chiara Lavorato, University of Pavia (aluzzago@unipv.it)Within a psychiatric judgment of the hypothetical author of a crime, the simulation and/or dissimulation ofone or more psychiatric disorders by the examined subject, raises complex methodological problems.Simulation is defined as the attempt to reproduce a disease that does not really affect the subject, whereasdissimulation is characterized by the attempt to hide actually existing disorders, therefore both thesebehaviors are oriented to the same purpose (the misrepresentation of the real status), moreover they bothoriginate from the same basis (manipulate data to trick the examiner). Furthermore, it is important toconsider the fact that simulation and dissimulation of a mental disease do not eliminate each otherautomatically, indeed a subject can deny a specific disease, but at the same time reproduce another. On theother hand, this behavior does not exclude nor confirm the presence of a psychiatric disease, as the subjectcould try to alter reality, not only to defend his juridical interests, but also as a consequence of an abnormalpsychiatric behavior. Three different elements have essential importance in a forensic evaluation: (i)personality of the subject (it permits the diagnosis of a mental disease, however the relevance of thisdisease from a juridical point of view, as an infirmity, has to be proved in a second moment); (ii)motivations leading him to simulate or dissimulate a psychiatric disorder (a more or less realistic benefit,that has to be determined); (iii) sort of simulation and/or dissimulation activated by the subject (how heaffirms or denies a certain suffering condition, trying to reveal sufficiently clear and precise signs of thecondition itself). The alteration of the world representation can take different forms, as a consequence ofboth the simulation-purpose relation, for which the individual’s will is directed to a final benefit, usuallymore social than clinical, and the simulation-situation relation, that induces the subject to reactive ordefensive behaviors to deal with particular circumstances of life, among which we have to consider also thefact of being under forensic evaluation. Elucidation of these aspects is not only a prologue, but has afundamental role in a forensic investigation, as the questions received can be answered correctly only afterhaving outlined the meaning assumed by the subject in the evaluation setting contest.

10533.2. Eugen Bleuler – Opinions on the Relationship Between Psychiatry, Society andthe Problem and DelinquencyArnulf Moeller, Psychiatric University Clinic, Halle, Germany (arnulf.moeller@medizin.uni-halle.de)One of the first scientific writings of Eugen Bleuler was dedicated to aspects of the antisocial personality(“Der geborene Verbrecher”). Bleuler rejected the question of the cause of criminality (“milieu” vs.predisposition) as insignificant, stating that a disease was not called a disease as a result of thecircumstances under which it arose. Rather, Bleuler was guided by a concept of normality integratingindividual adaptation to societal interests and assumed that “any deviation from the norm that harms theindividual or the species is pathological” (p. 39). The circumscribed defect of moral feeling could thereforebe described as “moral idiocy“ or “moral insanity,” the latter being an English term often used by Bleulerhimself as being synonymous with “moral idiocy.” Proceeding from the aforementioned comprehensiveunderstanding of delinquency caused by disease, a willingness to assume diminished responsibility in thecase of psychopathies and sexual deviancies can also be discerned. He wrote that it should generally beassumed that “the most powerful drive is the sex drive. Even the average person is usually unable to controlit in the way he is expected to”. Bleuler concluded on the basis of forensic aspects that “[i]t is not correctfrom the psychological viewpoint to impose the same standards on so-called sexuals as on healthy people”.The biographic constancy of Bleuler’s viewpoints and the relationship to a general, scientifically foundedethic is discussed.33.3. The Clinical Assessment of Volition and Intention in Forensic PsychiatryPatricia White, California Youth Authority, Stockton, California (marcrost@inreach.com)There are a variety of therapeutic and forensic contexts in which the psychiatric clinician is called upon toassess the voluntariness and intentionality of behaviour. Such assessments have moral dimensions andraise the perplexing issues of determinism, free will and personal responsibility.Forensic psychiatrists are frequently asked to assist the courts and other adjudicative bodies to determinewhether or not mental impairment is present and if so, to what degree such mental impairment erodes theperson’s capacity to exercise choice over action. The degree of accountability, level of personalresponsibility and legal punishment for both criminal and civil misconduct are all determined in large partby such assessments.In this presentation I intend to explore the impact of contemporary developments in neuroscience,neuropsychoanalysis and the philosophy of psychiatry on these basic concepts of voluntariness andintentionality.In addition I would like to address the understanding and use of these core concepts in the wider context ofthe moral basis of behaviour.

10633.4. Roots of Delinquency in Children with Prenatal Alcohol ExposureP.W. Kodituwakku, University of New Mexico School of Medicine (pkodituawkku@salud.unm.edu)Since a man with foetal alcohol syndrome convicted of killing two teenagers was put to death in 1992,there has been a growing interest in understanding the roots of criminal behaviour in people exposed toalcohol prenatally. A number of studies have documented that a disproportionately large number ofchildren and adults prenatally exposed to alcohol are incarcerated. A study conducted in British Columbiafound that 67 of 287 youth studied in a forensic inpatient unit had a history of prenatal alcohol exposure.Freedman and Hemenway (2000) reported that 3 of 16 men in a death row sample had a diagnosis of foetalalcohol syndrome or foetal alcohol effects. However, little is known about the roots of criminal behaviourin alcohol-exposed people.There exists a large body of literature on the variables contributing to the development of delinquency inchildren. It is well established that numerous environmental variables, including parenting practices (e.g.punitive, coercive parenting; inconsistent discipline, low parental care), exposure to violence, and life stresscontribute to the development of delinquent behaviours in children. Given that children with prenatalalcohol exposure often experience life stressors and disruptions of parenting, these adverse conditions canbe considered one of the sources of their delinquent behaviours. Researchers have also obtained evidencefor a genetic basis of conduct disorder. Utilizing twin and adoption studies, researchers have demonstratedgene × environment interactions in the aetiology of conduct disorder. Alcohol and substance abuse oftenco-occur with antisocial behaviours in parents, it is reasonable to hypothesize a genetic basis for delinquentbehaviours in at least a subgroup of children with prenatal alcohol exposure. Another line of research hasproduced evidence that early brain damage contributes to the development of antisocial behaviour inchildren. Anderson and colleagues (1999) have reported that early damage in the human prefrontal cortexwas related to later impairments of moral and social functioning. Researchers have found that children withprenatal alcohol exposure are deficient in abilities mediated through the prefrontal cortex.Therefore, we propose that central nervous system damage caused by alcohol exposure, family history ofantisocial behaviours and adverse environment independently and interactively contribute to thedevelopment of conduct disorder in children with prenatal alcohol exposure. This hypothesis is consistentwith interactional models of development, in which cognitive development is viewed as a product of aninteraction between environmental and biogenetic factors.33.5. Interrogation – Confession and False Confessions – Why They HappenRichard Ofshe, University of California at Berkeley (rofshe@aol.com)Richard Leo, University of California at BerkeleyPolice interrogation in America has been transformed from a methodology that depended on physicalcoercion to one that is a tour-de-force of psychological manipulation produced through the organization ofa number of tactics of influence. These methods are spreading to Europe. Both true and false confessionsarise out of interrogation methods that are fundamentally similar. Interrogations that are likely to only elicittrue confessions and interrogations that can elicit both true and false confessions can be distinguished bythe absence or presence of certain identifiable tactics.This presentation will report a model of police interrogation that explains the way in which the tacticsinterrogators are trained to use influence a suspect’s decision making and lead to a decision to confess. Themodel is based on the analysis of transcripts of hundreds of fully recorded interrogations, interviews with

107suspect’s whose interrogations were not recorded, observations of ongoing interrogations and the publishedliterature on interrogations influence.False confessions come about when interrogators make certain mistakes or deliberately rely on tacticsprohibited by law. The two sorts of interrogation induced false confessions are compliant false confessionsand persuaded false confessions. Compliant false confessions arise when a suspect makes a decision to givea confession he or she knows to be false. Persuaded false confessions happen when a suspect comes tobelieve briefly that he or she committed a crime about which they have no actually knowledge and did not,in fact, commit.The decision to offer a compliant false confession results from the use of particular interrogation tactics thateffect a suspect’s perceptions of his or her present situation, beliefs about the evidence supposedly linkingthem to the crime and the tactics the interrogator uses to manipulate their expectations for their future -- asa function of whether they comply and confess or resist and continue to be truthful. Persuaded falseconfessions come about when an interrogator relies on tactics that in combination with routine interrogationmanoeuvres undermine the suspect’s confidence in the mechanisms of their memory.33.6. Diminished Responsibility in ChinaWeixiong Cai, Institute of Forensic Science, Ministry of Justice, Shanghai, China (tsaise@126.com)At present, the assessment of diminished criminal responsibility is difficult in forensic psychiatry in China.There is a tendency to extend the use of diminished responsibility. When the experts diverge in drawing aconclusion during assessment, they used to make a compromise on diminished responsibility. Somejudicial professionals think diminished responsibility is too ambiguous to ensure the degree of mitigation.Thus some experts suggest that the diminished responsibility defence also be graded, to make it easier tofacilitate; also, grading the defence of diminished responsibility can make the assessment more scientific.The author explored the basis to grade diminished responsibility through retrospective research ondiminished responsibility cases, in order to provide a reference for making a measuring or evaluative tool todetermine the degree of diminished responsibility. Chi-square test, one-way ANOVA test, factor analysisand stepwise discriminant analyses were conducted for 92 cases that were divided into three groupsaccording to the degree of criminal responsibility. There were significant differences in rating score amongthree groups (mild group 21.04±2.60, moderate group 25.62±1.97, major group 31.21±2.75, F=119.78,p

10834. Cultural issues in Adolescent Forensic Psychiatry I34.1. Experts’ Opinions on Diversity in Legal Conflict and Forensic Assessment forCourt: Do Intercultural Issues Matter?Karen Jahn, Westfälisches Institute, Hamm, Germany (andrea.faust@wkp-lwl.org)Wolfgang Bilsky, University of MünsterSemi-structured expert interviews were conducted with police officers, lawyers, state attorneys, judges,correctional staff, interpreters and psychologists/psychiatrist experts in which occupation-centeredproblems, actual operation possibilities and demands regarding intercultural activities within the GermanCriminal Law were examined.Differences exist by the various occupational branches regarding the description of specific interculturalactivities which are mainly seen by participating persons and their interaction. Regarding forensicevaluation, inadequate bases and desiderative or false cultural/lingual knowledge are criticised. The resultsallude to structure quality (bases, etc.), process quality (education, networking etc.), and quality regardingintercultural activities. Demands are problem awareness, flexibility, participation of native speakingexperts, as well as changes of social-legal general conditions.34.2. On Intercultural Victimology, Honour and Shame: Lessons Learned from anInner-Ethnic-Minority Rape Case Judged by a Majority Culture CourtRenate Schepker, Westfälisches Institute, Hamm, Germany (r.schepker@wkp-lwl.org)Too little is known by psychiatric experts about adolescent male and female sexuality in ethnic minoritieslike the Turkish minority in Germany. While in public life virginity, marriage and traditional eastern valueslike seref and saygi prevail, adolescents growing up in the midst of a western society find their ownbicultural ways, thus creating different spaces of reality which usually do not interfere. They only clash inthe case of conflict or crime, and this is only very seldom processed through legal institutions of themajority 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 psychiatristdemonstrates that aspects of female sexual autonomy in ethnic minorities warrant more research andattention. Whereas from an intra-ethnic point of view the perpetrator was not to blame, the majority courtconvicted him to a prison sentence.In opening up the investigation and helping to support the victim, there was a possibility of creating a newintercultural dilemma and new dangers for her. The psychiatrist’s role as an expert in these cases mayinclude a partiality in favour of an affirmative action for human rights. An elaborate understanding of suchcases relies on the proficiency for an “intercultural code switching” on the side of the expert that parallelsthis ability on the side of the examinee.

10934.3. Family Risks and Resources in Migration – Their Impact for AdolescentDelinquencyMehmet Toker, Westfälisches Institute, Hamm, Germany (mehmet.toker@wkp-lwl.org)117 families in Germany (patient and field families) originating from Turkey were investigated by meansof semi structured family interviews and expert ratings, based on the contextual family theory approach. Afamily typology was drafted from family theory characterizing successful families with non-symptomatic,non-delinquent offspring and non-successful families. The typology developed for dysfunctional familieswith delinquent behavior of adolescent boys rendered three main risk types: mono-culturally frozenfamilies, uprooted families and co-dependent families. Uprootedness proved to be a specific risk factor fordelinquent behavior of the offspring. Parents’ views on the prevention of delinquent behavior ranged fromcontrol and strictness to care and support. Lack of parents’ insight in the rules of teenage mainstreaming inthe dominant culture caused another specific risk, especially if the family did not “allow” biculturalattitudes.The typology is commented by a bicultural family therapist and will be illustrated by case studies onadolescents who have committed severe crimes and were assessed by the authors for court.34.4. Ethnicity and Its Relevance in a Seven-year Admission Cohort to an EnglishNational Adolescent Medium Secure Health Service UnitNathan Whittle, Bolton, Salford & Trafford Mental Health NHS Trust, Manchester, England(njwhittle@gardener.bstmht.nhs.uk)Case notes detailing individual, clinical and family background information on 61 inpatients in a mediumsecurity adolescent NHS psychiatric forensic unit were analysed with the primary aim to determine thedistribution 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 significantover-representation of Black inpatients (21.5%). These results are discussed in relation to control, restraintand serious incidents during inpatient stay. The results are compared with data from studies of prison andcommunity populations and recommendations are made for the improvement of service provision andfuture research. The primary finding of the study is consistent with previous studies in adults, which is thatthere is a significant over-representation of ethnic minorities (36.1%) and more specifically a significantlyincreased prevalence of psychiatric admissions in the Black population compared to White. This is alsocomparable to data from adolescent psychiatric secure units in Holland. There are on-going debates aboutthe shortfalls in present day psychiatric services when dealing with ethnic minority cultures and fears aboutsuch ethnic minority patients being over-diagnosed with psychotic illnesses due to a lack of awarenessabout cultural norms. Progress is being made in the development of services and provision for youngpeople from ethnic minorities in terms of meeting their mental health needs, although there are many areasthat still need to be addressed.

11034.5. The Expert’s Role in Juvenile Court in Turkey and Germany – An InterculturalDialogueCahide Aydin, University of Ege (cahideaydin@yahoo.com)Renate Schepker, Westfälisches Institute, Hamm, Germany (renate.schepker@wkp-lwl.org)Legal and cultural differences have a great influence on possible roles of psychiatrists as court-appointedexperts in special cases.A total of 2 x 25 consecutive referrals for psychiatric assessments from juvenile courts in Germany andTurkey were analyzed as to possible intercultural differences. The cases were studied in a joint effort bytwo different Child and Adolescent Psychiatry institutes (Ege university Adolescent department,Izmir,Turkey, and Westfalian Institute, Child and Adolescent Psychiatry, Germany) according to thefollowing criteria:Enquiries of the court towards the expert relate to maturity (Germany) or social responsibility (Turkey);psychiatric history and symptoms; age and gender of the offender; type of offense; expert opinion,suggestion for intervention and prognosis.The expert’s role in the different legal systems is discussed pointing out intercultural similarities anddifferences: punishment vs. educational aims of the legal system, role of substance abuse in the assessmentof liability, cultural explanations for behavior of an adolescent, possibility of court-ordered therapy insteadof a prison sentence and severity of psychiatric disorder vs. severity of offense in determining judges’verdicts.35. Culture and Context I: Culture and Context in ProgrammeDesign35.1. Providing Culturally Competent Mental Health Services to America’s UnderrepresentedRacial/Cultural PopulationsHarvette Grey, DePaul University (hgrey@depaul.edu)This paper will focus on indicators of institutional racism within organizational structures and systems withsuggested clinical intervention methods for the 'diverse' populations who are often the victims. Suchtreatment aspects will include those methods that are recommended by representatives from the specificgroups. The audience will gain information pertaining to how these barriers to effective communicationoperate within the system and how they effect those 'diverse' populations who are employed in thosesystems. 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 thequality of life for America's 'minority' populations. This is often reflected in the stressors that lead to

111emotional problems such as anxiety and depression and physical health problems. Because of racism orwhite supremacy, the health status for many 'minority' populations reveals disturbing disparities related tolife span, death rates and susceptibility to illness. Traditional mental health care is often inappropriate andantagonistic to the cultural values and life experiences to this population. Clients, after being 'abused' inorganizational settings can easily feel that they have also been invalidated, abused, misunderstood andoppressed by those mental health providers.This paper will explore those indicators of institutional racism and discuss those culture-specific mentalhealth treatments consistent with the cultural values and life experiences of particular groups.35.2. The Procedure for Referring a Psychiatric Patient to Hospital in ChinaHu Jinian, Beijing AnKang Hospital, Beijing, China (hujinian@yahoo.com)Mental health services are provided in China in a very different way from that of the West. The presentpaper gives an introduction to the structure of China’s mental health service system today, and theprocedure for referring a psychiatric patient to hospital in China. This procedure varies greatly withdifferent types of psychiatric hospitals and with different kinds of patients. Some related problems, such asmental health legislations, are also introduced.35.3. Organizing for Beauty: A Model of Appreciating and Leveraging Difference toPromote Organizational ExcellenceWilliam Marty Martin, DePaul University (martym@depaul.edu)This paper will provide the participants with a historical analysis of the application of beauty to the designof organizational structures, processes, systems, and culture interlaced with the growing reality of diverseemployees working in organizations and serving diverse customer bases. Furthermore, this paper willhighlight specific strategies in which organizations must move beyond legal/regulatory requirements inorder to not only comply with legal/regulatory requirements but to fully embrace the rich talents of adiverse workforce to achieve and sustain organizational excellence. One of the critical measures oforganizational excellence is a healthy work environment because of the generally recognized principle thata healthy work environment results in higher productivity which results in a more financially viableorganization.The focus of this paper will be three-fold:• To explore the application of Appreciative Inquiry, Art, and Building on Strengths in thedesign and management of organizations.• To identify the potential of diverse human resources in a fashion that leader and organizationsdesign 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 willdescribe the leadership and operations of the Mayo Clinic and how diversity is managed for the sake ofcreating wonderful experiences for the patients, their families, their loved ones, the employees, and the

112students as well as a model of care [Planetree] that emphasize the beauty of physical spaces that result inhigher productivity, higher satisfaction, and greater smiles among diverse stakeholders.35.4. Dimensions of Diversity and the Phenomena of Diverse Groups within DominateCulture OrganizationsElizabeth Ortiz, DePaul University (Eortiz4@depaul.edu)Organizations recognize the significance of diversity as a strategic factor contributing to organizationalperformance. However current practices and strategic planning revolves around the organization. Thispaper however will focus on the individual’s experience verses the business enterprise. It will explore thedimensions of diversity with an emphasis on the behavior of diverse groups and their subsequent copingmechanisms within dominate culture organizations. Discussion will include the feelings of isolation andalienation as well as other issues that arise when one experiences “being the other” within a dominantcultures’ organizational structures, processes, and systems. This session will focus on the individual’sexperience and their process of navigating and surviving the sometimes chilly and hostile organizationalclimate. Issues of assimilation, acculturation and strategies for success will be highlighted. This paper willalso discuss the importance of effective approaches toward diversity in business organizations. Relatedaspects involve effective communications, employee relations, training and development, recruitment oftalent, customer service, and the redirection of potential workplace conflict toward positive organizationaloutcomes. Furthermore, this paper will detail how organizations can assist in this transition in order tomaximize the benefits of diversity and the contributions that a diverse workforce brings to an organization.35.5. Race Matters: Leadership Contentment and Discontentment at DePaul UniversityMarco Tavanti, DePaul University (mtavanti@depaul.edu)DePaul University is the largest Catholic university in the United States of America and the largest privateuniversity in Chicago. In a survey of thousands of students across the country, The Princeton Review foundDePaul's students to be the happiest in the nation. DePaul is also ranked 18th for "Diverse StudentPopulation," making it the only Illinois university ranked in the top 20. Such diversity is increasingly betterrepresented within University leadership for administrators, faculty and staff. However, Latino, Black andAsian leaders at DePaul show both satisfaction and frustration with the institution and its primary missionof teaching and service. Since 2002, the Hay Leadership Project and DePaul’s Office of Mission andValues have collected both quantitative and qualitative data from more than 300 people who have takenspecifically designed assessment instruments, the Vincentian Leadership Assessments (VLA-Self andVLA-Observed) and the Mission Values Instrument (MVI), and have participated in focus groups and indepthinterviews. Quantitative data of leadership practices collected through the Vincentian LeadershipAssessments are compared and contrasted with values and mission perceptions collected by the MissionValues 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 independentvariable Race is explained though additional findings in in-depth interviews conducted by the HayLeadership Project and confidential focus groups sponsored by the Office of Mission and Values. Thispaper 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 missionand values.” Minority faculty, staff, administrators and students perceive that “DePaul’s leadership needs to

113make sure their practices and policies align with the organization’s mission and values.” The outcomes ofthis study are relevant to the ongoing debate of value based practices and to the effectiveness of racial andethnic minority leadership participation in higher education.35.6. Care of the Mentally Ill in Ghana: Different Methods, Same Worrying IssuesSam Ohene, University of Ghana Medical School (sam_ohene@yahoo.com)Persons with major mental health or substance abuse disorders in Ghana have 3 main modes of treatmentopen to them. Cultural beliefs and limited access to formal psychiatric services dictate that all 3 systems areused jointly or severally by most affected persons.A Mental Health Law enacted in 1972 [currently under review], a Traditional Healers Act, the CriminalCode [1962] and the 4th Republic Constitution of Ghana are all relevant to the practice of psychiatry andtreatment of mentally ill persons. Despite the relatively strong human rights provisions of the laws, manypeople believed to suffer from mental disorders are often subjected to custodial care against their expressedwishes. 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 contravenethe letter and spirit of the regulatory laws.36. Culture and Context II: Definitional Issues on Mental Healthand TreatmentIn psychiatric medicine it is often observed that the definitions and accepted treatments of illness are liableto change under the influence of shifting cultural and economic forces. The historical analysis of suchchange in the past can be a powerful tool for illuminating how forces are similarly working change today inthe field of mental health. In this session we examine the origins and changing status of five differentpsychiatric illnesses in cultural context: addiction, anhedonic depression, bipolar disorder, chronic fatigue,and paranoia. The historians of psychiatric medicine shall explore how political and economic forcesimpressed themselves upon the definitions of all five conditions, and point to lessons for mental healthtoday.36.1. Charting Influences on Punitive vs. Medical Responses to Illicit Drug Use in theUnited StatesCaroline Acker, Carnegie Mellon University (acker@andrew.cmu.edu)Addiction’s ambiguous status as criminalized disease in the U.S.A. has resulted in a framework in whichpolicy was adjusted in more or less punitive directions in response to changing conditions over the courseof the twentieth century. Changes in class profiles of illicit drug use have played particularly important

114roles 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 prisonhospitals; second, methadone maintenance, introduced in the 1960s, and the most highly regulated form ofAmerican medical practice; third, the rise of white, middle class demand for drug treatment at the sametime that American hospitals faced serious fiscal pressures in the 1970s and 1980s , and the emergence ofprivate sector “chemical dependency” units in hospitals, independent of the criminal justice system; andfourth, the recent introduction of buprenorphine as a treatment for opiate addiction that can beadministered in the privacy of a physician’s office and its place in the two-tier where class and race remainpowerful determinants of who receives punishment for drug use, and who receives medical treatmentwithout criminal sanctions.36.2. “The Construction of Homosexuality and the Emergence of Sexology, 1868-1905”Ivan Crozier, University of Edinburgh (ivan.crozier@ed.ac.uk)Homosexuality -- sexual inversion, die conträre Sexulaempfindung, Uranianism, etc. -- became apsychiatric problem well after it was a legal one, as a number of prominent psychiatrists in the later 19thcentury such as Wilhelm Griesinger and Sir George Savage observed that some of their psychiatric patientswere not committing sexual crimes, and displayed a number of traits in common (including ‘perverse’desires). Initially, researchers looked for physical reasons to explain why someone was attracted sexually tomembers of the same sex, especially as it was a topic of legal sanction and moral opprobrium. Theseresearchers paid attention to physical type, especially to the conditions of the sexual organs, as well as toheredity and degeneration. Indeed, there was a key interest in showing that desire tied to the body, with, forexample, ‘inverted’ female sexual desires corresponding to ‘masculine women’, etc. Before long, however,a psychological model (derived from hypnotism) allowed for homosexual cases to be interpreted asacquired. These struggles between sexologists and psychiatrists committed to different theories ofhomosexuality soon turned into attempts to develop more general models of the sexual instinct, a task thatset some of the foundations for the development of psychoanalysis. In this paper, I will examine the earlywritings on homosexuality, showing how the development of a new psychiatric category was involved withthe formation of the new field of sexology. I will illustrate how one of the key events for homosexuality tobe defined as a psychiatric condition was the revision of the boundaries between the law and medicine.Attention will also be paid to the enrollment of case histories into sexological knowledge claims.36.3. 'The “Mindlessness” of the Mental Deficiency Categories. Notions, Actors, andTreatments, 1920-1950'Jean-Christophe Coffin, Centre Alexandre-Koyré (CAK), Paris, France(jean-christophe.coffin@univ-paris5.fr)Psychiatric investigation of children grew intensively in the early twentieth century, bringing concepts suchas mental retardation, feeble-mindedness, character and behavioral disorders to the forefront of psychiatricliterature. Clinical, psychological, and sociological definitions and expressions describing these conditionsvaried greatly, spurring controversies that have still not abated. During the late 1920s, some youngpsychiatrists such Pierre Mâle (1900-1976), Henri Ey (1900-1977), Jacques Lacan (1901-1981) started tocriticize the constitution theory. This hereditarian view dominated psychiatry, notably supported by medical

115authorities such as Georges Heuyer (1884-1977) and Etienne Dupré (1862-1921). The alternativeinterpretation elaborated in France, as in many other European countries in the interwar period, tended toturn away from biological determinism and question the link between mental retardation and juveniledelinquency, foregrounding instead the issue of social conformity. The ‘deconstruction’ of clinicalcategories related to the treatment of problem children as well as to psychological theory and social policy.Some psychiatric responses attempted to include the social dimension within the medical aspect, forinstance through the establishment of child guidance clinics -- particularly popular in the United States.Nevertheless, while psychiatrists were willing to improve treatment of young patients, some of them facedcriticism because of their shaky theoretical basis, for example in justifying distinctions between the child indanger and the endangered child, the feeble-minded and the idiot. Such debates around diagnoses calledinto question the ability of psychiatry to manage the issue within scientific medicine. In this paper I willdiscuss these debates and explore how the psychiatric framework for mental retardation developed betweenthe wars, ultimately shaping the development of child psychiatry after the Second World War.36.4. From Folie Ciculaire to Bipolar IllnessDavid Healy, Cardiff University (healy_hergest@compuserve.com)While madmen have been described as having mania since the time of Hippocrates, modern notions ofmanic-depressive illness stem from the description of Folie Circulaire in Paris in the 1850s, which wastransformed by Emil Kraepelin into Manic Depression in 1896. In clinical practice however maniacontinued to be used as a generic term for madness until approximately 1914, when patients with whatwould now be called a mood disorder began to be regularly distinguished from other cases of madness. In1966, shortly after the introduction of lithium, the notion of a bipolar illness was put forward to distinguishmanic-depressive disorders from recurrent unipolar mood disorders. Bipolar disorders remainedcomparatively unrecognised however until the late 1990s, when following the marketing of "moodstabilizers”, bipolar disorder emerged as the currently most fashionable disorder in psychiatry.36.5. Inventing the 'Antidepressant': Medical Science, the Drug Industry, andAnhedonia in Amphetamine’s Introduction to psychiatry, 1935 – 1950Nicolas Rasmussen, University of New South Wales (Nicolas.Rasmussen@unsw.edu.au)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 neuroticdepression that accompanied the construction of this novel drug category around amphetamine, and themarketing of both drug and drug category in psychiatric medicine from the late 1930s through the 1950s. Akey part of this marketing involved redefinition of depression, generally understood at the outset in terms ofneurasthenia or nervous exhaustion. The campaign for Benzedrine Sulfate instead promoted a thenmarginaltheory of 'mild depression' that characterized the condition as a failure of the mechanisms drivingpurposeful activity and reward, and thus promoted apathy and anhedonia as the fundamental symptomsrather than exhaustion and weakness. Measured by levels of interest in activities and by pleasurable activityitself, amphetamine indeed represented an effective antidepressant. This episode shows that redefinition ofpsychiatric disorders around drugs -- at least partly through the actions of drug companies -- is not so recenta phenomenon as is widely supposed. Furthermore, it raises questions about the extent to whichanhedonia’s continuing ascendance in psychiatric thinking about depression ever since the Second World

116War has depended on amphetamine’s original construction as an antidepressant, and on the subsequentintroduction of later antidepressants with similar (even if superior) clinical profiles.36.6. Cultural Safety and International Human RightsVicky Smye, University of Victoria (smye@interchange.ubc.ca)This paper explores the exportability of the concept of “cultural safety” from its use in a Canadian contextas a lens for examining policy affecting Aboriginal peoples in an International Human Rights context.Irihapiti Ramsden, a Maori nurse leader in New Zealand, developed the concept of cultural safety within anursing education context in response to colonizing processes in Aotearoa/ New Zealand and theconsequent inequities in health status and opportunity for the Maori people. Cultural safety is derived fromthe idea of “safety” as a standard that must be met, akin to an ethical standard – it involves recognition ofthe social, economic, and political position of certain groups within society that create disadvantage, suchas the Maori people in New Zealand or Aboriginal people in Canada. Importantly, it reminds us to considerthe historical context of peoples’ lives that shape those positions. I do not use cultural safety as a fact, entityor something to look at, but rather I use it as something to look through, as an interpretive lens. It promptsthe asking of a series of moral questions to unmask the way current policies, research, and practices mayperpetuate inequities in mental health care for Indigenous peoples. Here, “cultural safety” will be set withinthe context of eating disorders as a mental health issue.37. Culture and Legal Insanity I37.1. Legal Insanity and the Work of CultureMicah Parzen, Attorney-at-law, San Diego, USA (mparzen@luce.com)According to DSM-IV-TR, culture-bound syndromes (“CBS”) are “localized, folk diagnostic categoriesthat form coherent meanings for certain repetitive, patterned, and troubling sets of experiences andobservations . . . [that are] generally limited to specific societies or culture areas[.]” As thorns in the side ofthe biomedical model that dominates contemporary Western psychiatry, CBSs pose a direct challenge tothe universalizability of psychopathological processes and categories and force us to re-examine the extentto which all mental disorders are culturally constituted. At the same time, these patterns of psychosocialdistress that emerge only within particular cultures or cultural contexts also present a valuable opportunityto rethink how we assign criminal blame with respect to immigrant and minority offenders. Indeed, theintroduction of CBSs into the courtroom raises a wide variety of epistemological issues ranging from therelationship between culture and legal insanity to the admissibility of culturally-based evidence regardingmental disorder. Using CBSs as a springboard for examining some of these issues, this paper characterizesthe assignment of blame as a cultural task that suffers from a particularly myopic understanding of the waysin which human emotion and consciousness drive behaviour.

11737.2. Provocation, Insanity, and Culture: The Problem with “Non-Volitional” ExtremeEmotional Disturbance Defences in the Criminal LawJames J. Sing, Attorney-at-law, New York, USA (jjsing_2k@yahoo.com)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 appropriatedoctrinal analogue. This paper examines more closely the ways in which adequate provocation straddlesthe line between defences based on lack of criminal capacity (like NGRI) and defences bases onjustification (like self-defence), and in doing so, implicate a deeply-nested paradox that courts mustoverlook (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 whichthe propagation of cultural norms through the application of the criminal law appears in tension with thegoal of meting out individualized justice. Can it be, as previous commentators have suggested, that thenotion of a non-volitional provoked response is a legal myth whose existence perseveres for reasons ofeither convenience or affirmation of the dominant normative landscape? How far do the linkages betweencultural background and emotional behaviour extend, and what can we assume about a defendant’s capacityfor reason—as opposed to his or her capacity for hot-headed behaviour, when culture is added to thebalancing scales from which we aim to derive and mete out individualized justice? The answers to thesequestions, or the extent to which some are indeterminate, not only have implications for the relatively smallbody of cultural defence jurisprudence, but may also militate in favour of re-conceptualizing the culturaldefence’s doctrinal parent: adequate provocation.37.3. A Consideration of the Validity of the "Witchcraft" DefenceAlison Dundes Renteln, University of Southern California (arenteln@usc.edu)Modern legal systems differ from customary law systems in the extent to which arguments concerning thesupernatural influence legal proceedings. This paper considers a set of cases in which defendants, who killindividuals accused of harming others through the use of “witchcraft”, raise a cultural defence during theirtrials. 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 thisanalysis is the manner in which courts ascertain the validity of these “witchcraft” defences in cases takenfrom different countries. Ultimately the question is whether the “witchcraft” defence is a legitimate use ofthe cultural defence.

11837.4. The Insanity Defence in England: A Five-year Study Cases from 1997-2001Ronald Mackay, De Montfort University (rd@mackayr.freeserve.co.uk)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 whichthose 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 respectof such cases which was the equivalent of indefinite and indeterminate hospitalisation. Although the 1991Act did not change the legal test for insanity, which remains governed by the M’Naghten rules, it didintroduce much needed flexibility of disposal. This meant that in addition to the indefinite hospitalisationunder the 1964 Act, the court was given the discretion (except where the charge is murder) to orderadmission to hospital without the equivalent of restrictions; or the make a guardianship order under theMental Health Act 1983, or a supervision and treatment order, or an order for an absolute discharge of theaccused. An earlier study of the first five years (1992-1996) of the operation of the 1991 Act showed thatwith this new disposal flexibility the number of insanity verdicts had slowly begun to rise, although not asrapidly as might have been anticipated. This second empirical study of the insanity defence during the nextfive years (1997-2001), shows how often and in what types of cases the M’Naghten Rules have continuedto operate in England. It will examine the role of psychiatric reports and their impact on the use of theinsanity plea and will answer the question: how have the new disposal powers continued to impact on thenumber of insanity verdicts and with what effect?37.5. Reshaping the Boundary between Insanity and Provocation in IrelandJ Paul McCutcheon, University of Limerick (paul.mccutcheon@ul.ie)In Ireland the defence of insanity and the partial defence of provocation have been developed by the courtsin recent decades. Irish judges have departed from the strictures imposed by the M’Naghten Rules and thelaw 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 ofdiminished responsibility in the absence of legislation to that effect. At the same time the courts havefashioned a purely subjective version of provocation under which the elements of that plea are evaluatedexclusively in terms of the personal characteristics of the accused. In this regard the courts, unlike theircounterparts in England and elsewhere, have not been required directly to consider the effect of mentaldisorder on the plea of provocation: consistent with the subjective stance that is adopted the accused’smental condition is simply one of the personal characteristics to be taken into account in determining theapplication of that defence. These developments in the law governing insanity and provocation can betraced to judicial dissatisfaction with the prevailing law, but the unsystematic way in which the courtsengineered 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 diminishedresponsibility; a mentally disordered defendant cannot currently avail of the latter defence and is typicallyunwilling to rely on the defence of insanity. However, it is suggested that it is a distortion of the plea to useprovocation 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 legislativereform is in the offing. The Criminal Law (Insanity) Bill 2002 is progressing through the Oireachtas (theNational Parliament). That measure proposes to introduce a partial defence of diminished responsibility, torefashion the law on fitness to plead, to overhaul the dispositional arrangements and to introduce a systemof periodic review of detention by a Mental Health Review Board. However, the defence of insanity would

119remain unchanged. In 2003 the Law Reform Commission published a Consultation Paper on provocation inwhich it suggested a retreat from the current subjective approach to one closer in form to that which isadopted in Canada, Australia and New Zealand. These proposals prompt the question as to how the lawmight properly deal with disordered offenders; in particular which defence might appropriately be adoptedand how the boundary between insanity, diminished responsibility and provocation might be redefined.38. Culture and Legal Insanity II38.1. Civil Commitment and the Criminal NGRI in Israeli Law: A ComparisonAssaf Toib, University of Virginia (atoib@mscc.huji.ac.il)The presentation will focus on a comparison in the Israeli legal system between the rate of civilcommitment of patients suspected to present danger to society and the rate of commitment in criminalproceedings based on the plea of “not guilty by reason of insanity” (NGRI). The underlying presumption inthis comparison is that there is no fundamental difference between the mentally ill civil patients whopresent danger to society and the legal suspects eligible to use the NGRI plea. They both suffer from amental illness, both are presented as a danger to society and the danger is assumed to stem from theirillness. However, despite this lack of difference, the rate of compulsory admissions to hospitals of mentallyill people who are suspected to be dangerous to society is much higher than the rate of successful NGRIpleas in the courts. Data collected in Israel about civil commitment of people who present danger to societyand of NGRI pleas will be presented and these rates will be compared to rates in the USA. In the final partof the presentation an explanation for the observed differences between the civil and the criminal fields willbe offered.38.2. Forcing Shock: Legal and Cultural Dimensions of Involuntary ElectroconvulsiveTherapyJonathan Sadowsky, Case Western Reserve University (Jonathan.sadowsky@case.edu)In the United States, most law recognizes a right to refuse medical treatment, but does not consider thatright to be absolute. A major limitation of that right often involves emergency situations created bypsychiatric illness. But while the interest of the state to administer psychiatric drugs in certaincircumstances occasions only modest controversy, the situation is more complicated when the cliniciansbelieve the appropriate treatment is electroconvulsive treatment (ECT).The American Psychiatric Association made informed consent a typical requirement for administeringElectroconvulsive Therapy [ECT] in 1979. Involuntary ECT, however, is still administered, with courtapproval, in cases where the patients are deemed incompetent to assess their need for the treatment. ECT isa 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 inbetween.Although there are exceptions, much of this controversy is due to a gap in perception between lay

120and clinical perceptions. There is perhaps no other medical treatment is this gap so wide. Thiscontroversy, inherent to the treatment, inevitably inflects skirmishes over involuntary administration.American Jurisprudence (Rochester: Lawyers Cooperative Publishing, 1996) notes that “The provision ofelectroshock treatment to persons with mental impairments has received heightened court scrutiny, since itis seen as a highly invasive treatment.” This statement is true, but the use of the passive voice in thesentence is instructive, since it does not indicate by whom the procedure is considered invasive. Somerecent clinical textbooks on ECT portray the treatment as an inconvenience, no more “invasive” than atypical trip to the dentist. Indeed, while ECT’s “invasiveness” is a key feature of most legal writing on thesubject, 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 thelegal arena as a frontier where lay and clinical perceptions of ECT clash — but in a clash where tacitunderstandings of key words such as “invasive” carry implicit residues from the cultural history of ECT.38.3. Hypomania and Responsibility: A Phenomenological/Philosophical AnalysisBarbara Hannan, University of New Mexico (bhannan@unm.edu)Hypomania is a state of elevated mood experienced by persons with bipolar disorder. Unlike the moreextreme manic state, hypomania does not involve psychotic features such as hallucinations and delusions.The hypomanic person, while remaining in touch with reality, experiences increased energy, increased selfesteem,increased libido, decreased need for sleep, and a marked lessening of inhibitions. It is well-knownamong bipolar persons (and their doctors) that hypomanic states lead to behavior that in retrospectembarrasses the bipolar person and gives rise to a desire to disavow responsibility: "I was out of control;please don't blame me; it was my illness that made me do it".In philosophy and law, it is usual to say that a person is responsible for acts flowing causally from his/hercharacter. It is only when this normal causal pattern is interrupted in some extraordinary way, or when theperson's status as a rational agent is severely impaired (by psychosis, for example) that we say the person isnot responsible (has an excuse). This raises the following question with regard to acts performed in ahypomanic state: where does the bipolar person's character end, and her disease begin? Is there anyreasonable way of drawing the line between acts for which the bipolar person is responsible, and acts forwhich she is not responsible, short of the line between psychotic and non-psychotic states? I argue thatthere is not. What the bipolar person does when hypomanic, for better or worse, expresses the truecharacter of the individual, temporarily freed from normal social inhibitions. This may be embarrassing,but it is the truth, and it is "bad faith" (as the existentialists say) for the bipolar person to denyresponsibility.

12139. Death Penalty I: Historical and Theoretical Perspectives39.1. Adaptation: Employing Narrative Persuasion and Psychological Theory inAdvocacy on Behalf of Condemned InmatesPhilip N. Meyer, Vermont Law School (PMeyer6104@aol.com)This presentation develops materials from two chapters of a book-in-progress, Retelling the Story: A Guideto Narrative for Attorneys Representing Condemned Inmates (Amsterdam & Meyer). The bookreconceptualizes the representation of condemned inmates as a narrative practice, and systematicallyanalyzes techniques of narrative persuasion to assist attorneys and other professionals serving as advocatesrepresenting condemned inmates.Simply put, it is the quality and power of narratives (legal and factual), and the persuasiveness of thesestories, that determine outcomes in death penalty practice. Yet, the vocabulary and theory of storytellinghas never been systematically developed or applied to this discrete area of practice. This book seeks to dothat. The goal of Retelling is to transform narrative theory (and some psychological theory) into pragmatictools that postconviction litigators and other professionals can employ to better understand andreconceptualize the fundamental nature of their practice.Sample materials from two chapters are presented – Plotting and Style. Plotting presents an overview ofcomponents 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 includesanalysis of such diverse topics as: perspective and point of view, “voice”, rhythm and tempo, use of detailsand images, and developing scenes. Again, the relevance of these topics in legal argumentation isdeveloped 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 identifyseveral effective storytelling practices that will be relevant for mental health professionals testifying indeath penalty cases.39.2. Psychiatric Ethics in Death Penalty CasesJagannathan Srinivasaraghavan, Southern Illinois University (jvan@dhs.state.il.us)Although death penalty is abolished in most western countries, United States of America remains anexception. The ethical issues involving death penalty arise from one’s personal viewpoints and professionalstandpoint. Both American Psychiatric Association (APA) and American Academy of Psychiatry and theLaw (AAPL) prohibit participation in legally authorised execution such as administration or supervision ofadministration of lethal injection, pronouncing death and witnessing execution unless specifically requestedby the prisoner. Ethical issues arise in testifying as to aggravating factors in order for the prosecution to getdeath penalty verdict, performing an examination for competence to be executed, and treating a prisoner torestore competency to be executed. There will be discussion of “Dr. Death” who invariably testified in thesentencing phase of death penalty cases to stress the ongoing danger of the defendant to society. Thepresentation will deal with varying viewpoints that can only be realised in a country allowing death penaltyposing special challenges for the forensic psychiatrists.

12239.3. The Origin of Death Penalty Reform in IllinoisDaniel W. Hardy, Loyola University (DHSC5919@dhs.state.il.us)In September 1988, Anthony Porter was on death row, two days away from execution by lethal injectionfor a double murder committed in 1982, when the Supreme Court of the State of Illinois granted a stay ofexecution 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. was51 and who appeared to have suffered a psychotic decomposition, was not competent to be executed,another person in a nationally televised interview with a private investigator working with a team ofjournalism students from Northwestern University, admitted that he had committed the murders for whichMr. Porter had been convicted. Mr. Porter was shortly thereafter completely exonerated of any wrongdoingand released after 16 years of incarceration.These circumstances led to the creation of a special commission to review the death penalty process andprocedure in the State of Illinois, and ultimately resulted in the one-time commutation to life imprisonmentof 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 thereview commission.39.4. The Death Penalty in the United States: A Historical PerspectiveClaudia Kachigian, Southern Illinois University (dhsmhtb@dhs.state.il.us)Even as the international community continues to recognize the death penalty as a form of humanindignation and a desecration of the right to life, the number of executions in the United States continues toincrease. The Eighth Amendment of the Constitution of the United States bans “cruel and unusualpunishments”. Despite this ban, the death penalty has persisted as a legally sanctioned form of punishmentin 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 carriedout. For example, burning at the stake or drawing and quartering may have been considered cruel andunusual, but death by shooting was not. Subsequent case law continued to focus on the manner of death orthe 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 deathpenalty was being arbitrarily applied, and statutes would undergo strict scrutiny to assure that they could beequally and fairly applied. This effectively abolished the death penalty at the time, until states began to reframetheir capital sentencing statutes to conform to the requirements set forth by the Supreme Court in aseries of death penalty cases, starting with Furman. The focus of this presentation will be on the history ofthe death penalty, focusing on the United States, with some review of arguments for and against capitalpunishment.

12339.5. Death Penalty in Juveniles: What Did U.S. Supreme Court Say?Gagan Dhaliwal, University of South Alabama (gagandhaliwal@yahoo.com)Juvenile death penalty has been a subject of extensive debate and discussion both in United States and othercountries. The United States of America is one of a few countries in the world that until recently executedjuvenile offenders. Since the death penalty was reinstated in 1976, twenty-three juveniles have beenexecuted. However, Texas, Oklahoma, and Virginia remain the only states to have executed a juvenileoffender since 1999. There is a worldwide opposition to the juvenile death penalty outside the UnitedStates. United States Supreme Court recently decided ROPER v. SIMMONS. This case dealt withsubjecting a juvenile to death penalty. The Supreme Court resolved this contentious issue in the wake ofATKINS v. VIRGINIA, which made it unconstitutional to execute mentally retarded offenders. The courtdecided that it is against the concept of "the evolving standards of decency in a civilized society," to usedeath penalty in the case of juveniles. The driving force behind such a progressive legal transformation wasgrowing evidence that the physiological and emotional state of the adolescent brain makes juveniles in thesixteen and seventeen age range less culpable than adults who commit the same crime. The decisionfinding that death penalty in juveniles is unconstitutional is a great step forward in United States deathpenalty jurisprudence. It not only reflects the national consensus against juvenile execution, but it also hasbrought this country into line with the rest of the world. Finally, juvenile death penalty does not exist inUnited 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 andpainful labor" and deprived of various civil rights on charges of falsifying documents that resulted indefrauding the United States government of the Philippines Islands some 616 pesos. The Supreme Courtfound the sentence cruel and unusual punishment because sentencing should be proportionate to the crime.Supreme Court justices have two opposing positions in defining evolving standards of decency in juveniledeath penalty cases. One position allows their own personal judgments to enter into the analysis throughsubjective factors. The second position promotes disconnecting the personal beliefs of members of theCourt from the analysis, and focusing on objective analysis of numbers based on legislative enactments andjury findings. Despite the two opposing positions, the Court agreed that the cruel and unusual punishmentclause is not fastened to the obsolete and is a “progressive” concept that may acquire meaning as publicopinion changes with time; therefore, it must be reinterpreted based on current societal standards. In otherwords, the standards of justice and punishment should continue to grow, develop, and evolve withsuccessive generations. The members of the Supreme Court have differed in context of the relevance ofinternational 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 withcrime, culpability and punishment of juveniles. The paper will delineate criminal and judicial aspects of thecase and how it was decided at various levels of the legal system, until it reached the United StatesSupreme Court. Cognitive immaturity and diminished culpability in some juveniles in the context of therole of the death penalty in establishing deterrence and retribution will be specifically discussed. I alsointend to discuss the influence of increased scientific knowledge in the field of adolescent development andpositions taken by various professional associations, which probably played some role in the final decision.

12440. Death Penalty II: Practical Concerns40.1. The Death Penalty in Children and AdolescentsStephen M. Soltys, Southern Illinois University (ssoltys@siumed.edu)Many trace the origins of child psychiatry to the pioneering work of William Healy, who in 1909 came tobe 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 thistime children over the age of 7 years were generally treated as adults. In the 19 th century children as youngas 8 years old were executed for crimes as minor as theft. Healy established the Juvenile PsychopathicInstitute, which later evolved into the Institute for Juvenile Research. This began a trend of taking a morebenevolent attitude towards American offenders where by the juvenile courts attempted to focus on meetingthe mental and physical health care needs of the child coupled with social interventions with the goal ofpromoting rehabilitation. Unfortunately treatment resources and funding for the volume of cases has neverbeen adequate, resulting in many interventions failing to have any effect on hard-core delinquents. Withincreases in juvenile violence, public opinion is moving again towards removing juvenile court protectionsand treating juveniles committing serious crimes more like adults.This presentation will focus on the speaker’s experience as director of the South Carolina Department ofMental Health, when he was mandated to put together a violent sexual predator program that required thescreening of all juvenile sexual offenders as well as adults. Some individuals admitted to the program hadbeen sexually abused as children, sexually acted out as early adolescents and then were committed tosexual predator programs for as long as they were perceived to be a risk (perhaps for life). Given the lowerthreshold of evidence for being adjudicated a delinquent in juvenile court, youth with minor sexual offensescould be at risk for being shunted into this adult oriented system. The speaker will reflect on the attitudesthat resulted from this system being created and the potential implications that these attitudes can have foryouthful offenders who have committed murder.40.2. Death Penalty in the Mentally Ill and Mentally RetardedAngeline Stanislaus, Southern Illinois University (astanislaus@hotmail.com)Death penalty is the most controversial punishment in the world. In the United States, the court considersseveral mitigating factors and aggravating factors prior to death penalty sentencing. Mental healthprofessionals provide expert testimony in the determination of these factors. Presence of mental illness caneither be a mitigating factor or an aggravating factor. This depends on whether the presence of mentalillness is seen by the court as reducing the culpability of the crime or increasing the propensity for futureviolence. In the United States there are several seriously mentally ill convicts awaiting the death penalty. Ifthese convicts exhibit very acute psychotic symptoms while awaiting execution in the prison, an evaluationto determine their competency to be executed may be ordered by the court. These issues will be discussedin depth. Another controversial issue in the United States is the execution of defendants with mentalretardation. Recently, several states have banned the execution of the mentally retarded. But there aredifficulties in legally defining mental retardation. This is debated in several legal cases. This presentationwill provide a good review of the legal and clinical issues involved in the execution of the mentally ill andmentally retarded.

12540.3. Mental Illness/Brain Impairment as a Bar to the Death Penalty in the UnitedStatesMark E. Olive, Attorney-at-law, Tallahassee, USA (meolive@aol.com)The death penalty in the United States is regulated primarily through the Eighth Amendment to the UnitedStates Constitution which prohibits punishments that are cruel and unusual. One of the tests for whether apunishment violates the Eighth Amendment is whether it violates the “evolved standards of decency in acivilized society.” Because this test is dynamic and not static, a punishment that has been accepted maybecome unacceptable as standards of decency evolve. For example, in 1989, the United States SupremeCourt held that it did not violate the Eighth Amendment to execute persons who suffer from mentalretardation. In 2002, the Court found that standards of decency had evolved and that such executionsviolated the current standards of decency. The Court determined that “because of their disabilities in areasof reasoning, judgment, and control of their impulses, persons suffering from mental retardation do not actwith 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 theexecution of persons who suffer from other mental diseases and defects. A successful challenge to theexecution of the mentally ill or neurologically impaired would require, amongst other things: (1) adefinition of impairments that are sufficiently narrow (i.e. restricted to persons who dissociate or becomepsychotic); (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 illand impaired should not face the ultimate punishment. This presentation will invite the internationalmental health community to engage in a dialogue regarding how to: (1) develop categories of mentalimpairments that would justify exclusion from the death penalty based upon the considerations that led theUnited States Supreme Court to bar execution of the mentally retarded; (2) increase public understanding ofthe debilitating effects of mental illnesses and defects; and (3) convince policy and decision-makers tosupport protecting the mentally ill.40.4. Prosecutorial Misconduct in Capital CasesJames R. Merikangas, George Washington University School of Medicine (Neuropsych2001@hotmail.com)“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 Gallv. Parker U.S. Court of Appeals, 6 th 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, andnowhere is this more important than in the area of criminal justice. Psychiatric testimony has beenridiculed and disparaged by judges and prosecutors, resulting in injustice. The case of Gall illustrates the

126contempt in which psychiatric testimony is held, not only by the court, but also by the general public. Ajudge in Pittsburgh referred to psychiatric testimony as “MUMBO JUMBO”. When a prosecutor tells thejury 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 toa murder defendant’s showing of extreme emotional disturbance and insanity, including key experttestimony.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.41. Death Penalty III41.1. Incestuous Rape and the Death Penalty in the PhilippinesSeema Kandelia, University of Westminster (S.Kandelia@wmin.ac.uk)The majority of those on death row in the Philippines have been convicted of rape (including rape of aminor, rape of a family member and other aggravated forms of rape). Looking at incestuous rape inparticular, this presentation will examine some the problems associated with imposing the death penalty forsuch a crime. It will focus on the effects that the administration of the death penalty has on the victim andthe victim’s family. Some of the legal, evidential and procedural problems associated with rape cases in thePhilippines in general will also be highlighted. Despite the existence of the death penalty for incestuousrape, the number of cases has not diminished. Recognising this, local women’s groups in the Philippineshave called for root causes of incest and other forms of violence against women to be addressed rather thanimposing the death penalty for rape. This response will also be considered within the broader context ofFilipino gender relations.41.2. Gender and the Death Penalty Under Nigerian Sharia LawNicola Browne, University of Westminster (brownen@wmin.ac.uk)Since the first sharia death sentences were imposed in Nigeria in 2001, the state has been roundlycondemned 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 levelof censure that American executions rarely inflame. This paper aims to look at the imposition of deathsentences under sharia law in Nigeria. It will examine the reasons behind the outrage expressed by many inthe international community particularly in the wake of the death sentences passed on Amina Lawal andSafiya Husseini. The paper will consider the role Lawal and Husseini’s gender played in attracting such alevel of censure across the world stage. Was the wider world’s view of the disproportionality of thepunishment of stoning for the crime of adultery under sharia legislation in Northern Nigeria the reason forthe wave of condemnation? How does this sit in regard to the marked contrast in the level of internationalsupport attracted by Lawal and Husseini’s cases in comparison to the muted reaction received by several

127cases involving Nigerian males accused of child sex abuse and given stoning sentences. What can we learnabout the role gender and crime play in the politics of death penalty abolition?41.3. The Impact on Families of Homicide Victims of Replacing the Death Penalty withAlternative PunishmentsPeter Hodgkinson, University of Westminster (hodgkip@wmin.ac.uk)In countries retaining the death penalty, the latter punishment is often offered as the primary vehicle forjustice 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 downon violent crime. Both advocates and opponents of the death penalty often refer to the needs and rights ofthese “secondary” victims as part of their rhetoric and yet they rarely, if ever, offer any practical support tohelp victims cope with the aftermath of the loss of a loved one. One aim of this presentation is to highlightsome of the issues arising for victims from the use of different punishments as a response to murder. Theserange from the harshest punishments of the death penalty and life imprisonment without the possibility ofparole, to other terms of life imprisonment and the relatively new restorative justice programmes such asVictim Offender Mediation / Dialogue (where the victim and offender can choose to meet as a way ofunderstanding the crime and helping the process of accepting the loss of the family member). Thepresentation will thus compare and contrast some of the varying effects these punishments have on thebereavement process for victims, and attempt to reach some conclusions as to their relative value forfamilies of homicide victims.41.4. Good Women and Bad Mothers: Capital Punishment, Motherhood and InfanticideRupa Reddy, University of Westminster (R.S.Reddy@wmin.ac.uk)The response of criminal justice systems to crimes of infanticide committed by women has, over the courseof time, varied between punishment, treatment, or a combination of both. Women who kill their childrenare 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 havecontributed towards their unequal treatment within the law; in cases of infanticide this gender bias hascombined 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 thisgender bias. In the last century the approach to infanticide became more clinical, and in manycircumstances, it may now be viewed not only as a criminal justice matter, but also as a social and mentalhealth issue. This presentation will attempt to demonstrate that despite this new development, the earlierfocus on infanticide—as a crime against women’s nature that should be punished severely—is still presenttoday, albeit in a less open form. This issue will be examined with reference to the recent cases in Texas ofAndrea Yates and Deanna Laney, mothers who killed their infants in similar circumstances but receiveddiffering sentences within the same capital punishment system. These examples will help to highlight therole societal perceptions of womanhood and motherhood continue to play in cases of women who kill theirchildren, specifically in the context of capital punishment.

12841.5. Human Rights Implications of Recent U.S. ExonerationsRussell Stetler, Capital Defender Office, New York (rstetler@nycdo.org)Over the past decade and a half, two sets of wrongful convictions have attracted great interest in the UnitedStates: exonerations based on hard scientific evidence—chiefly DNA evidence and mainly in rape andhomicide cases, and death row exonerations based on intense postconviction scrutiny of the most seriousmurder cases. Both sets of exonerations now number well over a hundred cases. The rate of exonerationshas increased dramatically. According to one recent study, exonerations averaged about a dozen per year inthe early 1990s, compared to 43 per year after 2000. These exonerations have prompted both governmentalinquiries (such as the governors’ commissions in Illinois in 2000 and Massachusetts in 2003-4) to proposelegislation to reduce risks of wrongful conviction, as well as academic studies and bar association interestin the implications for the American criminal justice system. But placed in a global context, the lessons ofthese cases have even larger implications to the extent that they illuminate the practical common-senseunderpinnings 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 andin 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 individualrights were underscored as vital to a fair and just polity. Finally, the demonstrated high risk of wrongfulexecution has altered the public discourse on capital punishment itself in the United States.42. Definitional Problems in Forensic Psychiatry42.1. The Child Begets the Man: Childhood-onset Neuropsychiatric Background toPersonality DisordersOla Stahlberg, Göteborg University (ola.stahlberg@rmv.se)Anna-Kari Sjodin, Göteborg UniversityAnita Carlstedt, Göteborg UniversityThomas Nilsson, Göteborg UniversityAnders Forsman, Göteborg UniversityHenrik Anckarsäter, Göteborg UniversityChildhood conduct disorder and adult psychopathic traits according to the Psychopathy Checklist Revised(PCL-R), were the closest psychiatric covariates to repeated violent crimes in a comprehensive diagnosticstudy of 100 consecutive offenders under forensic psychiatric investigation in Sweden (Soderstrom et al,Psychiatry Res 2004). To explore the clinical factors captured by the PCL-R, we have compared the 3-factor model of psychopathy to other psychiatric diagnostics in a life-time perspective (Soderstrom, Nordic

129Journal of Psychiatry in press, Soderstrom et al, submitted manuscript). In this group, the behavioural andunemotional aspects of psychopathy were significantly associated with AD/HD, autism spectrum disorders,and a range of clinical symptoms of social interaction problems, poor mentalizing, and executivedysfunction. Using data from studies of adult neuropsychiatric patients for comparisons, childhood onsetneuropsychiatric disorders are clearly linked to the development of aggression, personality disorders, andmajor mental disorders (Stahlberg et al, J Neural Transm 2004, Soderstrom et al submitted manuscripts).We will present data from these studies, and from ongoing projects demonstrating the links betweenchildhood onset neurodevelopmental problems and adulthood psychopathic traits, and discuss the uniqueand discriminatory aspects of psychopathy, which seem to consist mainly of the interpersonal, dominanceseeking and manipulative domain.42.2. Can We Trust Self-descriptions in Forensic Psychiatry?: The Self-image ofPsychopathic TraitsThomas Nilsson, Göteborg University (thomas.nilsson@rmv.se)Anna-Kari Sjodin, Göteborg UniversityAnita Carlstedt, Göteborg UniversityAnders Forsman, Göteborg UniversityHenrik Anckarsäter, Göteborg UniversityTo assess the validity of self-descriptions of personality in forensic psychiatry, we compared expert-ratingsof psychopathic personality (the Psychopathy Checklist Revised (PCL-R) and personality traits (StructuredClinical Interview for DSM-IV Axis II personality disorders (SCID-II)) to self-ratings on the KarolinskaScales of Personality (KSP) and the Temperament and Character Inventory (TCI), in 78 violent and sexualoffenders. KSP-rated impulsivity, monotony avoidance, aggression, and immature character, according toTCI, correlated significantly with the total, behavioral, and affective PCL-R scores, with antisocialpersonality disorder, and with childhood conduct disorder. Interpersonal PCL-R aspects correlated with lowanxiety and low asthenia. The results support the use of self rate instruments in forensic psychiatry. Thedysfunctional dynamics of psychopathy, as a personality disorder, will be discussed in terms oftemperamental aberrations, neuropsychiatric dysfunctions, character immaturity, and poormentalizing/empathy.42.3. Paedophilia, Infantophilia, Gerontophilia and other Paraphilias: PsychiatricDisorders or Just Sexual Behaviours? Data from Studies of Sex OffendersAnita Carlstedt, Göteborg University (anita.carlstedt@rmv.se)Ulrika Tägnfors, Göteborg UniversityAgneta Brimse, Göteborg UniversityHenrik Anckarsäter, Göteborg UniversityParaphilias, and their relations to sexual crimes and other mental disorders, form one of the least clear areasof psychiatric nosology. As legislations in many countries include special measures in cases diagnosed withpaedophilia, special demands have to be addressed by forensic psychiatric investigations, challenging

130current diagnostic practices. Clinical interviews, structured rating scales, or assessment methods such aspletysmography may yield divergent results. It is also unclear whether paraphilias co-exist with othermental disorders and psychiatric problems or engage the sexual sphere specifically. In a series of studies ona total cohort of perpetrators of sexual crimes against children (n=185, including 35 infants) and adults(n=153, including a subset of 11 elderly victims) investigated in Swedish forensic psychiatry, we haveassessed deviant sexual activities and objects in relation to other crime characteristics and general mentalhealth. Paedophilia correlates significantly with repeated sexual offences and same-sexed victims, but notwith any other mental health problems (Carlstedt et al, submitted manuscript). The overall prevalence ofpsychosocial and neuropsychiatric dysfunctions and mental disorders, including substance abuse, was high.We will present diagnostic overviews in the various offender groups, with possible relationships to crimecharacteristics and paraphilias, in order to answer the basic question: do diagnoses of paraphilias add to thepsychiatric understanding of sexual crimes, or would it be as informative and more stringent to use just thebehavioural characteristics manifested in the crime histories of the offenders?42.4. Substance Abuse, Psychiatric Disorders and Crime: The Turn of the Screw orWhat Causes What?Harald Nilsson, Göteborg University (harald.nilsson@rmv.se)Christina Gustavson, Göteborg UniversityAnders Forsman, Göteborg UniversityHenrik Anckarsäter, Göteborg UniversityAttributable risk of violent offending to substance abuse has been consistently high (Grann & Fazel 2004),and chronic abuse or dependence on alcohol or narcotics is a common finding in offender groups. Subjectswith other prominent mental disorders, often have comorbid substance abuse, and drug influence on crimesis not limited to subjects with a diagnosed abuse or dependency. Using a forensic psychiatric study group(n=100, Soderstrom et al, Psychiatry Research 2004) and a consecutive, population-based cohort ofsubjects tried and sentenced for severe crimes against others (n=106, Nilsson et al, manuscript inpreparation), we will describe prevalence’s of substance abuse (52% and 48%, respectively), drug influenceat the time of the crimes (more common than diagnosed abuse), patterns of interactions betweenabuse/influence, and other mental disorders, and their relations to crime characteristics.42.5. Personality Disorders and Psychosis: Communicating Vessels According toChanges in the Legislation?Christina Lund, Göteborg University (christina.j.lund@vgregion.se)Anders Forsman, Göteborg UniversityThe legislation regulating sanctions for offenders with mental disorders has been under parliamentaryreview in Sweden, and major changes are now discussed. The legislation regulating mentally disorderedoffenders was changed in 1992, when a new medico-legal concept of “severe mental disorder” wasintroduced, common to civil and legal coercive psychiatric treatment. This concept aimed at reducing thenumber of offenders sentenced to forensic psychiatric treatment, and required the presence of a psychotic orseverely compulsive disorder, excluding personality disorders without psychotic comorbidity. When 187

131males, consecutively admitted for forensic psychiatric investigations three years before the 1992 change inlegislation, were compared to the 180 investigated three years after 1993, we found, contrary to theintentions of the legislators, an increase in sanctions to forensic psychiatric treatment. This was explainedby an increase in the proportion of offenders who were diagnosed with psychotic disorders, often in anunspecified form, with secondary diagnoses of personality disorders (Lund & Forsman, Nordic Journal ofPsychiatry, in press). A weak tendency of a continued increase in number of offenders with a “severemental disorders” is still present. The result of this study will be presented together with a new studyexamining discrepancies between diagnoses in forensic investigations and in clinical practise.42.6. Morality, Criminal Responsibility, and the Human BrainJeff Victoroff, University of Southern California (victorof@usc.edu)Morality evolved via natural selection to serve adaptive purposes in social species. The human brainevolved multiple functional capacities to help regulate behavior, partially influenced by morality. Culturesand individuals vary in their philosophical positions regarding moral behavior and free will, but a corefeature of human societies is common sense regarding the moral domain. Laws evolved via culturalevolution as social contracts based partly upon philosophical positions and partly upon common senseregarding human nature, free will, and moral responsibility. English Common Law, in particular,attempted to formalize rules for attributing criminal responsibility to individuals, as modified by commonsense understandings of the way in which atypical behavior does or does not diminish responsibility.Science, on the other hand, has claimed that rational inference from evidence will lead, via advances overtime, toward incontrovertible truth regarding human nature and human variability. In other words, unlikefixed understandings based upon philosophical opinion and common sense, science would claim that sharedunderstandings of human nature should be moving targets, subject to new evidence. In regard to moralresponsibility and the law, there exists a tension between the principles of philosophy and common senseand the principles of science, with an historical trend toward increasing emphasis on the latter approach.For example, changing standards regarding the exculpatory significance of cognitive limitations, mentalillnesses, or incomplete brain development are based not on changing common sense regarding humannature but on increased reliance upon scientific knowledge to explain how human variability leads tovarying degrees of responsibility for behavior.Two very different problems frustrate the most earnest efforts to incorporate neuroscience into ideal laws:first, the neuroscientific understanding of morality is in its infancy; second, some would argue thatmorality, responsibility, and free will are immutable principles that can never be satisfactorily explained byscience, and, therefore, that neuroscientific discoveries should not have ascendancy over the judgments ofcommon sense. This presentation will discuss some of the evidence that the scientific understanding ofmoral responsibility may provide insights that are complementary to the common sense approach, offeringlawmakers a method for resolving the tension between scientific discovery and philosophical imperatives inthe interest of optimizing laws regarding criminal responsibility that respect evolving knowledge, evolvingculture, and immutable principles in the pursuit of justice.

13243. Depressive Disorders: Trends and Challenges43.1. Challenging Normative Orthodoxies in Depression: Huxley’s Utopia or Dante’sInferno?John R. Cutcliffe, University of Northern British Columbia (Dr.johnr@shaw.ca, cutclifj@unbc.ca)Compelling evidence provided by the World Health Organisation indicates that the global rate ofdepression continues to rise, affecting approximately 121 million people worldwide. It is within thisepidemiological 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 sufferingfrom depression, then he/she needs ‘fixing’; if you are 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 bythe pharmacological industry, such ‘fixing’ inescapably means drug treatment. The highly addictive natureand questionable efficacy of some of these drugs notwithstanding, the entire treatment paradigm ignores ordismisses an essential axiom.Depression is an essential piece, if not maybe even a necessary component, of the human experience. Wecan no more deny this existential state of being than we can any other – including joy. Furthermore, thepivotal developmental task and immense experiential value of accepting the limitations of life and learningthat 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 mustpassively endure disappointment over and over again…Maturity demands that one must accept passivesuffering 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 pharmacologicalintervention that inhibits the person’s chance to explore the meaning of their experience, we are preventingpeople from individual growth and personal development. Interestingly, in worlds analogous to thispharmacologically 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 tosuffer, to be different or crucially, to be independent (Maris, 2004).43.2. Rurality and Depression: A Three-country Perspective of the Issues andChallenges of Providing Mental Healthcare for Rural PopulationsIan Blue, University of Northern British Columbia (blue@unbc.ca)Henry Harder, University of Northern British Columbia (harderh@unbc.ca)In this presentation we will focus on the issues and challenges faced by rural communities in threecountries, Australia, Canada and the United Kingdom, with respect to accessing and receiving adequatemental 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 theepidemiological figures for depression are more concerning for populations who live in the rural andnorthern areas. In British Columbia, Canada, for example, when compared to their urban counterparts wholive in the south of the province, health outcomes including those associated with depression and mooddisorders are markedly worse.

133Further, this presentation will illustrate that despite the huge geographical differences between the countriesand the cultural idiosyncrasies, there are significant areas of commonality and overlap in the issues andchallenges they each face. To date, the majority of research on rural mental health has been from theperspective of providers and not consumers; as a result there is a great deal we do not know about whydepression is common amongst these populations, why these populations do not seek formal healthcareinput, why the stigma associated with mental health problems appears to be a larger concern in thesecommunities 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 epistemologicalresources, engaging in international collaborative studies of depression in rural populations where there isobvious synergy and commonality, and by illustrating the direction of future research in this area.43.3. Co-Occurring Depression and Problem Substance Use in Women: PsychosocialFactors and Treatment ConsiderationsCorinne Koehn, University of Northern British Columbia (koehn@unbc.ca)Depression and problem substance use are relatively common co-occurring conditions in women. Eachdisorder has the potential to affect the onset, course, and treatment of the other. For example, substance usemay increase the risk of an individual becoming depressed, exacerbate depressive symptoms, or interferewith 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 andpsychological factors associated with depression in women. Poverty, gender socialization, negative lifeevents, cognitive distortions, and particular coping styles may increase women’s vulnerability fordepression. The multiple pathways in which these factors may link depression and problem substance usewill be explored.The second part of the presentation will examine ways in which co-occurring depression and problemsubstance use may lead to specific challenges in treatment. These challenges can be grouped into those thatpertain to how the client experiences herself, how she functions within the therapeutic process, and how sheperforms in activities intended for completion outside of the therapy session. Health providers need torecognize that women with co-occurring depression and problem substance use may require interventionsthat are designed to take into consideration the nature of both conditions.43.4. Psychological Recovery and Personal Responsibility in DepressionChris Stevenson, University of Teesside (C.Stevenson@tees.ac.uk)Sue Jackson, University of Teesside (sp.jackson@tiscali.co.uk)Jim Campbell, University of Teesside (Jim.Campbell@tees.ac.uk)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 generalpractitioners has doubled in the last ten years. Yet there is a growing recognition that depression might bethought of as part of the whole life experience. Indeed, this is difficult to deny as 121 million people are

134affected worldwide (World Health Organisation). One in five people will experience depression duringtheir lifetime.The psychological recovery research group at Teesside Centre for Rehabilitation Sciences (TCRS), incollaboration with the Institute for Mental Health Recovery in Ireland, have developed an approach torecovery as a multi-dimensional process, named ‘PROSPECT’ to indicate a positive outlook for peoplewho experience psychiatric distress. PROSPECT does not pathologise the person, as some models do bypredicting relapse (Copeland’s 1997). Nor does PROSPECT involve stripping the individual of freedomswhether over choice and responsibility, social control, nor moral or legal independence.The PROSPECT approach incorporates the view that we are all always recovering in our lives, to a lesseror greater degree. It synthesises existing best practice (e.g., the principles and practice of Barker’s [2000]Tidal Model) and makes use of insights from the TCRS programme of psychological recovery research thathas focused upon: how professionals can meaningfully respond to people in distress, models ofempowerment/service user involvement, and critical review of evidence and practice. PROSPECTencourages professionals to help the person make sense of their distress in relation to past, present andfuture lives. In so doing, the person is placed in the role of a central, responsible agent who is engaged in apartnership with the professional, rather than being the passive recipient of care.43.5. Three Generations at High Risk for DepressionMyrna M. Weissman, Columbia University (mmw3@columbia.edu)The familial nature of major depression (MDD) is well documented with about a three fold increased riskin the first degree relative of probands with MDD. None of the published studies have gone beyond twogenerations or have followed the families over many years. We report results of a high risk, longitudinalstudy of three generations at high and low risk for MDD.Methods: 161 grandchildren, their parents and grandparents were systematically assessed, blind to previousgenerations and previous interview on their psychiatric status and functioning. The first two generationswere assessed over 20 years.There were high rates of anxiety disorders in the grandchildren (mean age 12 years) with two generationsof MDD. Grandchildren with both a depressed parent and grandparent, as compared with those subjectswhere the parent was not depressed, had over a four fold increased risk of anxiety and over two foldincreased risk 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 threegenerations affected with MDD or anxiety could be the target for neuroimaging, genetic and otherbiological studies.

13544. Diagnosis and Treatment of Mentally Ill Offenders I44.1. Deficient Error-Monitoring in Violent Psychopathic Offenders: a ResearchProposalJacques van Lankveld, Pompe Mental Hospital, Nijmegen, The Netherlands(j.v.lankveld@pompestichting.nl)A substantial proportion of violent sexual offenders and other violent offenders are diagnosed withpsychopathic disorder, characterized by a failure to accept responsibility, lack of empathy and compassionwith the victim, shallow affect, a manipulative style, pathological lying, lack of remorse or guilt andimpulsive, antisocial behavior. Underlying to psychopathy, and more specifically to psychopathicindividuals with a history of violent offences, may be abnormalities in the response monitoring processduring conscious or unconscious, and during willed or unwilled error making. Executive control systemsregulate important global aspects of human behavior, such as decision making and planning, specifically inthe context of difficult and novel tasks. Errors during the execution of tasks are accompanied by the socalled error-related negativity (ERN) in the electrocortical waveform at approximately 80 ms after onsetover frontal-central regions of the skull, with maximum amplitude in a region over the supplementarymotor 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, andin general, with response evaluation. Researchers largely consent to the view that the ERN is generated bya high-level, generic, error-monitoring system, which is highly flexible and capable of dealing with errorsin widely varying scenarios. 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 bepresented. The new research aims to elucidate the cognitive processes during error making of violentoffenders employing the error-related electrocortical negativity (ERN) as a psychophysiological marker.This will be investigated in both sexual and nonsexual contexts to assess the contribution of sexual arousal.The modulating effect of psychotropic drugs on the response monitoring process during error-making willbe investigated.44.2. Do Remand Prisoners With and Without ADHD Differ in Their Patterns ofOffending?Marijke Drost, IJsselmeer Hospital, Lelystad, The Netherlands (M.Drost@IJsselmeerziekenhuizen.nl)The persistence of Attention Deficit Hyperactivity Disorder (ADHD) in adulthood increases the risk ofdeveloping other psychiatric disorders, addiction, social personality disorder and an increased contact withthe law. Regarding the age of onset of delinquent behaviour and type of offending, does this mean thatprison inmates with ADHD are different from inmates without ADHD? This paper discusses a studyamong 75 male remand prisoners aged 18-35 years in the Netherlands. The present subject is part of alarger design to determine the prevalence of ADHD in this population and the reliability of several ADHDquestionnaires.The diagnosis of ADHD was made by semi-structured interview. Information about the respondent´s age offirst contact with police, first arrest dates and types of offending were obtained from the interview and

136Diagnostic Interview Schedule (DIS). In 44 cases, objective information was obtained from thepenitentiary registration system.The study was conducted in two remand prisons. Subjects were approached in a non-select order by theprison 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 withFisher´s exact test.The range of offence-types was too wide to allow for further analysis in this small population. When theywere regrouped into violent and non-violent offences for the ADHD and non-ADHD groups, no significantdifference could be found. There was no significant difference between these two groups in terms of age ofonset and multiplicity of offences (more than three).These findings are based on incomplete objective data (44 of 75 subjects) and self-report. They can only beconsidered as an estimate. From the self-report it became apparent that in both the ADHD and non-ADHDgroups, very severe offences occurred in both groups, but the numbers were too small to allow for furtheranalysis.44.3. About the European ADHD Network: Differences between the Countries andImplications for Forensic PsychiatryKaren Foeken, Psychiatrist, La Gaude, France (k.foeken@wanadoo.fr)The subject of ADHD in adults is of great clinical and forensic interest. Internationally there is a search forreliable diagnostic instruments and the standards of treatment are being developed. The European ADHDnetwork is an initiative of Dr.S.Kooij, a Dutch psychiatrist and specialized in ADHD in adults. Actuallyabout 17 countries are represented. The purpose of this network is to come to consensus about the diagnosisand treatment of ADHD in adults. Also we would like to coordinate research done in this field.ADHD is well known as a diagnosis in children, and about one third of these children will still have thedisorder in adulthood. The estimated prevalence of ADHD in adults is between 1-5%. Although both DSMIV and ICD 10 criteria recognise that symptoms of ADHD persist beyond childhood into adulthood neithergives fixed thresholds for the number of symptoms required to make a diagnosis in adults. There is agrowing awareness nowadays that one seems to outgrow to criteria rather than the disorder. A lot ofresearch still needs to be done to adjust the criteria to diagnose ADHD in adults. There are some promisingresults 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 importantthat the illness should be diagnosed properly and treated properly. In some countries it is still not wellknown that ADHD can persist into adult life.Treatment varies in Europe. Stimulants are considered first choice, but the way they are prescribed differsfrom country to country. This also has implications for forensic psychiatry and forensic reports. People, inthis case mainly males, with ADHD may, because of their symptoms, come into contact with the police at avery early stage of life. This can lead to a long criminal record. The prevalence of ADHD in adult maleswith a criminal record is estimated around 16%. It is important to be able to recognize the illness in anearly stage, to be able to start a proper treatment in order to prevent relapse.A case of a forensic report will be presented.

13744.4. Psychiatric Characteristics and Service Use in Psychotic and PersonalityDisordered OffendersKris R. Goethals, Pompe Mental Hospital, Nijmegen, The Netherlands (k.goethals@pompestichting.nl)Hjalmar van Marle, Erasmus University Medical Centre, Rotterdam, The NetherlandsIn a recent study (Nolan & Volavka, 2003) the impact of positive symptoms of the psychosis on aggressivebehavior 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 wereantecedents of aggressive behavior. The temporal relationship between schizophrenia and crime wasstudied by Munkner et al. (2003). The following hypotheses were formulated:1. In psychotic TBS-patients, positive symptoms of the psychosis and psychomotor poverty are morefrequently seen than in general psychiatry psychotic patients. Paranoid delusions are particularly importantin cases of violence.2. a) Psychotic TBS-patients used less psychiatric services and took less medication before the indexoffence, compared to general psychiatry psychotic patients; b) Psychotic TBS-patients with a personalityhad earlier and more contact with psychiatric services, compared to psychotic TBS-patients without apersonality 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, moreoften a positive familiar anamnesis of substance misuse is seen, compared to psychotic TBS-patientswithout a personality disorder.4. More placements in institutions and in child psychiatry and more pervasive developmental disorders areseen 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 were recruited from forensic hospitals (TBS-hospitals) and one general psychiatryhospital (total number of patients = 147). All patients were matched to sex, age and ethnicity. Only severeviolent offences were included, no sex offences.The design is retrospective, meaning all information was taken from existing files. In addition to a list ofsocio-demographical, psychiatric and criminological variables, the following instruments were used: axisIV and V of the DSM-IV, the HCR-20 H-items and the PCL-SV. A SPSS statistical package was used toanalyse the data. Preliminary results are presented and recommendations are made for future research.44.5. Cultural Safety and International Human RightsVicky Smye, University of Victoria (smye@interchange.ubc.ca)This paper explores the exportability of the concept of “cultural safety” from its use in a Canadian contextas a lens for examining policy affecting Aboriginal peoples in an International Human Rights context.Irihapiti Ramsden, a Maori nurse leader in New Zealand, developed the concept of cultural safety within anursing education context in response to colonizing processes in Aotearoa/ New Zealand and theconsequent inequities in health status and opportunity for the Maori people. Cultural safety is derived fromthe idea of “safety” as a standard that must be met, akin to an ethical standard – it involves recognition ofthe social, economic, and political position of certain groups within society that create disadvantage, suchas the Maori people in New Zealand or Aboriginal people in Canada. Importantly, it reminds us to consider

138the historical context of peoples’ lives that shape those positions. I do not use cultural safety as a fact, entityor something to look at, but rather I use it as something to look through, as an interpretive lens. It promptsthe asking of a series of moral questions to unmask the way current policies, research, and practices mayperpetuate inequities in mental health care for Indigenous peoples. Here, “cultural safety” will be set withinthe context of eating disorders as a mental health issue.45. Diagnosis and Treatment of Mentally Ill Offenders II45.1. Subjective and Objective Short-Term Outcome of Inpatient Psychiatric Care:Impact of Coercion and Content of CareTuula Wallsten, University of Uppsala (tuula.wallsten@ltvastmanland.se)Lars Kjellin, Psychiatric Research Centre, Örebro, SwedenIn mental health care policies, treatment and care in the community is emphasized. The number ofpsychiatric beds for in-patient treatment has been reduced over the last decades and the average length ofstay 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, theimmediate 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 atadmission, coercive treatment, characteristics of the patients, and of the care they received.At four Swedish psychiatric departments, 233 legally involuntarily and voluntarily admitted patients wereinterviewed, using the Nordic Admission Interview within five days from admission and a semi-structuredinterview at discharge or after three weeks of care. Additional data was collected from the case records. Theoutcome was measured in two different ways: subjective reports by patients as improved or not improved,and change in level of functioning according to the Global Assessment of Functioning Scale (GAF). Anincrease in GAF scores of 10 or more was regarded as an improvement.Two thirds of the patients subjectively reported improvement and 58% showed improvement according toGAF. 40% showed improvement according to both measures. Legal status at admission, perceived coercionat admission or during care, were not associated with outcomes. The strongest predictors for a positivesubjective outcome involved the patient reporting that they had been well treated by the staff and that theyhad one or more contact persons in the ward. The most significant predictor for a GAF improvement was alow GAF score at admission, in conjunction with a mood disorder diagnosis.Subjectively reported outcome, and outcome measured by assessing change in level of functioning seem tobe different phenomena. The degree of coercion was not related to the result of the treatment during thehospitalisation period. The way the patient perceived they had been treated by the staff was strongly relatedto subjective outcome.

13945.2. Longstay-units in GermanyUwe Dönisch-Seidel, Düsseldorf, Germany (Uwe.doenisch-seidel@lbmrv.nrw.de)Until the end of the last decade in Germany, “long stay” was practically not considered a unique admissiongroup. Apart from a few exceptions, long-term patients were “treated” integratedly; specific conceptionsdid not exist. Activated by the Dutch developments, and also due to the distinct increase in the number oflong-term patients with or without little dismissal prospects, there is an increased demand in Germany toestablish specialized wards for these patients. In the federal state of North Rhine-Westphalia, we are aimingat implementing specialized wards and gathering a scientific evaluation of long stay departments. Inconnection with Dutch institutions, research is being collected in order to assess the arrangement,conception and necessary number of personnel for such an endeavour.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 funding as possible• The arrangement of long stay wards requires special attention concerning the followingaspects:• spacious design of the premises (one- or two-bed rooms, freedom of movement within thehighly secure institution)• work facilities (instead of work therapy)• leisure time facilities (instead of social / milieu therapy)• self-sufficiency (instead of supply by the clinic).45.3. The Effect of Treatment on Quality of Life of Forensic Psychiatric OutpatientsYvonne H.A.Bouman, Pompe Mental Hospital, Nijmegen, The Netherlands(y.bouman@pompestichting.nl)In general health, one of the most important outcome measures of treatment is the effect on quality of life.The primary aim in forensic psychiatry is protection of the society that is accomplished throughimprovement of quality of life. This is achieved by decreasing the factors of a patient's life that areconsidered to have a negative influence on behaviour. The general hypothesis of this study is that if apatient's quality of life improves, the need for criminal behaviour diminishes. To study a part of thishypothesis, the influence of treatment on quality of life needs to be established. In a multisite studyapproximately 100 patients in a community based setting were followed over a period of six months. Thestudy population was comprised 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 wasmeasured over an interval of six months.The number and kind of treatment sessions is linked to the outcome measures. Included in the results arethe number of no-shows, the number of sessions a patient skipped, and also if treatment stopped during the

140six-month period. The influence of life events (VRMG, Willige, G. van de, et al, 1985) and self reportedcriminal behaviour (ZRCG, van Dam et al, 1999) during that period is taken into account.Treatment implications of the results will be discussed.45.4. Exposing Myths Surrounding Preventive Outpatient Commitment for Individualswith Chronic Mental IllnessRaymond M. Deeney, Seton Hall University (raydeeney@comcast.net)Using New York’s “Kendra’s Law” as an illustrative vehicle, this article addresses the principal criticismslodged by opponents of preventive outpatient commitment. The authors argue that preventive outpatientcommitment is a useful adjunct to conditional release or placement in the least restrictive alternative thathas neither produced revolutionary change in psychiatric commitment standards nor will be usedinappropriately to assert governmental control over mentally ill citizens. The authors contend additionallythat preventive outpatient commitment does not violate federal constitutional norms or represent bad policymaking. The authors acknowledge, however, that the coercion inherent in outpatient commitment schemesmay produce certain undesirable side effects. Thus, they explore an alternative approach currently indevelopment in Australia that promotes community based treatment for chronically mentally ill personswithout judicial intervention.46. Dignity Theory and Mental Health Policy46.1. Clarity or Confusion: The Use of Human Dignity as a Justification for SciencePolicyTimothy Caulfield, University of Alberta (tcaulfld@law.ualberta.ca)The concept of human dignity is often used as a justification for science and research policy. Indeed, recentexamples of the use of dignity in science policy abound. UNESCO’s Universal Declaration on the HumanGenome and Human Rights recommends a ban on “practices which are contrary to human dignity, such asreproductive cloning” (1997). A 2003 WHO Report suggests that genetic databases create the need tobalance “human dignity and human rights as against public health, scientific progress and commercialinterests in a free market.” Recent Canadian legislation covering research involving human reproductivematerial, states that one of the primary objectives of the regulatory regime is to protect the dignity ofCanadians (Assisted Human Reproduction Act, 2004). And, of course, the concept of human dignitypermeates research ethics policy (Helsinki, etc). Canada’s primary research ethics document declares thatthe “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 ethicalmanner, as a means of empowerment that emphasises the rights of individuals (often with an emphasis onthe right to make autonomous choices). This is most apparent in the context of research ethics documents

141and informed consent policies. Some scholars have gone so far as to suggest this is the only appropriatenormative use of dignity (Macklin, 2003).However, despite such claims, dignity is increasingly used in the realm of science policy as a justificationfor the regulation of research by suggesting that some activities, such as human cloning and thecommodification of human tissue, are against or degrade some basic understanding of dignity (Beyleveldand Brownsword, 2001). The UNESCO statement about human cloning stands as a good example of such ause. Likewise, in the area of stem cell research, dignity is used as a rationale for limiting research on humanembryos. When used in this manner, dignity is meant to reflect a broader social or moral position about theunacceptability of a given scientific activity or technological innovation. It is not used as a source ofindividual rights, but as a rationale for a constraining policy response. Unfortunately, most policydocuments and legal instruments rarely provide an explicit definition of dignity or explain how humanworth might be degraded by a given technology or scientific activity (Macklin, 2003): “[dignity’s] intrinsicmeaning 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 conceptual use of human dignity creates a number of policydilemmas, including: obscuring the true social concerns motivating policy development and creating theimpression of social consensus when, in fact, no consensus exists. Further, I will suggest that in pluralisticliberal democracies, it will often be difficult to use human dignity as a primary justification for aconstraining regulatory policy (Brownsword, 2003). I will end by making recommendations about theconstructive use of the concept of human dignity. For example, when infringements on human dignity areraised as arguments against a particular scientific activity, it should cause us to question how, for thisindividual or community, human worth is degraded. It should be viewed as an opportunity to debate thevalues at play, and the cultural underpinnings of the concern. We should then ask how the concern can bemet, and how it, and any suggested regulatory responses, relate to or conflicts with other social norms.46.2. Human Dignity and Science Policy: The United Nations Cloning ConventionExperienceRosario M. Isasi, University of Montreal (rosario.isasi@umontreal.ca)In 2001, following appeals calling for an international convention banning human reproductive cloning, thegovernments of France and Germany launched a joint initiative in the United Nations to draw up anInternational Convention against the Reproductive Cloning of Human Beings.The General Assembly’s Sixth Committee—the legal committee— unanimously approved the proposal andadded 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 considerthe 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 andGerman proposal (an international ban on reproductive cloning), faced a proposal sponsored by the UnitedStates, Spain, and the Philippines, which called for a ban on both reproductive and research cloning in asingle treaty. Today, this sharp division remains among two factions. In 2003, the governments of CostaRica and the United States headed a forty-nation block that derailed efforts to reduce the human cloningban to cover only reproductive cloning.Both proposals aimed at enshrining the principles asserted by the Universal Declaration on the HumanGenome and Human Rights (adopted by UNESCO and endorsed by the United Nations General Assemblyin 1997), with particular reference to article 11 of the Declaration which sanctions, as a practice contrary tohuman dignity, the reproductive cloning of human beings; and invited States and internationalorganizations to cooperate in taking, at the national or international level, measures necessary to prevent it.

142Both proposals were “determine(d) to prevent, as a matter of urgency, such an attack on the human dignityof the individual”.Those factions appeal to the notion of ‘human dignity’ as the foundation of their position in favor ofprohibiting human cloning (whether for reproductive and/or therapeutic purposes), yet an analysis shows usa 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 principallydue 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 couldalso be explained in terms of opposing conceptual understandings regarding the notion of human dignity.46.3. Why Should We Care About an Ethic of Care?Kirsty Keywood, University of Manchester (Kirsty.Keywood@manchester.ac.uk)The ethic of care has received scant attention in mainstream analyses of psychiatric ethics. In the academicliterature it is frequently represented as normatively flimsy and methodologically flawed. At best, itattracts attention as an ‘also ran’ principle, which simply does not compete with the predominant ethicalprinciples that underpin and shape our understanding of psychiatry. Yet the ethic of care has been taken upby a host of disciplines beyond the health domain, ranging from cultural anthropology to architecture andplanning. In this paper, I seek to re-examine the ethic of care and reassess its utility in psychiatric ethicsand law by focusing on recent law reform initiatives in England and Wales. The law relating to decisionmakingby, with, and for people with mental disabilities, is to undergo considerable change in the light ofthe Mental Capacity Act 2005 and the anticipated mental health law reforms outlined in the draft MentalHealth Bill. I examine whether the ethic of care can provide a credible foundation for the systems andmodels of decision making that are anticipated by these legal measures.46.4. Defining a Regulatory Role for Human Dignity in International Bio-lawDaryl Pullman, Memorial University (dpullman@mun.ca)Although the concept of human dignity has served a general foundational role in international law datingback to the Universal Declaration of Human Rights (1948), the particular role of that concept with regardto specific international science policy has been given a higher profile in recent years. In the wake of rapidadvances in the area of human genetics and genomics in the past decade, appeals to human dignity havebeen invoked in various quarters to justify specific conservative policies. Hence, the Universal Declarationof the Human Genome and Human Rights (1997) describes reproductive cloning as a practice contrary tohuman 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 abouthuman dignity.As the concept of human dignity has evolved from something of a platitude to take on a more focusednormative force, numerous commentators have expressed concerns about the inherent ambiguity of thenotion. Some have complained, that appeals to human dignity are something of a subterfuge employed todivert attention away from more socially charged and politically motivated rationales for opposing a

143particular policy or practice (Caulfield, 2003). Others have simply suggested, that the term is redundant andserves 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 ofthis presentation is to outline an appropriate role for human dignity to play with regard to internationalscience policy and biolaw. Far from being a political diversion or otherwise redundant and unnecessary, itis argued that the concept of human dignity is absolutely essential to moral discourse in general and that itshould play a central role in framing the development of international biolaw in particular. Although thisdiscussion does not arrive at explicit policy recommendations regarding appropriate regulations for humancloning, research using embryonic stem cells, the development of chimeras, or a plethora of othercontemporary bioethical issues, it will demonstrate how a proper understanding of the notion of humandignity can inform the larger policy debate concerning such issues.46.5. Occam’s Razor -- Facing the Legal and Ethical Issues of Cloning in the 21stCenturyRobin Woellner, James Cook University (robinhw@hotmail.com)Julie Zetler, Macquarie UniversityMedical science has made amazing advances in cloning techniques over recent times, and clearly, there aregreat benefits for humanity in the use of stem cells for medical research, creating the prospect of usingcloned materials to eliminate diseases such as TB, HIV, and even cancer. There is, however, another sideto cloning research, reflected in the (perhaps dubious) claims in 2003 that human clones had beensuccessfully born. Whether or not this is true, it seem clear that we have—or soon will have—the scientificability to clone human beings. Inevitably, techniques will be refined, and, over time, science will be able tocreate 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 ordisease, 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 scientistswanting to clone human beings for either curiosity, or commercial purposes, and grieving (wealthy) parentswho will spare no expense to “recreate” a lost child? What will be the legal status and rights of an“identical” clone, when the original dies or becomes mentally ill? Will a clone (or disappointed parents) beable 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 pragmaticallythat even if we get the theory right, we may be unable to effectively enforce laws regulating cloningtechniques?46.6. The Role of the Consumer Voice in Mental Health Policy ReformJulie Mulvany, Swinburne University of Technology (jmulvany@swin.edu.au)The rhetoric of consumer and carer participation in the development of mental health policy, including theplanning and the delivery of services, has strengthened during the last few decades. This rhetoric appears tobe based on monolithic conceptualizations of the concept of ‘consumer’, which assume the existence of aclearly identifiable consumer voice. This paper examines the discourse surrounding consumer participationin policy development and implementation as portrayed in recent national policy documents in Australia. It

144also examines the portrayal of the needs of people with psychiatric disabilities within these documents. Thepaper further identifies a diverse range of consumer discourses emerging in the twenty first century. Thesediscourses are found in recent policy reports published by consumer and carer groups, as well in moregeneral 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 anassessment of the relevance of existing mental health policy and legislation to the needs of people withpsychiatric disabilities, in light of these discourses. The implications of the consumer voice or voices forfuture mental health policy and legislative development are explored.47. Diversion of the Mentally Ill from the Criminal JusticeSystem47.1. Results of an International Web-based Survey of Pre-arrest Diversion, CourtDiversion and Mental Health CourtsKathleen Hartford, University of Western Ontario (Kathleen.Hartford@lhsc.on.ca)To develop evidence-based, best practices we conducted an extensive literature review and an internationalweb-based survey of police pre-arrest diversion, court diversion and mental health courts in Canada, theUS, the UK, Australia and New Zealand during six months of 2004. Identifying individual email addressesfor the web-based survey involved a multi-stage effort and a convenience sample of 850persons/organizations was assembled. Three surveys were developed with commonalities among thequestionnaires: (a) mental health court survey with 60 questions, (b) court diversion survey with 41questions and, (c) police pre-arrest diversion survey with 38 questions. The surveys were pre-tested withpolice 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 byphoning the organization left 266 usable addresses. The distribution of responses by country, type of surveyand type of format will be presented. Although the response rate is typical for Web-based surveys, whenDillman was conducting his research in the late 1990s the volume of email that employees received waslower. Increased volume and the problems associated with spam make it easier for respondents to deleteunexpected email and for individual and corporate spam filters to eliminate unexpected email. Findingsfrom the web-based survey supplemented the literature review and themes from the court diversion surveywill be presented and include: (a) training needs, (b) outcomes and monitoring, (c) inter-agency need formemorandum of understanding, (d) treatment options and, (e) costs and cost-effectiveness.

14547.2. How Will Ye Knoweth that Your Pre-Arrest Diversion Program Maketh aDifference? Tracking Trends in Police Contacts with People with Mental IllnessLisa Heslop, London Police Service, London, Canada (lheslop@police.london.ca)Kathleen Hartford, University of Western OntarioLarry Stitt, University of Western OntarioThe London Ontario Police maintain a database to track events and information related to their involvementwith the public. An algorithm, previously reported on, was developed to identify contacts of persons withmental illness (PMI) and police. Individuals were classified as definite, probable or possible MI based onthese variables. This paper reports on trends from 1998-2003 in contacts of Definite-PMI compared to thegeneral population in the police database. Charge and disposition data were extracted through a manualsearch of the database. In 2003, London Police Service signed a service agreement with the London MentalHealth Crisis Service whereby a mental health worker would attend police calls involving PMI to ensure amore appropriate, seamless response to PMI. This data will allow us to monitor the following annualoutcomes of this pre-arrest diversion program: (a) contacts of PMI with police; (b) number of frequentcontacts; (c) arrests, and (d) dispositions.47.3. Evaluation of a Mental Health Court: Offense Recividism Outcomes of MatchedSamplesVirginia Aldige Hiday, North Carolina State University (Ginny_Hiday@NCSU.edu)Marlee Gurrera, North Carolina State UniversityThis paper describes the operation of one mental health court for persons with mental illness who arecharged with misdemeanours and/or felonies, including violent offences; and it evaluates the impact of thecourt on reducing criminal recidivism. Mental health court participants are matched with traditionalcriminal court defendants from the same jurisdiction in the year before establishment of the mental healthcourt on criminal history, race, and gender then compared with traditional criminal court defendants ontheir number of arrests and their severity of arrests in the year before and the year after their participation intheir respective courts. Mental health court participants are also divided by whether they completed orfailed to complete their agreed period of cooperation with the court; both groups are compared withtraditional court defendants on arrests and severity. Using paired T tests of matched samples, we find thatmental health court participants had no significant decline in arrests or in severity of arrests from the yearbefore entering mental health court to the year following; but that traditional court defendants hadsignificant increases in both their average number of arrests and in the severity of arrests. There were nosignificant changes in number or severity of arrests when mental health court participants were grouped bycompleters and noncompleters; however, there was a nonsignificant trend for the completers to show adecline in both arrests and severity while the noncompleters showed a nonsignificant increase.

14647.4. Diversion Systems in the UK: A Curiosity Whose Time Has Passed?David James, North London Forensic Service, London, England (david.james5@ntlworld.com)This presentation will consider the state of court diversion in the United Kingdom, some fifteen years afterits inception. It will provide a commentary on the development of services, and on the factors that havefacilitated and impeded their growth. A tour through all the published UK literature on the subject will begiven, including the major outcome study that we ourselves conducted for the UK interior ministry (HomeOffice). A sober assessment will be presented of the future of such services, and indeed on the issue ofwhether they should have a future.47.5. The Emergence of Therapeutic Courts: Research and ImplicationsJohn Petrila, University of South Florida (petrila@fmhi.usf.edu)One of the most important jurisprudential developments in the last decade has been the emergence oftherapeutic courts in a number of countries. These courts most importantly include drug courts and mentalhealth courts. Such courts are based on the principle of therapeutic jurisprudence and attempt to achievenon-traditional aims, e.g., access to mental health treatment, for criminal defendants. This presentation willdescribe briefly the origins and characteristics of such courts; describe the implications of these courts forthe traditional role of judges and lawyers; describe briefly the research on outcomes done to date; andsuggest new directions for research into the operation and impact of therapeutic courts.47.6. Mentally Ill Offenders in Provisional Criminal Commitment – A Relief for PublicWelfare?Joachim Scharfetter, University of Vienna (joachim.scharfetter@meduniwien.ac.at)E. Resinger, University of ViennaIn October 1997 a specialized psychiatric ward for mentally ill offenders in provisional criminalcommitmentt has been installed as part of the hospital department in the remand prison Wien-Josefstadt.Until then, mentally ill offenders in provisional criminal commitment were almost exclusively held inpsychiatric hospitals; the expenses had to be paid by the ministry of justice, as opposed to being funded bythe health ministry.In times of tight budget in the health system, reduced psychiatric admission capacity and hospitalization,coupled with a restrictive legal system for admitting patients against their will, it has been hypothesizedthat the rising numbers of mentally ill offenders reflects a systematic relief of the health system, frominconvenient patients (Schanda et al. 2000).In our presentation we will describe a sample of 150 patients having been admitted to our ward betweenOctober 1997 and October 2004 as a basis for further discussion.We want to highlight this population of psychiatric patients and encourage the general psychiatrichealthcare system to attend to this group in order to prevent crime and imprisonment; close cooperation in

147rehabilitative arrangements could lead to a combination of early onset diagnosis and consequent treatmentin addition to a shortening of imprisonment times.48. Domestic Violence I48.1. Motiveless Paternal Infanticide During Partial Limbic Seizures of BelovedChildren: "Limbic Psychotic Trigger Reaction": Two Cases with Certain OrganicFeaturesAnneliese A. Pontius, Harvard Medical School (anneliese_pontius@hms.harvard.edu)Paternal infanticide is rare compared to maternal infanticide. Two infanticidal fathers in their late 20'sunder discussion had however identified themselves with the maternal role to an unusual degree, asepitomized by Mr. A.’s statement: "Maria is not the mother of Jesus, God (father) is Jesus' mother". Thetwo men's motiveless unplanned infanticide implicates a proposed kindled partial seizure, "LimbicPsychotic Trigger Reaction” (LPTR), with the symptoms of a brief fronto-limbic imbalance. So far, 23cases of LPTR have met l6 inclusion and l3 exclusion criteria. There is a primate model of seizure kindling,with 12 symptoms and signs include a fleeting de novo psychosis, and retained memory of the out-ofcharacteracts afterwards including deep puzzlement and remorse, typically surrendering voluntarily to thepolice, and asking to be punished. LPTR implicates a partial limbic seizure, apparently elicited by a chanceencounter with an individualized trigger stimulus reviving past repeated hurts. The two men underdiscussion were overly worried about their infants' well-being, and when they encountered an actual triggerstimulus which kindled previous repetitive moderate stresses, Mr. A. reacted by slapping the infant on theback (which was helpful in the infant's previous choking attack) but resulted in infant death, and Mr. B.killed his two infants (daughter, age 1 and son, age 3) through suffocation (using nearby plastic covers).Mr. A., whose mother had just died a few days before, suddenly harbored grandiose delusions about hismother's wealth and his inheritance from her. This delusion seemed again to enhance a powerful maternalstatus. Mr. B. also experienced various visual hallucinations.From an organic viewpoint it is of note that both fathers had suffered closed head injuries (as had half ofthe 23 LPTR cases). Further, both men had actual or borderline brain dysfunctions, respectively. Mr. A hada "porencephalic cyst” involving the motor and limbic systems. He had a history of left-sided "Jacksonianseizures” and "absences", and had been on anticonvulsants but had skipped them on the day of theinfanticide. Mr. B.’s scalp-EEG and CT revealed borderline abnormalities in his temporo-occipital brainregion, more on the right side. It may be telling that, during the infanticidal acts he suffered six types ofpsychotic visual distortions for the first time ever. The visual distortions appeared as macroscopia, tunnelvision, seeing the infants' faces without any facial features, and visual intensification: "the ear ring wasextremely bright like a source of supernatural energy".This presentation will assess the condition of paternal infanticide and the conditions of its rare occurrence.

14848.2. Alcohol, Anger, Attachment and Domestic Violence: How Can Research DataInform Interventions?Elizabeth Gilchrist, Coventry University (E.Gilchrist@coventry.ac.uk)Survey data suggest that, similar to many other countries, domestic violence is not at all uncommon in theUK. Indeed, domestic violence constitutes the largest single type of violence against women and accountsfor 25% of all violent crime in the UK (Home Office, 2002). This paper considers data from a nationalstudy (funded by the Home Office) to explore the characteristics and needs of domestic violence offendersbeing referred for community-based interventions.Much of what we currently know about domestic violence offenders has come from influential studiesconducted in North America where suggestions regarding sub-groups of offenders has been the focus ofsome discussion,; different groups of offenders may evidence different needs and require differentinterventions above and beyond those traditionally offered.This study supported much of the North American findings; for example, research indicated that there wasa general criminogenic need for mental diagnosis across the sample (e.g. personality dysfunction, history ofantisocial 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 ofdomestic violence offenders (Borderline/Emotionally Volatile and Antisocial/Narcissistic offenders) withreduced or elevated need in certain areas (e.g. Borderline/Emotionally Volatile offenders have the highestanger levels and so it is suggested that this type of offender might particularly benefit from treatmentfocusing on anger management).This paper will use data from the file and psychometric assessments from about 300 offenders in order toexplore issues related to alcohol, anger and attachment, and will discuss implications for interventions,particularly those managed via the Criminal Justice system.48.3. Staying the Domestic Violence (Dis)Course: (E)racing the Battered Woman,Battering the Raced WomanAdele M. Morrison, Northern Illinois University College of Law (amorrison@niu.edu)This work explores the “battered woman” as a necessary and therefore privileged identity which hasbecome a fundamental object of domestic violence discourse. This identity is necessary because it is part ofan “empowerment continuum” that moves those who have been abused along a path from victim tosurvivor. The author asserts that the battered woman identity and supporting discourse speaks of multiracialinclusivity, but is actually single race focused - that single race being white. Women of color areerased from domestic violence discourse and are left to stay in the cycle of abuse. The mental and physicalimpacts of victimization continue while women of color remain unable to access the very identity necessaryfor the transformation from victim to survivor. The author then proposes a course to discursive racialinclusivity that should produce more positive outcomes for women of color. That course begins byreconstructing the battered woman identity with women of color; located at its center would be the core ofdomestic violence legal and service providing discourses. With women of color as the central subject,being the ones whose interests are most significant, the discourse shifts course and the battered womanvictim moves through the empowerment continuum to become a multi-racial survivor.

14948.4. Domestic Violence and Mental DiseasesVivian Peres Day, Psychoanalytical Society of Porto Alegre, Brazil (vivianday@brturbo.com)Recent studies concerning domestic violence show that most of that violence takes place at home. Theplace where people seek protection turns out to be a threatening and terrify place due to violent behavior inthe family. The author discusses the different determinants through a multidisciplinary perspective of theproblem.49. Domestic Violence II: Domestic Violence and thePsychological Impact of the Justice System49.1. Understanding the Psychological Impact of Domestic Violence on the Victim andthe Perpetrator in the Justice System: The Response to PerpetratorsJoani M. Moore, Ohio Department of Alcohol and Drug Addiction Services, Columbus, USA(Moore@ada.state.oh.us, Joani@stereolimited.com)Domestic violence is the single greatest cause of avoidable injury to women in the United States and strainsthe time and efforts of law enforcement, judicial and correctional personnel. Communities that have cometo understand the theoretical basis for this phenomenon and that have developed system approaches havebeen more effective in the management of domestic violence perpetrators.This presentation will provide a historical perspective on domestic violence. It will compare and contrastthe different types of batterers and the challenges presented to law enforcement, court personnel, probationofficers, drug and alcohol treatment providers, domestic violence clinicians and jail personnel. Specialattention will be given to how perpetrators may manipulate the justice system to further victimize theirpartners. The presenter will also discuss the skills and training that are necessary for probation officers toeffectively 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 abusecompounds the management and treatment of the offender.The presenter will discuss appropriate treatment for perpetrators of domestic violence based on standardsdeveloped by the Ohio Domestic Violence Network. The presentation will focus on delivering services todomestic violence perpetrators which enhance victim safety while maintaining perpetrator accountability.

15049.2. Understanding the Psychological Impact of Domestic Violence on the Victim andthe Perpetrator in the Justice Systems and Appropriate Community Response:The Response to VictimsTuesday A. Ryan Hart, Ohio Domestic Violence Network, Columbus, USA (tuesdayrh@odvn.org)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. Theexperience of domestic violence can result in a range of mental health issues including post-traumatic stressdisorder, anxiety disorders, depression, and substance abuse.This presentation will focus on acquainting the audience with common traumatic responses that survivorsof domestic violence experience. Most psychological literature deals with trauma as a discreet, acuteepisode or event, with fairly straight forward symptomatology. The presenter will discuss the differencebetween this type of traumatic experience and the chronic experience of trauma that characterizes domesticviolence.Common traumatic symptoms will be discussed, with particular attention being given to how thesesymptoms may be evidenced during civil and criminal court processes. The presenter will specificallydiscuss those trauma responses which may not be readily apparent or understood in the context of courtproceedings but which can affect those proceedings and outcomes.The presenter will discuss how the very nature of court processes may be revictimizing for survivors ofdomestic violence and exacerbate their current trauma symptoms. The session will end with a discussion ofthe coping strategies commonly used by victims of domestic violence which may help or hinder courtproceedings as well as a discussion of appropriate mental health treatment for victims.49.3. Understanding the Psychological Impact of Domestic Violence on the Victim andthe Perpetrator in the Justice System: The Legal ResponseAlexandria M. Ruden, Legal Aid Society of Cleveland, USA (amruden@lasclev.org)A victim’s behavior in court is consistent with being traumatized by violence and with being battered by apartner. Often, how the victim acts in court is a direct response to what the perpetrator did prior to the courtappearance, or is doing during the court proceeding. Some victims of domestic violence may minimize ordeny the violence or rationalize it by blaming themselves for making the perpetrator angry. Sometimesvictims may tell only parts of the violent episode in court. Sometimes they lie in court because of a fear ofretaliation 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: tomake the violence stop. When the violence does not immediately cease, the victim re-engages in priorsurvival strategies of complying with the perpetrator during the court process because it appears that theperpetrator is in more control than the court.While protection orders should provide victims with protection throughout the duration of the criminaljustice process, many judges avoid these legal remedies in an effort to prevent further violence. This onlyserves to further escalate the violence by reinforcing both the perpetrator’s and victim’s beliefs that nonegative consequences will result from the violence.This presentation will focus on the impact of domestic violence on the victim and perpetrator in thecourtroom, and appropriate and effective response by court personnel including judges, prosecutors,

151attorneys, and probation. The presentation will also examine the use of court orders as legal remedies andhow the dynamics of domestic violence affect child custody and divorce proceedings.49.4. Understanding the Psychological Impact of Domestic Violence on the Victim andPerpetrator in the Justice System and Appropriate Community Responses: TheCommunity ResponseNancy Neylon, Ohio Domestic Violence Network, Columbus, USA (nancyn@odvn.org)Domestic violence and in particular intimate partner violence has been identified as a widespread problemin the United States and across the world. The Council of Europe has stated that domestic violence is themajor cause of death and disability for women ages 16 to 44. The justice system processes domesticviolence as an isolated incident of physical assault while the relationship between the parties is verycomplex and dynamic. In all instances of criminal behaviour the justice system seeks to apprehend andsanction the offender. In domestic violence cases the justice system must also prevent future abuse andtrauma to the victim and connect them with mental health and community resources that will enhancesafety and address the trauma experienced. The victim of domestic violence frequently suffers from posttraumatic stress disorder and the perpetrator may experience a range of mental health problems. Theindividual mental health of both parties impacts the processes of the justice system and requires newapproaches to successfully intervene in these cases. These new approaches require a high level of coordinationand co-operation among the court, law enforcement, prosecution, probation, victim advocacyservices and mental health treatment providers. The most effective way to ensure this collaboration is toestablish a forum at which all of the appropriate personnel meet on a regular basis to develop policies andprocedures that promote effective intervention strategies and meaningful sanctions.This presentation will discuss this co-ordinated community response in detail. The co-ordinated communityresponse is critical in facilitating change within a community. It can improve the justice systems and mentalhealth systems responses to domestic violence, thereby reducing and ultimately preventing domesticviolence. The presentation will discuss initial planning necessary for this endeavour, includingmembership, needs assessment, data collection, policy development, organisational structure andevaluation. The critical components of a successful co-ordinated community response to domestic violenceinclude the quality of the infrastructure, the quality of internal working climate, the breath and nature of theactivities and the short-term outcomes of the group.49.5. A Study of Uxoricides (Men who kill their wives)Michael H Stone, Columbia University (mstonemd@aol.com)Men who kill their wives (uxoricides) constitute an important subgroup of persons committing murder. Thepresent study is based on the full length biographies of 97 men who have killed their wives. These must beconsidered “high-profile” cases, since we know, epidemiologically, that only a small proportion ofuxoricides become the subject of extensive biographical reporting.There are several remarkable features noticeable in this group. Confession, for example, is rare. Among the97, 2 resisted arrest and were killed by the police, one committed suicide, 2 made partial confessions, andone made a deathbed confession. Of the remaining 91, 71 never confessed (78%), even in the face ofincontrovertible evidence (the cases of OJ Simpson & Scott Peterson are exemplary). In 30% of cases there

152was “staging”; i.e., an effort made to obscure the evidence of a murder – by various means (such asdrowning a wife in a bathtub or pushing her off a cliff to make the death appear accidental). In 15 casesother persons were hired to kill the wife, while the husband was far from the scene. Three of the mendisposed of their wives in the ocean, such that their bodies were never found. The average age of the wiveswas 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 mento hide the nature of their crime and to refuse to confess their guilt, no matter the circumstances.50. Dutch Court Orders and Ambulatory Treatment Facilities50.1. Symbiotic Mother-Son Attachment as Marker for Perversion and Sexual AssaultsKarola M.Lehnecke, Tilburg University (lehnecke@planet.nl)Karel Oei, Tilburg University, (t.i.oei@uvt.nl)The symbiotic mother-son attachment and the resulting erotic parentification could have a significantstifling impact on the psychological and object relational development of a young boy. The authors basetheir contention on an in-depth study of 30 sexual delinquents who had very close symbiotic ties with theirmothers, excluding the fathers from their primary caretaker roles. Moreover, we found that in thefundamental 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 bephysically and/or sexually abusive, and caused feelings of persecution and traumatization in the child. Theauthors found in one ‘TBS’ group (an acronym for Forensic Mental Health Patient), all of the sexualperpetrators had been severely bullied, being chronically outcast from peer group activities during theirlatency and adolescence. Most men in this group tended to skip classes/school resulting in lowersocioeconomic employment chances. With regard to this trend, concerning their elementary and highschool periods, all of these TBS men reported to have felt extremely emotionally isolated because of theiroutcast positions. In our sample, very few (TBS) men were able to maintain a partner relationship. Somemen 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 gainaccess to women than to rape them. The authors will compare two groups of sexual perpetrators andpresent data to support their findings.

15350.2. Forensic Psychiatric and Psychotherapeutic Outpatient and Day Clinic ‘TheTender’Geert Schuthof, The Tender Psychiatric Clinic, Deventer, The Netherlands (schut657@wxs.nl)Karel Oei, Tilburg University (t.i.oei@uvt.nl)The Tender Clinic, started one decade ago, is an ambulatory forensic psychiatric clinic. This place wasoriginally meant for justifiable persons in preventive detention, under the Dutch mental health act byrehabilitation and reintegration programs. There seemed to be a need for treatment of offenders under otherjudicial titles of imposed treatment. Under the Dutch mental health act, patients who have conductedcriminal acts influenced by any psychiatric illness, or who are prone to do so, are sent by probation officersor by health care workers for proper diagnoses and treatment. The ‘core-business’ of our institute is toreduce risk of criminal offence. Treatment can consist of individual or group psychotherapy,psychopharmacological interventions or assistance in social embedment. For sex offenders the institutedesigned a total package of therapies in a day clinic setting. This review presents the treatment program,risk assessment, numbers of patients treated, and also some results; this review will also present theposition of the outpatient clinic in the field of forensic psychiatry and within the regular psychiatrichealthcare system. Some of the judicial aspects of the treatment imposed on patients by law will bediscussed as well.50.3. Partial Day Treatment and Prevention of OffencesAmeon Struijk, The Tender Psychiatric Clinic, Deventer, The Netherlands (schut657@wxs.nl)Karel Oei, Tilburg University (t.i.oei@uvt.nl)The judge can apply a partial treatment sentence if the defendant is willing to do so. The probation officeris participating in the execution of such sentences, especially in cases of sexual assaults. The motivation fortreatment is dependent on an agreement between court and defendant. In some cases, defendants receivegroup therapy in the Tender clinic. Beside programs of offence prevention, active techniques like screeningtherapy procedures are used as well. Through confrontation, different treatment facilities have intensifiedtheir therapy procedures. Preliminary results of the follow-up will be discussed.50.4. Psychopathy RevisitedMax Westerborg, Forensic Psychiatrist Services, Almere, The Netherlands (ambermax@wxs.nl)Karel Oei , Tilburg University (t.i.oei@uvt.nl)Psychopathic development belonged to the exceptional diagnoses within the realm of the neuroses(psychoanalysis/Freud). The diagnosis of neuroses was considered when the patient had considerable flawsin the superego structure, called lacunas. Such neuroses included emotional shortcomings, possibly causedby amydala dysfunction, excessive self-centeredness, not caring for other people and having instrumentalrelations, only to fulfil their own needs. It was then believed that psychopathic development was the tragic

154result 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 poorprognosis if not treated correctly. At that time the diagnosis was not limited to criminals or criminalbehaviour, although psychiatrists considered the diagnosis as a severe risk for social maladjustment andcriminal behaviour. What happened to the diagnosis since then? Is the diagnosis still valid or do we have torevisit the diagnosis psychopathic personality. The vicissitudes of this diagnosis, the way it disappearedfrom our diagnostic horizon (DSM - narcissistic and antisocial personality disorders) and the way itreturned, but now in criminal law and mental health (the PCL-R). The outline will be shown of thesimilarities 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 Auflage1971.51. Dutch Forensic Psychiatric Services: Evaluation, Services,and Process51.1. Psychiatric Screening as a Service for Forensic EvaluationsTheo Bakkum, Ministry of Justice, Rotterdam, The Netherlands (T.Bakkum@fpd.dji.minjus.nl)In the city of Rotterdam there are many requests from the court for forensic evaluations. The crime rate isfairly high and psychiatric and psychological problems seem to cluster in the city, which is overall poorerand socially less developed than most of Holland. The forensic psychiatric service, as the institution thattrains and checks on the psychologists and psychiatrists who make the forensic evaluations, states that inevery request from the court, a psychiatrist from the forensic psychiatric service (experienced and with anoverview of both prison- and hospital-facilities) sees the suspect for a psychiatric screening. Thesepsychiatrists are then able to give the court advice on which type of forensic evaluation should be done (ornot be done), and can give a first impression of the person and possible mental disorders.Because of the shortage of psychiatrists (especially child and adolescent psychiatrists), the system is notpractically feasible. Therefore some criteria were developed to identify cases in which a psychiatricscreening is necessary before further forensic evaluation takes place. Other criteria have been developed toidentify 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 superfluous in retrospect, whereas in othercases, the forensic evaluation would have been improved through psychiatric screening.The court and the forensic psychiatric service are discussing the criteria and the method of psychiatricscreening.This paper outlines the criteria for psychiatric screening and how they can be in court cases. For eachcriterion a case-description will serve as an illustration. Some general information about forensicevaluations (methods, locations) as performed in Rotterdam will be explained, emphasising psychiatricscreening early in the process, for both youth and adults.

15551.2. Care Consultancy by Forensic Psychiatrists in Dutch Penitentiary FacilitiesPaul Frodl, Ministry of Justice, Rotterdam, The Netherlands (P.Frodl@fpd.dji.minjus.nl)Karel Oei, Tilburg University (t.i.oei@uvt.nl)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 mentallydisturbed/psychiatric inmates. Patients with emergency psychic stress like suicidal behaviour can be theobject of psychiatric consultancy as well.Our work is primarily multidisciplinary. There is a panel consisting of the prison doctor, nurses (medicalservice), psychologists, and the psychiatrist. This panel discusses the patients’ psychological problemsbefore seeing them and, after having seen the inmate/patient; the results are presented and evaluated. Thispanel is the so-called PMO: psychic medical communication. Generally the psychiatrist goes to the sameprison twice a week. He/she sees inmates from different units. In nearly each prison, there is a specializedcare 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 on verbal basedone verbally in the PMO but also in by means of a medical letter for the medical service in the prison, thepsychologist, and the medical dossier/status. It is important that the psychiatrist sees his patient as often asnecessary in order to control the expected treatment effect. If the patient's condition worsens in hispsychiatric illness, there are possibilities to transfer him to a psychiatric hospital outside the prison walls,but preferentially preferably they mcan be transferred to the FOBA: Forensic Observation and TreatmentUnit within the Prison system, which is like a psychiatric clinical prison unit.51.3. Dutch Forensic Mental Health Aspects of Unfitness to Stand TrialFrans Koenraadt, Utrecht University (f.koenraadt@law.uu.nl)In this presentation we will discuss, from the mental health point of view, what it means to be fit to standtrial in the Netherlands and which (psychical, physical an/or intellectual) disturbances can reduce thiscompetence. 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 tomake a distinction between a mental disorder that originated after having committed the offence and amental disorder that existed at the time of committing the offence. The implications of this distinction willbe shown.Attention will be paid to two particular, completely different variants in mental health of the unfitnessdoctrine, namely war criminals and former dictators, in addition to mentally disordered persons whocommit crimes while being detained in a psychiatric hospital.

15651.4. The Criminal Non-Punitive Order as Seen From an Economic StandpointKarel Oei, Tilburg University (t.i.oei@uvt.nl)In the second half of the 19th century, there was an increasing societal need for an alternative topunishment as retribution and general prevention, all the more because the courts were only able tosentence mentally disturbed people based on the principle that they were either insane or not. In the eventof 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 theend of the treatment.As soon as the physician in charge was of the opinion that the insanity was over, the legal ground forfurther treatment under the old Lunacy Act (Krankzinnigenwet) disappeared, and, pursuant to (old) Section28, the administration of the institution had to release the patient. However, such a person often proved notto 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 thathelps to improve their behaviour, as well as the issue of whether the supply of non-punitive orders maypossibly be exceeding the demand as their effectiveness proves inadequate.51.5. Are Changes of Memories of Certain Offenders Comparable with AmnesiaVictims of Psycho-Trauma?Ruth van der Pol, Ministry of Justice, Rotterdam, The Netherlands (R.vanderPol@fpd.dji.minjus.nl)Over 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 thetraumatic event. Changes in memory are often seen in suspects, but also in those who have confessed tocrimes. Psychologists and psychiatrists mention lying, suppression and other mental processes as a cause ofthe partial amnesia and distortion of memory in suspects. The question is: are there significant differencesin memory change in the course of time between suspects and normal people? For research purposes thecircumstances during the offense and, for the control group of “normals” during the event should becomparable. Certain perpetrators accidentally find themselves in a situation that has all the aspects ofpsycho trauma. Comparative research of the process of memory should be possible between theseaccidental perpetrators and victims of psycho trauma. This presentation describes briefly the differentmemory processes during and after the events and tries to answer the question whether research may bepossible. Description of one case and some literature are discussed.

15751.6. Responsibility and the Relation Between Disorder and Offence, An EmpiricalStudyTitus van Os, Ministry of Justice, Rotterdam, The Netherlands (t.w.d.p.van.os@acggn.a.nl)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 thepresence of any mental disorder. Five levels of responsibility are distinguished, ranging from fullyresponsible to not responsible. The greater the influence of the disorder on the offence, the lower theresponsibility. In this presentation we will study a sample (300) of expert examinations for the level ofresponsibility assessed in relationship to the type of offence committed, and the mental disorder diagnosed.52. The Dutch Way of Deinstitutionalization I52.1. Organisation of Mental Health Services: EpidemiologyEllen van Hummel, Psycho-Mmedisch Centrum, The Hague, The Netherlands (hummee@parnassia.nl)The Hague has 450.000 inhabitants and is the third largest city of the Netherlands. As in many big citiesThe Hague has a population of severe mentally ill. In this paper we will explain how the care and thefinancing of the care for this group of patients is organised. We will present some epidemiological dataincluding data about compulsory admissions, financial data and global information about the mental healthcare system in the Netherlands.52.2. Care for Schizophrenic Patients in a Transmural ViewFred J. van Essen, Psycho-Mmedisch Centrum, The Hague, The Netherlands (essenf@parnassia.nl)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 abruptchanges in the institutions.The psychiatric hospitals remained largely unchanged into the early 1990’s, despite the formation ofcommunity mental health services in the 1980’s. By the late 1990s the institutions had been integrated intoone comprehensive mental health system. The incorporation of the community mental health centres by thepsychiatric hospitals had shifted the focus of services from the clinic to the community.Not surprisingly, the development of comprehensive services for psychotic patients fulfilled a leading rolein the ‘transmuralisation’. Several multi-disciplinary teams, modeled according to the Assertive

158Community Treatment principles, offer approximately 2500 psychotic patients integrated andcomprehensive care over their lifetime. This continuity of care provides a diverse range of services, whichwill be presented.Though the amount of support is dependent on the needs of the patient, an assertive engagement whennecessary cannot be avoided, resulting in compulsory admission of treatment (involuntary commitment) inextreme cases.52.3. Team for Public Mental Health Service (Team Oggz Parnassia)Jorijn M. Deenen, Psycho-Mmedisch Centrum, The Hague, The Netherlands (deenej@parnassia.nl)In this presentation we explain how we recently reorganized the care for the homeless who are mentally illor have severe addictions. The majority of patients have a combination of mental illness and addiction. Weoffer an integrated treatment based on the Assertive Community Treatment model. Through goodcollaboration with all partner institutions that in some way are connected with our target group, we are ableto reach most of the homeless. The integrated treatment is quite unique in the Netherlands.52.4. Normal Housing in ParnassiaHans Oolders, Psycho-Mmedisch Centrum, The Hague, The Netherlands (ooldej@parnassia.nl)Sometimes a major psychiatric disorder is constantly out of balance, comparable to balancing a broomstickon your finger. You always have to adjust your hand to keep the stick upright. If this is the case, a patientwith a major psychiatric disorder cannot leave the hospital if there is exacerbation of the symptoms withindays or weeks because of the potential adjustments and imbalances. To give these residents moreindependence or even a life of there own, with psychiatric guidance nearby, Parnassia has founded a placewhere this is possible. In this presentation will be given a detailed overview of how life is in Parnassia forthose residents and in what way we try to make this bearable or even a nice place to be. In the process ofnormalization, there are intentions for housing severe mental ill patients in the city, and offering themtreatment and daily life support.

15953. The Dutch Way of Deinstitutionalization II53.1. Suicide in ParnassiaRuud H.P. van Beest, Psycho-Mmedisch Centrum, The Hague, The Netherlands (r.van.beest@parnassia.nl)Parnassia covers the major part of psychiatric and addiction care in the city of The Hague;beside psychiatrist in private practice, there are youth facilities and nursing homes.Handling patients with suicidal ideations is a difficult task. It is possible to determine whether theindividual belongs to the risk group, however an a priori prediction for one person is difficult. As well,interventions are not always successful. Sometimes suicidal ideation is not reported by the patient evenwhen asked for.There is a need for common sense in clinical practice, particularly when there is a great psychic dysfunctionor in any case where the patient is non competent and protection is necessary. When the patient suffersform a personality disorder, protection however may have adverse side effects.Figures will be presented about the suicide of patients of Parnassia during 2000-2004 (20-25 p.a.). Lookingover a longer period, though the number of suicides have remained relatively stable, there has been apronounced shift from inpatient to outpatients.A comparison will be made with the city registration of suicide. Around half the persons that committedsuicide were recently in treatment at Parnassia.Prevention of suicide remains an important issue. When the person is in treatment there is an opportunity toshare the responsibility of the prevention of accidents. General prevention is complicated and some ideaswill be discussed.53.2. Rehabilitation/Probation and Integrated Mental HealthChris van der Meer, Psycho-Medisch Centrum, The Hague, The Netherlands (meerc@parnassia.nl)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 aretreatment resistant or forensic. The RPD is functioning as an intermediate service between the judicialsystem (the general prosecutor’s office, police, prison service) and the treatment facilities of Parnassia. TheRPD is trying to play a major role in reducing criminal behaviour of repeat offenders, especially those whoare suffering from mental and/or drug-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 has developed in the Hague. Repeat offenders fromthe city’s top 500 list who are on probation, are in an intensive case management and controlsystem, mostly in combination with a care or cure trajectory.• The Comorbidity project is a pre-treatment project for severely disturbed detainees in thespecial care department of The Hague House of Detention. In the project psychiatricallytrained rehabilitation officers give individual and group training to the detainees and prepare

160the referral to Parnassia or another facility. Since the start of this project in 2003, the numberof forensic patients who were successfully referred to Parnassia psychiatric and otheraddiction programmes has risen dramatically.• The programme for criminal addicts Triple-Ex. This is a modified therapeutic communitywith much emphasis on vocational training and social reintegration of long term drug abusers,mostly from ethnic minorities. Programme evaluation showed promising results, both forabstinence rates and for social integration indicators including criminal recidivism. TheJustice department has given the programme a provisional accreditation.53.3. Ambivalence in Legislation: Outpatient Commitment in the NetherlandsJ. (Remmers) van Veldhuizen, GGZ North Holland North, Heiloo, The Netherlands(remmersvv@hotmail.com)In 1994 a new Dutch mental health act ‘BOPZ’ started. Autonomy of the patient was the central issue. Thelaw regulates forced admission and ‘protects’ the patient against too intrusive of treatment. Involuntarytreatment is only possible in case of ‘danger’ at the ward.The law did not regulate community orders. After 1994 we saw an informal process in which conditionalleave 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 nolonger 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 patientdoesn’t cooperate with his treatment plan, involuntary treatment is not possible. If the patient continues torefuse treatment, the next step is forced admission, only possible after some formal steps (including asecond opinion by an other psychiatrist). Compared with the community treatment orders in othercountries, this legislation works time consuming and insufficient: it has no teeth and it leads to moreadmissions.This legislation reflects the ambivalence of the legislator. Mental health care services are urged to giveassertive outreach (or –forced- admission) to disturbing patients. But on the other hand the governmenthesitates to diminish the autonomy of the patient .The parliament starts to recognise this problem and is beginning to ask for other legislation. The Dutchdiscussion regarding ‘danger’ and ‘autonomy’ needs to be broadened with the aspect of ‘treatment’. Therecommendation Rec (2004)10 of the committee of Ministers of the Council of Europe concerning theprotection of human rights and dignity of persons with mental disorder will play an important role in thisprocess.53.4. Assertive Community Treatment (ACT) in the NetherlandsBert-Jan Roosenschoon, Rotterdam, The Netherlands (B.Roosenschoon@BavoRNOGroep.org)Assertive Community Treatment (ACT) is one of the evidence-based practices in the USA. It is the onlytype 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 AssertiveOutreach. In the Netherlands we try to implement ACT and carry out research to investigate whether the

161implementation shows fidelity; that is to say, according to the American ACT-model, are the principles ofACT being effectvol utilized in the Netherlands.We translated the DACTS (the Dartmouth Assertive Community Treatment Scale) to Dutch, and applied itto our ACT-teams. The fidelity of the implementation in the Netherlands proved to be moderate. Manyitems of the DACTS scored high in tests of subject in the Netherlands, however the integration of someservices in the ACT-team were low (e.g. Crisis-intervention, Double-Diagnosis Treatment, and parts of themedical treatment). According to the ACT-model, all services should be provided and carried out by theACT-team itself.Some people in the Netherlands would like to adopt a Dutch version of ACT, because the Dutch health caresituation is so different from the situation in the USA. The Dutch version of ACT has a lower degree offidelity compared to the American model. This is problematic because this Dutch-version would not beevidence-based, and therefore less predictable. To counter this, we would like to integrate as many items ofthe American model as possible. We think that it would be effective, particularly in urban areas, There isdiscussion however, as to whether high-fidelity is always possible/necessary, especially in rural areas. Inour presentation we show some results of our research on the high and low scoring ACT-items and thepossibilities and willingness to adopt the different parts of ACT-fidelity in the Netherlands.54. The Duty to Warn, Confidentiality and Patient Protection54.1. The Development of European Guidelines for Confidentiality in HealthcareRoy McClelland, Queen’s University at Belfast (r.j.mcclelland@qub.ac.uk)The Information Society and the technology upon which it is founded render obsolete the traditionalnotions of confidentiality between doctor and patient. In the modern context the concept of one-to-oneprivacy has been reinterpreted as patients’ rights to maintain control over information flow and to knowhow their personal data are used and processed.The need to safeguard the confidentiality of information that patients share with clinicians is, from aclinical perspective, as fundamental as the principle of consent. This issue has come to the fore in thecontext of the rapid developments and applications of information and communication technologies withinsociety 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 changesin health care organisation and practice, for example multi-disciplinary and multi-agency working. Mentalhealth 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 theexpectation of patients that information about them will be kept confidential.Confidentiality and privacy are also legal concepts and the relationship between healthcare professionalsand their patients carries with it legal obligations of confidence as well as moral ones. In addition, doctorshave a professional duty for maintaining confidence and the misuse of confidential medical information islikely to be regarded as serious professional misconduct.

162This European project consists of a detailed consideration of the ethical issues in confidentiality inhealthcare. Specific attention is allocated to: issues of concern for vulnerable groups; a review and analysisof existing laws, policies and guidelines on confidentiality in Europe; preparation and distribution ofconfidentiality guidelines for healthcare practice.54.2. Psychiatrist-Patient ConfidentialityKaren De Freitas, McMaster University (kdefreit@cogeco.ca)Physician-patient confidentiality is one of the cornerstones of medical practice. It is especially important inpsychiatric practice where patients often reveal intensely personal information. However, there are severalcommonly accepted exceptions to the rule of confidentiality. These exceptions are usually justified on thebasis that the benefit to a third party of having the information exceeds the harm to the patient of revealingthe information. Examples include the duty to warn third parties of threats made against them, and theobligation to inform child protection agencies of suspected child abuse. This presentation will review someof the more commonly encountered exceptions to physician-patient confidentiality, especially as it appliesto psychiatric practice.It will also explore the issue of role conflict, which can occur when a single clinician must assume the dualroles of both caregiver and evaluator. An example of this is the case in which a treating psychiatrist mustreport on a patient’s condition to an insurance company in order to aid in the processing of a disabilityclaim. Finally, this presentation will explore some of the potentially detrimental effects that the existence ofexceptions to confidentiality can have on the psychiatrist-patient relationship.54.3. The Development of the Tarasoff Principle and its Application in EuropeColin Gavaghan, University of Glasgow (c.gavaghan@law.gla.ac.uk)It is well established in U.K. law that, in certain circumstances, a medical professional is permitted todepart from his or her duty of confidentiality, to issue warnings about a patient who is believed to present areal and serious threat to other parties (W v. Edgell, R. v. Crozier). However, what was less certain waswhether a medical professional could ever be duty-bound to give such a warning. The approach adoptedthroughout much of the U.S.A., and famously expounded in the Tarasoff judgment does in fact impose sucha 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 theTarasoff approach into the U.K., and indeed throughout Europe. The case concerned an alleged failure bythe police to prevent a schoolteacher from attacking and seriously injuring a pupil with whom he hadbecome obsessed, and killing the pupil’s father. The Court recognized that article 2 of the Conventionimposes a duty on employees of signatory states to take positive steps to safeguard the lives of all citizensof that state. I will suggest that this decision could apply equally to those working in medicine andpsychiatry (at least those employed in the state sector), requiring them to breach patient confidentiality insome circumstances and notify identifiable endangered parties of the risk posed by “dangerous” patients.

16354.4. The Duty To Warn In A Prison: Should the Tarasoff Principle Apply?John L. Hill, Barrister and Solicitor, Toronto, Canada (conlaw@pathcom.com)Prisons, by their very nature, contain dangerous people that are constantly at risk of doing harm to staff andother inmates. How far should prison authorities go to ensure that persons inside a penitentiary should beprotected 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 beenturned on its head: prison authorities who have access to confidential prisoner information have beenshielded from liability when assaults upon unsuspecting inmates have occurred. It has come to be acceptedthat no liability attaches unless the inmate victim has first informed the Correctional Service of thelikelihood of harm.It will be argued that by ignoring the Tarasoff principle to avoid civil liability, there is an inducement forthe Correctional Service of Canada to turn a blind eye to suspected trouble. Thus we have a situation thatarose in a 2004 decision of the Supreme Court of Canada, R. v. Kerr, where an inmate was acquitted ofpossessing a knife in a penitentiary and subsequently killing another inmate because no other protectionwas available.54.5. The Duty to Warn and the Duty to ProtectJohn Wilton, Anglican Archdiocese of Toronto, Canada (jwilton@stgeorgestoronto.ca)The duty to warn is not limited to doctors and lawyers. Increasingly we are learning that in virtually allorganizations there are expectations that the organizations will not put persons who deal with it in harm'sway. This is especially true for churches. Like other faith communities, the Anglican Church of Canada hasemerged from a period where sexual abuse by clergy and parishioners that has been highly publicized. It istime for reconciliation between the abusers and the abused.However, how this reconciliation can proceed raises serious issues needing to be explored. How does thechurch respect its obligation for confidentiality in dealing with its members and yet ensure that membersare safe from exploitation from others in their midst? Should the church seek out information on the privatelives of its members in order to inform itself of potential risk? How far should it go in this regard? Whatspecial precautions should be taken to ensure that past incidences of abuse do not reoccur? How can thevalues of forgiveness be balanced with the need to ensure the safety of all members of the faithcommunity?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. Thispresentation will focus on the initiatives taken within the church and suggest that the experience within thechurch can be a model for other secular organizations wanting to be proactive in avoiding future problems.

16455. Dynamics of Societal Re-entry for Offenders with MentalIllness55.1. Criminal Justice and Mental Health Systems Collaborations for Prisoner Re-entry:Boundary Spanning or Picking Up the Ball?Jeffrey Draine, University of Pennsylvania (Jdraine@ssw.upenn.edu)Amy Blank, University of Pennsylvania (Ablank@ssw.upenn.edu)Prisoner re-entry efforts have gained great policy interest with the increase in prison releases that followsthe incarceration increase of the 70s to 90s. We conducted a national assessment of the structure andpractices of re-entry programs for people with mental illness. The goal was to develop a classification ofservice strategies based on an understanding of operating programs rather than relying on a prioriclassification schemes.A national survey was conducted to identify the spectrum of service strategies being used by mental healthprograms to bridge the transition from incarceration to the community for mentally ill offenders. A total ofsixty-one re-entry programs were identified. Fifty-two are included in this analysis. Whenever possibletelephone 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. Interviewnotes were transcribed immediately after each interview. Other sources of program information includedconference presentations, program brochures, published articles, and internet websites. A constantcomparison of information gathered from programs was used to develop variables that operationalizedimportant program characteristics. These characteristics were used to develop a typology of re-entryprograms 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 servicesystems. The findings of this survey supported the use of a 2 by 2, four group typology of initiatives, withone factor being which system initiated the program (criminal justice or mental health); and the other factorbeing whether or not there is significant collaboration between the mental health and criminal justicesystems. Of the 52 mental health treatment services included in this analysis 37 were classified as beinglocated 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/programsas well as how program effectiveness may be measured. If the funding trend identified in this surveycontinues, the criminal justice system will quickly become the primary funder to treatment services formentally ill offenders returning to the community. What are the ways in which the shift in funding willaffect the provision of mental health services?

16555.2. Understanding How Operationalization Affects Implementation: The Case ofSelection and LinkageWendy Pogorzelski, Rutgers University (wpogorzelski@ifh.rutgers.edu)Amy Blank, University of Pennsylvania (Ablank@ssw.upenn.edu)Connecting persons with mental illnesses (PMIs) to needed services is integral to successful offenderreintegration. Research on specialized programs for PMIs primarily focuses on client outcomes (such asadherence to treatment and recidivism) yet we know very little about the process of identifying clients forprogram participation (selection) and how PMIs are connected to the services (linkage). This analysisdraws on data collected during an evaluation of three jail-based re-entry programs for persons with mentalillnesses. 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 communityservices. Identification and selection of clients depends on the quality of the institutionalized and informalrelationships between the service provider and the jail, whether the service provider is jail-based orcommunity-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 servicesystem’s capacity to meet them. This includes issues such as the menu of services available in a specificservice system, accessibility of these services, and the ability of the service system to provide clinicallymeaningful treatment that meets the specific needs of this client population. In addition we will examinehow the concepts of selection and linkage are operationalized in daily practice and how contextualdynamics, such as agency collaboration and access to relevant institutional resources, facilitate and inhibitthe delivery of services and program operation. The paper will conclude by assessing how programimplementation differed from the proposed intervention due to the way selection and linkages wereoperationalized in practice.55.3. In Search of Employment: Community Reintegration for Incarcerated Womenwith Mental Health ProblemsCynthia L. Blitz, Rutgers University (cblitz@ifh.rutgers.edu)Kris Paap, Rutgers University (paap@rci.rutgers.edu)Increases in women’s incarceration in the United States have led to an increasing number of women whomust struggle through the processes of reintegration into their families, into educational and socialinstitutions, and into the paid workforce after their release from prison. These already difficult transitionsare further complicated by the fact that women in prison are more likely than men to be diagnosed asmentally 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’sprison in a northeastern U.S. state was surveyed about the women’s individual employment-relatedstrengths and deficits. The survey included questions about the women’s work skills and experience, theireducational history, their perceptions about their upcoming return to life and work outside of prison, andtheir previous experiences with mental illness and/or mental health services. The women’s occupationalskills and histories were then compared to the jobs available in the areas where women from this institutionare most likely to settle after their release, thus providing supply and demand-side comparisons. Resultssuggest not only that mental health continues to be a viable factor in post-release vocational planning, but

166also that demand-side planning must be at the fore of intervention designs. We conclude with suggestionsfor practice and policy.55.4. Social Capital and Re-entry: The Case of La Bodega de la FamiliaNancy Wolff, Rutgers University (nwolff@ifh.rutgers.edu)Jane Siegel, Rutgers University (jasiegel@camden.rutgers.edu)Most people returning to the community from prison rely to some extent on their families and communitiesfor assistance. Resource exchange through family, friends, or professional affiliations is known as socialcapital. The ways through which social capital translates into reduced recidivism and desistance from crimeamong returning prisoners is unknown. This study identifies and measures the value of resourcesexchanged through the social networks of people who, because of their criminal behaviors, are involved asclients 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 theISU'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 thestudy. 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 areaffected by the return of the ISU. Findings from this study would inform policy by providing a moreaccurate representation of the way in which families and communities contribute to the welfare of thosewho are leaving prison and jails and help to reduce recidivism and foster community reintegration andrecovery post release.55.5. Providing Mental Health Care at the Prison’s Back Door: Re-linking Mentally IllOffenders to Community TreatmentKathryn A. Burns, Case Western Reserve University (burns@cccmhb.org)All offenders returning to civilian life after a period of prolonged prison incarceration have a difficult timeadjusting to non-inmate life. The situation is particularly difficult for offenders with serious mentalillnesses: securing community treatment without lapses in medication from supplies provided at the time ofprison release, delays in processing of disability benefits for basic necessities, medical care and prescriptioncoverage; problems in securing safe, affordable housing that will accept convicted felons, and exacerbationof psychiatric symptoms during periods of high stress all contribute to the problems experienced byoffenders 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 beendeveloped in Cleveland, Ohio to address these problems. The specialized ACT team developed representsa unique collaboration between the state prison system and a county mental health treatment provider. Thestaffing composition, frequency of contact with parolees, housing options, treatment protocols, and otheroperating procedures, including selection criteria for participation in the program will be presented.Parolee sociodemographic and psychiatric diagnostic characteristics will be presented. Finally, ACTprogram outcomes, including psychiatric stability attained, housing stability and criminal recidivism will bediscussed and compared to a sample of similar released offenders receiving non-specialized mental healthcare.

16756. Eating Disorders and the Law56.1. Clinical Decision Analysis and Anorexia NervosaC. Laird Birmingham, University of British Columbia (clbirm@interchange.ubc.ca)Lawyers are frequently asked to help with decision-making in cases of anorexia nervosa, a diseasecharacterised by extreme weight loss due to a pathological fear of fatness. However, deciding when andhow to intervene is difficult in anorexia nervosa. Clinical decision analysis was first used by businesses topredict the potential profitability of competing options. Clinical decision analysis can be used in anorexianervosa to assist health-professionals to make treatment decisions or to help lawyers understand the risksand benefits of each treatment option, without detailed medical knowledge. A decision tree is constructedwith each treatment option assigned to an arm. All treatment alternatives, including no treatment, must beincluded. A numerical figure is assigned to each option based upon the known value, or relative benefit ofthe possible outcomes (e.g. death is usually scored as 0 and good health is scored as 1) and the probabilitiesof the various outcomes (it is adequate to have a range of the probability, e.g. 0.2-0.6). Simple arithmeticor a decision analysis computer program can be used to calculate the value of the various treatment armsand rapidly differentiate the best from the worst options for treatment. If there is uncertainty about theprobabilities and relative benefits you can either calculate each of the possible outcomes separately orperform a sensitivity analysis. A sensitivity analysis produces a range of outcomes of the decision analysisover a range of probabilities or relative benefits. Clinical decision analysis is quick, precise, forcesdiscussion of the likelihood and benefit of the treatment options and can be carried out with a computer anda decision analysis software program.56.2. Social Relations are a Catalyst for Change in the Treatment of Eating Disorders:The Hong Kong-Vancouver Canada ExperiencePatricia Kitchener, Practicing Psychiatrist, West Vancouver, Canada (patkhome@telus.net)By expressing 'world view' human rights values and beliefs of equality with diversity in treatment, atherapist can foster relationships which welcome the opportunity to explore and examine culturallyembedded discrimination and practices. This exploration is particularly useful in the treatment of EatingDisorders as there are, inherently, many hidden biases and underlying assumptions presented in thesymptoms of the disorder. Although it is always important that the therapist consistently model respectfulinteractions, verbally as well as non-verbally, the need for respectful role modeling is especially acute intherapy for the treatment of eating disorders. According to author Susie Orbach, Hunger Strike, this isbecause eating disordered clients have a heightened sensitivity to, and absorption "from an early age, aboutthe ways in which they are to live as women”. Unable to articulate intensely experienced internal needsand desires, which contradict socialization processes designed to suppress those needs, eating disorderclients act out the discrepancies. The Hong Kong-Vancouver, Canada experience will illustrate that, whengiven language and voice, eating disorders clients 'acting out' can be understood as a manifestation ofa sense of ‘injustice’ or ‘unfairness’. The meaning of the symptoms of denying and overriding hunger andappetite viewed as a metaphor for the demands that a young woman look a certain way, not take up toomuch space etc., can illuminate eating disorders as clear reflection and expression that she curtail her needsin general. The constructive use of the dynamics of a social relationship between the therapist and client,

168the therapist and family system, and other combinations of participants in therapy, used to addressembedded inequities and practices can become the catalyst for change. The advantage of cross-culturaltherapy lies in a culturally sensitive offering of an alterative lens to view contradictions and multiplerealities. Previously unexamined issues such as gender inequality, hierarchy, individual versus grouprights, cultural stereotypes, etc. can be seen from 'outside' the cultural system. By increasing awareness, thetherapy process facilitates a unifying perspective which brings about fundamental shifts in the socialsystems, encouraging the tolerance of diversity and potentially reducing human rights infringements.56.3. Fraudulent Misrepresentation: Case Law and Regulator Rules in Relation toEating DisordersPatricia O’Hagan, University of British Columbia (pohagan@providencehealth.bc.ca)The International Obesity Task Force (IOTF) found that at the global level, few countries report obesityrates below 10%. Moreover, IOTF reported that the rising international trend in obesity is now estimated atmore than 320 million adults and 40 million children who are obese (BMI>30). These findings and theconcurrent popular culture emphasis on thinness have supported the growth of the weight-loss industry withmarketing and sales in: dieting programs, “magic bullets” (pills and capsules), and phony devices andgadgets. The weight loss industry is a $40 billion-a-year business in North America where advertisementscover all areas of mass media (film, newspapers, magazines, radio, and television); genre fiction such asmysteries, science fiction and romance novels, popular music, fashion, websites and commercial e-mails.These converging trends have been expressed in courts decisions and regulator rules that represent asignificant and valuable expansion of case law related to disordered eating. Court decisions dealing withbody shape, weight and eating disorders are expanding to include the health and safety of clients related tothe availability and qualifications in the provisions of services. Regulator rules are protecting clients fromfalse 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 forprofit services. Consumers are particularly vulnerable when it comes to unsubstantiated productperformance claims related to weight loss.Perhaps the best approach is to set out overriding principles for guidelines in the delivery of mental healthservices. The U.S. Federal Trade Commission (F.T.C.) has identified weight-loss advertising claims thatshould meet the standard of fraudulent misrepresentation because they are not scientifically feasible. Thetest of FTC findings has been met in US settlements and now under NAFTA, Canadian marketers doingbusiness in the US have settled fraudulent weight-loss products as a result of the FTC charges.56.4. Experiences of 'Control' in Anorexia Nervosa Treatment: Delayed Coercion,Shadow of Law, or Disseminated Power & Control?Terry Carney, University of Sydney (terryc@law.usyd.edu.au)Mim Ingvarson, Mental Health Legal Centre. Victoria, AustraliaDavid Tait, University of CanberraAnorexia nervosa is often chronic, with one of the highest death rates for psychological conditions. Lawcan compel treatment, but is rarely invoked, at least formally (though the strategic possibilities of orders

169confers internal authority within the clinical setting). Instead, 'control' (or management) is exerciseddiffusely, through disciplinary practices embedded in everyday clinic life, such as daily routines of eatingand washing, behavioural 'contracts', regular surveillance and measuring, interactions with staff, visits andactivities. The regulatory regime not only touches on such 'practices' but also targets 'identities' (includingself-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 orthe success of less restrictive options that explains why law is so infrequently engaged. Rather, based on aninterpretation of Foucault, we concluded that the regulatory regimes that shape treatment of anorexianervosa, is 'the law', in a sense. The regime of governmentality within the clinic is shaped by practiceswhich operationalise 'duty of care', or translate medical expertise into medical authority, or show howinteractions between 'experts', 'carers' and patients are mediated through conventions and rules, or whichconscript '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 legalintervention. 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 thenew identity. The patient has become an active participant in the governance of self.56.5. Ethical Issues in Clinical Nutrition: Obesity, Anorexia, Terminal IllnessEugenio Rasio, University of Montreal (eugenio.rasio@sympatico.ca)The nutritional state of the patient is a major determinant of the outcomes of treatments and quality of lifeduring illness. Nutritional interventions need to be assessed in terms of their scientific validity and ethicalappropriateness. Achieving a negative calorie balance is a sine qua non requirement for reducing weight inthe obese: the psychological cost of failure to achieve and maintain a significant weight loss often prevailsover the intended benefits of reduced physical risks. Minimal but persistent weight loss in the obese, with aliberal and realistic approach to dieting, can be beneficial without imparting the stigma of the inability torespond in visible fashion to more aggressive food restrictions.In anorexia nervosa, compulsory artificial nutrition and hydration may be lifesaving. However, metabolicimprovements can often be achieved in a natural and less dramatic fashion, which sustain the vitalfunctions without creating additional mental distress by an undue weight gain. A very modest positivecalorie balance is often agreed upon by the emaciated anorexic, if it is designed to increase the metabolicrate, and not to replenish the body energy. Rehydration should be attempted cautiously as incongruoustreatments result in excess water retention with rapid, important and often prolonged body weightincrements, which the anorexic cannot endure.In the terminally ill cachectic patient, legal, medical and ethical issues on how to manage hydration andnutrition in the context of palliative care may be intricate and difficult to resolve. Withholding orwithdrawal of water and nutrients to incompetent patients is a most difficult decision. Among the factors toconsider are the patient’s comfort, the family members perceptions and the improvement or delayeddeterioration of the clinical condition that can be expected by providing optimal or minimal nutritionalsupport. One should also eventually consider that water retention and accelerated proteolysis precedingdeath in cachectic patients might be best dealt with by withholding nutritional support, a decision which hasno bearing on ethics.Useful nutritional interventions can be achieved in harmony with ethical principles, despite apparentconflicting situations.

17057. Elder Law I57.1. When Abusers Seek Guardianship: How Adult Protective Services andGuardianship Courts Can Work Together to Protect the ElderlyMarguerite Angelari, Loyola University at Chicago (MANGELA@luc.edu)Adult guardianship is a court process through which an individual loses virtually all of his rights, and asubstitute decision maker is put in place to make all major decisions. The aging of our population has ledto a dramatic increase in the need for court ordered guardianships, which is severely straining court systemsin 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. Undersuch circumstances, it is not difficult for an abuser to become his victim’s court appointed guardian andthereby obtain full legal control over his life. Elder abuse investigators can offer critical information onwhether proposed guardians may be exploiting their wards. Unfortunately, in Illinois, and throughout theUnited States, adult protection services agencies and guardianship courts operate independently of oneanother. Therefore, a judge conducting a guardianship proceeding and an investigator in an elder abusecase are unlikely to be aware that the two proceedings are occurring simultaneously. Furthermore, elderabuse investigators report that even when they become aware of the guardianship proceeding and appear incourt, they are often unable to present evidence of abuse at the guardianship hearing. As a result, they havestood by while alleged abusers have been appointed guardian. This paper presents the findings of aresearch project on the interaction between elder abuse investigations and guardianship cases. The studyincluded face-to-face interviews with elder abuse investigators about particular investigations followed by areview of corresponding guardianship court files. This paper documents the need for greater interactionbetween guardianship courts and adult protective services and offers recommendations for reform.57.2. Elders and Models of Testamentary Undue Influence in the United States, UnitedKingdom, Australia and CanadaFiona Burns, University of Sydney (fionab@law.usyd.edu.au)Since the 19 th century common law jurisdictions, unlike their civil law counterparts, have espoused andapplied the principle of freedom testation (subject to modifications such as the statutory or forced share inthe United States, or family provision legislation in the United Kingdom). A will is subject to scrutinywhere there are allegations that the principle of freedom of testation has been compromised; for example, incases where there are allegations that the testator was subject to undue influence at the time that the willwas made. This paper will examine the doctrine of testamentary undue influence with special attention tothe wills of elderly testators where the elderly testator exhibited some mental impairment or physical illnessat the time the will was made; or lived in a situation where he or she was dependent upon the assistance ofothers 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 theimpact upon their right to exercise testamentary freedom. It will be contended that there are, broadlyspeaking, two very different doctrinal versions of testamentary undue influence in common lawjurisdictions – the United States model and the United Kingdom model. The former addresses the abuse ofa relationship of special trust and confidence; while the latter focuses on coercive action which has

171overcome the testator’s will and autonomy. The paper will: compare and contrast both undue testamentaryinfluence models; evaluate to what extent courts in both jurisdictions rely on undue influence and how thismay affect the outcome of individual cases; consider the impact that each model has on the goal ofpreserving the testamentary autonomy of elders and suggest which approach is more desirable; determinewhich model (if any) has been applied in two other common law jurisdictions, namely Australia andCanada; finally, this paper will examine how effectively testamentary undue influence has been applied inelder cases in these jurisdictions.57.3. Responding to the Financial Abuse of Older People with Impaired Capacity: theChallenges for Guardianship and Administration TribunalsCheryl Tilse, University of Queensland (C.Tilse@social.uq.edu.au)Financial abuse of older people is an area of increasing concern as a result of the extent and nature of olderpeople’s assets and increasing longevity which brings with it a higher risk of impairment in cognitivecapacity. Evidence from research and practice suggests that financial abuse is under reported as a result ofattitudes towards the use of older people’s assets, older people’s unwillingness to disrupt familyrelationships and practitioners’ concerns that interventions may not be in the best interests of the olderperson. Legal provision in Australia to protect older people with impaired decision making capacity fromsuch abuse includes: enduring power of attorney legislation, guardianship/administration legislation andguardianship and administration tribunals. There is no provision for mandatory reporting of elder abuse. Insuch conditions, it is particularly important to understand who reports financial abuse of older people withimpaired capacity to appropriate tribunals, the circumstances under which abuse is reported and theinterventions that result. This paper reports on a research program exploring the management of olderpeople’s assets. It focuses on a systematic analysis of cases coming to the attention of a State Guardianshipand Administration Tribunal in 2002-2003 in order to explore how and why cases of financial abuse cometo the attention of legal institutions and what decisions are made as a result. It concludes that legalframeworks and institutions have an important but limited role in protecting older people with impaireddecision making capacity in the area of financial abuse.57.4. Grappling with the Gray Zone: Creative Legal Tools for Partial IncapacityKate Mewhinney, Wake Forest University (mewhinka@law.wfu.edu)This presentation will assess the legal tools being developed in different countries to address partial mentalincapacity among the elderly. How can laws best provide for mildly impaired elders to select someone tohelp with financial decisions?Using a comparative law approach, we will focus on concerns such as supervision of surrogates, options forthe mildly impaired older person, and simplicity of court procedures. For example, the U.S. modelprovides for a “power of attorney”. Generally, this person acts without supervision. Would this approachbe improved by the requirement of a monitor or by registration with a court? Will impaired elders takeadvantage of court procedures, if they are given a more active role in financial decisions? Japan, withexploding numbers of elderly, offers a partnership model, in recent reforms of its guardianship laws. Italy,another country with very high percentages of elderly, has modified its guardianship laws to offer moreoptions for the mildly impaired person.

172The 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. Theyalso help to keep the impaired person involved in decision-making, while still protecting the person fromexploitation. In addition, they are easier for courts and litigants to handle.58. Elder Law: II58.1. Principle Without Elder Policy: Are Lower Courts in Australia Taking the AgedSeriously?Fiona Burns, University of Sydney (fionab@law.usyd.edu au)The centrality of free, open and voluntary transactions in common law jurisdictions has been anoverarching principle which has underpinned the judicial consideration of contracts, sales and gifts madeby competent adults. In Australia, appellate courts have recognised that although an adult may exhibitsufficient competence to enter into a transaction, his or her freedom of action may be severelycompromised by a variety of external pressures such as: coercion, manipulation, duress, undue influence,misrepresentation and unconscientious advantage-taking. Accordingly, a number of legal principles havebeen adopted from the English common law and refined by the Australian High Court to address suchinappropriate conduct. Nevertheless, this paper challenges the assumption that there has been a consistentand systematic approach to protecting vulnerable persons, such as elders, who enter into a contract or makea gift. From the perspective of the elderly claimant, there are two significant problems with the presentregulatory framework which will be explored in this paper in the context of unconscionable dealing andundue influence; such principles have been framed to address a particular kind of conduct generally, ratherthan to protect vulnerable elders specifically. Therefore, the law has not conferred upon elders a specialstatus at either the pre-transactional or enforcement stages. The lower courts, in which most claims aremade, have remained reluctant to set aside such transactions, and have applied principles in a rigid andmechanical fashion. Reasons for this trend include: the over-emphasis on the apparent intention of the elderto enter into the transaction; a lack of appreciation of the effects of aging, the circumstances in which theaged find themselves and the potential of financial exploitation; the focus on the process of transactingrather than the ultimate outcome. Therefore in this paper it will be contended that there is an urgent need tounite legal principle and elder policy to protect vulnerable elders. Suggestions on how the legal needs ofelders could be addressed will be posited.

17358.2. Guardianship Laws for the Elderly in JapanFusako Seki, Yokohama National University (seki@iblaw.ynu.ac.jp)Japan has only recently managed to establish Guardianship Laws for the elderly. The so-called “AdultGuardianship Law (AGL)” was legislated with the revision of Civil Code and enactment of other laws in1999. AGL updated the old guardianship laws; in particular it adjusted the laws concerning cases whereelderly people have lost mental capacity.AGL was instituted in accordance with the enactment of Long-term Care Insurance Law, whose systemwas based on the elderly contracting with care associated companies and institutions. In order to make acontract, the elderly have to be either mentally capable or supported by a guardian. Thus the legislationsought to solve many hurdles concerning different mental capacities among the elderly. Moreover, AGLwas established after studying many other countries’ guardianship laws. Thus the law was supposedly wellthought out, examining other countries experiences and problems. However, its enforcement is facing manyobstacles. 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 goodsupport-system networks between attorneys, health care workers and others. At the same time, contractsunder AGL need refining.This presentation will first give an outline of the new Guardianship law, since Japanese AGL - which isinteresting in that it was enacted as a result of comparative studies - has not yet gained internationalrecognition. Second, this presentation will analyze the complicated legal dilemmas associated with elderlymental capacity that the AGL confronts.58.3. Autonomy in Preserving and Passing on Wealth: Cross-Cultural Practices in Willsand Intervivos GiftsNathalie Martin, University of New Mexico School of Law (martin@law.unm.edu)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. Thispresentation will explore these differences in two contexts, testamentary autonomy and autonomy inmaking intervivos transfers.Testamentary FreedomTestamentary freedom can be limited by statutes, court decisions and public policy considerations. SomeEuropean nations have forced heirship doctrines, in which a certain portion of the estate must be left tochildren 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 adhereto testamentary freedom above all other considerations. Rather, many are more committed to ensuring thattestators 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 dutyof the testator, but require strict compliance when the testator’s wishes are non-conforming. Enforcement ofstated testamentary intent may be even less predictable when the decedent is female or from a culturalminority. Thus, in contrast to some European nations that have forced heirship rules, American law

174considers 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 thosenonconforming wills are invalidated and estates are distributed according to intestacy statutes that favorclose family relationships, the effect may not be much different from those nations that have forcedheirship.Apparent Freedom in Intervivos GiftingA person’s freedom to dispose of his or her assets as he or she wishes can also be limited by familymembers, attempting to take advantage of tax and public benefit laws that favour intervivos transfers. Forexample, most developed societies provide government-supported long-term care to at least some membersof society. Many countries provide this care based upon need (also called means testing), but this variesfrom place to place. The U.S. and U.K. spend down rules (as compared to those in places like Germany, forexample) create large incentives to transfer assets prior to death, which can further restrict the freedom andfuture choices of many elderly people.58.4. When Abusers Seek Guardianship: How Adult Protective Services andGuardianship Courts Can Work Together to Protect the ElderlyMarguerite Angelari, Loyola University at Chicago (mangel@luc.edu)Adult guardianship is a court process through which an individual loses virtually all of his rights and asubstitute decision maker is put in place to make all major decisions. The aging of our population has ledto a dramatic increase in the need for court ordered guardianships, which is severely straining court systemsin 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. Undersuch circumstances, it is not difficult for an abuser to become his victim's court appointed guardian andthereby obtain full legal control over his life. Elder abuse investigators can offer critical information onwhether proposed guardians may be exploiting their wards. Unfortunately, in Illinois, and throughout theUnited States, adult protection services agencies and guardianship courts operate independently of oneanother. Therefore, a judge conducting a guardianship proceeding and an investigator in an elder abusecase are unlikely to be aware that the two proceedings are occurring simultaneously. Furthermore, elderabuse investigators report that even when they become aware of the guardianship proceeding and appear incourt, they are often unable to present evidence of abuse at the guardianship hearing. As a result, they havestood by while alleged abusers have been appointed guardian. This paper presents the findings of aresearch project on the interaction between elder abuse investigations and guardianship cases. The studyincluded face-to-face interviews with elder abuse investigators about particular investigations followed by areview of corresponding guardianship court files. This paper documents the need for greater interactionbetween guardianship courts and adult protective services and offers recommendations for reform.58.5. From Elder Guardianship to Long Term Legal-CareIsrael Doron, Haifa University (idoron@univ.haifa.ac.il)Since the 1987 Associated Press report that found "[t]he nation's guardianship system, a crucial last line ofprotection for the ailing elderly, is failing many of those it is designed to protect," the legal landscape inthis field changed dramatically in the United States and many other Western countries. Law reform

175concerning guardianship swept these countries. Yet despite deep and extensive reform activity, debate anddisagreement 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" isa totally new path. Not just another wave of reform nor further attempts to educate or train, but rather atotally new model: the long-term legal-care model (LTLC). The key to the proposed model lies in anunderstanding that the challenge for guardianship is its transformation from a narrow substitute-decisionmakingmechanism into an integral part of community-based long-term care program.58.6. Self-Neglecting Elders: Is intervention by Protective Services for Adults anEthical Dilemma or Legal Obligation?Susan B. Somers, International Network for the Prevention of Elder Abuse, Nassau, USA(sbsomers5@aol.com)Self-Neglect occurs when older people refuse the help or care they need; for some, it is a symptom ofmental 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 selfneglect(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 behaviorto 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. 11No 2, 1999; Pies & Polpi, 1995, p 580).This presentation will focus on the practical aspects and integral roles of Protective Services for Adults andthe Mental Health Professional, in investigating self-neglecting elders, and in achieving protection throughthe least restrictive intervention. The factors of capacity (self-determination) and risk in determining theappropriate nature and level of intervention for the protection of at-risk populations will be evaluated. Thispresentation will discuss the guardianship process designed to protect the interests and well being ofvulnerable adults.59. Ethical and Psychological Reflections on Restorative JusticeI59.1. Trust and Power-distance: Implications for Restorative JusticeDiane Sivasubramaniam, University of New South Wales (dsivasubramaniam@psy.unsw.edu.au)Youth Justice Conferencing (YJC) is a Restorative Justice (RJ) procedure, operating in the Juvenile Justicesystem. Many studies examining YJC have found that conferencing increases participant satisfaction,

176compared 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 RJis working, and whether it is working differently for different people (Polk, 2002). Research involvingHofstede’s (1980) power-distance variable suggests that people who measure low on power-distanceemphasise procedural justice concerns in their fairness evaluations, whereas those who measure high onpower-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 culturalbackgrounds respond to mediation. This project investigates differences in the ways in which high and lowpower-distance participants determine fairness in a facilitative mediation, such as YJC. Conferencingprocesses 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 participantsevaluate that procedure. Based on evidence that young people of ethnic minorities often view the police asuntrustworthy, bias in this experiment was manipulated through the use of a police (bias) vs. civilian (nobias) convenor. Results are discussed in terms of their implications for procedural justice theory, for debateon RJ procedure, and for culturally-relevant police practices.59.2. Making Amends for WrongdoingAntony Duff, The University of Stirling (r.a.duff@stir.ac.uk)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, focuson 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 widercommunity. This then raises the question of what can count as ‘restoration’, or ‘repair’, in the aftermath ofcriminal wrongdoing.It seems natural to say that the wrongdoer should ‘make amends’ to those whom he has wronged (to thedirect victim, if there was one; to the wider community, if the wrong was a ‘public’ wrong); but how canamends be made? Apology is central to making amends, and I will focus on three questions about apologyin 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 ofsincerity 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 ofpunishment as giving forceful material form to the apology that the offender owes the victim and thecommunity.

60. Ethical and Psychological Reflections on Restorative Justice:II17760.1. Restorative Justice, Emotion and Therapeutic CultureGerry Johnstone, University of Hull (J.G.Johnstone@hull.ac.uk)One of the most significant recent developments in the sphere of crime, criminal justice and penal policyhas been the emergence of a complex of ideas and practices known as restorative justice. The pros and consof restorative justice as a feasible and effective form of crime control have been much debated. This paperforms 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’, asothers who have asked such questions tend to do, this paper relates the rise of restorative justice to a ratherdifferent 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 totherapy, as the dominant institution of regulation and social control. Whilst such a shift has often beencelebrated as ‘progress’, social theorists have been concerned to explore its darker side. Amongst the latestcontributions to this debate is Frank Furedi’s book Therapy Culture (London: Routledge 2004). Furediclaims that we now live in a society in which the challenges and misfortunes of everyday life are regularlyinterpreted as threats to our emotional well-being and hence as targets for therapeutic intervention. ForFuredi, this development is highly undesirable. This paper asks:To what extent can the emergence of restorative justice – with its emphases on the emotional consequencesof victimisation and on the need to heal the injuries of crime - be understood as an aspect of a broader riseof therapeutic culture?To the extent that restorative justice incorporates the assumptions of therapeutic culture, how does thisaffect our assessment of it?60.2. Doing Justice to Victims of ViolenceAlbin Daering, Legal Advisor, Vienna (office@weisser-ring.at)The presentation inquires into the functions of the criminal justice system (police, the public prosecutor’soffice 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 constructan account of this event/process• Experiencing justice• Social reintegration

1782) Police and the criminal justice system have to understand - and to adapt their interventions to - thesephases 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 andin 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 ofvictims and to the cooperation with victim support organizations.3) On the basis of recent Austrian reform projects related to domestic violence and trafficking of personsthe preconditions and the results of victim-centered approaches in policing and in shaping an adequateresponse of the criminal justice system’s response are explored.60.3. What Can Victims Reasonably Expect of State-sponsored Restorative Justice?Christopher Bennett, University of Sheffield (c.bennett@shef.ac.uk)The notion of restorative justice draws intuitive power from a certain conception of restoration as it ispracticed in non-institutional or informal interpersonal relationships. However, in this paper I argue that thestandards 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 adequacyof restoration in the non-institutional or purely informal case. I claim that it can be the case that offendersshould be regarded as restored even if they fail to co-operate with the restorative process or do soreluctantly. But taking this line requires changing what we expect (as opposed to hope) to come out ofstate-sponsored restorative justice. In particular, victims may have to revise their expectations of offenderswhen engaging in such a process, and be prepared to accept results that would be unacceptable in everydaylife. This may be a difficult shift to make. But I argue that it is important to make it, and that restorativejustice so understood can still be important for victims when compared with going through the courts.

17961. European Evaluation of Coercion in Psychiatry: LegalDimensions61.1. Involuntary Outpatient Treatment (IOT) of Persons with Mental Disorder – TheCurrent Legal Discussion Across EuropeGerhard Hegendörfer, Saxon Ministry for Social Affairs and Health, Berlin, Germany(g.hegendoerfer@arcor.de)In most mental health systems as well as in Europe there are persons with severe mental illness, mentaldisorder or alcohol and drug abuse problems who are prone to relapse after repeated hospitalisations orcontacts with the criminal justice system because of their persistent risk of harm to themselves or to otherpeople due to illness. Another group of mentally disordered people often have the disposition to selfdestructivebehaviour or the incapacity to realise the necessity of a medical intervention and therefore mayalso represent a significant danger for their life or health. Such individuals habitually fail to pass a medicalexamination or therapeutic treatment, worsening their condition. For both characteristics a furtherinvoluntary impatient commitment such as an admission or placement to a psychiatric hospital or facilitywould particularly imply conflicts with the patient's right of liberty and also question the legal principle ofproportionality. So many states discuss the Involuntary Outpatient Treatment (IOT) as an alternative tohospitalisation, and intent to improve that way the effectiveness of psychiatric therapy for involuntarypatients. Simultaneously they hope to tackle the increasing costs of psychiatric impatient services byproviding a decentralised psychiatric health system composed of private doctors and therapists and adaptedto compulsory forms of treatment.The presentation emphasises on legal questions of IOT with regard to European statutes and nationalregulations across Europe. It comprises a survey of European principles and standards on this issue like theoutcoming Recommendation of the Council of Europe concerning the protection of the human rights anddignity of persons with mental disorder (CDBI/INF 2004/5) and illustrates their impacts on nationallegislation. The following questions are supposed to be pointed out in particular: How should be the legalprerequisites for IOT? How has IOT been implemented in European states that currently use it and whichdifficulties do arise? How does a court order an individual to comply with a specific outpatient treatmentregimen? How will a treatment be implemented if the patient does not co-operate and refuses it by usingphysical force? Who should be vested with power to order and enforce coercive measures in those cases?61.2. Design of the EUNOMIA Project and Preliminary Cross-National Comparison ofSocio-Demographic and Clinical Characteristics of Legally Involuntarily andLegally Voluntarily Admitted Patients Who Feel Coerced to Hospital AdmissionThomas Kallert, Dresden University of Technology (thomas.kallert@mailbox.tu-dresden.de)Previous (mostly national) research has shown significant variation of different aspects of coercivetreatment measures. Therefore, clinical practise and outcome of these measures should be assessed at aninternational level facilitating cross-national comparisons.

180This is the general research objective of the EC-funded ongoing EUNOMIA-project whose naturalistic andepidemiological study design has been implemented in 12 regions in 12 European countries. Using astandardized battery of instruments (e.g. covering psychopathology, perceived coercion, satisfaction withtreatment, 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 afterhospital admission): legally involuntarily admitted patients (aimed at figure of complete cases in eachcentre: N=140) and legally voluntarily admitted patients who – according to a screening procedure – feelcoerced 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 recruitmentperiod (ca. 800 – 1000) patients and focus on the initial assessment of these patients (within the first weekafter 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 theparticipating catchment areas. In particular, consequences for the clinical practice of involuntary hospitaladmissions across Europe will be demonstrated.61.3. Legal and Cultural Aspects of Involuntary Psychiatric Treatment Regulation inPost-Totalitarian Milieu: The Bulgarian PerspectiveBoris Boyadjiev, National Center for Public Health, Sofia, BulgariaGeorgi Onchev, Sofia Medical University (georgeonchev@hotmail.com)The characteristics of the legal systems and social practices concerning involuntary psychiatric treatment inpost-totalitarian societies are reviewed from historical perspective, with delineation made between differentcountries from the post-Soviet space. Totalitarian law and its application were dominated by insensitivity topersonal rights, prejudices, and legal nihilism. Their impact on present changes in legal regulation ofmental health care, and involuntary treatment in particular, in Bulgaria, is analyzed. Cultural and legaldevelopments are far from being parallel, and totalitarian legacy in the area of patients’ rights and coercionin psychiatric treatment has been worked through in a milieu with transitional rules. The basic challengingturnabouts in such context concern more cultural issues rather than legislative ones. While legal changesnowadays could be best described as “forced normalization” (illustrated with Bulgarian legal traditions asan example), the major cultural shift in regards to human rights and health care impacts novel conceptualframes, e.g. autonomy vs paternalism, and high tolerance to insecurity vs fatalism that mobilize defencesand confusion. Culture, and de-culturation in times of transition for that matter, is the limiting factor forpractical implementation of law, and contributes to the demarcation between written law and applicablelaw. Key issues subject to current changing legislation, such as informed consent to treatment, legalcompetence, disability and guardianship, compulsory placement and treatment, as well as the promotingand are discussed in the context of a changing culture.

18161.4. Rules and Regulations for Involuntary Placement or Treatment of Mentally IllPersons - Results from a Structured Survey Instrument in 12 European Countries,and Results from a Quality Assurance Project on InvoluntaryPlacement/Treatment in PolandJoanna Rymaszewska, Wroclaw Medical University (ankarym@psych.am.wroc.pl)Stanisław Dąbrowski, Institute of Neurology and Psychiatry, Warsaw, PolandThe aim of the study was to gather and analyze information about differences and/or similarities of therules, regulations and practice for compulsory admission and involuntary treatment of mentally ill patientsacross the European countries.Evaluation of implementation of the Mental Health Act provisions concerning coercion in Poland will bealso presented. Data was collected by means of a detailed questionnaire by Salize et al. which was filled inby legal experts* of 12 European countries (Bulgaria, Czech, England, Germany, Greece, Israel, Italy,Latvia, Poland, Slovakia, Spain, Sweden). The questionnaire addressed four main areas: legislation,practice, patients’ rights and epidemiology. Quality assurance project on involuntary placement/treatmentin Poland was based on analyses of the data from Polish psychiatric hospitals: psychiatric opinions ofcoercive admissions and reports on physical restraint episodes.Only half of the assessed countries have the specific mental health act. A separate mental health actconcerning child and adolescent psychiatry exists in two countries. There were essential differences in legalcriteria 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. Few countries have epidemiological data oncoercion.Findings reflect rather heterogeneous attitude towards coercion in psychiatry within Europe. It should leadtowards discussion and harmonization in legal and everyday practice level.61.5. Main Differences in Legal Control Procedures Referred to Coercive TreatmentMeasures in Psychiatry – Comparing the Situation in 12 European CountriesFrancisco Torres-González, University of Granada (ftorres@ugr.es)The normative frame that regulates the use of coercive measures in psychiatry has been directly influencedby 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 regionalmodels); and c) the different historical development of this normative framework dealing with issues ofmental health care.According to the main international treaties on the matter, in particular the Universal Declaration of humanrights, the European Agreement of human rights and the Agreement of Oviedo, all legislations consider twomain 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 acrossEuropean countries. The majority clearly defines the circumstances for non-voluntary admission (Belgium,Germany, Greece, Slovakia, Poland, Sweden, Israel, Italy). However, this is not the case in Spain, wherethere is only a reference to the lack of self-control. The procedures of involuntary ordinary admissioncorrespond basically to the following models: a) medical; b) administrative or judicial according to the

182circumstances (Germany), or administrative, with a-posteriori judicial control; c) pure judicial model,which corresponds to Spain; and 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 theadministrative authority or by the doctor, and followed by judicial ratification.Standards for the use of coercive measures have been developed in some countries. Particularly, thesemeasures refer 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, ingeneral 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 thateverybody has an autonomy that should be protected); and c) the one executed by the HealthAdministration. There are countries in which several control procedures are established although theyclearly lack rigor and efficacy.62. Falun Gong62.1. Falun Gong: The Real StoryErping Zhang, Association for Asian Research, New York, USA (erping_zhang@ksg05.harvard.edu)Falun Gong has become an international phenomenon. As a traditional Chinese meditation system, it isnow legally practiced in over 60 countries around the world, except in Mainland China. Like other faithgroups such as Tibetan Buddhism and underground Christians in China, Falun Gong, rooted in Buddhistprinciples of “Truthfulness, Compassion, Forbearance”, has become another victim of the atheistCommunist Party since 1999 when the campaign of persecution started. Ironically, Falun Gong waspromoted by the government of China between 1992 and 1999 and was touted for its health benefits andmoral contributions.My presentation, through the visual aids of power-point slides, will help answer some of the frequentlyaskedquestions 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 changeits mind and is now persecuting it? What is the current situation of Falun Gong in and out of China? Andhow 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 religionsand/or spiritual disciplines since 1949.

18362.2. Abuse of Psychiatry, Psychological Torture, PTSD and Genocide of Falun GongPractitioners in China, 1999-2005Viviana Galli, China Mental Health Watch, Hyde Park, USA (Vg10@hushmail.com)Sunny Lu, China Mental Health Watch, Hyde Park, USA (Lusy@mail.uc.edu)The systematic persecution launched by the former Chinese leader, Jiang Zemin, in July 1999, has usedover 100 methods of torture. This persecution, unlike many others in history, is aimed directly andindirectly at the human mind. It aims to extinguish belief in Falun Gong and violates the very basic humanrights of freedom of thought and belief. This not only affects Falun Gong practitioners (about 100,000,000in China) and their families, but also affects those who execute the orders of persecution. It includes alllevels 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 moralconscience of millions has also been affected.This persecution is also causing a large number of psychiatric casualties. We have been collectingevidence through face-to-face interviews with the victims of labor camps and brainwashing classes as wellas family members who lost their loved ones through the persecution. According to preliminaryinvestigations, there are a large number of Post Traumatic Stress Disorder cases, even some left completelyincapacitated, due to physical and mental torture in labor camps and “re-education” centers. Otherpsychiatric sequelae such as insanity due to torture, major depression, grief and loss, have occurred whichcomplicate the issue of psychiatric commitment. Disrupted families, loss of livelihood, long hours offorced 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 Gongpractitioners, 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 isunprecedented in terms of the number of victims, hospitals involved, the brutality of methods used and theseverity of the consequences. According to incomplete data, over 1000 healthy Falun Gong practitionershave been involuntarily admitted to mental institutions, many of whom were forcibly injected with highdoses of psychotropic drugs. Some have been subjected to electro-shock and others have been tied up andforce-fed for long periods of time.The Chinese authorities extensively use “brainwashing” as a form of torture. Such practices entailintimidation, threats of terror, forced repetition of detailed information, and deprivation of sleep and foodsometimes with the use of loud high pitched sounds for long periods of time. Physical torture such asbeatings, 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 thispsychological chaos, and a mental breakdown soon follows. Under these circumstances some victims thendenounce Falun Gong and sign documents known as “repentance statements” against their own will only toavoid further torture. This forced “transformation” inflicts long term anguish, and emotional pain leavinginvisible scars.62.3. Social Control in the People’s Republic of ChinaChu-Cheng Ming, National Taiwan University (jz.ming@msa.hinet.net)Since the emergence of human politics, effective social control has been the central concern ofgovernments. In the Western tradition, the Kings relied on religion, morality, law and eventually violence

184to achieve this goal. In Imperial China, however, the emphasis was placed more upon moral education, lawand violence. Religion, in contrast to the West, played a secondary role.After 1949, as the Chinese Communist Party (CCP) claims to be atheistic, they now completely dismiss therole of religion, relying on the use of violence, political movements and law to maintain social order in thePeople’s Republic of China (PRC). In addition, propaganda is also heavily used as an importantsupplementary tool.For people lacking the experience of living in a totalitarian society, it is very difficult to imagine, the CCPconstantly launching 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-RightistMovement, Great Leap Forward Movement, Four-Cleaning Movement, Cultural Revolutionary Movement,Criticism of Lin Biao and Confucianism Movement, and the Revelation and Criticism of the Gang of FourMovement, etc. In these movements, harsh criticism, organizational and group pressure, and publichumiliation are commonly used methods of exercising psychological control. In some movements, the CCPresort 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 monopolizedby the state, the PRC can easily denounce a single person, a group (political or non-political), a class, orany 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, quickly fall victim to the propaganda. What follows for thevictims is totally reliant on the mercy of the CCP.It is worthy noting that despite adopting the policy of comprehensive reforms, the CCP’s methods ofexercising social control has not changed very much. The 1989 Tiananmen Massacre and their effort toeradicate Falun Gong serve as two prominent examples.The core argument of this paper is that the CCP is excessively power-sensitive. It tends to view events,people and other organizations through the lens of political power, and it is too suspicious of others, whichalmost leads to the aforementioned phenomena inevitably. Until the CCP change their mentality to suitpolitical changes at large, it is difficult to imagine substantial changes in the nature of society.62.4. Justice Against Crime of GenocideTheresa Chu, International Advocates For Justice, New York, USA (Theresa.chu@4new.org)Since Jiang Zemin, the former leader of China and the former chairman of the Chinese Communist MilitaryCommittee, publicly announced, 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 Gonggroup. 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 Internationalverify that China’s rule of law has already become a tool in Jiang’s hands to persecute the Falun Gonggroup; at present, the practitioners of Falun Gong cannot obtain any fair and just trial under Chinese law.To eliminate the Falun Gong group, who believe in “Truthfulness, Compassion, and Forbearance”, Jiangexhausted huge amounts of the nation’s resources and established the state-run “Leading Office Handlingthe Issue of Falun Gong”, which is also known as the “610 Office”. They murder, torture, brainwash, andeven have the media controlled by Jiang in order to frame, fabricate, defame, smear and instigate thepublic’s hatred against Falun Gong. What Jiang and the Chinese government have done has caused thedeaths, 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 ateliminating Falun Gong. Even though many enjoy the legal protection of the democratic countries, many of

185the Falun Gong practitioners in each area have suffered various degrees of threats and injuries to theirfreedom and rights because of the enforcement of Jiang’s genocidal persecution.At this time, there are more than 30 lawyers from 29 countries (including, but not limited to the US,Canada, Germany, Spain, Belgium, Greece, Austria, Russia, Portland, France, Finland, Taiwan, Korea,Australia, New Zealand, and Bolivia etc) assisting Falun Gong practitioners worldwide in suing JiangZemin, former Beijing Mayor, former Education Minister, Culture Minister, Minister of Commerce,Minister of Information etc for genocide, crimes against humanity, torture, and other serious internationalcrimes. Since WWII, Falun Gong’s case is known as the biggest international legal effort in times ofpeace.The Taiwan Falun Gong practitioners’ experiences can be used to explain a link in Jiang’s initiation of aglobal persecution in the 21 st century. Through this, I hope to urge 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, and those organizations and individuals who promotepeace for humankind and ensure international human rights, to reflect and reconsider all provisionsregarding “Genocide” in the Convention and the Rome Statute. The international community has to facethe severity of Jiang’s genocidal persecution of Falun Gong and to bring Jiang to justice internationally, inorder to end the largest human rights farce of the Chinese community in the early 21 st century.

18663. Family Therapy in Assessment and Treatment63.1. Shared Care: What Does It Mean and How Does It Work?Evelyn Vingilis, University of Western Ontario (evingili@uwo.ca)Jann Paquette-Warren, University of Western OntarioAnne Marie Crustolo, St. Joseph’s Hospital, Hamilton, CanadaNick Kates, St. Joseph’s Hospital, Hamilton, CanadaJaimi Greenslade, University of Western OntarioSharon Newnam, University of Western Ontario“Shared care” involves the collaboration among professionals with various expertise to provide the mostappropriate primary care-based treatment for patients with a variety of mental health problems andconsequences ranging from psychosis to addiction to legal issues to family problems, to name just a few.Key elements of shared care and multiple team approaches have been described; however the nature ofshared care and the responsibilities of providers within such programs are unclear. A shared care programincluding 38 family medical centres has been in existence in the Canadian city of Hamilton since 1994.This presentation will provide the results of a process evaluation to determine if the program is beingdelivered as intended and whether program objectives are being met. A full process evaluation begins witha detailed description of the program via the development of program logic models. The short,intermediate, and longer term objectives from the logic models identify the indicators by which todetermine whether or not program objectives are being met. Both quantitative and qualitative data werecollected to assess program fidelity to its objectives. The quantitative data showed that a wide range ofpatients are being assessed/treated in primary care, as well as referred among team members. Also, thequalitative data demonstrated extensive collaboration and education opportunities for providers andpatients, and elaborate involvement of the central management team and providers in program qualityimprovement. The program logic models and evaluation results highlight the complexity of shared careprograms and the important role they play in improving access to a variety of services.63.2. Multisystemic Treatment (MST) of Serious Behavior Problems in Youth – A TwoYear Follow up Study of Clinical OutcomesTerje Ogden, The Norwegian Center for Studies on Conduct Problems and Innovative Practice, Oslo,Norway (ogden@online.no)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 in reducing outof-homeplacements 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 multisiterandomized controlled outcome study (RCT) are presented. Participants in the RCT were 100 seriouslyantisocial youths in Norway who were randomly assigned MST or usual Child Welfare Services (CS)treatment conditions. Data was gathered from youths, parents, and teachers before and after treatment. Prepostresults showed that MST was more effective than CS at reducing youth internalising and externalising

187behaviours and out-of-home placements, as well as increasing youth social competence and familysatisfaction with treatment. Site effects were registered and the treatment results covaried with differencesin treatment adherence at the four sites. The sites with the highest Treatment Adherence Measure Scores(TAMS) were also recorded as producing the best treatment results. Furthermore, the sustainability of theclinical outcomes were documented at three out of four sites in a follow up study two years after intake.63.3. The Effectiveness of Functional Family Therapy with Violent and OffendingAdolescentsThomas L. Sexton, Center for Adolescent & Family Studies, Bloomington, USA (thsexton@indiana.edu)Violent and behavior disordered youth are among the most prevalent in justice systems across countries andcultures. 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 ofoutcome and process research studies spanning over three decades. These results have lead the UnitedStates Center for Substance Abuse Prevention (CSAP, 1999), the Office of Juvenile Justice andDelinquency Prevention (OJJDP), and the Surgeon General’s Report (U.S. Public Health Service, 2001) toidentify FFT as a “model” program for both substance abuse delinquency and violence prevention. Thecumulative data suggests that FFT is effective on two critical fronts. First, the results indicated that FFTwas in engaging and retaining families in treatment. Engagement rates in FFT studies range from 78% to89.8%. This outcome is fairly dramatic given the traditionally high rates of drop-out (50-75%) in mosttreatment 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 probationservices (Alexander, et al., 2000). These positive outcomes of FFT remain relatively stable even at followuptimes as long as five years and the positive impact also affects siblings of the identified adolescent. Inaddition, it appears that FFT not only results in significantly lower recidivism rates, but if the adolescentrecidivated at all, they committed significantly fewer severe crimes, even when pre-treatment crime historywas factored into the analysis.This presentation will briefly describe the FFT model, the specific research data regarding the effectivenessof FFT, and the application of FFT in various cultures and populations.63.4. Engaging with Families in the Adolescent Forensic Service. Issues Raised in theAssessment and Treatment of Young PeopleBeverley Stowell, Salford & Trafford Mental Health NHS Trust, Manchester, England(Bstowell@gardener.bstmht.nhs.uk)Lynn Aulich, Bolton, Salford & Trafford Mental Health NHS Trust, Manchester, EnglandWe know that young people with mental disorders and offending behaviour do not live in well functioningsupportive families. Many of the young people we assess and treat no longer live with their families andoften have infrequent sporadic contact with them. Whereas for young people who do live with or havesignificant contact with their families it is often difficult to work with and engage family members in theprocess of assessment or support of their children’s treatment. It is even more challenging to engage parentsin family work or to offer supportive interventions.

188The presentation will discuss some of the psychodynamic factors at work in the relationship between theservice and the families whose children we assess and treat. The young people and their families can beequally difficult to engage and manage. Taking these factors into account we are developing a strategy ofintervention that is based on building up trust, being non-judgmental, managing hostile and dependentfeelings and fostering a sense of confidence and capability.The talk is based on clinical experience. From assessments we will draw on case material including kineticfamily 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 offamilies our young patients bring with them, that the established traditional methods of psychodynamicinterventions in families will not apply. We will discuss some of the cases in which we saw a chance forintervention but did not have the means to offer one and how this has led us to think about how to extendour service to families in a form they can use.63.5. Functional Family Therapy in a Day Treatment Protocol Treating JuvenileDelinquents: Results of a Pilot StudyRene E.Breuk, The Bascule, Amsterdam (r.e.breuk@planet.nl)Functional family therapy (FFT) is ‘a family-based empirically supported treatment for adolescentbehaviour problems’ (Alexander, & Sexton, 2002; Sexton & Alexander, 2003). FFT was well founded inoutcome research with over fourteen published clinical trial studies, comparison group studies andevaluation results, which suggest that when implemented properly FFT has favourable outcomes inreducing 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 lessnegativity 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 forjuvenile delinquents with psychiatric disorders.To collect data concerning the treatment, effect-questionnaires were filled in by parents and children beforetreatment (baseline), directly after both the engagement motivation phase, after the behaviour change phaseand after finishing functional family therapy. The diagnostic assessment consisted of the QuestionnaireFamily Problems (Vragenlijst Gezins Problemen) (VGP, Koot, 1997) and the Parent Child InteractionQuestionnaire (Ouder Kind Interactie Vragenlijst) (OKIV, Lange, Blonk, et al, 1997), both Dutchquestionnaires based on the Family Assessment Measure (Steinhauser). Also FFT adherence andcompetence measures were taken.Results of the pilot study of 10 families are presented.

18963.6. Applying Family Therapy to People Found Not Criminally Responsible onAccount of Mental Disorder: Rebuilding Networks to Ensure SuccessfulCommunity ReintegrationSergio Santana, University of Alberta (sergio.santana@amhb.ab.ca)Family therapy is an increasingly influential therapeutic discipline. However, its application to psychiatryin general and forensic psychiatry in particular has been fraught with difficulties. Indeed, in spite of theevidence of its therapeutic potential and the emphasis of governments and psychiatric organizations on thecooperation of professional and non-professional carers, family based treatments are rarely used in adultmental health.In this presentation the difficulties faced by people who have been found not criminally responsible (NCR)on account of mental disorder are discussed in regards to coming to terms with their crimes andsuccessfully returning to society, and how family based treatment have improved the treatment of thesepatients.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 facilitatedtheir treatment and enabled a successful community reintegration. If left unresolved, the psychological andemotional connotations of their crimes hindered not only the treatment of the individual patient but also thewell-being of the family system as a whole. However if the conflict and alienation caused by theperpetrators 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 familymembers, thus rebuilding a network of support, which in turn facilitated their treatment and promoted asuccessful community reintegration.Concepts derived from the work with these families and how family therapy interventions were used toimprove both community reintegration and community tenure will be discussed.64. Female Juvenile Offenders: A Unique Challenge for Law andMental Health Collaboration64.1. Female Juvenile Offenders: Gender specific patterns and challengesGeorgia B. Calhoun, University of Georgia (gcalhoun@uga.edu)Research in the field of juvenile justice has only recently begun to conceptualize female delinquencyindependently from male delinquency. The prevailing thought has been that similarities exist within thepath and trajectory of offending patterns for both male and female juvenile offenders. Male criminalbehavior has historically been attributed to such psychosocial factors as peer influence, sociopoliticalinfluences, occupational and labor market factors. In contrast, female criminal behavior has historicallybeen attributed to personal maladjustment issues. Programming and treatment for female juvenile offenders

190emanated from research that was based largely on male samples and the results generalized to females whoneeded intervention. This presentation will review the current research regarding female juvenile offendersand will provide an overview of the unique needs and challenges associated with this population.64.2. Female Juvenile Offenders: Working from a University-based projectBrian A. Glaser, University of Georgia (gcalhoun@uga.edu)This presentation will present and discuss the development of a model of intervention for female juvenileoffenders based on the integration of an etiological understanding, service delivery, student training anddata 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 Juvenilecourt, the State Department of Juvenile Justice, a large Research University, and the community. Using thisintegrated research, training, and service model, the GIRLS Project draws together services, research andtraining in a collaborative and facilitative manner to meet the needs of female juvenile offenders. Themodel of intervention allows emerging professionals to learn an effective, empirically based method ofserving a therapeutically challenging population while delivering quality services to young offendingfemales in collaboration with community agencies.64.3. Female Juvenile Offenders: The Critical Role of the Probation OfficerTres Stefurak, Auburn University at Montgomery (gcalhoun@uga.edu)Recent research findings suggest that relationships with significant adult figures can serve as a protectivefactor for the female juvenile offender. While researchers and clinicians have frequently focused theirattention on the importance of the family, school, and personality variables of the juvenile offender, littleattention has been paid to the critical role of the probation officer. This presentation will focus on the roleof the probation officer and the need to provide these professionals with relevant training in the genderspecific needs of female juvenile offenders.64.4. Female Juvenile Offenders: A View From the BenchJames McDonald, Clarke County Juvenile Court, Athens, Georgia (gcalhoun@uga.edu)This presentation will offer a perspective of female juvenile offending from the bench of a juvenile courtjudge. 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 willbe discussed. The judge, who has served on the bench for more than 20 years, will also discuss thechallenges and concerns related to equity and justice as specifically related to gender.

19164.5. Female Juvenile Offenders: Trends and ThemesRobin Shearer, Clarke County Juvenile Court, Athens, Georgia (gcalhoun@uga.edu)Gender has traditionally been one of the strongest correlates of delinquent behavior. Whereas males stillaccount for the majority of crimes committed among those under the age of 17, females are now the fastestgrowing segment of the juvenile justice system. Over the past two decades there has been an exponentialrise in the number of girls in detention facilities, jails and prisons. Delinquency cases involving girlsincreased by 83% between 1988 and 1997 and female juvenile violent offences increased 129% between1981 and 1995, more than doubling the increase of male juvenile violent offences. By 1999 girls accountedfor 27% of the total juvenile arrests made that year. This presentation by the court administrator willprovide an overview of trends seen in a local juvenile court, specifically as they relate to the rise in femalejuvenile delinquency.65. Forensic Evaluation in an International Perspective65.1. Forensic Assessment in Brazilian InstitutionsDr.L Telles, Psychoanalytical Society of Porto Alegre, Brazil (sppa@sppa.org.br)A transversal and descriptive study was implemented in order to evaluate the mental disease prevalence andalso to describe sociodemographical, pathological and criminal variations of a group of defendants whowere submitted to the Penal Responsibility exam. This study was performed in a Brazilian psychiatricforensic institution. The profile of those who were examined was: white, single men from the countrysidewith low education levels. The most frequent criminal act was the physical one. The most prevalentdiagnosis was the disturbance caused by the use of alcohol and other substances and remarkable differenceswere found between the categories of guilty, diminished responsibility and not guilty by reason of insanity.Three associations were observed through logistical regression: the probability of being considered notguilty by reason of insanity increased 2.5 times when there was no preceding crime, having an occupationdecreased the probability of being considered not guilty by reason of insanity, and that the crimes against aperson are more related to not being guilty by reason of insanity than are the crimes against property andcustoms.

19265.2. Routine Assessment of Needs and Outcome in Forensic Psychiatric HomeTreatmentRob van den Brink, University Medical Center Groningen, The Netherlands(R.H.S.van.den.Brink@med.umcg.nl)Alex HooijschuurMarkwin JetzesDurk WiersmaForensic Psychiatric Home Treatment (FPHT) is a relatively new form of treatment, intended for FPpatients in need of support in building up or maintaining an independent and safe existence in thecommunity. 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 thepatient’s home situation, in which new aspects of the patient’s functioning may be observed. By this, FPHToffers 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 onpatient functioning, designed for use in routine practice. It is a widely advocated strategy in general mentalhealth care, that is however, as of yet unsupported by robust evidence of clinical or cost effectiveness(Cochrane Review; Gilbody et al., 2005). We are currently involved in a randomized clinical trialconducted in six European countries that evaluates the effectiveness of routine assessment of needs andoutcome in community care for patients with severe psychosis. The FPHT study, to be presented here, is apilot project of routine assessment of needs and outcome in outpatient forensic mental health care. Routinemeasures of needs and outcome included in this study are: the Camberwell Assessment of Need - ForensicVersion (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 ofthe HCR-20). Data will be presented on: the FPHT patient population, the needs of FPHT patients, the careprovided to them, and outcome in terms of patient functioning, assessed risk and incidents.65.3. A Follow-Up Study on Disposition of Post-Psychiatric Assessment for 171Mentally ill Offenders in Hunan, ChinaXiaoping Wang, The 2 nd Xiangya Hospital of Central South University, Hunan, China(Xiaop6@yahoo.com.cn, xiaop@public.cs.hn.cn)The purpose of this study is to follow-up the disposition of mentally ill offenders after undergoingpsychiatric assessment. 240 criminal cases that include psychiatric evaluation in our department from Jan.2001 to Dec. 2002 are included in this study. A self-developed questionnaire was mailed to all thesepatient’s family members to investigate the disposition of these patients. The results showed that 171 letterswere received and the reply rate was 71.3%. The forensic psychiatrists in the hospital judged 109 cases asbeing not criminal responsible, 28 cases were deemed as diminished responsibility and 34 cases wereconsidered to be full responsibility. Further, 110 cases were judged not guilty, and 61 were judged as guiltyby judges in court trials. The total consistence rate between psychiatrists’ opinion of criminal responsibilityand 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 forensicpsychiatric hospital for treatment, and one of them (0.9%) received the psychiatric treatment in outpatientdepartment. 68 of them (61.8%) received an absolute discharge to their communities without any

193psychiatric treatment. The authors concluded that in most cases the judges agree with the psychiatrists’opinion of criminal responsibility. The disposition of mentally ill offenders required urgent improvement inHunan, China.65.4. Issues of Safety in Forensic Psychiatry Services In TurkeyÖzge Canbek, Bakırköy State Hospital for Psychiatric and Neurological Diseases, Istanbul, Turkey(ozgecanbek1@yahoo.com)Detainment of the dangerous criminal patients, as well as their treatment, is very important for the safetyand sensitivity of the community. In developed countries, the detainment and treatment of dangerouspatients in special hospitals (high security hospitals), with the security system taking precedence overmedical treatment, is criticized by some. The rate of patient absconding from high security hospitals in theU.K. is

19465.5. Progressive Discharge: a Brazilian Experience of FreedomLuiz Carlos Illafont Coronel, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre(coronel@pro.via-rs.com.br)The present paper reports a 35-year experience of a forensic psychiatric program called progressivedischarge, 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 agoand treats around 800 inpatients (90% male and 10% female) who have committed or attempted to commitmurder (in 75% of the cases). Until the adoption of progressive discharge, the judicial enforcement of asecurity measure was, in fact, translated into a life sentence. After progressive discharge was set up, theannual rate of discharges went up from 8-9% to 25%. The number of discharges in these 35 years isreported herein and compared to variables such as relapse, clinical diagnosis, and forensic treatment. It isconcluded that the program was proven to be so successful that it has since been recognized in other placesin the country, as well as by the Brazilian Penal Code.66. Forensic Evidence in Criminal Trials I66.1. Take it from an Expert: Authority and Hearsay in Psychiatric and PsychologicalEvidenceTony Ward, University of Hull (A.Ward@hull.ac.uk)The reluctance of English judges to admit psychological evidence about ‘normal’ people reflects an anxietythat experts will assume undue authority and usurp the role of the jury. Such concerns are largelymisplaced. Unlike many other kinds of expert witnesses, psychologists often draw inferences which juriescan evaluate for themselves, or bring to the jury’s attention points which they may wish to consider indrawing their own inferences from the evidence of other witnesses. There is, typically, relatively little needfor the jury to accept their evidence merely on the basis of authority: i.e. to assume that the inferences theexpert draws are sound even though the jury cannot evaluate the reasons for them. Judges themselves usurpthe role of the jury when they appeal to ‘common sense’ to exclude evidence that juries might reasonablyfind helpful.However, the very fact that juries can draw their own inferences from the factual evidence relied on bypsychologists or psychiatrists raises serious concerns about the quality of that evidence, particularly when itcomprises hearsay evidence which may have been selectively gathered or relayed by the expert. Under theCriminal Justice Act 2003, hearsay evidence about the facts of the case, as opposed to evidence of generalknowledge in the expert’s field, should (unless all parties agree to admit it) be evaluated according to thesame criteria as other forms of hearsay evidence. These criteria provide a basis for addressing the legitimateconcerns raised by the evidence adduced in some of the leading English cases.

19566.2. Judicial Decision Making About Mental Health Evidence: Current Knowledgeand Implications for Forensic PracticeRichard E. Redding, Villanova University (redding@law.villanova.edu)The presentation will provide an overview of the current state of research and knowledge on thepsychology of judicial decision making with respect to the admissibility, relevance, and dispositive weightof psychological and psychiatric evidence introduced in trial and appellate cases in Americanjurisprudence. Empirical and theoretical research will be reviewed and future directions identified forresearch 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, JudicialDecision Making on Criminal Forensic Issues, and Judicial Decision Making on Civil Forensic Issues. Forexample, research indicates that in trial court cases, judges favor evidence about clinical diagnosis andultimate 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 correctlyapply (or to apply at all) the Daubert criteria for the admissibility of scientific evidence. Thus, the litigantsthemselves must effectively educate -- through their advocacy -- judges on how to apply Daubert to theparticular case. The focus throughout will be on these and other practical implications for how mentalhealth professionals can best present evidence to the courts and best influence legal decisions at both thetrial and appellate court levels.66.3. Assessing the Impact of Eyewitness Guessing and Lineup Bias on EyewitnessPerformanceSteven Penrod, John Jay College of Criminal Justices (penrod@jjay.cuny.edu)Lisette Garcia, John Jay College of Criminal Justice (ligarcia@jjay.cuny.edu)Rommel Robertson, City University of New York (RRobertson@gc.cuny.edu)A recently published study (Behrman & Davey, 2001) of actual police records relating to 58 attemptedlineup 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 onethirdof 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 somewitnesses 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 aperpetrator 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 selectedthrough guessing. In a perfectly fair six-person lineup (where, for example, the 24% foil guesses notedabove, are distributed across five foils; an average of nearly 5% each) we would expect 5% of witnesses toguess 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 againstsuspects, 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 witnessidentifications of lineup bias in target-present and target-absent arrays, witness guessing, and the mixture oftarget-present and target-absent lineups presented to witnesses, 2. the implications of ignoring guessing in

196experimental research, 3. a model of witness choosing that takes into account witness guessing to provide amore complete picture of witness performance in lineup situations, and 4. implications for police andjudicial practice.66.4. Empirical Observations of the Formation of False MemoriesLena Hellblom Sjogren, Psychological Consultant, Fagersta, Sweden (mail@testimonia.se)False memories formatted in the process to help children and adults to tell and to remember about abuse arefocused with examples taken from criminal and custody cases investigated by me. An eagerness to help canexplain why investigating police and other professionals develop tunnel viewing and put suggestivequestions resulting in confirmation bias, though not often identified as sources of error with seriousconsequences for the alleged victims of abuse. The difficulties to erase false memories are discussed inconnection with the concept of deprogramming as a way to help a child who has developed a ParentalAlienation Syndrome, partly because of false memories.67. Forensic Evidence in Criminal Trials II67.1. Expert Psychological Evidence in English Criminal Courts: An Under-usedResource?James McGuire, University of Liverpool (merc@liv.ac.uk)The admissibility of expert psychological evidence in court has been a topic of extensive interest amongstboth lawyers and psychologists in several countries. In numerous studies and commentaries, authors havedelineated several key elements of this, focusing on a wide range of issues including evaluation of witnessaccuracy, 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. Thegreatest headway in establishing the value of psychologists’ evidence has been made with respect to falseconfessions and miscarriages of justice, and in assessment of vulnerable witnesses. A search of legaldatabases yielded very few cases that showed psychologists providing evidence beyond their traditionallyperceived role in ‘mental testing’. In the present paper, this state of affairs will be examined. Discussionwill focus on the extent to which it is attributable to the pervasive effects of the Turner Rule in Englishcourts. The paper will consider whether, on the basis of recent scientific advances, an increased use ofpsychological evidence could be advantageous in making legal decisions.

19767.2. A Critical Examination of the Court of Appeal’s Decision in R v Gilfoyle [2001] 2Cr.App.R.57Faye Boland, University of Liverpool (fblaw@liverpool.ac.uk)Traditionally, admissibility decisions in the United Kingdom have required scant attention to the reliabilityof evidence tendered in criminal trials. Rather, decisions on the admissibility of evidence have focused onthe expert’s qualifications or experience (R v Robb (1991) 93 Cr.App.R.161) and on whether the profferedevidence is likely to be outside the experience and knowledge of a judge or jury (R v Turner [1975] QB834). However, Davie v Edinburgh Magistrates 1953 S.C.34 provided that expert witnesses must furnishthe court “with the necessary scientific criteria for testing the accuracy of their conclusions, so as to enablethe judge or jury to form their own independent judgment by the application of these criteria to the factsproved in evidence.”In R v Gilfoyle [2001] 2 Cr.App.R.5 the Court of Appeal declined to receive evidence of a psychologicalautopsy offered by a distinguished psychologist. The basis of its’ decision was the absence of any literatureor body of knowledge or experiments by reference to which the Court could test the methodology or theexpert’s particular application of it. The Court of Appeal held that psychological autopsies were notrecognised as having any real scientific basis and so should not form the subject of expert evidence, citingthe Texas Court of Appeal decision in Thompson v Mayes 707 S.W.2 nd 951 (1986). Furthermore, the Courtplaced some reliance on the decision of the U.S. Supreme Court in Frye v U.S. (1923) 293 F 1013 whichheld that “the thing from which the deduction is made must be sufficiently established to have gainedgeneral 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 theadmissibility of psychiatric evidence in the United Kingdom and in particular, it will focus on whether thecriteria set out in Gilfoyle will involve an increased focus on reliability. When questioning if the Court ofAppeal’s approach is an improvement on the former approach of the English courts towards theadmissibility of psychiatric evidence, particular regard will be paid to the controversial operation of theFrye general acceptance test in the United States. This paper will address the English courts’ somewhatstricter approach to psychological rather than psychiatric evidence and in this light will question thegeneralizability of the Frye test in the United Kingdom after Gilfoyle. This approach will involveexamining whether the general acceptance test is likely to be confined to the particular type of evidenceoffered in Gilfoyle (novel psychological evidence) or whether it is likely to apply more generally to novelscientific evidence.67.3. The Brave New World of Expert Evidence in the Adversary System – Part IElizebeth Brimer, Barrister, Melbourne, Australia (George.Hampel@law.monash.edu.au)There are a number of successful steps and procedures developed to improve the compilation andpresentation of expert evidence. They include exchange of reports, joint conferences between experts, jointexpert reports identifying points of agreement and issues in dispute and the “Hot Tub” procedure in theFederal Court of Australia designed to identify and isolate issues. There are also education programs forexperts 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 beachieving the right balance between maintaining the right of the parties to use expert evidence and a moreefficient and focussed system of using expert evidence without destroying the fundamentals of theadversary system.

19867.4. The Brave New World of Expert Evidence in the Adversary System – Part IIGeorge Hampel, Monash University Law School (George.Hampel@law.monash.edu.au)The use of Court appointed experts and single experts are developments which are bound to produce moreproblems then they are intended to solve. The test of these developments should be by reference to thedifficult cases, not the easy ones. In a difficult case, where there is genuine dispute between experts, whowill be the single expert? Will a party against whose interest an expert opinion is expressed by a singleand/or court appointed expert be entitled to call its own experts? If so, what is being saved? If not, is itunjust? Who will choose the single expert? Will the Court be prepared to reject the evidence of experts ithas appointed? What sort of experts will be on the Court panels? Will there be a need for “shadowexperts”?Not only are these real problems, but the whole approach so undermines the good qualities of the adversarysystem that it tends to have the potential of producing unjust results.68. Forensic Psychiatry and Special Needs Programmes68.1. Shame and Conflict in Delinquents and Non-DelinquentsJoost J. Baneke, University of Twente (j.j.baneke@utwente.nl)Shame is one of the most important, and simultaneously one of the most neglected emotions in humanbehaviour, communication and interaction. According to Tangney (1995) shame is a main cause of manyforms of psychopathology and delinquency. Even the development of the brain and processes of attachmentand early dialogue can be influenced by shame reactions in the child. However, by regulating arousalsystems shame has also a very positive function, by preventing escalation of aggression and conflict(Schore, 1994). In clinical and forensic practice, we see many delinquents handicapped by shamelessness,which may easily lead to impulsive behaviour and escalation of conflict. Scheff (1997) emphasizes that socalledbypassed (unconscious or defended) shame is the most important cause of negative conflict.In our own research program of shame and guilt we started collecting descriptions of shame situations, inparticular by persons who were at that moment in social or psychological conflict, as delinquents,psychiatric patients and various other groups. These short narratives are examined in relation to scores onseveral self-report personality, shame (and guilt) questionnaires, in order to obtain information aboutrelevant qualitative and quantitative aspects of shame.Hypotheses, based on the theories of Tangney, Scheff and Schore, are tested. The latest results of thesetests will be presented.

19968.2. Mental Disorder, Substance Abuse & Crime [MSAC]: Presentation of a FollowupStudy of Mentally Disordered Offenders with Special Focus on Interventionsfor Substance AbuseClara Gumpert, Karolinska Institute, Stockholm, Sweden (clara.gumpert@neeurotec.ki.se)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 NationalBoard on Health and Welfare concluded that a large group of mentally disordered offenders suffer fromsubstance abuse disorders, and that this factor has a large impact on relapse into crime.Each year, approximately 650 individuals undergo forensic psychiatric evaluation (FPE) in Sweden. Eventhough only half of these are sentenced to prison (the remaining receive psychiatric care), the majority arediagnosed 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 offenderswith substance abuse problems. Included are Stockholm patients who have undergone FPE and who havebeen released from prison or care. The focus of the study is to map care consumption in this group, bothwith regard to regular after-care such as probation but with particular focus on interventions focusingsubstance abuse problems. The study will use register data as well as personal follow-ups. Preliminaryfindings will be presented.68.3. Risk Management and Rehabilitation of Mentally Disordered OffendersPer Lindqvist, Karolinska Institute, Stockholm, Sweden (per.lindqvist@neeurotec.ki.se)Risk of violence among the mentally ill has been an issue of controversy in the past. However, in the1990´s, methodologically robust studies clearly indicated that mental illness was associated with amoderately increased risk of violent offending. Subsequently, research on this issue has developed in twodirections, 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 psychoticsymptoms), and risk management where the focus is set on finding the most appropriate approaches to dealwith dynamic risk factors (e.g. proper outpatient supervision, control of substance abuse and theorganisation 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 takeon a rehabilitative perspective where re-offending is just one facet of the problem. Forensic psychiatry isdealing with people who have a number of problems, besides offending, that need and should be addressed.In doing that, the discipline of forensic psychiatry will acknowledge its role as a patient-focused, medicalactivity. 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 inforensic psychiatry with special emphasis on the role of academy to provide the clinical world with relevantinformation.

20068.4. Methods for the Assessment and Evaluation of Inpatient ViolenceTom Palmstierna, Karolinska Institute, Stockholm, Sweden (Tom.palmstierna@neurotec.ki.se)Assaultive inpatient behaviour is a challenge for mental health service providers as it poses a threat notonly for the staff, but also to fellow-patients, as well as endangering the treatment procedure. In recentresearch on inpatient violence, a common European standard during the last decade has been to use theStaff Observation Aggression Scale in its revised version (SOAS-R) to record violent incidents. Apart fromadequate incident registration, it is imperative to adequately predict who is going to be assaultative as wellas when. During the last decade several research efforts have been made to elucidate which patient is goingto assault in the psychiatric inpatient setting. Recent research within both forensic and acute psychiatricsettings has resulted in effective checklists for imminent inpatient violence, such as the Broset ViolenceChecklist (BVC) and the Social Dysfunction and Aggression Scale (SDAS). In future research, it isnecessary 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, as well as ratingscales adequately predicting short-term violence within the acute or forensic psychiatric setting will bepresented. Also, the possibility to effectively analyse the combined effect of short-term predictive measurestogether with actuarial predictors by modeling multivariate survival data will be presented.68.5. Probation and Mental Health: Defining and Responding to the ChallengesJennifer Skeem, University of California at Irvine (skeem@unlv.nevada.edu)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, thechallenges associated with supervising this population, or the ways in which probation agencies andprobation officers are attempting to meet these challenges. In this presentation, I will discuss a systematicline of research conducted in the U.S. that is designed to address these issues. I will briefly review thefindings of studies on (a) the prevalence of mental illness and dual diagnosis (mental illness with cooccurringsubstance abuse) in the probation population, (b) perceived sources of influence on theseprobationers’ adjustment and outcomes, and (c) probation agencies’ strategies for organizing theirresources to work with these probationers. This line of research suggests that “firm but fair” relationshipsbetween probation officers and probationers with mental illness are a pivotal influence on outcomes. Astudy of the nature and importance of these relationships will be emphasized.

20169. Forensic Psychiatry in Germany69.1. Cognitive-Behavioural Therapy of Sexual Offenders in Mental HospitalsKlaus Elsner, University of Duisburg-Essen (Klaus.Elsner@lvr.de)In Germany sexual offenders with diminished responsibility or without responsibility for their offences arecommitted 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 delinquentbehaviours of the offenders are treated in groups with a cognitive-behavioural approach. The treatmentfocuses on the reconstruction of the offences and the development of individual criminal history. Otheraims are the change of dysfunctional cognition, the amplification of empathic feelings towards theoffenders´ victims, the explanation of functional connections between delinquency and the individualbiographic history and the elaboration of relapse-prevention-strategies.In each group there are patients with various mental disorders and different sexual offences. For themajority of patients a personality-disorder was diagnosed and the two major offences were sexual abuse ofchildren and rape. The treatment for each group requires 4 years. Altogether 18 sexual offenders finishedthe treatment, so far.Besides the description of the patients’ characteristics and the contents of treatment, thispaper focuses on presenting the first results of our group treatment. For the evaluation ofthe therapeutic success we used psychological tests and clinical assessment.69.2. What Makes Drinkers Dangerous?Norbert Schalast, Institute for Forensic Psychiatry, Essen, Germany (norbert.schalast@uni-essen.de)Considering a random sample of drinking situations, one wouldn’t come to the conclusion that alcohol andviolence are closely connected (Pernanen 1991). But in a specific subgroup of individuals, alcohol abusegoes along with a heightened risk of violent and impulsive delinquent behaviour. Characteristics of thissubgroup will be presented, referring to data from an assessment of 150 violent alcoholics treated inGerman forensic psychiatric institutions (§ 64 of the penal code). Three comparison groups were includedin 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, familyviolence, broken home, parents’ substance abuse), anger, symptoms of personality disorder, andpsychopathy.The paper will discuss treatment needs in the forensic patients, rational targets of treatment, and risk factorsfor a failure of therapy.

20269.3. Brain Activation During Visual Sexual Stimulation in Hetero and HomosexualChild Molesters: An FMRI StudyBoris Schiffer, University of Duisburg-Essen (boris.schiffer@uni-essen.de)Thomas Paul, University of Duisburg-EssenTillmann Krüger, University of Duisburg-EssenElke Gizewski, University of Duisburg-EssenManfred Schedlowski, Swiss Federal Institute of Technology, Zurich, SwitzerlandNorbert Leygraf, University of Duisburg-EssenMichael Forsting, University of Duisburg-EssenThe etiology of paraphilias, in particular the neurobiological processes of deviant sexual preferences arelargely unknown. The aim of this study was to investigate brain activation during visual sexual stimulationin sexual offenders who were exclusively attracted to children in comparison to non-deviant healthycontrols.19 pedophile (11 attracted to males, 8 attracted to females) patients from two German forensic hospitalsand 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 whilesubjects were viewing sexually arousing respective emotional neutral slides. In addition, appetitive andconsummatative sexual behaviors were assessed by questionnaires.As compared to viewing sexually neutral slides, slides of nude male and female adults, slides of children inboth conditions led, to some extent, to similar activation of brain areas known to be involved in processingvisual stimuli of emotional content in all groups according to their sexual orientation. The sexual offendersin general did not show a pattern very different to controls while viewing slides of the nude children oftheir each sexual orientation except in the bilateral orbitofrontal cortex. This finding became stronger whenpatients and controls were compared in regard to their specific sexual stimulation conditions. These resultsdemonstrate that brain response to visual sexual stimuli of both, the respective and other sexualpreferences, is to some extent similar and suggest that it partially corresponds to processing emotionallycharged stimuli in general. For the sexual arousal in pedophiles, we did not observe very differentactivation patterns than in controls regardless of sexual orientation (hetero vs. homo). However, the findingof an OFC overactivation as an area known to be involved in revaluation of emotional stimuli and sexualdisinhibition may represent different cortical networks in processing emotional and sexual stimuli inparaphilia.69.4. The Importance of Clinical Risk Factors in Deciding to Release Forensic Patientsin GermanyDieter Seifert, University of Duisburg-Essen (Dieter.seifert@lvr.de)Risk assessment questionnaires of mentally ill patients are mainly based on historical items, while clinicaldynamic criteria have not been unattended but up to now insufficiently integrated. The Essener prospectiveprediction study tries to offer more insight into the role that clinical items play in a multidimensional modelto simplify prognostic decisions.

203Altogether 23 forensic psychiatric hospitals in Germany have been involved in the study. Since 1997 a totalof 333 patients had been examined directly before their release from hospital by the treating psychiatrist orpsychologist who had to fill out the Essener prognostic questionnaire.At present 255 patients have been released within a minimum of 2 and a maximum of 6 years. During thistime 22% of the patients failed reintegration.Essential results of the study are that clinical items are more important than historical items in predictingdangerousness (in the contrary to HCR-20, PCL-R). For example, patients, who are relatively natural incontact with women and men, unstrained, less anxious and/or distrustful, who show a high potential ofaggression, have a high position in the patient hierarchy and seem to be less reflective are likely to failreintegration. Furthermore it is obvious that the quality and intensity of forensic aftercare plays a significantrole in preventing relapses. In this presentation, the crucial results of the study will be introduced anddiscussed.69.5. The Challenge of Diagnosis and Treatment of Migrant Patients With Regard toForensic PsychiatryMehmet Toker, Institute for Child and Adolescent Psychiatry, Hamm, Germany (m.toker@wkp-lwl.org)Migration is a decisive feature of the world that is progressing as a global community. This feature is alsosignificant to German society specifically. With regard to forensic psychiatry, additional problems oftenresult from linguistic and cultural deficits in communication – both in the process of examination and thedevelopment of treatment measures. In this paper the most frequent problems in the diagnostic process willbe itemized and possible solutions be discussed on the basis of case study examples, particularly the dangerof overemphasizing or denying cultural aspects. In the last section legal and institutional conditions of thetreatment (or lack thereof) for forensic patients will be subject of the discussion.70. Forensic Psychiatry in the Netherlands70.1. Mean Genes and Forensic PsychiatrySiegfried Tuinier, Vincent van Gogh Institute, Venray, Netherlands (stuinier@freeler.nl)Almost any personality trait, cognitive and behavioral, is etiologically linked to genetic endowments. Thisis also true for the major psychiatric disorders. Antisocial personality, schizophrenia and bipolar disordersand many others share a substantial genetic causation. The variance in all kinds of cognitive functions isexplained by about fifty to sixty percent genetic factors. Recently this research, which was initially mainlybased on twin studies, is augmented by association studies of specific genes and behavior. Genes as acausative factor in a variety of disorders or disturbed behaviors is a finding that cuts across psychiatricsyndromes and behavioral dysfunction. The forensic science is thus confronted with causation thattranscends the current divisions: an illness, a personality disorder or maladaptive behavior. These results

204should have an affect on the assessment that the forensic psychiatrist makes. Diminished responsibilitycoupled with specific disorders is a division that is on a scientific level no more tenable than other defenses.The situation is complicated by the fact that clinical genetic examination in individual cases is at themoment not feasible. Besides that, experts have to consider whether or not social or psychologicalcausation are in principle of a different nature than genetic causation. Even more complex is the fact that itis generally accepted that a complex interaction between genes and environment is plausible. Moderngenetics will ultimately lead to a disappearance of the distinctions that are now made in court and inforensic psychiatry. This presentation will present an overview of the available data and will focus on theapplicability of modern genetics to forensic psychiatry.70.2. Aggression Replacement Training in Forensic ClinicsEd J.P. Brand, Flevo Future, Amsterdam, The Netherlands (candide.wv@move12.nl)In January 2004 the results were published of an Aggression Replacement Training Program in three Dutchforensic-psychiatric clinics. An essential element of the strikingly successful training of a total of 110patients was to elaborate their cognitive skills of the perception and comprehension of bodily sensations ofanger.In Great Britain, the Home Office has acknowledged the aforementioned training as a highly effectivetraining program for delinquent adolescents in residential institutions. What could be a theory to explainthe success of this kind of training? One of the necessities of a possible explanation stems from anadequate description of the mental process that occurs when offenders, or people in general, when angry,succeed in controlling their negative emotions and refrain from impulsive, violent (re)actions. Tounderstand the psychology of staying in control of one’s behavior or, on the contrary, of an eruption ofuncontrolled violence, it is instructive to look at how young children learn to cope with stress in unpleasantsituations and the resulting, negative emotions.In the course of their upbringing children learn to adapt to given rules; adaptation is the external conditionfor socially acceptable behavior. Internally however, the child has, for that cause, to live up to yet anothercondition: to gain a degree of sensitivity to bodily cues of stress and anger and to give these bodilysensations a mental status (of an emotion). The paper will illustrate in detail the psychological process ofgetting and staying in control of negative emotions and possible violent impulses, and of being able torefrain from acting out behavior.70.3. Problems with TBS Court Order for Aliens in the NetherlandsHannah Huizenga, Tilburg University (Huizenga@kabelfoon.nl)A.M. van Kalmthout, Tilburg UniversityKarel Oei, Tilburg University (t.i.oei@uvt.nl)There is great difficulty enforcing the TBS-measure involving aliens. At the centre of the debate is the factthat the criminal law system clashes with the Dutch Alien Act. An alien, without a residence permit, thathas been sentenced to a TBS-measure is restricted from going on leave, as this person is not allowed to beon Dutch territory. As a consequence, the TBS-measure cannot be terminated and may therefore effectivelyresult in a life sentence. In some cases however, the principle of proportionality demands the TBS-measure

205to be terminated: the crime and the sanction should be proportional. Such a termination of the TBS-measurehowever, results in the delinquent being released without any proof that the delinquent no longer constitutesa danger to society. One of the primary goals of the TBS-measure being a safe reintegration in society ofthe delinquent, both termination of TBS-measures without leave and lifetime TBS sentences are thereforeundesirable.Thirty experts, all working in the field of criminal or alien law, have been interviewed about theirexperiences with aliens sentenced to TBS-measures and the deadlock at issue. Possible solutions are oftenthe result of great efforts on the side of employees of TBS-clinics. The intent is to transfer the TBSmeasureor the phase of resocialisation to the country of origin of the delinquent. However, in practice thisoften seems impossible due to the distinctiveness of the Dutch TBS-measure. Although not identical to theDutch 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 totransfer the alien delinquent to the country of origin. More and better research in other countries withregard to this type of cooperation is required to successfully carry out more transfers. A second problem isconstituted by the Convention on the transfer of sentenced persons which requires the alien delinquent’sconsent for the transfer. Indeed, this problem remains to be solved. However, the Additional Protocol thatbelongs to the Convention on the transfer of sentenced person’s states that consent is not required in casethe criminal sanction also leads to a measure of administrative law resulting in the denial of right ofresidence in the country where the sanction is carried out. Therefore, this AP will have to be signed bymore countries in order to prevent the alien delinquent from frustrating the transfer.70.4. Constructing Elements for a Heuristic-Generalising PsychopathologyMarcel Tóth, Practicing Psychiatrist, Rijn, The Netherlands (martoth@xs4all.nl)Karel Oei, Tillburg University, (t.i.oei@uvt.nl)There is a growing awareness in psychiatry nowadays that the current psychopathologicalconceptualisations and nosological classification systems, such as DSM-IV and ICD-10, are seriouslyinadequate. This pertains to their (1) diagnostic validity, (2) diagnostic precision and (3) very limitedapplicability in neurobiological research. The WPA Congress ‘Diagnosis in Psychiatry: integrating thesciences’ (Vienna, June 2003) was partly about these issues. Researchers in this field are becoming moreconvinced that the identified inadequacies are more fundamental and may not be amenable to solutionswithin the confines of the currently used psychopathological systems.In view of these problems the Dutch psychiatrist Herman van Praag has proposed to focus diagnosticthinking in psychiatry on the development of a more functional psychopathology. In such a diagnosticsystem 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 andfeeling.In this contribution a specific implementation of such a functional psychopathology is proposed byintroducing some general concepts, which apply to psychopathological phenomena and can be treated to acertain extent as quantifiable mathematical variables or vectors. Therefore this psychopathology ischaracterized by a heuristic-generalizing approach.To conclude this contribution, the potential application of this approach to forensic psychiatric diagnosticpractice will be illustrated.

20670.5. Categorical Psychiatric Diagnoses and the Explanation of CrimeSiegfried Tuinier, Vincent van Gogh Institute, Venray, Netherlands (stuinier@freeler.nl)Criminal behavior is determined by a multitude of causal factors: developmental, social, genetic andpsychological. Among these factors clinical psychiatric diagnoses play a minor role unless the behavioritself 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 scientificliterature of the last decennia is devoid of substantial empirical studies on these phenomena. Nowadaysother diagnoses replace these ancient ones: borderline personality disorder, antisocial personality disorderand intermittent explosive disorder, and infrequently also psychoses. The explanation of criminal behaviorby these vignettes is fruitless and should be replaced by research on psychological dysfunctions that are asa rule, not specific for any categorical diagnosis. In fact, neuropsychiatric research is severely hampered bythe usual expert testimonies in court, in which almost automatic links are constructed betweenpsychopathology and a crime. Abandoning this habit most certainly will lead to many situations in whichthe 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 thecase without being able to give a full explanation. The less the psychiatrist pretends to know in court, themore will relevant research be felt as an urgent social obligation.71. Forensic Rehabilitation and Support Services71.1. Criminality in Women Prison Inmates Before and After Participation in theReasoning and Rehabilitation ProgramAnne H. Berman, Karolinska Institute, Stockholm, Sweden (anne.h.berman@neurotec.ki.se)Per Konradsson, Karolinska Institute, Stockholm, SwedenBackground: This study explores the effects of Reasoning & Rehabilitation, a cognitive-behavioraltreatment program, on 30 female prison inmates.Method: Short-term within-group effects were measured with the Sense of Coherence-scale (SoC), theCriminal 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 comparisonto 99 matched controls.Results: The strongest within-group correlation was between having committed violent crimes and low preprogramempathy-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 withpost-program improvement on said scales. A negative correlation was found between propensity for crimeand the number of days to reconviction. A negative correlation was also found between age at time of firstoffense 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

207number 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 ofcrime committed after being released from prison. In a five year-follow up, the women convicted of violentcrime who had participated in the program were reconvicted to a significantly lesser extent (46,5 %) thancontrols (60 %).Conclusion: This study supports extending Reasoning & Rehabilitation to women sentenced for violentcrime.71.2. Love Among Schizophrenic CouplesBrenda Geiger, Bar-Ilan University (geigerb@netvision.net.il)G. Friedman, Bar-Ilan UniversityH. Ordan, Bar-Ilan UniversityA. Lasry, Bar-Ilan UniversityT. Ohn, Bar-Ilan UniversityJuan Bar-El, Bar Ilan UniversityThis qualitative study examines rehabilitative aspects of the subjective experience of love on the mentalhealth of couples living in secure facilities and half-way homes for the mentally ill. In-depth semistructuredfocused interviews were conducted with 20 heterosexual couples both diagnosed asschizophrenics and treated with “atypical” antipsychotic drugs. Content analysis of the interviewsindicated that the actions that participants engaged in to express their love, were circumscribed by the rulesof the institution, the participants’ ethnicity and religion, and their level of sexual freedom. Yet, despitethose constraints, the love that participants experienced referred to feeling good, no longer feeling alone,giving and receiving affection, and at times experiencing negative feeling such as anger and jealousy. Loveallowed the partners to escape social and emotional withdrawal and to exhibit various degrees of awarenessand empathy for the other’s needs and emotions; love gave participants the strength to escape lonelinessand depression, to take care of themselves, to hope and plan for their future. No longer in a world of theirown, couples requested some privacy and physical space in which they could be intimate in the institutionor hostel. Love relationships between persons diagnosed as schizophrenics must, therefore, be recognizedand reinforced in and out of institutions, as one of the best indicators of recovery, and mental health andadequate socio-emotional functioning. Legal issues of consent, the right to privacy and the right to makelove with dignity are addressed; and so is the schizophrenic’s right to have children.71.3. Providing Recovery Services for Offenders with Co-occurring DisordersElizabeth Piper Deschenes, California State University (Libby@csulb.edu)Christine B. Kleinpeter, California State University (Ckleinpe@csulb.edu)Numerous defendants in the criminal justice system continue to re-offend due to untreated primary mentaldisorders and co-occurring substance abuse. It is estimated that up to 25% of inmates in the county jails andstate prisons are mentally ill and about 80% of those defendants also have a co-occurring substanceaddiction problem. Providing adequate treatment for this population is a challenge, particularly during the

208current budget crisis in the state of California. The Orange County Superior Court of California hasimplemented a special program that targets drug offenders who are seriously mentally ill and fail to complywith the conditions of probation under Proposition 36. This is the first dual diagnosis court of its kind inOrange County. The Dual Diagnosis Court is designed to help offenders through the recovery process byoffering them specialized treatment and services. Similar to other collaborative courts (such as drug courtsand mental health courts), the team includes a judge, probation officer, mental health worker, publicdefender, and district attorney. Offenders receive integrated treatment services including mental health andsubstance abuse treatment, as well as housing, financial, and health services. Offenders are randomly drugtested, and are monitored for treatment compliance by the court. Program compliance leads to positiverewards whereas non-compliance leads to various types of sanctions.This paper presents the implementation and outcomes of the Dual Diagnosis Court. Data were collectedthrough observation and coding information from participant records into a computerized database. Thedemographics, criminal and substance use histories of this population are described in addition to measuresof mental health and quality of life at intake. The evaluation presents an overview of program participationand retention. Policy implications regarding program design and implementation are discussed.71.4. Learning from Patients the Healing IntegrationJohn L Young, Yale University (john.young@po.state.ct.us)Criminal codes in most countries provide specific criteria for recognising that a small minority ofdefendants bear significantly reduced criminal responsibility due to mental illness. They also provideprocedures for these offenders to be treated as patients rather than as inmates. With varying degrees ofinformed consent, these individuals then agree to accept treatment towards the goals of recovery andfreedom. Because of their criminal history, it is not enough for them to make a conventional recovery frommental illness. These patients also have to integrate their current self-awareness with the reality of havingat least once seriously offended while under the influence of mental illness. Achieving remorse is a majorpart of this challenge. Also required is a coming to terms with oneself as one with a serious criminalhistory related to a mental illness. The patient must integrate this reality with all the other facets that makeup 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 remissionand 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 past15 years we have observed a wide range of results with our patients; we are now explicitly focused on whatwe can learn by reflecting on them. This presentation will utilise a series of varied case examples from ourwork experience in order to discern the characteristics that distinguish the more successful patients, and togarner useful applications for the benefit of their less successful peers.

20972. Gender and Mental Health I72.1. Normalizing Exclusions: Black Mothers as Inadequate MothersAnne Phoenix, Open University (a.a.phoenix@open.ac.uk)Increasingly, literature on parenting acknowledges that there has been an over emphasis on mothers as thepeople 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 thatinadequate 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 countriesis becoming increasingly ethnically diverse, there is a need for research to clarify the relationship ofethnicity to parenting. Some recent attempts to make allowances for cultural difference have led totolerance of genuinely poor parenting, as in some celebrated cases of child abuse where social workersconsidered that harsh discipline was culturally appropriate.This paper explores the ways in which psychological knowledge on mothers in general and about blackmothers in particular has exclusionary consequences. It uses a mixture of literature review and empiricaldata to argue that much of the literature on motherhood continues a ‘normalized absence/pathologisedpresence’ focus, where black mothers are omitted in studies of ‘normal mothering’ but included whenproblematic mothering is the focus. One result of this is that black mothers are often unfavourablycompared to white mothers and constructed as inadequate. From their own accounts, however, blackmothers do not consider themselves to be providing poor mothering, even though they sometimes viewother black mothers as problematic. Furthermore, constructions of black mothers as inadequate mothersfrequently fail to appropriately analyse the contexts within which mothers live, and so lack ecologicalvalidity.72.2. The Deployment of Motherhood in Psychiatric TreatmentRalph Sandland, University of Nottingham (ralph.sandland@nottingham.ac.uk)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 bypsychiatric professionals and institutions in the treatment of female patients. The paper will suggest thatthere is, at least, a need for greater awareness on the part of treatment providers of the genderedassumptions which underpin their interventions.

21072.3. Why Should There Be a Disproportionate Number of Black Women HavingAbortions in the UK?Salma Siddique, Napier University (s.siddique@napier.ac.uk)The 1967 Abortion Act made abortion legal in the UK. However, as in many other countries, abortionremains a controversial issue. This is demonstrated in the limited set of grounds that the Act allows atermination to be based upon (i.e., injury to the mental or physical health of the woman, risk of the childsuffering from physical or mental abnormalities, and a pregnancy of less than 24 weeks), as well as inmedia 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 receivedrelatively little attention in the literature or the wider culture: why are a disproportionate number ofabortions performed on ethnic minority women? Statistics obtained from health authorities in England andWales show that black women are seven times more likely than white women to have an abortion. WhileBlack Caribbean and African communities make up only 2% of the UK population, 14% of abortions areperformed on women from these groups. The present paper examines reasons for this inequity.72.4. The Role of Psychological Research Methods in Constructing Good and BadMothersSuzanne Zeedyk, University of Dundee (m.s.zeedyk@dundee.ac.uk)Developmental psychology has long been concerned with the ways in which parenting, and particularlymothering, practices impact on children’s emotional and cognitive development. One consequence of thisfocus is that mothers are often judged, on the basis of those practices, to be either ‘good’ or ‘bad’. Thispaper explores the way in which contemporary developmental research methodologies explicitly reflect andreinforce such judgements. Observational video methods are now commonplace in infancy research, withexperimenters coding and classifying maternal behaviours through the application of labels such as‘appropriate/inappropriate’, ‘sensitive/insensitive’, and ‘accurate/inaccurate’. Such classifications overlapwith societal views about what constitutes good and bad mothering, yet developmental researchers oftenseem unaware of (or unconcerned with) that correspondence, because the labels derive ostensibly fromtheoretical frameworks accounting for children’s development. The paper argues that coding behaviours inthis associative fashion makes it impossible to disentangle the observed phenomena from the range ofinterpretations that can be placed upon it. Such conflation yields misleading conclusions about the natureof parenting, and it obscures the role that science continues to play in constructing motherhood.72.5. Gender Issues in Medicine: The Role of a PsychiatristCarol C. Nadelson, Brigham and Women’s Hospital, Brigham, USA (carol_Nadelson@hms.harvard.edu)This paper will discuss the roles and career advancement of women in academic medicine, including thedifferences in the career trajectories of men and women, the disproportionate paucity of women at higheracademic ranks, and the challenges women face when seeking leadership positions. The paper will review

211issues of overt and covert discrimination, intellectual and sexual harassment, differences in leadershipstyles and personality, as well as some of the psychological factors that impede women’s progress in theirchosen specialties. The facilitation of academic advancement, especially the recruitment and retention ofwomen, is the mandate for the Director of the Partners Office for Women’s Careers at Brigham andWomen’s Hospital in Boston, Massachusetts, a major Harvard teaching hospital. This unique office worksto identify ways to assist in the academic and administrative promotion of women. In addition to womenfaculty, the constituencies include supervisors, department chairs, hospital administration, and the HarvardMedical 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 careeradvancement and address challenges in incipient stages, often preventing loss of valuable faculty. Hospitalleaders encourage women to meet with the Director, and women faculty refer each other or come on theirown. The office provides a major mentorship function. Working with both junior and senior womenfaculty, the office also performs an ombuds role. The ongoing relationship with the hospital administrationinforms policy and influences choice and direction of leadership. The office also works with hospital legalcounsel 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 andaction. As a psychiatrist, there is an added dimension brought to the role of Director. The professionalexperience, training, and knowledge of a psychiatrist is valued, especially in the recognition and approachto dysfunctional situations involving individuals and hospital departments. Data will be presented on thepromotion and advancement of women, as well as examples of effective collaborations, communications,and interventions designed to facilitate progress.73. Gender and Mental Health II73.1. Arrest Patterns of Women during Perinatal & Non-Perinatal PeriodsKatherine Maeve, Private Practice, North Augusta, USA (kmaeve@comcast.net)Women's unique (and normal) brain and hormonal chemistry result in a vulnerability to mood disorders atcritical times in their lives, including the times when women give birth. There are many types of perinatalmood disorders, such as prenatal depression, and numerous postpartum disorders, including simple "babyblues," postpartum depression (PPD), postpartum obsessive compulsive disorder, postpartum onset panicdisorder, and postpartum psychosis. There is a growing awareness that the risk factors for any perinatalmood disorder, and predictors of PPD specifically, are overwhelmingly present among the aggregate ofwomen (> 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 aperinatal period. The sample consisted of women (n=3454) who gave birth in a time frame that would allowaccess to arrest records in the 21 month period immediately preceding conception, and for 21 monthsimmediately following the conception (9 months prenatal, 12 months postnatal). Only women who hadbeen arrested at least one time during this 42 month period were included in the study. Of the women in thesample, 37% only had arrests during the post-conception period. Of the 37% (n=1865), women were twiceas likely to be arrested during the postpartum period as the antepartum period.The physical limitations of pregnancy and birth, and caring for a new baby would seem to diminishwomen'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

212women is proposed as a way to contemporaneously screen women involved with the criminal justicesystem for perinatal mood disorders, and connect findings with arrest events. Implications for prevention,early identification, and early intervention are discussed.73.2. Battered Women, Equality and Feminist LawmakingElizabeth Schneider, Brooklyn Law School (liz.schneider@brooklaw.edu)This presentation will examine the last thirty years of developments in the law of domestic violence in theUnited States, focusing on law and mental health issues, based on my book Battered Women and FeministLawmaking (Yale University Press 2000) and many articles that I have written. It will explore tensions incharacterizations of battered women’s experiences in law and mental health as reflecting themes of bothbattered women’s agency and their victimization, and explain why issues involving battered women raiseequality 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 accurateand nuanced psychological and social characterizations that are based on the lived experiences of batteredwomen. I will closely examine these problems in cases of battered women and custody, battered womenwho kill their assailants, and even in treatment of domestic violence in civil rights and international humanrights legal contexts. The presentation will argue that both lawyers and mental health professionals mustincorporate these more complex perspectives into their work with battered women.73.3. Criminal Law Ambivalence in Domestic ViolenceNatalie Des Rosiers, University of Ottawa (Nathalie.DesRosiers@uottawa.ca)The paper will review several developments in Canadian law in recent years dealing with domesticviolence. The thesis is that there are two contradictory law reform agendas that make formal legalpronouncements diverge more and more from practice. One law reform agenda continues to value a strongcriminal response to the issue of domestic violence: it is anchored in a respect for victims’ voices, desire foraccountability, and deterrence ideas. A second agenda stems from the disenchantment with the criminalprocess. As police officers start laying complaints on both women and men in cases of domestic violenceand as jail terms are imposed in a way that isolate families and communities, there is an anti-criminal lawmovement 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 ofcriminal law” reform movement. It suggests that the tension can be resolved along certain values andstrategies. Among others, it presents the ambivalent development of domestic violence problem solvingcourts as a symptom of the conflicts in law reform.

21373.4. The Importance of Positive Social Support for Children Who Have Experiencedthe Death of a Parent by Intimate Partner ViolenceElaine Spencer-Carver, University of Missouri (carvere@umkc.edu)Violence is an integral part of the American landscape. Urban communities reel from violent deaths inneighborhoods, precipitated by mundane arguments. Violence infects families through intimate partnerviolence, as individuals misuse power and control. Violence erupts in relationships between adults andchildren, leading to child abuse. The impact of violence can be seen in the headlines of local papers, in thenewscasts 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 thatchild’s other parent or caretaker, the change goes to the very core of the child’s existence. In 1998 therewere 1,317 women and 512 men killed by intimate partners. There is little known about the experiences oftheir 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 aparent killed by a partner when these adults were children. Discussion will include recommendations forassisting children in this situation, and the role that both social service and the law can play in securingtheir future.73.5. Reproduction and the American MindPamela D. Bridgewater, American University (pbridgewater@wcl.american.edu)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 regardingreproductive choices, while matters related to the use of advanced reproductive technologies are largelyseen as outside of the public gaze. Other issues, such as contraceptive and sterilization abuse, arecompletely marginalized as they tend to involve segments of American society about whom manyAmericans have already made up their minds.The ability to compartmentalize these issues regarding reproduction is due, in large part, to the psychic splitcaused by the damaging affects of not focusing on the role class, gender, race, and sexuality play inexperiencing reproduction generally, and in making reproductive decisions individually.This paper will posit that, this compartmentalization of the varying aspects of reproduction in the Americanmind, 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 howthe 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 thatmany of the insurmountable differences between the reproductive camps can be addressed by incorporatinga more complete and accurate historiography of reproduction in America.

21474. Gender and Mental Health III74.1. Risk Trajectories in Adolescent Mothers and their PartnersBárbara Figueiredo, University of Minho (bbfi@iep.uminho.pt)Alexandra Pacheco, University of Minho (alexandrap@iep.uminho.pt)The main aim of the present study is to characterize the conditions in which adolescent pregnancies occurin Portugal. We analyzed the changes that may happen during gestation in order to contribute to a betterunderstanding of the difficulties associated with this issue.During the third trimester of gestation a sample of 161 pregnant adolescent women, outpatients of the JúlioDinis Maternity Hospital, were interviewed based on a 125 close-questioned questionnaire. This interviewallowed us to gather information about socio-demographic data regarding the participant, partner, andnuclear family, as well as medical, psychological, and social-risk circumstances.Literature from studies done in Portugal and other countries around the world, have shown that an overrepresentationof participants belonging to the unfavorable population can be observed, despite the sociodemographicvariability of the sample. Our results also indicate a high frequency of problems in the familyof origin and of previous adverse life experiences, such as history of suicide attempt (9.3%), neglect orviolence (11.8%), sexual abuse (3.1%), and long-term hospitalization during childhood (3.7%). Manyparticipants shared further troubles and had lived in highly unfavorable conditions (6.2%), experiencedsocial or familiar isolation (0.6%), problems with justice (3.1%), domestic violence (13.0%), psychologicalproblems (1.2%), or came from families with histories of drug/alcohol abuse (13.7% and 18.0%,respectively). Frequently, couples had identical histories of adverse life conditions, for example: neglect(X 2 (1) = 11.097, p = 0.006), long-term hospitalization during infancy (X 2 (1) = 7.539, p = 0.048), living inhighly unfavorable conditions (X 2 (1) = 9.715, p = .033), domestic violence (X 2 (1) = 4.894, p = 0.050),alcohol consumption (X 2 (1) = 5.329, p = 0.030) and problems with justice (X 2 (1) = 11.134, p = 0.027).During the 3 rd trimester of pregnancy, a significant number of adolescent women smoked tobacco (21.7%),though less than before the pregnancy (47.2%) (X 2 (1) = 23.111; p = 0.000). Most partners were tobaccoconsumers before (71.7%) and during pregnancy (70.6%) revealing no significant differences. Someadolescent pregnant women were regular alcohol consumers (3.7% before and 1.2% during pregnancy).One in four partners consumed alcohol before and during pregnancy, and some were addicted to alcoholbefore (0.6%) and during (1.2%) pregnancy. Adolescents abused drugs to a further extent before (5.0%)than during pregnancy (0.6%), indicating a significant reduction (X 2 (1) = 5.601; p = 0.018). Partners alsoshowed a reduction in drug abuse (X 2 (1) = 4.545; p = 0.024): 17.6% before and 9.4% during pregnancy.This study alerts several difficulties and risk conditions in which adolescent pregnancies may occur. It alsoshows that in many cases, supplementary professional help is justified to prevent deviant developmentaltrajectories in adolescent mothers and their families.

21574.2. Naming Oneself Criminal: Gender Difference in Offenders’ Identity NegotiationBrenda Geiger, Bar-Ilan University (geigerb@netvision.net.il)Michael Fischer, Norfolk UniversityThis qualitative research examines gender differences in offenders’ ability to negotiate a positive identityonce the pejorative labels of criminal, prostitute, drug dealer, and incompetent parents have been imputedonto them. In-depth semi-structured interviews were conducted with a purposeful information-rich sampleof eight male and eight female offenders. Content analysis reveals that male offenders were much moreadept than females at juggling conventional and street norms to justify/resist stigmatizing labels in order toconstruct a favorable identity. Personal strengths such as expertise, competence, loyalty, and followingcodes of honor appealed to male offenders, thus challenging the boundaries between conventional anddelinquent worlds while giving them a sense of efficacy perception and an optimistic explanatory style. Incontrast, even though female offenders were able to justify the labels of drug dealer, prostitute, and thief byclaim to higher loyalties, such as their children, and were able to reject the label of insane, all of theirjustifications collapsed when having to negotiate the identity of incompetent mother. Negative internalattributions and deprivation of the normative center-motherhood led female offenders to apathy, anomie,and lack of confidence in their ability to do something worthwhile. Rehabilitation and legislativeguidelines must allow female offenders to build personal strengths, while redirecting the strengths exhibitedby male offenders into lawful enterprises.74.3. Gender and Recidivism Trends in the United StatesBarbara Owen, California State University at Fresno (barbarao@csufresno.edu)Elizabeth Piper Deschenes, California State University at Long Beach (libby@csulb.edu)This paper explores the recidivism of female inmates released from state prison through secondary analysisof data on the recidivism of prisoners released in 1994, available through ICPSR from the 3-year follow-upstudy conducted by the Bureau of Justice Statistics (U.S.). We will discuss the various analytic strategiesthat will model the impact of prior criminal history on post-release recidivism by examining the criminalcareers of the 23,583 females, who represent 8.7% of the total sample. We have already examined initialfrequency distributions of female recidivists and began to examine the potential of this data set for testinghypotheses, related to gender differences in criminal careers, by repeating many of the initial analysesseparately for females and males. A retrospective longitudinal design will be used to examine the criminalcareers and recidivism of a prison release cohort of female offenders during a 3-year follow-up period.More specifically, the analysis will focus on the relationships between age at onset, offense specialization,career escalation, time served, age at release and persistence or desistance, and the possible impact ofincarceration and prison programs on post-release recidivism. This study will test the utility of variousanalytic techniques, including survival analysis, Markov chain analysis, multivariate linear regression, andlogistic regression in answering these questions. In terms of policy, this project addresses two primaryinitiatives of the US Department of Justice: re-entry and gender-responsiveness in corrections. Addressingthe priority of re-entry issues, this project will add to an understanding of the recidivism among womenoffenders and develop specific information for building gender-responsive policy. Decision-makers willbenefit from this greater understanding on female recidivism as federal, state, and local jurisdictions beginto examine differences in their female and male parole populations.

21674.4. Outcomes of Forensic Rehabilitation in Auckland: Community Tenure andReoffending Rates Following Inpatient and Assertive Community RehabilitationSandy Simpson, University of Auckland (Aif.Simpson@waitematadhb.govt.nz)Ceri Evans, University of AucklandBrian McKenna, University of AucklandRoland Jones, University of AucklandBackground: All forensic patients in the northern part of New Zealand are rehabilitated through theARFPS. The service involves inpatient rehabilitation followed by assertive community treatment, oftenthrough supported community accommodation. Rehabilitation includes focus on: illness and non violenceeducation, individual and family therapy, cultural interventions, and vocational integration within a legallymandated framework. Very low rates of reoffending have been noted with this group. This paper presents aretrospective study of all patients discharged over the last 7 years, to determine patterns of successfulcommunity tenure, and reasons for relapse and readmission.Methods: A retrospective review of case notes was undertaken to describe the patient population enteringthe service in terms of demographic data, psychiatric illness, offending behaviour, history of substancemisuse, and risk profile using the HCR 20. Variables used to indicate outcome were measured includingsocioeconomic variables, rates of re-offending, and readmission to hospital. Patient details were crosschecked against court appearances, imprisonment and readmission to hospital. Details of any such outcomewas recorded.Results The results of 105 patients will be described, including their clinical and risk profile. Therapeuticprocesses engaged in and outcomes in terms of community function described. Implications in terms of theelements necessary for successful rehabilitation will be considered.74.5. Opioid Maintenance Therapy in Intermediate Term In-patient TreatmentS. Scheubmayr, University of ViennaE. Resinger, University of ViennaJ. Scharfetter, University of Vienna (joachim.scharfetter@meduniwien.ac.at)The Schweizerhaus Hadersdorf (SHH) is a center for intermediate term in- and out-patient treatment ofdrug addicted patients with an emphasis on compulsory therapy according to §11 of the Austrian narcoticsact (“therapy instead of punishment”).In Austria and, to the best of our knowledge, in all of Europe, we this is the sole institution of its kind,offering opioid maintenance therapy for intermediate term inpatient treatment with methadone and longacting morphine.Our program offers a treatment period of twelve month comprising of:1) A 6 month period of inpatient treatment with a focus on patient information and reorientation, includinggeneral medical and psychiatric care, psychological testing, social support and specific psychotherapy.2) An outpatient period of an additional 6 months with attended living, continued individual psychotherapy,social support and resources for crisis intervention.

217This concept aims, above all else, at providing patients in maintenance therapy, that are traditionallyexcluded from inpatients treatment programs, with a specific, intermediate term psychotherapeuticalsetting.In our presentation we will provide data for further discussion.74.6. Childhood Sexual Abuse and Adult Sexual Re-victimization Among IncarceratedWomenMegan R. Hebert, Rhode Island Hospital, Providence, USA (Mhebert@lifespan.org)Recent studies have concluded that the strongest factor associated with Adult Sexual Assault (ASA) is ahistory of Childhood Sexual Abuse (CSA). In addition, alcohol abuse and/or illicit substance use have alsobeen found to be possible risk factors for ASA re-victimization. The majority of research on ASA revictimizationhas been limited to college student populations with a number of other studies involvingcommunity or probability samples. Research on this topic is lacking in the incarcerated population wheresubstance use and other risk factors for ASA, such as family history and sex trade work, are highlyprevalent. Given the high rates of both CSA and ASA in this population, it is important to examine notonly the relationship of CSA to ASA re-victimization, but also other factors that may potentially increaseincarcerated women’s risk for ASA.A sample of 484 incarcerated adult females was interviewed to determine the prevalence of CSA and ASA.An analysis was then conducted to compare rates of ASA between women with and without a history ofCSA. In addition to examining whether women with a history of CSA were more likely to experienceASA, self-reported substance use, negative family history factors, and current sexual risk behaviors werealso analyzed as potential correlates of re-victimization.Of the 484 women interviewed, 42.58% reported that they had experienced sexual abuse before the age of18, either by a family member, known acquaintance, or stranger. ASA was reported by 21.52% of thesample and 12.24% reported both CSA and ASA. Of the women who were survivors of CSA, 28.9%reported ASA, a significantly higher rate than the 15.5% of women who had not experienced CSA, whoreported ASA (χ 2 (1) = 12.33, p = .0004). Women with CSA histories were 2.2 times more likely to sufferfrom ASA than women CSA histories. Both substance use and sex risk behaviors were found to besignificant independent correlates of ASA. Of the women interviewed, 55.79% reported the use of illicitsubstances and 31.86% reported engaging in high-risk sexual behaviors. Parental substance use andparental incarceration history were not predictive of ASA.A history of CSA, illicit substance use, and engaging in high-risk sexual behaviors were found to beindependent correlates of ASA re-victimization among incarcerated women. Given that all three correlatesare highly prevalent among this population, it is imperative that future research examines possiblemediational relationships. Through such research, insight into the underlying structure of theseassociations may enable the development of interventions tailored to address these risk factors specificallyfor incarcerated women, with the goal of decreasing ASA re-victimization.

21874.7. Violence Against Women Associated with Arrests for Sex Trade But Not DrugChargesJennifer Clarke, Rhode Island Hospital, Providence, U.S.A. (jclarke@lifespan.org)Theorists propose that women’s incarceration for drugs and sex trade is largely a consequence of theirvictimization from gender-based violence; little research has explored this issue. The purpose of this studywas to examine associations between gender-based violence and arrests due to sex trade or drug-relatedcharges among a statewide sample of incarcerated women. Incarcerated women in Rhode Island were askedto participate in brief pre- and post-test surveys of their experiences of violence, sexual risk and substanceuse behaviors, as part of a study on the effectiveness of a family planning program in a state correctionalfacility; data from pre-test surveys were used in the current analyses. Logistic regression analyses adjustedfor demographics were used to assess significant associations between gender-based violence variables(i.e., adolescent intimate partner violence (IPV), adult IPV, childhood sexual assault (SA), adolescent SA,and adult SA) and arrests due to sex trade or drug-related charges.Participants (N=447) ranged in age from 18-56 years; median age was 31 years (Std. Dev.=9 years). Themajority of study participants were White (56%); 16% were Black and 9% were Hispanic. Over a third(37%) did not complete high school or receive a GED; 12% were homeless prior to their currentincarceration. Half of participants (49%) were incarcerated for less than 14 days in prison, and 67% hadpreviously been incarcerated. Significant relationships were observed between arrests for sex trade andadult SA (OR=2.1, 95%CI=1.2-3.6), adolescent IPV (OR=2.5, 95%CI=1.5-4.1), and adult IPV (OR=1.7,95%CI=1.1-2.6); no significant associations were observed for drug-related charges. Findings from thecurrent study demonstrate that experiences of gender-based violence are associated with arrests for sextrade but not drug-related charges. Interventions for incarcerated women are needed to consider and addresshistory of victimization from gender-based violence and its relation to women’s historic and future sextrade involvement.75. Gender Issues in Adolescent Psychiatry I75.1. Girls Behaving Badly: Trauma Exposure, Post-traumatic Stress and PsychiatricComorbidity in Female Juvenile OffendersAngela Dixon, University of Sydney (angelad@psych.usyd.edu.au)Pauline Howie, University of SydneyJean Starling, University of SydneyThis study documents the rate of posttraumatic stress disorder (PTSD) in a sample of Australian femalejuvenile offenders, and its relation to trauma history, co-morbid diagnoses, attributional style and familyfunctioning.One hundred juvenile offenders were matched with a comparison group of 100 females on age andsocioeconomic status. Psychological profiles and trauma histories of both groups were assessed using the

219Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and LifetimeVersion (K-SADS-PL). Two self-report measures were used to assess family functioning and attributionalstyle.Rates of trauma and psychopathology were higher for offenders than controls (P < .001), with particularlyhigh levels of conduct disorder, substance abuse disorders, depression and PTSD. Offenders also reportedhigh rates of both victimization and witnessing traumatic experiences. Posttraumatic stress disorder wasdiagnosed in 37% of offenders, with sexual abuse the precipitant in 70% of cases. Offenders with PTSDhad significantly more co-morbid diagnoses than those without. The majority (73%) of co-morbiddiagnoses appeared concurrent with or following PTSD onset. Offenders with PTSD were more likely tohave attempted suicide at least once. The presence of four or more psychiatric diagnoses and a history ofsexual 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 infemale juvenile offenders. This highlights the importance of comprehensive diagnosis and treatment of thisand other co-morbid disorders in order to ensure the effectiveness of interventions designed to treatantisocial behaviour.75.2. Juvenile Delinquency and Substance use: data from a Portuguese StudyAntonio Castro Fonseca, University of Coimbra (acfonseca@fpce.uc.pt)Aims: This paper intends to assess the complex relationship between self-reported juvenile delinquencyand substance use in a large sample of Portuguese adolescents, including boys and girls.Participants: The data presented here were gathered in the context of a longitudinal study initiated in1993 and still going on in the region of Coimbra (Portugal). More specifically, our analysis focuses on 450boys 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, whichincludes 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 antisocialbehaviour and substance use both for boys and girls. However results varied somewhat in function of themeasure used to assess antisocial behaviour.Discussion: These findings were confronted with those reported in previous studies conducted in othercountries and interpreted on the light of recent research on gender differences in the field of juveniledelinquency.

22075.3. Psychopathology, Aggression, Trauma and Risk Behavior in Girls from 12 to 18years in Youth Custodial Facilities in the NetherlandsSannie Hamerlynck, Free University of Amsterdam (s.hamerlynck@debascule.com)Robert Vermeiren, Free University of AmsterdamTheo Doreleijers, Free University of AmsterdamLucres Nauta-Jansen, Free University of AmsterdamPeggy T. Cohen-Kettenis, Free University of AmsterdamA 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 asemi-structured psychiatric interview (K-SADS, items ADHD, ODD, CD, alcohol, drugs, suicidality) andself-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 withthe parents, which included the administration of the disruptive behavior disorder part of the K-SADS, theSDQ, the trauma questionnaire and questions on the socioeconomic status. Teachers in the institutions wereasked 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, almostall girls have a psychiatric diagnosis. Both internalizing and externalizing behaviors are frequent in thispopulation. 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, andtherapeutic interventions should be available in these institutions.75.4. Forensic Treatment of a Female Pyromaniac (Fire-setter)O. Bilke, Clinic for Psychiatry and Psychotherapy, Littenheid, Switzerland (o.bilke@littenheid.ch)The case of a 17 year old female patient who is being treated in a psychiatric clinic since April 2003 for firesetting and violence against property will be presented.Life events: The patient grew up with her two younger siblings and her mother. The unsteadiness of hermother brought about an early undertaking of responsibility for her siblings that led to growing tensionsbetween 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 sexualabuses by adolescents. This fact and three suicide attempts in 2002/2003 resulted in outpatient treatment inadolescent 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 andpathology. When assuming a developing emotionally unstable personality disorder, the main goals oftreatment are the self-perception of emotions and self-regulation as well as adjustment of the interpersonalbehaviour – using parts of M. Linehans manuals. A further integral part of daily work and treatment of thepatient is the experience of constant pedagogic and therapeutic relations. The explicit therapy of the

221chronic post-traumatic stress disorder is not yet the intention of the patient. Elements of trauma therapywould be possible for the future.In regard to a pharmacological support the patient feels very ambivalent, such that the current settingincludes only sedative pharmacotherapy on demand.Conclusion: The successful treatment of this patient necessitates a long-termed planning that has to includethe further clarification and settlement of offences. Currently no direct correlation of psychiatric disordersand offences are being observed, so that the previous therapy strategy is unchanged.75.5. Longitudinal Gender-Specific Patterns of Psychopathology and SocialEnvironment Associated with Severe Behavior Problems in American Inner-cityYouthVladislav Ruchkin, Yale University (vladislav.ruchkin@yale.edu)Robert Vermeiren, University of LeidenMary Schwab-Stone, Yale University School of MedicineThe objective of the present study was to assess changes in three major domains: psychopathology (anxietyand depression), family (parental involvement and supervision), and other close social environments(friends’ delinquent behavior, and attitudes of important other adults to deviancy) in relation to severebehavior 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 urbaninner-city community in the US. Using longitudinal data, the study evaluated the transition from 6 th to 8 thgrade in four groups of youth, based on their longitudinal patterns of severe behavior problems (SBP). Thestudy demonstrated that the patterns of change across the three domains are different for boys and girls andvary depending on the level of youth’s involvement in the SBP, with more psychopathology, less supportfrom the family and important other adults, and greater involvement with delinquent peers in those withhighest levels of SBP. The study suggests that specific risk factors are differentially related to severebehavior problems in boys and girls. Findings are discussed from both developmental and clinicalperspectives with some consideration given to implications.

22276. Gender Issues in Adolescent Psychiatry II76.1. Psychic Trauma in Juvenile Delinquents: Gender SpecificsElena Dozortseva, Serbsky National Center for Social and Forensic Psychiatry, Moscow, Russia(edozortseva@rambler.ru)Psychic trauma consequences in adolescents with delinquent behaviour have been explored in a number ofstudies (Boswell, 1995; Cauffman et al., 1998; Ruchkin et al., 2002 etc.). In some of them gender specificsin 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 psychicconsequences in juvenile delinquents in Russian closed educational institutions considering gender relateddifferences. The sample includes 61 adolescents (23 boys and 38 girls) from 13 to 17 years old whocommitted various criminal actions and were placed into special closed institutions of the Ministry ofEducation. An inventory developed for children and adolescent on the basis of DSM-IV criteria for PTSDassessment (Tarabrina, 2001) was used, as well as questionnaires for evaluation of anxiety, depression andsomatic 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 underwentphysical abuse mostly within their families, the boys – both inside and outside families. Both groupsexperienced 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. Theboys denied similar experiences, but indirectly displayed some serious problems in this sphere. Otherpsychic 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 traumaticevents in their past. The scores of the most PTSD criteria were higher in girls than in boys. Emotional andsomatic problems were also significantly more expressed in girls. Trauma indices correlated with emotionalproblems in girls and only with somatic problems in boys. It can be supposed that somatization might beconsidered 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.76.2. Female Juvenile Offenders Compared to Male Ones: Later Recidivism Risk andNew Results from the Psychiatric Assessment of Personality and OffenceDynamicsMichael Günter, University of Tübingen (michael.guenter@med.uni-tuebingen.de)Anne Miller, University of TübingenA previous study of our group showed interesting findings with respect to psychiatric characteristics andoffence dynamics in young female offenders. These findings were re-examined by a more rigorous designcomparing them with a matched control group of male offenders.The study included all female juvenile offenders who came to a forensic psychiatric assessment in ourdepartment between 1970 and 1994. They were compared to a male control group matched according toage and offence type. We compared characteristics from the intensive forensic psychiatric assessment after

223the index offence with later recidivism taken from the criminal records. Forensic reports were evaluatedsystematically with an evaluation form to assess the offence dynamics and social distress factors. Interraterreliability 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 offencedynamics, especially the contribution of close relationships to the offence, some distress factors andrecidivism 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 juvenilefemale offenders, especially when acute bodily harm or homicidal attacks are considered.76.3. Sick Girls – Bad Boys: Gender Differences in Antisocial Behavior of YouthUlrich Preuss, University of Bern, Switzerland (ulrich.preuss@kjp.unibe.ch)Marc Walther, Clinic for child and adolescent psychiatry, Lausanne, SwitzerlandDaniel Gutschner, IFB Institute for forensic counselling in Children and Adolescents, Bern, SwitzerlandMatthias Schmelzle, IFB Institute for forensic counselling in Children and Adolescents, Bern, SwitzerlandMonika Egli-Alge, Forensic Institute Eastern Switzerland forio & Clinic for child and adolescentpsychiatry, Weinfelden, SwitzerlandThe objective of our study was to review current literature on gender related differences of antisocialbehavior in underage individuals in youth. Based on a medline and psylit and psyindex search studies werecompiled to give information about the current body of knowledge in the forensic domain of genderdifferences. The available literature on gender differences is restricted. A small number of study approachesare 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 donot show such a high number of offences as boys. In substance related offences, girls do not differ. Overall,more delinquent behavior in shown by boys in the delinquent category, and girls who are in intimaterelationships to older and social men. The etiology of gender differences in delinquent behavior is open.There exist a number of hypotheses but no unifying theory has been settled. From our findings we canconclude 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 girlsin the last decade etc. Especially research on protective factors for delinquency would probably offer someapproaches to prevention of antisocial behavior in underage men.76.4. Physical Culture as Means of Development of Offender PersonalitiesLiudmila Rogaleva, Ural State University (Malkin@mail.lyceum.usu.ru)Nowadays we can find many reasons for the difficulties in offenders’ social adaptation. One of them is theabsence 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/herpersonality believing that it would be important for him/her. In this case, we can witness the formation of aperson who is able to create, be responsible for his/her deeds, solve problems, and use these solutions inpractice. All these aspects characterize the basis of psychic health. According to these principals we can

224help the offenders form certain psychological characteristics, mentioned above, if we manage to involvethem into forms of useful and meaningful activity. We are hopeful that it would work effectively in reallife.The research was carried out with teenagers (girls 12-16 years old) in a special school. During the research,we defined the spheres of activity that the girls considered essential for them. In the basis of this work, weused the method of ranging analysis. A result of this, was that we discovered the most valuable things forthese girls are:• Self-confidence• Communicativeness• Independence• Ability to move gracefully• Musical culture geared towards youthThese data confirmed the idea that doing sports, dance aerobics, and performing at aerobics festivals aresome activities that may help the girls self-realize.Preparation for festivals of sport and dance aerobics required the girls’ effort: the independence to createthe compositions, to select music, design costumes, cooperate, be attentive, and help and support eachother.The result of this work appeared hopeful. Within 2 years of our work, we observed the psychologicalatmosphere improving: levels of stress/anxiety and conflicts in the girls’ relationships decreased, and selfconfidenceincreased sufficiently. From our research, we found that 67% of girls bettered their selfassessment.On finishing school, 40% of the girls continued to do sport aerobics. This is a much-wanted result of ourwork.76.5. A Comparison of Attachment Styles Between Incarcerated Adolescent Femalesand a Control SampleJoanne Grigor, St Nicholas’ Hospital, Newcastle-upon-Tyne, UK (Joanne.Grigor@nmht.nhs.uk)The importance of childhood experiences in understanding juvenile delinquency is well recognised withinthe literature. More recently attachment theory has been proposed as a valuable model for conceptualisingemotional problems and behavioural difficulties in children and adolescents. To date however, littleresearch has examined these concepts utilising a control group methodology. A better understanding of therole that attachment styles impact upon behaviour can assist with developing more comprehensiveaetiological models and possibly also improving intervention and treatment strategies. This studycompared the attachment styles of two groups of adolescents; one group being incarcerated in a mediumsecure setting and the other a control group. Significant group differences that emerged within thedelinquent group were more likely to endorse the dismissive attachment style. Significant groupdifferences also emerged in regards to parental rearing styles: delinquent individuals perceived parentalfigures to be more emotionally cold, indifferent and generally disengaged than the normal sample. Thejuvenile sample were also more likely to have perceived themselves as having experienced an ‘affectionlesscontrolling’ type of parental style. The implications of these findings in regards to attachment theory andaetiological models of juvenile delinquency are discussed. Finally, potential clinical intervention strategiesare considered.

22577. Globalization of Mental Disability Law77.1. The Globalization of Mental Disability LawArlene S. Kanter, Syracuse University (kantera@law.syr.edu)This presentation will discuss recent international legal developments which address the plight and rights ofpeople with mental disabilities, including the current movement for the adoption of a United Nations treatyon the rights of people with disabilities.In 1990, the United States enacted the Americans with Disabilities Act which prohibits discriminationagainst people with disabilities in nearly all aspects of life. This law is arguably the most comprehensivedomestic 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 ofwhich 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 mentaldisabilities. People with mental disabilities are more than twice as likely as their peers without disabilitiesto be poor and unemployed. Many remain in institutions throughout their lives, and those who do live in thecommunity and work earn substantially less than their co-workers who do not have disabilities. Manyadults with mental disabilities want to work, with appropriate accommodations or assistance. As they knowonly too well, with unemployment comes fewer opportunities to participate in the life of a community, andin recreational and social activities.The plight of people with disabilities, including people with mental disabilities, has now become aninternational human rights issue. The United Nations itself is on the verge of adopting a Convention on theRights of People with Disabilities. Consequently, at no time in history has the confluence of internationalefforts with and for people with disabilities challenged policy makers, professionals, scholars, and activiststo frame the meaning of human rights for people with mental disabilities. This presentation will explorethese recent legal developments, particularly the potential international impact of the United NationsConvention on the Rights of People with Disabilities.77.2. Globalisation of Disability Rights Law: The Impact in AustraliaLee Ann Basser, La Trobe University (l.basser@latrobe.edu.au)The Australian Institute of Health and Welfare estimates that people with disabilities make up 19% of theAustralian population. In addition, Australian Bureau of Statistics figures show that one in five people inAustralia, 19 years or older, meet a criteria for a mental disorder (ABS: The National Survey of MentalHealth and Well Being, 1997). In the early 1990’s, the Australian Human Rights and Equal OpportunityCommission conducted a National Inquiry into the Human Rights of People with a Mental Illness. Thereport emphasised the importance of economic, social and cultural rights, as well as civil and politicalrights. The Commission’s final report was handed down in October 1993. It found that there werewidespread human rights abuses of people affected by mental illness. A number of positive outcomesfollowed this Report – an increase in resources, the development and implementation of a National MentalHealth Strategy, and legislative reforms. At around the same time, the Australian Parliament enacted the

226Disability Discrimination Act 1992 (Cth) – aimed at reducing the inequality experienced by people withdisabilities in all aspects of their daily lives.More than 10 years after the National Inquiry, people with disabilities and people affected by mental illnesscontinue 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 internationalhuman rights instruments and despite the fact that Australia has been a pioneer in many areas of disabilityrights laws, including laws relating to anti-discrimination, alternate decision making and mental health.This paper will assess the extent to which the current legislative regime gives effect to the human rights ofpeople with disabilities, and will consider the impact that the proposed UN Convention on the Rights ofPeople with Disabilities might have on domestic Australian law.77.3. Patient Rights in Seclusion and RestraintsAnne Koplin, Waukesha County Mental Health Centre, Milwaukee, USA (akoplin@hotmail.com)This presentation will discuss the issue of seclusion and restraint of potentially dangerous psychiatricpatients as practiced in the United States and in Israel, including new federal regulations implemented inthe 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. Theseactions can clearly be seen as a temporary, yet necessary, denial of patient rights for the benefit of theindividual and others.Seclusion and restraint have been accepted forms of treatment for decades. Most recently, the UnitedStates has implemented new guidelines regarding their use in certain settings. These changes are meant toprotect the patient from harm that may occur as a result of this form of treatment. These regulations clearlydefine the parameters for using these measures, and demand face-to-face physician evaluation within onehour of the written order for either seclusion or restraint. Israeli law regarding seclusion and restraint willalso be reviewed.Protecting patient rights while at the same time using forceful means of confining the patient, can be afragile balancing act. The trend towards more limited use, and a higher degree of supervision andmonitoring regarding their use, has made an impact on patients and psychiatry in general. Increasedregulation of the use of seclusion and restraint is a positive, essential step towards greater patients’ rightswhile providing a necessary limit upon dangerous behavior.77.4. Economic and Scientific Determinism as a Means of Privatizing Disability: theImpact of the Globalization of Disability Rights LawMarcia Rioux, York University (mrioux@yorku.ca)This paper looks at the limitations of economic and scientific rationalization of public policy decisions, andthe welfare state itself, to demonstrate that social citizenship needs to be re-thought within a framework ofpublic good. It explores the way in which the frontier between public and private is not static anddemonstrates that what is determinant for the lives of people with disabilities are the economic pressures toreduce redistributive policies. This is important because in the area of social policy a necessary condition

227of 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 thenthe development of binding international and national disability rights law is imperative. The presentationwill draw attention to the way in which the boundary between the private and public falls is alwaysdynamic and is a consequence of economic and legal pressures to shift the responsibility for disability fromone sector to another.77.5. Developments in Mental Disability Rights LawEric Rosenthal, Mental Disability Rights International (erosenthal@mdri.org)Mental Disability Rights International, based in Washington, D.C., researches abuse and mistreatment ofpeople with disabilities worldwide. Since 1993, MDRI has documented deplorable and inhumaneconditions in institutions to which people with mental disabilities have been subjected, published reports onhuman rights enforcement, and promoted international oversight of the rights of people with mentaldisabilities. Drawing on the skills and experience of attorneys, mental health professionals, human rightsadvocates, people with mental disabilities and their family members, MDRI trains and supports advocatesseeking legal and service system reform. and assists governments to develop laws and policies to promotecommunity 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 peoplewith mental disabilities. Even today, international human rights organizations are not always aware of theplight of people with mental disabilities in the countries they investigate. But in recent years, the rights ofpeople with mental disabilities has indeed become an issue of global concern. MDRI alone has preparedreports about conditions of people with disabilities in Uruguay, Hungary, Russia, Mexico, Peru, andKosovo, and most recently in Paraguay. In addition, the UN is now considering a treaty on the Rights ofPeople with Disabilities, and governments of many countries have now enacted laws and changed policiesregarding 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 invarious countries regarding conditions of people with mental disabilities, particularly in institutions, anddiscuss developments under international and regional law to protect and expand the rights of people withmental disabilities.

22878. Health Care Restructuring in South Africa78.1. Children Infected and Affected by HIV/AIDS in South Africa: Legal, Ethical, andMental Health IssuesGretchen Domek, University of Oxford (gretchen.domek@balliol.ox.ac.uk)South Africa has been hit particularly hard by the AIDS epidemic, largely a repercussion of oppressiveApartheid policies. Currently, one in five adults across South Africa is living with HIV/AIDS, resulting ina rapidly increasing population of orphans. The most conservative estimates expect there to be over 2million South African orphans by 2010. The HIV/AIDS epidemic impacts children in many ways. Thesechildren suffer trauma and grief as they watch their parent(s) die, some contract HIV from their mother,many live in poorer households or children’s homes, and most experience stigmatization anddiscrimination. This presentation will examine the multifaceted issues facing children affected by AIDS inSouth Africa.First, there are important ethical and legal issues involved in testing children for HIV who cannot giveinformed consent. Establishing the HIV infection status early in a child’s life is important to facilitateadoption 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 SouthAfrican government uses the cheap HIV ELISA test that indicates whether an infant has been exposed toHIV rather than infected with the virus, many children are wrongly identified as having HIV. In theabsence of interventions to prevent mother-to-child transmission, 75% of children exposed to HIV will beuninfected, most of whom will have positive ELISA results. These false positives have devastatingimplications for both the child and the state. It is in the best interest of all parties involved to use the moreexpensive 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, theadvent of improved treatments and increased accessibility to medications have resulted in children livinglonger and healthier lives. As these children become adolescents and young adults, the issues of HIVdisclosure, education, confinement in a children’s home, and mental health and psychological well-beingbecome increasingly important and must be addressed.78.2. The Mental Health Care Act of South Africa; Implications for Mental HealthServicesRita Thom, University of the Witwatersrand (thomrg@medicine.wits.ac.za)Since the establishment of a democratic government in South Africa in 1994, there has been a new cultureof human rights in the country. While major restructuring of health services has taken place in South Africaover the last 10 years, mental health policy makers and service providers have worked hard to ensure thatmental health services are integrated into general health services and that they receive a proportionatelyjustified share of the available resources. As part of this process, and to ensure that mental health legislationreflected a human rights approach, in addition to taking account of new developments in the treatment ofpeople with mental illness, a review of the existing mental health legislation was carried out, and newlegislation was developed. This resulted in the passing of the Mental Health Care Act, No.17 of 2002. This

229legislation is likely to be implemented in the first half of 2005. The presentation will outline the mainfeatures of the legislation within the context of events and health services in South Africa, will compare thelegislation with that of other countries, and will discuss some of the implications for implementation in thepresent context in South Africa.78.3. Clinical Mental Health Care and the New Mental Health Care Act in South AfricaBernard Janse van Rensburg, University of the Witwatersrand (bernardj@gpg.gov.za)New mental health legislation (The Mental Health Care Act, No.17 of 2002) was promulgated in 2002 andis expected to be implemented during 2005. The aim of this act is: to provide for the care, treatment andrehabilitation of persons who are mentally ill; to set out different procedures to be followed in theadmission of such persons; to establish Review Boards in respect of every health establishment; todetermine their powers and functions. Main aims of the act include: the promotion of human rights ofpeople with (mental) disabilities; improvement of mental health services through a primary health careapproach and an emphasis on community care; protection of the safety of the public; setting out theframework and statutory roles with respect to voluntary users, assisted users, involuntary users, statepatients and mentally ill prisoners.Health services in general are rendered on three tiers: primary, secondary and tertiary level. Mental healthservices 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”/Super-specialist) facilities.The author is currently employed as a full time state psychiatrist jointly responsible for service delivery instate hospital to the Gauteng Provincial Authority, but also to the University of the Witwatersrand foracademic duties including (under- and post graduate) teaching of health sciences students and research. Anoption for part time private work by clinicians is also currently still maintained by the State Service throughthe so-called “Remunerative Work outside the Public Service” (RWOPS) agreement and contract. Thispresentation will review the mental health care environment (public and private) from a clinician’sperspective and will report on the changes in, implications for, realities of, and challenges for mental healthcare provision within the context of the new mental health legislation.78.4. Complexities of the Discharge Process from Long-term Psychiatric Institutions ina Developing CountryMarilyn Lucas, Monash University (Marilyn.lucas@arts.monash.edu)John Victor Weinkove, Witbank Hospital, South AfricaBernard van Rensburg, University of the WitwatersrandPrior to the 1994 elections in South Africa that brought democracy to the country, patients with chronicpsychiatric illnesses were usually cared for in large institutions. Care was generally custodial and alongracial 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, includesdeinstitutionalisation and reintegration into the community. However, these interventions have proveddifficult to implement for a variety of reasons including lack of community facilities and support for the

230mentally 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 thefamilies of patients. This presentation has two components. First, it will provide a case study about thesearch 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 anunusual situation in South Africa and this case study poignantly highlights how such alienation occurs. Italso highlights the extreme steps sometimes required to find and return a discharged patient to their familymembers. Second, the results of a quantitative study carried out at a similar institution are presented. Theresults of this study explain the process of identifying suitable candidates for reintegration into thecommunity, and the efforts made to arrange and obtain successful alternative placements. Problemsencountered in this process included limited community resources, reluctance of other organizations toaccept psychiatric service users, and the nature of the time constraints placed on the institutional staff topursue successful alternative placement options.78.5. Advancing Advocacy for Schizophrenia in South AfricaMarilyn Lucas, Schizophrenia Foundation of South Africa, Gauteng, South Africa(info@schizophrenia.co.za)The Schizophrenia Foundation of South Africa began in August 1999 with high expectations. South Africahad been a democracy for five years and, at a government level, conceptual shifts had been made in howmental illness was viewed. The National Department of Health planned to address previous inadequaciesin mental health services by promoting deinstitutionalisation and reintegration of previouslyinstitutionalised persons into community life, incorporate mental health care into the primary health systemand revise the Mental Health Act. The goals of the Foundation were to lobby both local and internationalcommunities for illness awareness, provide advocacy, information and counselling to those withschizophrenia, their family members and the larger community. Five years later, the Foundation has, interalia, produced numerous guidelines and public responses resulting in improved knowledge and awarenessin the media and general public, but failed to reduce stigma surrounding mental illness or motivate familiesto contribute to advocacy responsibilities. The reasons for these failures include: i) schizophrenia not beingan “attention getting” disease, ii) lack of funding and iii) lack of implementation of policy changes. Thetrials and tribulations of operating an Advocacy group in the developing world are discussed.78.6. Deintitutionalization, Community Care and the New Mental Health Care Act inSouth AfricaDorothy Sekhukhune, Lifecare Special Health Services, South Africa(Dorothy.Sekhukhune@newname.co.za)Lifecare Special Health Services with 9000 beds in 22 hospitals provides a specific range of acute, subacuteand chronic healthcare services on a contract basis to provincial government of South Africa. It is oneof the largest public-private partnerships in the country. The large component of the services provides formedium to long term care treatment and rehabilitation of the chronic mentally ill and intellectually disabledpatients, 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

231rehabilitation of chronic psychiatric patients with the aim of integrating these patients back into thecommunity.Lifecare began the de-institutionalization programme post 1994 and has since reduced the psychiatric bedsfrom 10,000 to 6000; patients have been placed back into the community with either the family or withinNon Government Organisations ( NGO ).This paper examines the issues pertaining to the role played by the multidisciplinary team, the patients,their families and the community in preparing these patients for integration, and their experiences in theimplementation 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 communitybased care supported by the hospital, multidisciplinary team and family involvement within the NGOstructures in the community has resulted in patients who were institutionalised for years being able to copein the community with minimal support.79. Homicide and Mental Illness79.1. “I’m Sorry I did it…But He Started it”: A Comparison of the Official and Self-Reported Homicide Descriptions of Psychopaths and Non-PsychopathsStephen Porter, Dalhousie University (sbporter@dal.ca)Mike Woodworth, University of British Columbia – OkanaganAlthough psychopaths are notorious for their prodigious use of deception, little empirical research hasexamined the manner in which they deceive. In this study, we concurrently examined the nature of violencein 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, theincarcerated homicide offenders (N = 50), classified as psychopathic or non-psychopathic according to thePsychopathy 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 theiroffence in as much detail as possible, followed by open ended questions relating to the crime. Theinstrumentality/reactivity and major details of their violence were coded from the official files, after whichthe offenders’ own accounts were similarly coded. Results indicated that psychopaths were more likely tohave committed instrumental (premeditated, goal-driven) homicides. However, this instrumentalitydifference disappeared when the offenders’ narratives were examined. Psychopaths exaggerated the

232reactivity 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.79.2. The Historical and Cross-National Study of Homicide and Other Social IssuesLeonard Beeghley, University of Florida (lbeegh@soc.ufl.edu)This paper makes use of the ideas of Max Weber, Emile Durkheim, Robert K. Merton, and others tosuggest a theoretically informed empirical strategy for understanding homicide. First, data was assembledhistorically and cross-nationally. Historical data allows for an assessment of change over time. Crossnationaldata allows for an assessment of variation across nation states. Questions arise based on the data.Second, social psychological and structural explanations were distinguished between, noting that theexplanatory variables differ at each level. Social psychological explanations always focus on whyindividuals commit homicide (or some other behaviour). Structural explanations always focus on how ratesof homicide (or some other behaviour) vary over time and across society. Structural variables are ofinterest in this paper. We want to understand why rates of homicide vary over time and across severalsocieties, such as the United States, Sweden, France, and Germany. Third, a logical experiment wasdeveloped to test these key variables. This “experiment” is analogous to a regression analysis, except thatthe variables are manipulated logically rather than arithmetically. This strategy is necessary because it is aparadox of criminology, sociology, and many other disciplines that some of the most important issues arenot susceptible to precise measurement, even though – as with homicide – their component parts aremeasurable. Although imperfect, this strategy provides the only way to solve this dilemma. Note that theissue, here, is not between a correct and incorrect answer, but between the best answer that can be givenand no answer at all. The result, especially when dialogue occurs, leads to a working hypothesis thatexplains variations in homicide rates. As implied, this strategy can also be used with other problems ofinterest.79.3. Characteristics of Homicide Perpetrators Among Italian Forensic HospitalsInmatesAngelo Fioritti, Department of Mental Health, Rimini, Italy (afioritti@auslrn.net)Vittorio Melega, Regione Emilia-RomagnaElisa Ferriani, Azienda USL BolognaThe objective of this study was to identify distinctive clinical and social features of the psychiatric patientswho committed homicide among inmates of Italian forensic hospitals. Clinical and social characteristics offour cohorts of patients were compared: 64 inmates who committed or attempted homicide (Hs), their 64matched controls from community services caseloads, 54 inmates who committed other crimes and their 54matched controls from community services caseload. When compared with other inmates, patients whocommitted 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 andsuspiciousness factor), better premorbid adjustment (socioeconomic status, employment), and surprisinglybetter behavioural profile (less compulsory admissions, less previous criminal records, less substanceabuse, less frequently in charge by community services). When compared with their matched controls Hshad lower psychopathology, better adjustment, and similar behavioural profiles. Italian inmates of forensichospitals who committed or attempted homicide have clinical features and personal histories which are far

233from the stereotype of the violent and dangerous psychiatric patients. The risk assessment proceduresroutinely performed in several countries may detect violent, but not homicidal behaviour.79.4. Patricidal Juveniles and Questions of Early AbuseCarl P. Malmquist, University of Minnesota (Malq001@Atlas.Socsci.umn.edu)Parricidal acts by juveniles are one type of homicide which requires that specifics be elicited to understandthis type of behaviour in contrast to other types of homicides. In many cases it immediately raises aquestion of certification to adult criminal courts when the perpetrator is in the juvenile age range and thereis no requirement that he or she be handled in the adult criminal system. In some cases legal issues ofcompetency 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 legalquestions. After the act has occurred, the issue of preceding physical or sexual abuse may be raised. Thisnot only leads to questions of determining alleged past facts in courtrooms, but also leads to questionsregarding the role of clinicians when this type of issue is raised. This especially becomes a problem if anindependent psychiatric evaluation cannot be conducted.There is also the continuing debate on whether a specific syndrome regarding child abuse exists. Whilethere is some agreement in the psychological and psychiatric literature about the effects abuse can have ona child, the conclusions are tentative in view of continuing investigations. The analogy is often usedbetween battered child syndrome and battered woman syndrome, but this is not based on empirical andclinical work but rather an analogy that is used in legal proceedings.80. Housing and the Homeless80.1. The Use of Compulsory Hospitalisation as an Intervention Strategy withHomeless Mentally Ill PeopleTim J. Amor, Soho Centre for Health and Care, London, England (timamor@doctors.org.uk)Wendy Harding, Soho Centre for Health and Care, London, EnglandThe Westminster Joint Homelessness Team (JHT) was established in 1990 as part of the UK government’sHomeless Mentally Ill Initiative (HMII) to address the growing recognition that a significant proportion(perhaps 30-50%) of rough sleepers had a serious mental illness. The JHT is one of 5 such teams acrossLondon, employing a range of professionals including social workers, mental health nurses andpsychiatrists, that target the homeless mentally ill who are not already in contact with existing mentalhealth services.The ethos of the team was initially to attempt to engage individuals on a voluntary basis, with those whorefused help being left alone unless they seemed to present obvious risks to either themselves or others.

234However, there has been a gradual realisation that once such people have been hospitalised otherinterventions such as housing, improving social skills and decreasing psychotic symptoms by thecompulsory use of medication, become possible. With such help it has been possible to move people intoaccommodations where they have been able to maintain a higher level of functioning over time. This wouldseem 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 ofthe homeless mentally ill had only become homeless subsequent to the onset of their illness and weretherefore 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 initialoffers 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 ofconsidering the use of planned compulsory detention in hospital for assessment under the Mental HealthAct. In the JHT’s experience, this tends to improve longer-term outcomes, enabling a significant proportionof individuals to move away from street living to a more settled and secure lifestyle. However, the successof such a policy relies upon the accessibility of a range of good quality housing and support service options.80.2. Charities and the Mentally Vulnerable in England and Wales: Housing ProblemsWarren Barr, University of Liverpool (wbarr@liv.ac.uk)Nicola Glover-Thomas, University of Liverpool (nglover@liv.ac.uk)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-000-22-0286). This empirical project seeks to gain a better perception of the current role of charitiesin the provision of housing for the mentally vulnerable in England and Wales by seeking to classify thenature or type of housing provision made for the mentally vulnerable by charities. It also aims to ascertainthe legal and practical problems experienced by those organisations that are involved in providing housingto this group.The background to this research is as follows. The replacement of hospital based care of mentallyvulnerable individuals by care in the community environment did not recognise that housing would play animportant role in this policy's implementation. This oversight had led to many mentally vulnerableindividuals living in accommodations that are not appropriate to their particular needs or becominghomeless. 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 thoseindividuals whose needs have not been met by other means. Indeed, there is evidence to suggest that theactual role of charities goes well beyond the role that the charitable sector might be expected to play inhousing policy terms. Preliminary research has also indicated that some possible legal problems are alsofaced by these organisations in the provision of housing but owing to the dearth of empirical data on thisissue, 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 havethe 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 withdealing with social housing management or providing suitable accommodation to vulnerable groups, orthose considering policy and/or legal reform of the area (both including and excluding England and Wales).In the wider context, the experience of the voluntary sector in England and Wales highlights, at a microlevel,the difference between policy and practice in housing policy, and the dangers associated with the lackof a cohesive and well-supported housing strategy at a governmental level.

23580.3. Mental Capacity Issues in England and Wales: The Housing ContextNicola Glover-Thomas, University of Liverpool (nglover@liverpool.ac.uk)The Charity Law Unit (which is part of the Liverpool Law School) is conducting research into 'HousingThe Mentally Vulnerable - The Role of Charities', following an award from the Economic & SocialResearch Council (Award No: RES-000-22-0286). The empirical project seeks to understand the role ofcharitable organisations that are involved in the provision of housing for the mentally vulnerable inEngland and Wales. The research project has gathered qualitative data allowing a classification of thenature 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 organisationsin 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. Relianceon charitable bodies and other housing management services is also increasing. Since mental healthprovision in England and Wales became the subject of significant policy change over the last 25 years, caremethods have radically altered. Where the emphasis was once placed on psychiatric care being within aninstitutional setting, care is now offered to the mentally vulnerable within the less restrictive environmentof the community. Alongside this policy shift, housing the mentally vulnerable has become an increasinglydifficult proposition. The role of housing in the community care policy was ill conceived; little thought wasgiven to the nature and availability of housing stock that mentally vulnerable individuals would need. Thislack of foresight had led to many mentally vulnerable individuals living in accommodations that do notmeet 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 thisvulnerable 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 howobligations to house the mentally vulnerable living in the community are discharged in practice, narrowedwith particular reference to the difficulties associated with lettings being offered to those whose mentalcapacity might be subject to question. This paper will interest those who work within the field ofcommunity psychiatry and social service provision. It will also be of interest to legal academics andpractitioners who are interested in policy development and legal reform from a national and an internationalperspective.In considering the issue of housing provision for the mentally vulnerable, the nature of mental capacity andits impact on housing provision will be considered. How such capacity issues present difficulties fororganisations 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 toreform the law in order to facilitate housing provision will also be considered. Reflections will be made asto whether these legislative reforms have recognised the practical problems which stem from thepsychiatric policy shift let alone whether it deals with the issue of housing the mentally vulnerableeffectively.

23680.4. Changing Views of Homelessness: Moving from a “Management” to a"Business" ModelMary L. Durham, Center for Health Research Kaiser Permanente Portland, USA(Mary.Durham@kpchr.org)After twenty years of failed attempts to stem the rising tide of homelessness in American cities, a highprofile group of 39 U.S. Mayors signed an agreement in December, 2004 that changed the model foraddressing 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 abusiness model with a goal of eliminating homelessness within a 10 year period. The business model is adeparture from the typical “management” approach for the homeless which has failed to produce resultsnationwide. The Covenant relies on the identification and exchange of best-practices, the development andsharing 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 modelthat will ultimately be necessary in order to demonstrate value and a return on investment expected bymajor investors.81. Human Rights and the Mentally Ill I81.1. Human Rights of the Mentally IllJulio Arboleda-Flórez, Queen’s University (Ja9@post.queensu.ca)Over centuries, persons suffering from mental conditions were regularly subjected to deprivations andabuses of their most basic rights by virtue of laws or statutes aimed at taking them out of circulation in totalinstitutions for reasons that were more attuned to the protection of others than to their treatment, recoveryand reintegration to society. Institutionalization itself came fraught with abuse and deprivations beyondthose meted out to common criminals. Although much has been achieved to redress these abuses andimprove on discriminatory policies and statutes, much remains to be done before mental patients regain fullstatus as free members of society. This paper will review historical antecedents and practices and map outa course of action to improve on the human rights of mental patients.

23781.2. Mental Fitness and the Right to a Fair Trial; A Comparison of Legal DoctrinesPeter Bal, Maastricht University (Peter.Bal@strafr.unimaas.nl)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 mentaldisorder, the criminal prosecution will be adjourned so that the defendant can be committed to a psychiatrichospital and treated until he or she can later be rendered fit to stand trial. This adjournment of theprosecution can be for an indefinite amount of time.A comparable option for adjournment exists in many European or ‘inquisitorial’ criminal law systems (likethe Netherlands and Germany). However, unlike Anglo-American criminal law systems where adjournmentbecause of a defendant’s mental unfitness, is fairly common, in the continental systems this ground foradjournment is not often invoked.Concerning the legal aspects of this doctrine, a comparative analysis of differences and similarities in itspractical application in the diverse criminal law systems will be presented. In particular, this applicationwill be analysed from the perspective of human rights, specifically the right to a fair trial: is the doctrine offitness to stand trial a guarantee or an obstruction of this right?81.3. Mitigation Themes and Human Rights AbusesScharlette Holdman, Institute for Human Rights Investigation, San Francisco, USA(Ccascharlette@aol.com)Mitigating factors stem from the diverse frailties of humankind and are presented to the fact finder andsentencer to provide insight into the offender’s behavior. Mitigation is complex and multifaceted. Theoriesof mitigation are governed by principles of individualized sentencing and allow for great variation in theinformation presented to and considered by the court. Mitigation evidence is based on respect for theuniqueness of the individual and requires thoughtful presentation of the character and record of theoffender. It covers all relevant facets of the character and record of the individual in order to minimize therisk that a penalty will be imposed in spite of factors which call for a less severe penalty. It is based on theconstellation of factors that give insight into the offender’s behavior and functioning at the time of theoffence 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 ofthe offence under the theory that punishment should be proportionate to the offence. Circumstances of theoffence often shed light on an otherwise inexplicable act and call for a less severe penalty. Facts of theoffence may show that others were equally or more culpable but were not charged or exploited theoffender’s vulnerabilities. Relevant evidence may contradict the prosecution’s theory of the offence andprovide a basis for mitigation.

23881.4. Mental Health and Human Rights Law in the Americas: a New ApproachJavier Vasquez, Pan American Health Organization/World Health Organization (vasquezj@paho.org)According to recent studies and reports of international and regional human rights treaty bodies, in manyparts of the Americas, persons with mental disorders (and specially those who live in psychiatricinstitutions) continue to face mistreatment and stigma. Persons with mental disorders are often isolated inpsychiatric institutions, long term care facilities for older persons, prisons or other public facilities underliving 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 thecurrent situation of admission and subsequent retention of persons with mental disorders in psychiatric orother kinds of institutions is essential to achieve the “de-institutionalization” of the referred persons andconsequently to develop community based services where the right to freedom and security of person canbe exercised. Unfortunately, most of the countries of Latin America and the Caribbean have still notenacted mental health legal frameworks that refer specifically to the right to due process of law, judicialguarantees and other related human rights and fundamental freedoms in the context of the aforementionedinstitutions. Thus, the first section of the presentation will discuss the most relevant general human rightsand fundamental freedoms, which are intrinsically related with the highest attainable standard of mentalhealth, 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 HealthOrganization/World Health Organization (PAHO/WHO) is currently conducting to promote and protectmental health in the Americas through international human rights principles, instruments and bodies, andthe impact that this new approach is having on the reform of mental health policies, domestic legalprocedures, practices and services. For instance, the presentation will refer to the outcomes of the “nationalhuman rights training workshops” in areas such as the monitoring of living conditions in public institutionsand the empowerment of consumers, among others. In addition, PAHO’s technical collaboration withregional human rights bodies such as the Inter-American Commission on Human Rights (Organization ofAmerican States) and the use of regional human rights mechanisms to protect the right to the highestattainable standard of mental health and other related human rights will be explained.81.5. Mental Health, Obesity, and Human Rights PolicyLeo B. McGrady, Barrister and Solicitor, Vancouver, Canada (lmcgrady@mbwlaw.ca)Over the past quarter century, one of the primary health policy instruments employed in Canada to addressproblems with the mental health of populations has been human rights legislation. Many human rightsregimes have developed thoughtful and sophisticated analyses of mental disability as a prohibited ground,as it occurs in different settings: publications, accommodation, landlord-tenant relationships, andemployment.That is not the case, however, with issues of obesity and mental health matters associated with obesity. Theapproach of many legislators, human rights tribunals, as well as legal writers, has been muddled andcontradictory. Cases often fail over the requirement in some legislation, for example, that the disabilityhave its origins in an illness; or an inquiry into whether obesity is within the complainant’s control; or somesimilarly unproductive and in itself often discriminatory inquiry.Increases in obesity rates have been experienced for at least the past 20 years. However, obesity hasreached the point where a 2003 World Health Organization Food and Agriculture Report used expressions

239like “global obesity epidemic”. Nor is the problem localized, nor peculiar to developed or undevelopedcountries. The rapid acceleration in problems flowing from obesity is being experienced in the UnitedKingdom, Ghana, Brazil, the U.S., and Canada, to name a few. Obesity appears in perhaps its most acuteform 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 commentatorsemployed in dealing with mental health and other issues flowing from obesity are exacerbated by the factthat obesity is often associated with conditions of poverty. Recent U.S. and French studies suggest thismay be the case. Yet other than a rather oblique protection offered by the Québec Charter of HumanRights and Freedoms, Canadian human rights statutes simply do not address issues of poverty, nor indeedof any economic rights. We thus have obesity-related mental health problems only occasionally addressedby human rights legislation, and the associated problem of poverty simply not covered at all. At the sametime, 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 misconceptions about obesity/mental health issues arising fromlegislation 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 frommental disability and obesity, and in the treatment accorded the issue by the courts and human rightstribunals.81.6. Mental Health Law and Human Rights: The Australian ExperienceBernadette McSherry, Monash University (Bernadette.McSherry@law.monash.edu.au)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 concerningchanges to mental health law in Australia. Its prime recommendation was that mental health should beevaluated against human rights standards. Since then, while there have been attempts to measure civilcommitment legislation against human rights instruments, there have been significant developments thatindicate 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 rightsprinciples. The analysis will approach the question of whether mental health law in Australia measures upto human rights standards. Unlike other countries, Australia does not have a Bill of Rights. It has aConstitution which was drafted at the end of the nineteenth century and which contains few references toindividual 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 Illnessand for the Improvement of Mental Health Care (1991) into domestic legislation. This paper reconsiders therecommendations of the Burdekin Report and assesses what progress, if any, has been made in relation tomental health law and human rights.

24082. Human Rights and the Mentally Ill II82.1. With restraint: Towards the Elimination of “Cage Beds” in Central EuropeDiana Beth Hoover, Mental Disability Advocacy Center, Budapest, Hungary (dhoover@mdac.info)Oliver Lewis, Mental Disability Advocacy Center, Budapest, HungaryThis paper will outline the campaign by the Mental Disability Advocacy Center (MDAC) to end the use ofcage beds in the Czech Republic, Hungary, Slovakia and Slovenia. These ex Austro-Hungarian countrieswithin the enlarged European Union have all historically used cage beds, defined as netted or metal cagesenclosing 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 laysout the circumstances in which cage beds are used, justifications given by staff and testimony of victims ofcage bed use. The use of cage beds violates the absolute prohibition in international law of inhuman anddegrading treatment. The United Nations, Council of Europe and European Union – as well as the author ofthe Harry Potter books – have all called for the eradication of this widespread and dangerous form ofrestraint. To what extent have these countries’ governments taken steps to meet their international legalobligations to eradicate cage bed use? Are cage beds merely symptomatic of the broader issue, namelysystems of institutional and custodial care, which place little emphasis on integration and (re)habilitation?82.2. Proving Madness under Article 5(1)(e): The Burden and Standard of ProofPaul Bowen, London, England (p.bowen@doughtystreet.co.uk)Until 2001, patients detained in England and Wales under the Mental Health Act 1983 were required toprove that that they were no longer mentally disordered or dangerous before they could secure theirfreedom from a Mental Health Review Tribunal. This rule was the subject of one of the first challengesunder 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 onHuman Rights (R (H) v Mental Health Review Tribunal [2002] QB 1). The Mental Health Act wassubsequently amended. A similar challenge was made to the Scottish Mental Health Act in the Strasbourgcase 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 sothe burden of proving those criteria in Article 5(4) review proceedings rests upon the State. No English orStrasbourg case-law has yet considered the question of what the appropriate standard of proof should be insuch proceedings. Prior to the change of the law in England and Wales it was accepted that the ordinarycivil standard of ‘balance of probabilities’ applied. In the USA, on the other hand, the US Supreme Courthas ruled that the 14 th Amendment requires proof of mental disorder and dangerousness in civilcommitment proceedings to a higher standard of ‘clear and convincing evidence’, although the criminalstandard of ‘beyond reasonable doubt’ is not necessary (Addington v Texas). In a later case the USSupreme Court ruled that the same principle applies in relation to mentally disordered individualscommitted in criminal proceedings (Foucha v Louisiana). In a separate development, the House of Lords ofEngland and Wales has recently decided that in some civil proceedings where what is at stake for theindividual is very serious, the civil standard of proof may be a ‘heightened’ one that is ‘indistinguishablefrom the criminal standard’ of ‘beyond reasonable doubt (R (McCann) v Crown Court at Manchester [2003]

2411 AC 187). The question of whether, in the light of these developments, Articles 5(1) and 5(4) of theConvention 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 thecase of R (N) v Mental Health Review Tribunal. Judgment is expected shortly.82.3. Legal Responses to Deaths in Psychiatric and Social Care Institutions in Centraland Eastern Europe and Central AsiaOliver Lewis, Mental Disability Advocacy Center, Budapest, Hungary (dhoover@mdac.info)Marit Rasmussen, Mental Disability Advocacy Center, Budapest, Hungary (mrasmussen@mdac.info)There is disturbing evidence that in a number of countries within Eastern Europe and central Asia mortalitylevels in psychiatric and social care institutions have at times been grossly elevated, effectively convertingpsychiatric morbidity into mortality. Notwithstanding the limited financial resources devoted to treat andcare for this population, many of avoidable deaths are caused by deprivation of basic human necessitiessuch 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 byoutside organizations.In case law developed in the 1990s, the European Court of Human Rights has interpreted Article 2 of theEuropean Convention on Human Rights – the right to life – as imposing on a State procedural obligationsto investigate cause of death by an open and independent system of inquiry, in addition to the substantiveobligation reasonably to preserve life. High and avoidable mortality rates undoubtedly violate thesubstantive rights of those at risk, but in addition there is widespread non-compliance with the proceduralobligations which the Court has developed. This paper will outline the legal obligations on States, examplesfrom around the region and strategies for challenging cursory or non-existent death investigations andfailures of the State to preserve life.82.4. The African Commission on Human and Peoples’ Rights and Mental Health LawPaul Moore, MIND in Barnet, England (ppepininth@hotmail.com)The African Commission on Human and Peoples’ Rights is the youngest of the three regional human rightssystems, and it was only in 2003 that it considered its first mental health case: Communication 241/2001Purohit and Moore/ The Gambia 16 th Activity Report.The African Commission decided in the above mentioned case that the following human rights articles inThe African Charter had been violated: the right against discrimination, the right to equality, the right todignity and prohibition of torture and inhuman treatment, the right to a fair trial, the right of politicalparticipation, the right to the best attainable state of mental health, and the right to special measures ofprotection. The Commission surprisingly found that the right to liberty and security had not been violated.An application for revision of the decision regarding the right to liberty and security has been tabled forconsideration at the forthcoming Session of the African Commission to be held from 27 April to 11 May2005.This paper will look at: who can bring a communication before the African Commission, admissibilityunder the African Charter, the regional human rights treaty, the specific details of the case of Purohit and

242Moore/The Gambia and an examination of the potential benefit that the (soon to be established) AfricanCourt on Human Rights may provide to people using mental health services in Africa.One of the recommendations made by the Commission in the decision is that The Gambia should reform itsmental health legislation namely, the Lunatics Detention Act 1917. This could have repercussions for otherAfrican countries that have similar mental health legislation.82.5. The Realization of the Austrian Commitment Law in the Mental Health Hospitalin Graz: A Statistical ComparisonMichael Scherf, Association for Guardianship and Patients’ Advocacy, Graz, Austria(graz@patientenanwalt.at)The Austrian Commitment Law is in force since January 1 st , 1991. Within periodical intervals the PatientAdvocacy carries out statistical investigations in order to show how this Act affects the in-patient treatmentin 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 ofcommitment in the closed area, the manner and reason for the commitment, the frequency of recommitmentin the closed area within one year respectively since the Act is in force and the result of thejudicial review. By means of such statistical recordings subjective perceptions in discussing theimplementation of the Commitment Law shall be evaluated.82.6. The Implications for People in Europe with Intellectual Disabilities of theDecision of the European Court of Human Rights in L. v. U.K. (the “BournewoodHospital” case)Mark Mullins, Outer Temple Chambers, London, England (mark.mullins@outertemple.com)This presentation will analyse the judgment 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 considerthe Court’s latest thinking on the meaning of “detention” under Article 5 of the European Convention ofHuman Rights, the Convention’s procedural requirements for the detention of people with intellectualdisabilities and the right of detained persons to an effective judicial review of their detention. It willcompare 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 theindividual rights of people with intellectual disabilities.

24383. Human Rights and the Mentally Ill III83.1. International Aspects of the Human Rights of Mental PatientsMarianne Kastrup, Centre Transcultural Psychiatry, Copenhagen, Denmark(marianne.kastrup@rh.hosp.dk)According to the UN Human Rights Declaration, a basic assumption is that all men have certainfundamental rights. All men have a wish to live free from violence, famine, disease, torture anddiscrimination as pointed out by the UN Secretary General, and such rights belong not to a chosen few, butto all of us.In recent years, we have witnessed an upsurge in the attention paid to the ethical and human rights aspectsof the psychiatric profession.Today, the psychiatric profession is guided by a number of rules and declarations. Some are common to allmedical professionals like the WMA Tokyo Declaration. Others reflect the specific role and problems ofthe 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 ofspecific concern for our discipline contrary to other medical disciplines, namely the potential risk of thepsychiatric profession to take part in any abuse of the profession.Much attention has been paid to alleged political abuse where psychiatric care and psychiatric diagnoseshave been used on non-mentally ill persons. To avoid this, it is imperative that a psychiatric diagnosisshould be determined according to internationally accepted standards and difficulty in adapting to certainmoral or social values in it self should not be considered a mental illness.83.2. Patient Rights in Psychiatry: Clinical Guidelines and International PerspectivesFederico Allodi, Ministry of Health, Toronto, Canada (fallodi@pobox.com)In the last decade the international human rights movement has had a profound effect on the practice ofpsychiatry across the globe. Primarily, UN legislation concerning the rights of persons, and specifically therights of the mentally ill, has found its way into national and provincial or state legislations. This paperreviews this international legislation as well as other mental laws existing in English speaking and othercountries at different stages of development, and the mechanisms existing in various countries for theadministration and the implementation of the law. It offers the clinician the required knowledge of thelegislation with emphasis on involuntary admission or detention in an institution and on the patient’scapacity to consent to treatment. The legislation also refers to the assessment of the mental competence toexamine or consent to the disclosure of the patient’s own records, managing property and admission to ahealth care facility.Specific guidelines are given to the practicing psychiatrists to examine the patient, assess grounds forinvoluntary detention/admission, capacity/ competence to consent, to document findings and proceduresand inform patients of the findings and consequences of the same. Should the patient, next of kin orsubstitute decision maker challenge those decisions the doctor has the legal responsibility of justifying themin front of government officials or legally constituted board or tribunal. The paper emphasizes the need for

244training the psychiatrist in the preparation and presentation of his/her case in the quasi-judicial oradjudicating nature of the hearings. To this purpose a number of principles and guidelines are offered. Thepaper concludes with the proposition that these historical and critical changes in our clinical field representin 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 providedtruly deserve.83.3. Mentally Ill Offenders and the European Court of Human RightsPauline M. Prior, Queen’s University at Belfast (p.prior@qub.ac.uk)Mentally ill offenders find themselves at the intersection of the healthcare system and the criminal justicesystem in most countries. Decisions about their care often involve lengthy discussion on the more generaldebate of care versus control in society. In this paper, we focus on one aspect of this debate - that of humanrights. Though governments have a duty to protect the rights of all their citizens equally, it is often the casewith mentally ill offenders that the emphasis is on the protection of society from possible danger rather thanon 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 thedifficulties inherent in ensuring appropriate care to individuals and safeguards to the public at the sametime. The countries represented in this selection of cases include the United Kingdom, Belgium, Norwayand Austria. The issues debated in the ECHR relate to the right to assessment and to a review of treatmentand detention, the right to appropriate treatment at all stages of the detention, and the right of the state tointervene in the life of an individual in order to prevent suicide. Many of the ECHR judgments have led toclarification of the issues involved in the imprisonment of mentally ill offenders during and beyond thetariff time for their offence. They have also led to improvements in services for this group of people, someof whom are serious offenders and some of whom are not.83.4. Prisoners’ Rights: Protection by Inspecting JudgesAlbert Kruger, High Court, Bloemfontein, South Africa (albertkr@global.co.za)Prisoners are a vulnerable group. Their rights can easily be abused. The Constitution of South Africa, Act108 of 1996 in section 35(2) guarantees certain rights for all sentenced prisoners, including the right toconditions of detention that are consistent with human dignity. The Inspecting Judge of Prisons, JudgeFagan, 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 for114747, we have 184806 prisoners crammed in, i.e. 70000 above capacity.” Goyer, Prison Privatisation inSouth Africa, says that overcrowding inevitably leads to poor sanitation and hygiene, and impacts on theprovision of basic services including adequate nutrition and hygiene. She says that due to poor medicaltreatment of contagious diseases which thrive in the prison environment, prisoners return to the communitysicker than they left and take their sicknesses with them. She estimates the current HIV infection rate inSouth African prisons to be at least 30%.Chapter III of the Correctional Services Act 111 of 1998 contains provisions for minimum conditionsregarding accommodation, nutrition, clothing, bedding and health care. The Department must provideadequate health care services. Chapter IX of the Act provides for the judicial inspectorate, an independant

245office under the control of the inspecting judge, who inspects prisons in order to report on the treatment ofprisoners and on conditions in prisons.A prisoner may not, even with his or her consent, be subjected to any medical, scientific experimentation orresearch. A prisoner may not participate in clinical trials except with the Commissioner’s approval given onapplication 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 prisonswere visited by judges. The only power which the Act gives judges is to report to the minister. During thesame period, judges ordered the release of two terminally ill prisoners. Judges can make an importantcontribution to ensure that prisoners’ rights are respected, in reporting abuses and ordering release inappropriate cases.83.5. Protecting the Human Rights of Patients: The International Legal FrameworkAnna-Lena Svensson-McCarthy, Lawyer - Human Rights Consultant and Trainer(al.svensson.mccarthy@bluewin.ch)Increasing detailed knowledge about international human rights law and practice is becoming ever moreimportant 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. Internationalhuman rights law is applicable to all persons, and thus protects the rights of medical patients, includingthose deprived of their liberty for varying reasons. Lawyers and physicians share the duty to work for thebest interests of their clients, and inter-professional exchanges of knowledge can be indispensable forpurposes of increasing the understanding of the patient’s/client’s problems and for ensuring the effectiveprotection of his/her rights. This presentation will focus on the major sources of law of interest to medicalhealth 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 HighCommissioner for Human Rights in Geneva and the International Bar Association in London. ThisManual, while not addressed to medical health professionals, as such, still provides essential basicinformation for all professions regarding legal texts and jurisprudence on a considerable number of relevanthuman rights and fundamental freedoms.

24684. Hunger Strikes: Ethical and Medico-psychologicalImplications84.1. Medical, Psychological and Ethical Aspects of Prolonged Hunger Strike:Consequences and Follow-up of the Experience in Turkey, 2000-2003Metin Bakkalci, Human Rights Foundation of Turkey, Ankara, Turkey (tihv@tr.net)Umit Sahin, Human Rights Foundation of Turkey, Ankara, Turkey (tihv-w@tr.net)In the year 2000, Turkey faced many hunger strikes in the prisons. The reason was launching new F-typetype prisons which were designed with high-security facilities and isolation cells. Thousands of prisonerswent on prolonged hunger strikes to protest the introduction of these new F-type prisons. Duration ofhunger strike periods was up to 300 days or more. Because of these hunger strikes, 112 people died, andhundreds of people lost their health and became disabled.As a result of the hunger strike actions, diverse numbers of health problems have arisen. Duration of theaction, the way the action ended (forced or willingly), the amount of food and beverages taken during thehunger strike and the individual characteristics of the striker had particular effects on the type and severityof the health problem occurred. Wernicke's Encephalopathy, Wernicke-Korsakoff Syndrome, nutritionalperipheral polyneuropathy, common and proximal muscle weakness, severe or temporary amnesiaconditions, 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 theseclinical pictures, the Wernicke's Encephalopathy and Wernicke-Korsakoff Syndrome are known as the oneswhich develop due to a decrease in the Thiamin (vitamin B1) supply. Other clinical pictures mentioned aremostly related to malnutrition or to a lack of essential nutrients, primarily proteins, fatty acids and othervitamins. Also PTSD, depression and other psychiatric pictures were to be occurred. These medical andpsychological conditions need intense and long term care and follow-ups.HRFT currently offers medical and psychiatric treatment, physical therapy and rehabilitation to 614 hungerstrike survivors. 563 of such consist of hunger strikers who admitted to HRFT subsequent to the hungerstrike actions made in the year 2000 and later. Most of the admissions were made in the years 2001 and2002 (in 2001, 338; in 2002, 185; in 2003, 40 admissions). 51 of the total admissions were made as a resultof the similar hunger strike actions made prior to the year 2000 (such as the hunger strikes made in 1996and before).In this paper, we present some detailed medical and psychological consequences of this specific period ofhunger strike actions. Also ethical aspects of hunger strikes in the light of the experience by the HumanRights Foundation of Turkey and Turkish Medical Association are to be discussed.84.2. Discussion: Guidelines for Treatment and Nutrition After StarvationSiroos Mirzaei, Wilhelminenspital, Institute of Nuclear Medicine, Vienna, Austria (mirzaei@gmx.at)Medical assistance after starvation includes nutritional and therapeutic measures to prevent side effects of anon-adequate food re-intake. Through discussion with other speakers and participants easy to useguidelines will be presented.

24784.3. Pathophysiology of Hunger StrikeSiroos Mirzaei, Wilhelminenspital, Institute of Nuclear Medicine, Vienna, Austria (mirzaei@gmx.at)Food deprivation for periods of several weeks has been reported whereby the average weekly weight loss is2-3 Kg. However, significant weight loss occurs during the first week. During starvation there arepathophysiological changes in the body which reflect the adaptation of the body to the situation of caloricdeprivation. The protein synthesis and immune response are altered. The body mass Index (BMI, weight inkg divided by the square of the height in m) decreases. Reportedly, individuals with a BMI of less than 18.5kg/m² should be regarded as undernourished and evaluated for possible treatment. The disadvantage ofBMI for monitoring of the individuals in hunger strike (as in the case of prisoners on hunger strike) is that itis static and rather insensitive to small changes in weight. Measuring of skinfold at one or more places onthe body are indirect measures of the body’s total fat mass. The most common technique used for this is thetriceps skinfold, using a calliper on the back of the upper arm. A starved body attempts to reduce proteincatabolism, uses preferentially ketones and fatty acids and recycles glucose from gluconeogenesis. It savesits more essential proteins, such as haemoglobin, albumin, and cardiac muscle. In this paper we’ll discussmeasurable parameters for monitoring of individuals with food refusal, especially in the case of prisonerson hunger strike.84.4. The Hunger Strike as Political, Medical, Moral and Human Rights ProblemJames Welsh, Medical Program Amnesty International, London, England (jwelsh@amnesty.org)Hunger strikes can pose acute difficulties to the striker, to the striker's supporters, to medical staff and tohuman rights organizations. They represent a very particular form of protest in which the striker maygamble her or his health, or even life, against the moral or strategic response of the power holder who hasthe means to grant or withhold concessions. Most hunger strikes, or other forms of food refusal, resolvethemselves in a short time, either because the striker intended only a short symbolic protest or theexperience of the strike causes the hunger striker to end her or his action quickly. However extendedperiods of food refusal, including those conducted as part of a mass political action, can lead to deaths orlong-term physical and mental deterioration. They reflect politically motivated action, in terms of both ahealth and ethical dimension; they touch on the moral values of the striker, carers and state decision-makerand challenge both supporters of the hunger striker and civil society organizations working to promotehuman rights. Current autonomy-based ethical standards call on doctors (and arguably others) to respectpatient autonomy and to abjure non-consensual feeding. However some professionals oppose acquiescingin 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 ofdual loyalty obligations. The ethical considerations escalate as the hunger strike progresses and thequestions of patient competence and best interests become more complex and the political environmentevolves. This paper discusses the hunger strike as a political, medical, and moral and human rightsproblem.

24885. Indigenous Peoples’ Issues85.1. Social Suffering: An Anthropological Analysis of the Embodiment of InequityNaomi Adelson, York University (nadelson@yorku.ca)The study of social suffering and structural violence emerges out of critically and sociallyengaged social scientific theories that address the embodied effects of traumatic and protracted histories ofsocial inequalities. Medical anthropologists draw upon the category of social suffering as a way toexamine, 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. Usinga specific ethnographic example, I address the nuanced complexity of the social and cultural contexts ofsuffering at the interface of the body and society and, through this, illustrate the ways in which a history ofinequity impact on Aboriginal peoples’ present-day social worlds.85.2. Western Genetic Researchers and Indigenous Populations as Human Subjects:Three Dimensions of Indigenous Psychology That Influence ResearchJanet K. Brewer, The Institute for Indigenous People's Rights, Lewes, USA(JKBrewer@indigenouspeople.us)Increasingly, Western genetic researchers are looking to indigenous populations, deemed genetic isolates,as subject pools for genetic research. However, typical research protocols and consent guidelines embodyWestern culture and beliefs, the implications of which have spawned heated international debate. Threedimensions of indigenous psychology underlie the clash of cultures: self and non-self, locus of control, andtemporal orientation. In essence, many indigenous populations are collectivist cultures whose members aregoverned externally, termed “ensembled individualism,” and conceptualize time as cyclical, orientedtoward the past. A thorough understanding of indigenous psychology is critical to ethically sound geneticresearch.85.3. Maori Gambling and Imprisonment: Interface of Addiction and CrimeLorna Dyall, University of Auckland (l.dyall@auckland.ac.nz)Gambling is increasingly being used by governments as a strategy to provide tax revenue to fund theirpriorities. Problem gambling is now recognized as a serious public health issue especially for Maori (theindigenous population in Aotearoa /New Zealand). It is estimated that one in three prisoners in NewZealand have had a gambling problem sometime in their life and over a third of women prisoners currentlyhave a gambling problem. Research in New Zealand has found that compulsive gambling is often the

249underlying reason why people are in prison and this situation is made worse with considerable gamblingtaking place within prisons.One in two New Zealander prisoners self identify as Maori. With this demographic profile this suggeststhat there exists a close relationship between New Zealand Government gambling policies and theimprisonment of Maori. This paper will discuss issues of gambling, criminal offending, imprisonment andinterventions which are needed for an indigenous population, such as diversion options. The mental healthstatus of Maori will also be discussed, as well as implications for recognition of excessive gambling as aserious public health issue.85.4. Aboriginal Community-Based Healing Initiatives in Canada: Making a DifferenceKimberly Fever, Aboriginal Corrections Policy, Ottawa, Canada (kimberly.fever@psepc.gc.ca)Issues of abuse within families and particularly Aboriginal families have been brought to the surface inCanada over the last decade. Part of the legacy of the residential school experience, sexual and other formsof abuse are affecting generations of Aboriginal families. As part of a community-based response to helpbreak the cycle of abuse and offending from being passed from generation to generation, Aboriginalcommunities and community-based organizations are developing holistic models of treatment forAboriginal victims and offenders with a focus on healing families.These projects are unique in that they offer culturally appropriate approaches to offender and familytreatment. The approach taken is one that addresses the root causes of criminal activity and proactivelyengages offenders, victims and families to break the cycle of abuse.These initiatives work within the current criminal justice system while bringing a unique alternative toimprisonment that can lead to stronger and safer communities. Communities engaged in these healingapproaches have seen benefits in terms of significantly reduced criminal activity, improved physical andmental health of individuals, attainment of higher education and an increase in positive parenting. All ofthese things contribute towards personal, family and community wellness.This presentation will highlight three models in Canada; two in first nation communities and a thirdregional model encompassing several small towns. While each process is unique to that community, thereare some common threads and lessons learned that could be utilized and adapted to other Aboriginal ornon-Aboriginal communities.85.5. Health Promotion School Approach to Providing Interventions for Children withFetal Alcohol Syndrome: a Pilot Project in South AfricaPiyadasa W. Kodituwakku, University of New Mexico (pkodituawkku@salud.unm.edu)Rubin Adams, Western Cape Department of Education, Cape Town, South AfricaRecent research has revealed disturbingly high prevalence rates of fetal alcohol syndrome, which isconsidered the leading preventable cause of mental retardation among children in some regions of SouthAfrica. Among children aged 5 to 9 years from a community of mixed ancestry (known as ‘colored’) in theWestern Cape Province, the prevalence rate of fetal alcohol syndrome was estimated to be 40.5 to 46.4 per1000 (May et al., 2000). These rates would have been even higher if those children without the fullsyndrome had been included in prevalence estimates. There is evidence that children with prenatal alcohol

250exposure demonstrate a range of disabilities, including behavioural problems, emotional disturbances, andpoor academic performance. A significant number of these children drop out of school and eventuallybecome alcoholics themselves, continuing the vicious cycle. Contributing to the poor outcome for thesechildren are alcohol related brain damage, adverse conditions at home, and classroom conditions that arenot conducive to learning. Children with FAS experience a multitude of life stressors associated withparental alcoholism such as poverty, domestic violence, and sexual/physical abuse. At schools, largeclassroom sizes and limited resources further compromise the ability of these children to learn.A group of investigators from the community (Rubin Adams et al.) conducted a pilot project to investigatethe effects of intervention with parents and classroom modifications on the academic performance ofchildren with FAS. The project was based on the health promotion school model (World HealthOrganization, 1986), which underscores the importance of improving the environment of the child forhis/her academic success. Interventions with parents were conducted in groups, the focus of which being onlistening to feelings, building self-esteem, and teaching problem-solving and parenting skills (e.g. havingfamily meetings). Along with parental intervention, specific classroom accommodations such as reducedsize and one-on-one instructions were provided for the children. Outcome data for those children whoreceived interventions were gathered over a period of one academic year. The results showed the childrenin the intervention group made good progress, with about one third of the group moving into a mainstreamplacement at the end of the year.Thus, this pilot project shows the utility of applying the health promotion model in improving schoolperformance in children with FAS living in an impoverished environment. This model is currently beingtested in a larger intervention study of fetal alcohol syndrome in South Africa.85.6. Crime Prevention and First Nation Peoples and Communities in CanadaMichelle Woods, National Crime Prevention Centre, Thunder Bay, Canada(Michelle.Woods@psepc.gc.ca)The National Crime Prevention Strategy is situated within the Department of Public Safety and EmergencyPreparedness Canada. It is one of several federal (national) government initiatives with policies andprograms inclusive of Aboriginal peoples. The main focus of the National Crime Prevention Strategy is tobuild understanding and knowledge on how to effectively address the conditions that can lead people toengage in criminal behaviour or become victims of crime. This “crime prevention through socialdevelopment” approach is based on identifying at an early stage the factors in an individual’s life that canbe changed to improve the quality of life and decrease the potential for criminal involvement or chances ofvictimization. These factors are often inter-related and can include: abuse, violence, unemployment, drugand alcohol abuse and low literacy. With respect to Aboriginal peoples, social, economic, demographicand geographic factors as well as the negative impacts of historical decisions on this population areimportant 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 Aboriginalcommunities so that it supports projects that address relevant risk factors and promote protective factors inculturally 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 helpprovide the resources and supports to build understanding, knowledge and practice. The presentation willprovide an overview of the work that that National Strategy has undertaken in Canada in Aboriginalcommunities, with a specific focus on its work in the Province of Ontario.

25186. Informed Consent in Psychiatry86.1. Capacity to Consent to Treatment in Mania – A Cross Sectional StudyJonathan Beckett, Springfield University Hospital (jpdbeckett@aol.com)The involvement of patients with mental illness in decisions about their treatment is becoming increasinglyimportant. 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 chronicstages of the illness. Depressed in-patients have shown relatively unimpaired capacity. The capacity ofpatients hospitalised with acute mania has not, to our knowledge, been studied. It is therefore a clinicalpriority 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 ofsymptomatology; alcohol and substance use; Mental Health Act status; and other basic demographicdetails. Pre-morbid IQ was estimated using the National Adult Reading Test (NART) and from theireducational history. Capacity was determined using a clinical interview by an experienced psychiatrist (thegold 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 fivedomains were deemed to have overall capacity in making treatment decisions.The study recruited 49 of the intended sample of 50 inpatients by June 28 2004. 92 patients admittedduring the study period were considered for participation. 23 were excluded due to incorrect diagnosis orYMRS score < 20. 69 were therefore considered appropriate to include. Two of these 69 weresubsequently considered too ill to approach. Of the 67 approached to consent: 2 were unable to consent; 7refused; 3 consented but subsequently failed to meet the YMRS eligibility score and 6 were missed due toearly discharge. 49 therefore completed the interview. Patients were scored as either having or not havingcapacity 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 domainswill be available by September 2004. A logistic regression analysis will be employed to investigate therelationship between illness and demographic variables and each domain of capacity, and will be completeby October 2004. The relationship between Mental Health Act status and each domain of capacity will alsobe determined by October 2004.The implication of the study's results on capacity and its impact on clinical practice will be discussed, withreference to possibilities for treatment collaboration and detention in hospital. The limitations of themethodology will be presented.

25286.2. “Above all, do no Harm”: A Psychoanalytic Perspective on Inhibitions in theWork of Medical Mental Health Practitioners Relating to the Ethical Oath that theDoctor must Avoid Damaging their PatientJames Johnston, Private Practice, Harrogate, England (a.bogle@zetnet.co.uk)Mental health practitioners trained in the medical model tend to think in terms of illness, treatment and curein their relationship with their patients. Freud suggested that he had never considered himself a properdoctor because he lacked sufficient sadism in his personality to feel driven to cure his patients. In thispaper I explore the psychoanalytic relationship between unconscious sadism and conscious desires to healthe other. I will use the oath sworn by medical practitioners ('above all, do no harm'), which contains anunconscious 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. Tobe in contact with reality is to be in contact with the depressive realisation that we have damaged our goodinternal object. The unconscious motivation to heal (a vocation) is borne from a reparative wish to repairour damaged objects. The more the doctor is in conscious contact with the damage s/he has done to hisobject, i.e.; the more s/he is in a depressive relation to their vocation to heal, the less the drive to undertakea cure of the patient. This is to argue that the fantasy of cure involves an omnipotent unconscious wish toheal one's own internal damaged objects through a manic repair of the damage in the other. If the doctorcan tolerate the destructive aspect of his/her own personality they will be less anxious that their love fortheir patient (shown in their wish to heal) will be overcome by their own hatred. They will then be able torespond to their patient as a separate person with their own capacities to undermine their own developmentand learning from experience. This will foster an attitude of profound respect for the autonomy of thepatient in the pursuing understanding of themselves. It is an attitude which embraces freedom andresponsibility with all the anxieties associated with such liberation of the self.The psychoanalytic approach to mental health work invites the patient to be an active rather than a passiveparticipant in their own process of potential change. It is an attitude which accepts the limitations of allpractitioners and all treatments and seeks to avoid the drive to 'cure' the other. It is an approach whichrecognises that the change process causes inevitable psychic pain as the confrontation with reality isinevitably painful. In this sense 'above all, do no harm' is replaced by an acceptance that we should be lessfrightened of the harm we fear we have already done in order to feel less frightened of doing harm in thehere and now. This liberates the doctor to becoming a more robust practitioner who is not dominated byprojected superego anxieties into legal or ethical external structures because their internal ethical and legalstructures are more closely linked to guilt which has been worked through. Such a working through allowsa more benign (less persecutory) superego which is less susceptible to rigid and inflexible expectations ofthe self or the other. Internal values guide practice rather than rules laid down by a projected fantasy of apersecutory anonymous external authority.'Above all, do no harm' then becomes a principle borne from one's personal recognition of the capacity toharm as well as the capacity to heal the other.

25386.3. Informing Patients about Tardive DyskinesiaJohn Laugharne, Osborne Clinic, Stirling, Australia (laugharne@iinet.net.au)Tardive dyskinesia (TD) is an involuntary movement disorder associated with the long term use ofantipsychotic drugs and is potentially irreversible. The introduction of “atypical” antipsychotic agents inrecent years may have reduced the risk of TD but evidence is currently limited. This presentation willreview the data relating to the attitudes and behaviours of psychiatrists internationally towards informingtheir 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), theNetherlands and Spain which investigated attitudes to informing patients about the risk of TD using a postalquestionnaire. Completed questionnaires were returned by 81(42%) of UK psychiatrists, 106(20%) ofDutch clinicians and 43(22%) of Spanish Psychiatrists. 20% of Dutch respondents, 17% of UK respondentsand 10% of Spanish respondents indicated they would routinely inform patients of the risk of TD. Majorissues to be considered for clinicians in all three countries were risk of decrease in compliance withtreatment, lack of capacity, the patient’s rights and anticipated length of drug use. In regard to factorsaffecting a patient’s ability to make informed decisions about treatment, Dutch clinicians gave moreemphasis to clinician-related factors than UK or Spanish clinicians. UK respondents were the mostconcerned about the possibility of future litigation whilst less than 50% of respondents in each of the threecountries were in favour of standardised consent forms.Overall there was considerable variation in views from clinicians from all three countries. There was noclear consensus on many of the issues raised. These data will be discussed in the context of other relatedstudies and international recommendations in regard to informed consent in psychiatric practice.86.4. Patient Choice in Mental Health CareRichard Laugharne, Wonford House Hospital, Exeter, England (r.laugharne@exeter.ac.uk)Patient choice in mental health care has become a controversial issue in the NHS in the UK. This practicalissue is influenced by the philosophical spectrum between paternalism and autonomy in the relationshipbetween the patient and clinician. This presentation will present a literature review on the evidence forpatient choice. This has suggested that patients are keen to have more information about their care, but donot necessarily want to choose what treatment they receive. A study, examining how much choice mentalhealth patients want and how age, gender and diagnosis influences desire for choice will be described.86.5. Mental Health Law Reform in New South Wales, AustraliaMilton Orkopoulos, Parliament of New South Wales, Australia(catherine.watson@parliament.nsw.gov.au)New South Wales commenced a review of its Mental Health Act 1990 in February 2004. This Act regulatesthe care, treatment and control of mentally ill and mentally disordered persons in New South Wales. The

254review 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 whichthe Act has been operational. In that period there have been substantial changes in the way that mentalhealth services are organised and provided. The two discussion papers were designed to stimulatediscussion, public comment and suggestions for reform. The next stage of the review will be the release ofan exposure draft bill for further consultation in May 2005. Major areas of proposed change to thelegislation include: information sharing with carers; the impact of developments on mental health servicesin privacy law; admission to and care in hospitals; management of forensic patients including the structurefor their review and release; care and treatment outside hospitals; medical and therapeutic treatments; theproceedings of the NSW Mental Health Review Tribunal. This presentation will discuss the major issuesraised in the review of the Act as well as significant changes proposed within the draft exposure Bill.87. Intellectual Disability I87.1. The Role of Law in Shaping the Lives of People with Intellectual Disability:Implications for PolicyDeborah M. Spitalnik, Robert Wood Johnson Medical School (deborah.spitalnik@umdnj.edu)The lives of people with intellectual disabilities and their families are, in many ways, shaped by the lawsand resulting public policies that govern supports, services and opportunities. In the United States, since1963 when President John F. Kennedy defined a role for the federal government in the lives of people withintellectual disability, there has been a continual interaction between the role of the federal(national)government and the role of the states. Reform efforts affecting people with intellectual and otherdevelopmental disabilities have been an iterative process, shaping legislation and court decisions, as well asbeing shaped by legislation and court decisions. Although US policy has been influenced by internationalideas, including normalization and inclusion, larger social views in the US have also had an impact onpeople with intellectual disabilities and in may have served to limit access to health care and other basichuman services.This presentation will trace the major developments in the past three to four decades that have shaped thedirections in services and supports. In addition to legislation and court cases, the evolving definition ofintellectual disability as codified by AAMR and being used internationally, will be reviewed as the reflectthe forward movement to community membership and full participation of people with intellectualdisability.

25587.2. Research on People with Intellectual Disabilities: The Vexing Problems ofCapacity, Consent, Surrogacy and ParticipationRobert D. Dinerstein, American University (rdiners@wcl.american.edu)Increasingly, people with intellectual disabilities are in situations that call for them to give informedconsent to various kinds of intervention. Informed consent requires the person to have the capacity to makethe decision in question, to have sufficient knowledge about the decision and to be able to decide freely andwithout coercion. While many people with intellectual disabilities have the ability to give or withholdconsent 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 surrogateconsent. There are numerous kinds of surrogate arrangements, many of them problematic. One area inwhich surrogate consent for people with intellectual disabilities raises particularly troubling issues is that ofexperimentation, especially experimentation that does not offer the prospect of direct therapeutic benefit tothe person with intellectual disabilities.For many reasons, including the historical context of past efforts to get consent from people withintellectual disabilities (many of whom were in institutional settings where they or their family memberswere subjected to highly coercive circumstances), we are right to be skeptical about any form of surrogateconsent in experimentation. However, at least some individuals with intellectual disabilities make theclaim that they should be able to participate in such experiments as an element of their citizenship andmembership in the community. Whether one argues for participation or not, the problematic nature ofdeterminations of capacity, notions of consent, and the role of surrogates makes this area a fruitful one fordebate and discussion.This topic is particularly well-suited to a panel that honors the extraordinary work of my friend andcolleague, the late Stan Herr. Stan was one of the earliest scholars and advocates to focus on theimportance of (and abuses surrounding) determinations of competency and capacity, as well as on theabuses suffered by people with disabilities who were institutionalized.87.3. Protecting People with Mental Disabilities and Impairments against BiomedicalResearch AbuseJohn H. Noble, Jr., The Catholic University of America (jnoble4@cox.net)Vera Hassner Sharav, Alliance for Human Research Protection, New York, USAPeople with mental disabilities and impairments have been targeted historically by biomedical researchersand their governmental and industrial sponsors for exposure to risky experiments that impose high riskswithout offsetting therapeutic benefits on the theory that the future good of society justified what was doneto 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 mentalretardation in such places in the United States as Willowbrook in New York and the Walter Fernald Schoolin 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 AcuteRespiratory Distress Syndrome (ARDS), experiments on children with AIDS under state guardianship,artificial blood experiments on unconscious traffic accident victims, and lead poisoning experiments onhealthy poor children that caused ensuing neurological impairments. It notes the ubiquitous invocation of

256"surrogate consent" to enrol persons incapable of understanding the risks and benefits of the research intowhich they recruited.The paper reviews the weaknesses of surrogate consent laws and practice, pointing out efforts bybiomedical researchers and their sponsors to weaken even the provisions that now exist. Further, membersof the American biomedical research establishment and officialdom have been systematically trying toweaken the provisions of the Declaration of Helsinki (1964) that prohibit the conduct of non-therapeuticresearch.The paper sets forth a number of recommendations to strengthen protections afforded to people with mentaldisabilities and impairments, including definition of such human subjects as a "protected class" that wouldrequire judicial registration and appointment of a court officer to assess the risks and benefits of theproposed research and to monitor how the research is actually conducted.87.4. What are Appropriate Legal Responses to the Challenging Behaviours of Adultswith an Intellectual Disability With or Without a Dual Diagnosis of MentalHealth?Paula Scully, Department of Justice, Queensland, Australia (paula.scully@justice.qld.gov.au)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 justicesystem. The Queensland Guardianship and Administration Act 2000 provides for guardianship orders foradults with impaired decision making capacity. The Adult Guardian, an independent statutory officer, canbe appointed as guardian of last resort for such adults when there is a need to make decisions onaccommodation, health care and services.Some adults with an intellectual disability exhibit challenging behaviours which can result in violence tothemselves or others, but in most cases, a mental health diagnosis is excluded. There are disputes bydisability workers with psychiatrists as to whether the considerable abnormal behaviours of such adults areAxis I or II diagnoses under DSM IV. If they are not Axis I, then compulsory psychiatric hospitalisation isnot an option. They are left in the community in their own homes, and in some cases accompanied bysupport workers on a 24 hour basis with restricted community access.Debates range from whether this amounts to civil detention, in breach of international human rights norms,to whether there is a need for a new legislative regime based on the recent Victorian Law ReformCommission report on People with Intellectual Disabilities at Risk: A Legal Framework for CompulsoryCare Report. There is considerable controversy over the shortage of suitable accommodation for the needsof these adults, and whether they should be kept in secure accommodation under a compulsory order.87.5. Maintaining Integrity and Cultivating CompassionSteven J. Schwartz, Center for Public Representation, Northampton, USA (Sschwartz@cpr-ma.org)The evolution and deepening of our work as advocates for persons with disabilities is informed by a varietyof personal experiences and the exploration of a number of different paths. These paths also have specificcharacteristics associated with them which we can learn to cultivate, if we are interested in deepening ourunderstanding of the art of advocacy and our commitment to that path. I will try to name a few of these

257characteristics, 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 ownpurposes. I do not profess to understand why we pursue different paths in search of the same goals. I onlyknow what I have personally witnessed, and speak from that voice.88. Intellectual Disability II88.1. The E.M.D.R. Therapy for People with Mental Retardation and ChallengingBehaviourIrena Burdova, Hoeve Boschoord, Boschoord, The Netherlands (i.burdova@hoeveboschoord.dji.minjus.nl)Eye Movement Desensitisation and Reprocessing Therapy is an efficient treatment for people withposttraumatic stress disorder (PTSD), but does it also work for people with MR/DD and serious challengingbehaviours? In our treatment centre (Hoeve Boschoord, The Netherlands) we provide a complex treatmentfor this population. One half of our clients have been convicted of criminal offences, the rest volunteer forthe treatment. All our clients are vulnerable and many of them have experienced very traumatic events intheir past. Consequently, they feel powerless, ashamed, and guilty and view themselves as bad, weak anduseless. The events are for them unspeakable, both figuratively and literally. During the treatment we offermuch therapy and training to increase their competence, get them ready to go back to the community andlead the most integrated life possible. Still, we often have to witness how their unprocessed traumas slowdown or block their treatment. Would EMDR be the therapy to ‘unblock’ it? Can EMDR help to processtheir traumatic experiences and make their anxieties, intrusions and flashbacks disappear? Can we combinethe EMDR with other therapies? What are the long-term results? In this presentation/ workshop we wouldlike to share our experience and give some answers to these questions. We will offer some videotapedmaterial to illustrate the EMDR sessions with our clients.88.2. Treating Adult Sexual Offenders with Mental RetardationB. le Grand, Hoeve Boschoord, Boschoord, The Netherlands (B.le.Grand@hoeveboschoord.dji.minjus.nl)This presentation will discuss the development and content of a program designed to treat adult sexualoffenders with mental retardation and developmental disabilities. Hoeve Boschoord is a treatment-clinic inthe Netherlands for mentally retarded adults with severe behavioural disorders. In this clinic we havedeveloped a specific treatment program for mentally retarded sex-offenders. This program is based on thecognitive-behavioural therapy and makes use of elements of the ‘relapse-prevention model’. The fact thatthe 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. Attentionalso has to be paid to the generalisation and the integration of the learned behaviour. To accomplish this,we arrange a therapeutic environment in which new learned behaviour often can be practised in variousways and in various contexts: the surplus of repetition. We will demonstrate by use of causal examples how

258we make an analysis of the ‘offence-chain’ and how we strengthen the vulnerable areas in the deviant cycleby increasing competences.88.3. Intellectual Disabilities and the Origins of Special Education Laws in the USJeff Kahana, Mount Saint Mary College (Kahana@msmc.edu)This paper offers a historical portrait of educational policy in the US for the disabled child in the nineteenthand early twentieth century. Its main focus is how an awareness of intellectual disabilities at the turn of thetwentieth century sparked a legal agenda that sought passage of special education laws. These laws sortedthe disabled child into special classes by virtue of intellectual rather than physical disability. Through thiscase study we also see how a public-private partnership approach to educating the blind and deaf child inthe nineteenth century became transformed into a primarily public initiative in providing educationalservices for the disabled child by the early twentieth century.88.4. Risk Assessment of Offenders with a Mild Intellectual Handicap or BorderlineIntellectual FunctioningBernadette Lutjenhuis, Hoeve Boschoord, Boschoord, The Netherlands(B.Lutjenhuis@hoeveboschoord.dji.minjus.nl)Results of the completion of several risk assessment instruments have found that about 70 offenders withmild Intellectual Disability or borderline intellectual functioning are presented. Among the instruments arethe PCL-R, SVR-20, HCR-20, STATIC and HKT-30. Practical and ethical problems concerning the correctand appropriate use of the instruments on the target group are discussed.88.5. Theory of Mind in Individuals with an Intellectual DisabilityA. Solodova, Booschoord, The Netherlands (A.Solodova@hoeveboschoord.dji.minus.nl)The presentation will address the concept of Theory of Mind (TOM) and the development of a newinstrument measuring this concept. This instrument is specifically designed for the population ofintellectually disabled adults with severe behavioural problems. TOM is a concept which has been theobject of research during the last couple of decades. Mostly the focus has been on children with autisticfeatures and normally developing children. There are hardly any instruments designed to measure TOM inadult individuals and as far as we know they are not specifically developed for individuals with anintellectual disability. The need for such an instrument for the above mentioned population will beaddressed during the presentation. Next, the pilot-version of the instrument will be presented.

25988.6. Evaluation of a 4 Phased Treatment in a Therapeutic Environment for Offenderswith Developmental DisabilitiesAnke C. ten Wolde, Boschoord, The Netherlands (A.ten.Wolde@hoeveboschoord.dji.minjus.nl)Results of the research project ‘Interaction as Assignment’ will be presented. The research was carried outin Hoeve Boschoord, a Dutch centre for the study, assessment and treatment of offenders with belowaverage intellectual functioning. In-patient specialised treatment is given according to a 4 phased treatmentmodel in a purposefully arranged therapeutic environment. In a longitudinal study, treatment procedures ofsocio-therapists with their patients were portrayed and evaluated. Outcome of the Best Index, programintegrity, effects and side-effects of the 4 phased treatment model are discussed. Special attention is givento the way in which the treatment program and the staff deal with patient deficiencies.89. Interdisciplinary Issues in Mental Health Law Arbitration89.1. Cultures of Law and Medicine in the Service of Those We ServeMichael Bay, McMaster University (baylaw@sympatico.ca)It is now accepted wisdom in our multicultural world that a great deal of effort must be invested in order tobridge the cultural gaps created by ethnic, linguistic, racial, and national differences. Programs designed toaddress these problems have become matters of high priority in nations across the globe. Perhaps the timehas now arrived to understand that equally profound cultural chasms exist in the sphere of law and mentalhealth. It is impossible to deny that policy makers, legislators, lawyers and psychiatrists each exist in theirown parallel universe with little communication and less respect between them. They speak differentlanguages and carry on their work based on profoundly different ideologies and assumptions. It cannot berefuted that 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 andpatients are to be well served, then urgent, positive, and ongoing steps are required on all sides to findcommon ground and establish mutual respect and communication. While it may not yet be necessary tobring 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 theculture, conduct and relationships of the various professional/cultural groups in the province. It will alsomake some modest suggestions for addressing the problem.89.2. Implications for the Community of Professional Identities and Approaches toCollaboration in the Practice of Mental Health LawSharon Carson, Psychologist, Toronto, Canada (splec@rogers.com)

260The member on the community panel has equal weight in the procedure and process of the Board, duringthe Hearing and participating in the deliberation. There is the expectation that the Community member isfamiliar with the mental health law relevant to a given Hearing, and that there is some understanding of thetype of illness to which the psychiatrist refers in the clinical presentation. Educational sessions are part ofthe preparation after appointment to the Board.The equal membership of the Community member helps to ensure that the purpose of the Hearing remainsin focus. The independent perspective of the non-professional member is added to experience and otherexpertise, and can overarch the worldviews inherent in the formation of the identities of the professionalsengaged in their differing tasks.The perspective of the client-patient may be understood differently by the Community member, togetherwith 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 thelawyer with the conduct of the current case. Enquiry by the Community member may assist theprofessionals participate as “cultural” consultants in the respecting of rights, safeguarding of society andtaking into account the type and stage of illness of the individual, which brings about the Hearing.89.3. Ethical Issues and Professional Tasks in Mental Health Tribunal HearingsJoseph Glaister, University of Toronto (Joseph.glaister@utoronto.ca)Examination of the tension between the legal profession and the psychiatric profession requires anawareness of ethical dimensions in mental health law. The differences in perspective of the professionsoffer the potential for misunderstanding, with frequent misconceptions about the roles and functions of theprotagonists. 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. Thepsychiatrist’s task is to focus on interaction with an individual patient, mind and body, in a personal contextwhich includes the internal values of the person. The lawyer relates to external principles, in the context ofthe 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 theHearing, so that the values of each side can be applied in the hearing of the client-patient’s case.89.4. Development of Professional Identity and «Cultural » Competence in the Serviceof Mental Health LawRosemary Meier, University of Toronto (Hmr.meier@utoronto.ca)The differing perspectives of Law and Medicine reflect the different developmental journeys of theirpractitioners, the degree of assimilation of individuals in the culture of their profession and the context oftheir practice. Lawyers esteem liberty, while psychiatrists value thinking and functioning. The Law isinvoked when there is an infraction or rights need protection. Medicine is involved when knowledge ofpathology or skills for treatment of illness are required.

261As in the development of personal identity, a sequence of developmental tasks leads to the manifestation ofprofessional identity and the competences needed for professional practice. “Cultural” competence isrequired in the encounter of the professions, this is epitomised in the mental health law forum. Interprofessionaltension may be inevitable in the process of a Hearing. Cross-examination, for example, may beexperienced by the psychiatrist as culturally dissonant adversarial at a personal level, and disrespectful ofthe case presented on behalf of the person whose functioning is compromised by an illness. Theenvironment 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 professionalmembers on the Board can serve as “cultural” consultants in their area of experience and expertise whentaking into account the evidence provided to support the certification and the grounds for the appeal to theConsent and Capacity Board, adding the value of professional and cultural competence to the adjudicationof the client-patient’s rights to liberty and care, and the safeguarding of society as experienced by thecommunity.90. Intersexuality I90.1. A Changing Intersex Paradigm: Has It Changed Standard of Care among PediatricEndocrinologists in the United States?Stephen F. Kemp, University of Arkansas (KempStephenF@uams.edu)The traditional clinical paradigm for treatment of intersex children was developed in the mid-20 th century,and was founded on the principles that gender identity is neutral at birth and 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 aPediatric Endocrinology textbook from 1969. This clinical paradigm has been challenged since the late 20 thcentury. An ethical analysis favors the new clinical paradigm in that the new paradigm shows greaterrespect for autonomy and is more likely to meet the demands for beneficence and non-malfeasance. Inorder 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 standardpediatric endocrinology textbooks published since 2002. The most progress has been made in the area ofdisclosure; no longer is it recommended to keep details from the parents, or to evade disclosure by usingphrases such as, “the child knows its gender, we only have to discover it and finish development of theincomplete genitalia”. There seems to be a recommendation that the determination of the sex of rearingshould involve the parents as part of the team. Further, a clear difference is the dismissal of old notion thatin the absence of a penis of a certain size, a female gender be assigned. The area where there is stillpersistence of the traditional paradigm is whether there should be genital surgery in the newborn period. Atext in 2002 recommended early genital surgery, and, while softening the recommendation, the same authorin 2004 still recommends clitoral recession before the age of one year in some situations. Two texts (2003and 2004) recognize that this area is controversial, while another (2003) acknowledges that it may bepreferable to postpone genital surgery until the intersex individual can participate in such a decision.Reasons for the slow acceptance of delaying genital surgery include resistance to change, lack of outcomedata, and 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 collectoutcome data, participate in the development of protocols, continue to discuss the issue of the appropriate

262treatment of intersex infants, and be prepared to revise our paradigm as new information becomesavailable.90.2. International Legal Developments Protecting the Rights of Sexual Minorities andTheir Effect on the Doctrine of Informed Consent as it is Applied in the ClinicalManagement of Intersex InfantsJulie A. Greenberg, Thomas Jefferson School of Law (julieg@tjsl.edu)Medical decisions made by parents on behalf of their minor children are generally accorded great deferenceto protect family privacy and parental authority. Courts rarely intervene in a parental decision about achild’s medical treatment, even though the child’s long-term interests may be seriously compromised. Insome circumstances, however, courts will carefully scrutinize parental decisions because judges areconcerned that parents are not able to distinguish objectively the interests of their child from their own selfinterest.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 toachieve 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 autonomyrights of sexual minorities.Recently, the Constitutional Court of Colombia specifically addressed this issue. The Court severelylimited 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 courtoutside 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 theirvulnerability, need special care and protection. In addition, the European Court of Human Rights and theEuropean Court of Justice recently issued rulings that provide greater protection to transgender individuals.Finally, a recent United States Supreme Court decision also recognized that the Fourteenth Amendment tothe United States Constitution protects some decisions relating to sexuality because these decisions arecentral to personal dignity and autonomy.This paper will explore the doctrine of informed consent as it applies to the parental consent of surgicallyaltering an intersex child. It will analyze recent international developments that portend a trend towardgreater legal protection of those individuals whose sex, gender, and sexual orientation do not conform tothe norm.90.3. From Guilt to Injustice: Towards a Discursive Recognition of IntersexIain Morland, University of London (iain@icfm.freeserve.co.uk)Are clinicians who have performed genital surgery on intersexed individuals guilty of negligence? Toanswer this question, I analyze the contemporary debate over the traditional surgical management ofintersexuality—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 ofscience explains how its medical management has emerged as an exemplary injustice of recognition. Thesurgical protocol that aims to make unusual genitalia invisible, and the medical obfuscation of

263intersexuality’s ramifications for the cultural construction of gender, have been written by feministscientists Anne Fausto-Sterling and Suzanne Kessler as a failure of recognition. However, this is not tosuggest that intersex surgery is purely “rhetorical,” nor is it to deny that such surgery has been experiencedas injurious by many patients. Instead, by mapping intersex treatment as a discursively produced injustice, Iargue that it is accordingly within discourse that the wrongs of intersex treatment may be redressed—not byundoing past surgeries, or by punishing clinicians as personally “guilty.” In this way, it is possible tounderstand intersex treatment as a genuine injustice of recognition without confrontationally calling intoquestion doctors’ competence and intentions—an approach that facilitates dialogue between all involved.90.4. The Use of Dexamethasone to Prevent Virilization of Female Fetuses at Risk ofCongenital Adrenal HyperplasiaSharon E. Sytsma, Northern Illinois University (ssytsma@niu.edu)Dexamethasone (Dex) has been used as a prenatal treatment to prevent virilization of female fetuses causedby Congenital Adrenal Hyperplasia (CAH) in the USA since the 1980’s. Many studies have indicated thatits use is safe and effective in either preventing or minimizing virilization. However, there have been somereports, both in the United States and abroad, of ill effects of the drug in children treated as fetuses. Furtherconcern about the effects of fetal Dex treatment comes from recent reports that premature infants treatedwith Dex to prevent pulmonary problems later manifest neuro-developmental impairment and a higherincidence of cerebral palsy. Little follow-up has been done to determine whether fetuses treated in uteroare at risk later in life for neurological problems.The justifications for Dex use for CAH are the following:• It would spare the child with CAH the trauma of going through life with ambiguous genitalia.• It would spare the child the need for genital surgery.• In the case of severely virilized female fetuses, it would prevent the possibility of assigningthe child to the male gender.Objections to these justifications will be examined. First, given that unacceptable risk has not been ruledout, it is questionable whether the burdens of virilization justify that risk. Second, in most cases there is noactual medical need for genital surgery. Third, for those infants so severely virilized that they might bemistakenly assigned to the male gender, it is not clear at present that going through life as a male would bea worse alternative than being subjected to vaginoplasty, especially since vaginoplasty is of dubious benefitand is associated with significant burdens. Finally, given that the drug must be administered as soon aspregnancy is established and before tests can reveal the sex of the fetus or whether the fetus is afflicted withCAH, 7 out of 8 fetuses treated with Dex are being subjected to risk but do not stand to benefit from it.90.5. Intersexuality: Exploring its Challenges for Christian Sexual EthicsPatricia Beattie Jung, Loyola University Chicago (pjung@luc.edu)There is a growing consensus that new scientific data and experiential insights about intersexuality haveraised 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 manyreligiously grounded systems of sexual ethics. In this paper, Jung critically re-examines Christian axiomsabout heterosexual gender complementarily in light of these emerging accounts of this paradigmatic

264expression of human sexual diversity. She explores the implications of new scientific and experientialaccounts of intersexuality for the reinterpretation of key biblical passages (especially Genesis 1-2 andEphesians 5) and conventional “natural law” teachings about gender considered foundational by manyChristians to sexual ethics.90.6. Authenticity and IntersexualityHerman Stark, South Suburban College (hermanestark@yahoo.com)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 ambiguousgenitalia and so forth is in fact a threat to their authenticity. The standard treatment is to decide what sexthe intersexual should be and then to perform surgery accordingly (to operate on the genitalia). In recentyears, there has been a growing movement, composed in part by people who have undergone suchprocedures, 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 inBeing and Time, which is the locus classicus for contemporary philosophers. Heidegger’s analysis isintriguing and germane because he is careful to separate authenticity from moral concepts, such as goodand 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 thinkthe doctors are immoral and indeed admit most doctors are trying to do the right thing). One thingHeidegger’s analysis lacks is a tracing out of implications, especially to biomedical ethical type issues, andthus I turn to subsequent philosophers who attempt to do precisely this, i.e., trace out the ethicalimplications of Heidegger’s analysis. The paper then applies authenticity and its ethical implications tointersexuality, and considers, along the way, related ideas such as autonomy as well as the mutuallyinstructive way that authenticity helps us think about intersexuality and intersexuality helps us think aboutauthenticity.91. Intersexuality II91.1. Telling Children about a Physical Intersex Condition: What Stops Us?Polly A. Carmichael, Great Ormond Street Hospital for Children, London, England (Carmip@gosh.nhs.uk)It is generally agreed that intersexed individuals should be fully informed about their medical history andtreatment. However, how, when, and by whom this intent is best translated into action remains uncertain.There is relatively little consistent psychological research to assist parents in disclosing the details of anintersex condition to their child (Viner, 1997). It is apparent that the process of disclosure does not beginwith telling the individual. There is evidence that, psychological support as soon as a diagnosis is made, is

265associated with a better outcome (Slijper et al. 1998). The timing and content of ‘support’ requiresevaluation, for despite apparently being given information, parents often remain confused about theirchild’s diagnosis and fear the impact of giving information, sometimes waiting many years after the initialdiagnosis (Carmichael & Ransley, 2002).The sparse published recommendations for sharing information with an intersexed child suggest a stagedapproach, taking into account the stage of cognitive development of the child (Goodall, 1991, Warne, 1997& Slijper, 2000). It is proposed that information about karyotype, when it is discordant with gender ofrearing, should be given last at about the age of 16 or 17 (Something is very wrong her two options twovery different meaning: should be given last, at about the age of 16 or 17; or: should be given at the latestwhen the child is 16 or 17). This is potentially problematic if children are to be fully involved in treatmentdecisions, 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 ofinformation on the developing child and adolescent, rather than by the child’s ability to understand.91.2. Cultural Differences in Medical Risk Assessments during Prenatal GeneticDiagnosis: The Case of Sex Chromosome Anomalies in Israel and GermanyYael Hashiloni-Dolev, The Hebrew University (hashi@post.tau.ac.il)The paper reports findings from a comparative study of Israeli and German genetic counsellors, focusing oncounselling concerning Sex Chromosome Anomalies (SCA). SCA are a collection of atypical diagnosesinvolving too many or too few sex chromosomes. The specific SCA addressed in this study are Klinefeltersyndrome (XXY) and Turner syndrome (X0 or 45X). Males with Klinefelter syndrome have an extra Xchromosome. They are tall and infertile. In rare instances they may also be mentally retarded, though themajority of people with Klinefelter syndrome lead completely normal lives, and their condition is onlydiscovered 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 areinfertile. In some cases, the syndrome involves other physical irregularities, such as heart problems. Thepaper starts with a theoretical discussion of the medical concept of risk. Subsequently, data collected byquestionnaires (N=297) that address reproductive genetics and which were distributed among geneticcounsellors in Israel and Germany at two different time periods (1994-6 and 2000-1), as well as datacollected through in-depth interviews with counsellors in both countries (N=32) are presented. The findingsshow that Israeli genetic counsellors are for more supportive of selective abortions of fetuses with SCAsthan their German counterparts. In order to understand this difference, the types of claims experts deploy intheir personal and professional estimation of the risks involved in SCA are analyzed. The paper concludesby suggesting that the counsellors' estimations of risk, and their rhetoric concerning SCA, whose majormanifestation 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 professionalnon-directive global ethos. Hence, in order to understand the practice of genetic counsellors in two latemodernsocieties, one must understand the unique relationship between the individual bodies of pregnantwomen and the body politics of their nations, a relationship which is mediated by the counsellors, who arethe bearers of knowledge and expertise in this field.

26691.3. Vaginal Reconstruction and the Role of the PsychologistLih-Mei Liao, Elizabeth Garrett Anderson Hospital, London, England (lih-mei.liao@uclh.nhs.uk)Historically, reconstructive surgery has been the main treatment option for intersex and non-intersexwomen with a small vagina. More recently, dilation has been recommended as the first line of treatment. Inthe 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 raiseawareness of complex psychological issues in vaginal (re)construction and to outline the important role ofthe psychologist.Pre-treatment, reconstruction is often understood by women as an unproblematic means of conferringnormality. But reconstruction in itself often fails to deliver a ‘normal’ (female) identity, and many womenbecome acutely aware of their distress only after surgery or during their dilation treatment. These fears actas barriers to normative relationship experiences – the implicit goals of vaginal reconstruction.Furthermore, emotional barriers often interfere with a woman’s ability to adhere to a dilation treatmentregime which could lead to stenosis, thereby having exposed herself to the risks of surgery without derivingany benefit.The role of the psychologist is three-fold. First, women may require implications counselling relating todiagnosis and treatment. Secondly, psychological interventions can help to explore thoughts, feelings andbehaviour relating to relationships and intimacy, in order to foster a positive self identity and to increasepersonal control in sexual situations. Lastly, the psychologist also has responsibility to contribute to thebuilding of a clinical team that is sensitive to the expressed and unexpressed needs of women. Within sucha clinical context, examination of the genitals should be kept to a minimum and, where repeat monitoring isnecessary, patients should be given a genuine choice and debriefing must follow each occasion. Negativeexperiences of professional consultations could undermine the positive sexual outcomes that reconstructionseeks to create. Finally, it is well to remember that a decision not to have reconstruction is also a viableoption.91.4. Discordant Sexual Identity: Genetic Males with Severely Inadequate GenitaliaReared FemaleWilliam G. Reiner, University of Oklahoma (william-reiner@ouhsc.edu)Because genetic male neonates with a severely inadequate penis have long daunted clinicians (unable toconstruct a functioning penis), a clinical paradigm developed in the last half of the 20 th century assigningsuch newborns to female, socially, legally, and surgically with orchiectomy and feminizing genitoplasty atbirth. The Standard of Care for about 30 years, this approach presupposes a tabula rasa of psychosexualdevelopment and especially of sexual identity development. Outcome data on psychosexual developmentin these children has been sparse.77 genetic male subjects with severely inadequate genitalia due to cloacal exstrophy (a severe error ofembryogenesis leading to complex pelvic organ anomalies including virtual absence of the genitalia) orintersex 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 ofsubjects ranged from 1 to 10 years, and included longitudinal mental status assessments.

26746 subjects (60%) declared themselves male some time before or at varying times after follow-up frominitial 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 rearedfemale from birth. All 77 displayed mostly male-typical behaviors and interests. All subjects transitioningto male, who were reasonably old enough to discuss sexual orientation, expressed exclusive orientationtowards females. Only 3 subjects living as female were willing to discuss sexual orientation, expressingsexual orientation towards females. Mental status of those subjects transitioning to male improvedlongitudinally, with no suicidal ideation elicited from any subject living as male. In subjects living asfemale mental status remained stable or intermittently deteriorated; 4 subjects experienced recurrentsuicidal ideation.This study demonstrates that prenatal active-androgen exposure in genetic males may have a powerfulinfluence on an ability to recognize male sexual identity despite assignment to female at birth, female sexof-rearing,and female genitalia. Additionally, genetic males with a severely inadequate penis reared maleor transitioning to male may experience improved mental status.91.5. Adult Outcomes of Feminizing Genital SurgerySarah Creighton, Elizabeth Garrett Anderson Hospital, London, England (Sarah.Creighton@uclh.nhs.uk)Traditional surgical management of the virilised female infant has centred on restoring “normality”. Oncethe 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 majorfactor in the selection of sex of rearing. Only recently, reports by adult intersex women with poor outcomesof feminising surgery have focused research on adult outcomes including effects upon sexual function andsexual satisfaction. Or: Only recently, following reports by adult intersex women with poor feminizingsurgery outcomes, has research begun to focus on adult outcomes including effects upon sexual functionand sexual satisfaction.Although there is now an expanding literature and current studies provide more information, despite thewidespread policy of feminising surgery, control groups are usually small. Vaginoplasty is an integral partof feminizing genitoplasty; this procedure is currently performed during the first year of life, although thechild will not menstruate for a further 10 or so years (if she has a uterus) and is unlikely to be sexuallyactive until after puberty. Early infant vaginoplasty may be justified if there were good evidence that itproduced 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 stenosisand frequent requirements for repeat reconstructive surgery in adolescence before tampon use orintercourse. Other vaginoplasty techniques, such as using an intestinal segment, involve major surgery andlong term problems, such as persistent vaginal bleeding and mucus discharge, are not uncommon. Clitoralsurgery 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, therole 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 thesurgery and the risks to their daughter’s future sexual function. The option of specialised psychological andpeer support, as a realistic alternative to surgery, must be made available to all families.

26892. Japan’s New Legislation for Mentally Disordered Offenders92.1. Japan’s New Legislation for Mentally Disordered Offenders: From the Point ofView of Comparative LawMiwa Kojimoto, National Institute of Mental Health, Tokyo, Japan (kojimoto@ncnp-k.go.jp)The Act for the Medical Treatment and Supervision of Insane Persons who Caused Serious Harm, Japan’sfirst legislation for mentally disordered offenders, will go into effect in July 2005. The Act emphasizes theimportance of the rehabilitation of offender patients and creates a system where community treatment willbe promoted.From the point of view of comparative law, the Act has two significant characteristics. One is that the Actis strongly linked to the system of criminal responsibility. That is, it is applied to only three kinds of peoplewho 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 prosecutedbecause of insanity and diminished responsibility. Mentally disordered prisoners and those who are notcompetent to stand trial are excluded from the scope of the Act. The second characteristic reflected in theAct is the wide discretionary powers given to prosecutors. If prosecutors find, as the result of a psychiatricevaluation, that the accused is insane or of diminished responsibility, the charge will be dropped even if theact committed is murder or manslaughter. Those accused will then become the subject of the Act, and it isexpected 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.92.2. The Evolution of Mental Health Legislation in Japan: Continuing Pressures andNeedsDavid N. Weisstub, University of Montreal (admin@ialmh.org)Tsunemi Hasegawa, Hasegawa Hospital, Tokyo, JapanSince the late 1980’s Japan has undergone a series of reforms pointing towards more progressive modalitiesof dealing with the large institutionalized population of civil patients. The introduction of more responsiveguardianship provisions as well as the creation of a new Forensic System have created expectations of amore humane and benign treatment of the mentally ill. Review procedures have also held out potential forgreater ethical sensitivity towards individuals whose liberties have been curtailed. Despite cultural, familialand social differences criticism remains of the actual system in place from both internal and internationalperspectives. Despite repeated efforts for reforming the mental health system there has still been areluctance 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 frustratedachieving the stated goals of the mental health law reforms. Policies must be put into place to encourageprogressive hospitals to undertake increasing responsibilities, with adequate remuneration, for addressingthe myriad of problems that exist not only in the context of high-risk civil patients but also in view of newpressures that will be forthcoming as side effects of introducing a Forensic System in Japan.

26992.3. The Medical Treatment and Supervision System under Japan’s New Legislationfor Mentally Disordered OffendersSaburou Matsubara, Matsubara Hospital, Ishikawa, Japan (matsubarahospital@ishikawa.med.or.jp)This paper illustrates the treatment system for mentally disordered offenders under the new legislation inJapan. The Act for the Medical Treatment and Supervision of Insane Persons Who Caused Serious Harm of2005 stipulates that the district court shall provide two types of treatment: compulsory admission tohospital and outpatient treatment under supervision. The Act also offers guidelines for psychiatric evidence,hospital treatment, and community care for such patients. (1) Psychiatric evidence shall not only providemedical diagnosis but also assessment of treatability and risk of dangerous act. (2) Given that an estimated300 persons will be hospitalized annually under the new system, 24 public hospitals are scheduled toestablish a special ward equipped with 30 beds. The guidelines recommend that treatment shall besegmented in accordance with the recovery of the patient: acute phase, stabilizing phase, and rehabilitationphase. In principle, the duration of inpatient treatment shall be 18 months. (3) The guidelines indicate thatoutpatient treatment shall be carried out in three stages: initial stage, intermediate stage, and end stage. It isrecommended 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,make rehabilitation plans, and collaborate with hospital staff, community mental health centers, andofficials of local governments.92.4. Managing Mentally Disordered Offenders: A Japanese SolutionYoji Nakatani, University of Tsukuba (ynakatan@md.tsukuba.ac.jp)After a long debate and repeated attempts, Japan has finally reached a solution for the management ofmentally disordered offenders. The government enacted legislation that goes into effect in July 2005. Thenew act, 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 returnto the community without repeating the offence. Debate on the problem dates back to the 1960s, when theMinistry of Justice attempted to revise the Penal Law to provide special management of offenders withmental disorders. However the plan faced strong objections from human rights movements, who suggestedthat patients may possibly be excluded from society. After several years of exchange between proponentsand opponents, the Ministry of Justice suspended the plan. The second attempt was made in the late 1980s,when the Mental Health Law was revised to develop community-based psychiatry. The Ministry of Healthconducted a plan for the management of refractory patients including offenders. The plan stipulated thatpublic facilities, with sufficient security and staff, be established for such patients. The Ministry of Health’splan confronted a criticism: that the establishment of a special system would inevitably intensify the role ofpsychiatry in social defence. The plan had to be suspended. Thus two attempts failed. The first intended tosolve the problem within the criminal justice system, while the latter aimed to treat a particular group ofpatients within the framework of the mental health system. These circumstances may account for theeclecticism of the new legislation. According to the act the court orders the application as well as theconclusion of treatment, wherein the committee established in the court for judgment includes a psychiatristwho is equally empowered as judge. Besides, a greater importance seems to be attached to the patient’sopportunity of resocialization than to his/her future dangerousness. The author will discuss thedistinctiveness of the Japanese system in comparison with some European systems.

27092.5. On the New Law for the Mentally Disordered Offenders in JapanIsao Takayanagi, Arisawabashi Psychiatric Hospital, Toyama, Japan (yagiisao@aqua.ocn.ne.jp)The Criminal law and The Mental Health and Welfare Law of Japan had not provided for well forthe treatment of the mentally disordered offenders. Ninety percent of these persons had beeninvoluntarily admitted to the mental hospital without judicial procedure. This situation has brought alot of problems to many mental hospitals. Since the Draft for the amendment of the Criminal Law toimprove the legal deficiency issued in 1961, serious conflicts has occurred among thepsychiatrists, 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 theoperation. After all, the Law titled “The Treatment and Observation Law for the persons whocommit serious offence under the incompetent, or partially competent condition” was enacted on10 th , 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 andpsychiatrist is formed. More details of the Law will be presented and discussed.92.6. Current Priorities in Japanese Mental Health Policy; Two Special PopulationsDavid N. Weisstub, University of Montreal (admin@ialmh.org)Both the aging population in Japan as well as mentally disordered offenders represent challenges not onlyto the public budget of the State but as well, present serious challenges to the society. In the case of theaged, it is recognized that Japan’s population will be among the oldest in the world by 2020 and there willbe less than three persons to support one elder. The exponential increase of health costs for the elderlycoupled with profound social transitions in the culture means that Japanese policy makers must concernthemselves with multiple factors ranging from hospital stays, policies with respect to medications, andoptional living arrangements. Interestingly the creation of a new Forensic System for Japan, although froma very different perspective raises many of the same elements in public policy. Japan has the highest rateamong industrialized countries of institutionalized patients suffering from mental disorders. Until nowhowever 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, notonly with respect to the criminal population, but as well for the civilly committed. Special policies arebeing put into place for community discharge. At the same time, the new Forensic System will create a hostof new stresses and priorities. Establishing a properly coordinated set of systems, between criminal andcivil populations, will become a preoccupation of mental health policy planners in Japan during the nextdecade. Whatever the outcome, the treatment of Japan’s vulnerable populations will have far-reachingconsequences not only of a financial, but also ethical nature. Specific recommendations will be made abouthow this can be best achieved.

27193. Jury Decision Making: The Psychological Research93.1. Jury Decision-making in Death Penalty Cases: The Impact of Victim ImpactEvidenceEdie Greene, University of Colorado (egreene@uccs.edu)Early empirical studies of the death penalty examined one of four issues: 1) the deterrent effects of capitalpunishment, 2) public opinion about the death penalty, 3) the pro-prosecution biases of “death qualified”jurors (those jurors selected to decide capital cases), and 4) the possibility that capital punishment isimposed in a racially discriminatory manner (White, 1995). More recent studies, including the presentpaper, involve experimental analyses of the cognitive processes underlying juror and jury decision makingin capital cases.This paper examines the effects of victim impact evidence on jurors’ reasoning and decision making.Victims of crime (or, in murder cases, the survivors of the victim) are frequently given the opportunity todescribe the impact of that crime at the sentencing hearing of the offender. This evidence—referred to asvictim impact evidence—may convey the physical, psychological, and/or financial impact of the crime onvictims or survivors, victims’ and survivors’ opinions about the crime and the offender, and in murdercases, information about the personal qualities of the deceased. There is heated debate about the use ofvictim impact evidence in capital cases: proponents reason that jurors should know the extent of the harmcaused by the offender; critics argue that this evidence infuses the trial with highly emotional andprejudicial information.The purpose of this study was to assess the effects of various forms of victim impact evidence on mockjurors in a capital case. Results showed that different forms of victim impact evidence exert subtle anddifferential influences on jurors’ sentiments about the victim and the victim’s survivors. Portions of thispaper are described in a forthcoming article (Myers, B., & Greene, E. [In press]. The prejudicial nature ofvictim impact statements: Implications for capital sentencing policy. Psychology, Public Policy, and Law.)93.2. Effectiveness of Different Forms of Voir Dire in Insanity Defense CasesJennifer Groscup, John Jay College of Criminal Justice (jgroscup@jjay.cuny.edu)Michelle Galietta, John Jay College of Criminal JusticeMaureen O’Connor, John Jay College of Criminal JusticeThe purpose of voir dire during jury selection is to determine who will be able to serve as a fair andimpartial juror, as guaranteed to criminal defendants in the United States. Part of the duty of a juror is togive full consideration to all of the possible verdicts based on the evidence presented. Special forms of voirdire have been developed for types of cases in which this concern is of paramount importance, mostnotably in death penalty cases. Many members of the public hold attitudes against the insanity defence,and some of these people would not fully consider rendering a verdict of not guilty by reason of insanityregardless of the evidence presented at trial. Although the issue raised in insanity cases is similar to thoseraised by the willingness to impose the death penalty, attorneys use no standard procedure during voir direto identify potential venire persons who are unwilling to render a not guilty due to an insanity verdict. The

272research in the proposed presentation is part of a larger body of research examining attitudes toward theinsanity defence, juror decision making in a variety of insanity cases, and the development of a moreeffective voir dire procedure for insanity cases. The presentation will address the preliminary results ofstudies examining the effectiveness of different types of voir dire questions in identifying potential jurorswith biases against the insanity defence.93.3. Exploring the Legal and Psychological Underpinnings of Jury Selection inInsanity Defence CasesMaureen O’Connor, John Jay College of Criminal Justice (moconnor@jjay.cuny.edu)Michelle Galietta, John Jay College of Criminal JusticeJennifer Groscup, John Jay College of Criminal JusticeIn the United States, there is a Constitutional guarantee to a trial by a fair and impartial jury of a criminaldefendant’s peers. The voir dire process is designed as one of the guarantors of the Sixth Amendment’srequirement of an impartial jury. Part of the duty of a juror is to give full consideration to all of thepossible verdicts based on the evidence presented. Special forms of voir dire have been developed fortypes of cases in which this concern is of paramount importance, most notably in death penalty cases.When the death penalty is a possibility, only jurors who express a willingness to impose that sentence canserve on the jury in both the guilt and sentencing phases of the case. Much jury research has examined theeffects of empanelling a jury with this procedure, indicating that so-called “death-qualified” juries becomemore conviction-prone in addition to their willingness to consider the death penalty. In spite of this effect,selecting a capital jury this way is considered necessary in order to empanel a jury that is fully capable ofperforming all of its duties, namely considering all verdict options.The same legal issue concerning jurors’ abilities and willingness to carry out a part of their legal obligationarises in cases in which the defendant raises an insanity defence. Research has suggested that manymembers of the public in the United States hold attitudes against the insanity defence, and some of thesepeople would not fully consider rendering a verdict of not guilty by reason of insanity regardless of theevidence presented at trial. However, there is no standard procedure used by attorneys during voir dire toidentify potential venire persons who are unwilling to render a not guilty due to an insanity verdict. Thepresentation will discuss the legal and psychological issues raised by insanity voir dire.93.4. Hearsay Evidence and Jurors’ Reactance in a Civil TrialDaniel A. Krauss, Claremont McKenna College (krauss@mckenna.edu)Dae Ho Lee, Claremont Graduate UniversityJoel Lieberman, University of Nevada- Las VegasA substantial body of research suggests that jurors are able to appropriately weigh hearsay evidence (i.e.,evidence of a statement made other than by a witness testifying in court) when it is presented in thecourtroom. Under the United States federal rules of evidences, judges are required to sustain objections tohearsay evidence and adjudicate the suspect evidence inadmissible while admonishing the jurors to notweigh the inadmissible evidence in their decision, if a legitimate objection is raised (i.e., it is not excusedby the hearsay exception). This judicial admonition may not, however, be heeded by jurors.

273In a simulated civil personal injury case, this experiment investigated whether mock jurors: (a) are able todisregard hearsay evidence when admonished to do so, (b) experience psychological reactance and“backfire effects” in proportion to the strength of judicial admonition instructing them to disregard hearsayevidence, and (c) are able to recognize and disregard hearsay evidence without judicial instructions.One hundred thirty-one (93 females; 38 males) participants were randomly assigned to five conditions: a)critical evidence as non-hearsay evidence (i.e., real witness), b) critical evidence as hearsay evidencefollowed by strong judicial admonition, c) critical evidence as hearsay evidence followed by weak judicialadmonition, d) critical evidence as hearsay evidence without judicial admonition, and e) critical evidenceabsent.Analyses revealed that juror backfire effects were evident in both the jurors’ confidence in their liabilityverdicts and in their decisions to grant punitive damage awards. Results also indicated that jurors haddifficulty disregarding hearsay evidence when evaluating hearsay witness without judicial instruction. Thelegal and policy implications of these findings are discussed.93.5. Juror Reasoning about Expert Psychological TestimonyLora Levett, Florida International University (lora.levett@fiu.edu)Margaret Bull Kovera, John Jay College of Criminal JusticeIn Daubert, the Supreme Court opined that opposing expert testimony is an effective safeguard against junkscience in the courtroom. Although jurors may be unable to identify flaws in scientific research withoutsome assistance, social psychological research suggests that people can be trained to make moresophisticated judgments about scientific quality. In previous studies, an opposing expert who addressed themethodology of proffered expert testimony was unsuccessful in educating jurors about scientific validity,but it is unclear whether a non-adversarial expert may be a more effective method of educating jurors. Anexpert who is not associated with either adversary may be seen as an unbiased source, and therefore, theexpert’s testimony may be processed systematically rather than dismissed because of the jurors’ use ofheuristics in evaluating the testimony. If an expert is adversarial, jurors may view the expert as a hired gunand therefore dismiss the content of the testimony and use the heuristic in decision-making. We tested theeffectiveness of the non-adversarial expert as an educator and the presence of the hired gun heuristic bymanipulating the methodological quality of defense expert testimony, the heuristic cue (i.e., amount ofmoney the opposing or non-adversarial expert received for testifying), and the type and presence of nonadversarialor adversarial opposing expert testimony within a written trial transcript. Experts testified in thecontext of a murder trial, addressing the insanity of the defendant at the time of the crime. The defenseexpert presented evidence of insanity based on scales of malingering, which were either reliable orunreliable. The opposing (either adversarial or non-adversarial) expert addressed or did not address thereliability of the malingering scales. Preliminary results using undergraduate students suggest that jurorsrespond differentially to the adversarial and non-adversarial opposing experts in that adversarial opposingexpert testimony causes jurors to be skeptical of all expert testimony rather than sensitizing them to flawsin the defense expert’s testimony. The non-adversarial opposing expert testimony does not cause the sameskepticism. We will report these results in addition to findings obtained from a sample of communitymembers eligible for jury service.

27493.6. The Importance of Legal Information for People Working in Health ServicesL. M. Marzi, University Hospital, Vienna (marzi@moser-marzi.at)Nowadays fewer and fewer patients are willing to accept medical treatment without the possibility of beinginformed about the facts or even the details. In case of malpractice, patients often (successfully) demandcompensation. The science of medicine has made great progress during the last few decades, however inWestern society, patients have become partners in their treatment and thus have contributed to medicaladvancements; patients have, in Western society, been given rights which they have never had before. Onerisk for people working in the health sector is that patients are increasingly informed about their rights. Inthe past, health service workers have received little or no training about the legal aspects of their job. Theonly solution to these discrepancies seems to be life-long learning, not only with regard to their ownprofession, but also to the basics of law in the health sector. This educational endeavour needs to besupported by the employers, by providing sufficient sources of information in different forms such asseminars, books and e-learning.93.7. Rational and Experiential Processing in Juror Decision-makingJoel Lieberman, University of Nevada-Las VegasDaniel Krauss, Claremont McKenna CollegeMaribeth Lehoux, University of Nevada-Las Vegas (jdl@unlv.nevada.edu)Past research has examined the effects of actuarial and clinical expert testimony on defendantdangerousness assessments in death penalty sentencing. This research has found that jurors are moreinfluenced by less scientific pure clinical expert testimony (based on an expert’s personal opinion and pastexperience) and less influenced by more scientific actuarial expert testimony (where actuarial evaluationsare based on empirically verified risk factors that predict future dangerousness). This trend occurs despitethe fact actuarial based evaluations have been shown to be superior predictors of defendant dangerousness.Through the application of Cognitive Experiential Self-Theory (CEST) to juror decision-making, thepresent study was undertaken in an attempt to offer a theoretical rationale for these findings. One hundredand sixty-three mock jurors were directed into either a rational mode or experiential mode of processingand presented with expert testimony regarding defendant dangerousness in a death penalty case. Consistentwith CEST and inconsistent with previous research using the same stimulus materials, results demonstratethat jurors in a rational mode of processing more heavily weighted actuarial expert testimony in theirdangerousness assessments, while those jurors in the experiential condition were influenced by clinicalexpert testimony. The policy implications of these findings and results of a replication study are discussed.

27594. Juvenile Justice and Mental HealthRecent studies confirm the high prevalence of symptoms of mental disorders among youth in correctionalfacilities. These symptoms include not only disruptive behaviours, but also severe emotional difficulties.Specialized screening tools for use in juvenile justice provide improved assessment and a more detailedpicture of the symptoms encountered, such as the MAYSI-2 in the United States and SIFA in England andWales. Numerous procedural issues still confront clinicians and agencies in appropriately assessing andtreating mental disorders among incarcerated youth, such as suicidal and self-injurious behaviors. Inresponse to these concerns, professional standards were recently developed for the proper assessment andcare of youth held in the justice systems in the United Kingdom and United States. This session will presentan overview of the extent and nature of mental health problems of incarcerated youth, the special issues inscreening and treating them, and the development and implementation of professional guidelines for mentalhealth clinicians working with them.94.1. Meeting the Mental Health Needs of “Hard to Reach” Young OffendersSue Bailey, University of Central Lancashire (ntattersall@gardener.bstmht.nhs.uk)A joint programme of research between the University of Manchester, UCLAN, and clinical services atBolton, Salford & Trafford Mental Health Trust, the findings are presented of:The development, validation, and implementation of a semi-structured interview to help identify keymental health symptoms (SIFA) for all young people entering the Youth Justice System in England andWales. Based on the Salford Needs Assessment Schedule for Adolescents (SNASA), the screen covers 8areas of mental health, alcohol misuse, substance misuse, depressed mood, deliberate self-harm, anxietysymptoms, 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 allyoung 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:• The level of mental health needs among this population, and• The current models and effectiveness of service delivery and the comparative needs of youngoffenders, in the community and those in custody.Implications for practice parameters, service delivery, and an integrated multiagency approach to youngoffenders, by health, education, social care, and justice will be discussed in the context of long term costs tothis group as they present to adult services in the future, bridging the transition of service delivery.94.2. Mental Health Needs of Youths in Juvenile Justice Facilities: Results of aNationwide Study in the United StatesThomas Grisso, University of Massachusetts (Thomas.Grisso@umassmed.edu)Recent research in the United States has indicated that two-thirds of youths entering pretrial juveniledetention centers meet criteria for one or more mental disorders. As a consequence, mental health

276screening at admission to juvenile detention centers has become routine in the past five years. Thispresentation focuses on a screening tool—Massachusetts Youth Screening Instrument-Second Version(MAYSI-2)— developed and validated specifically to identify symptoms of mental and emotionaldisturbance 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 18of those states has allowed for the analysis of 70,000 MAYSI-2 cases, focused on identifying reliablepatterns of MAYSI-2 symptoms (generalizable across the United States) by age, gender, ethnicity, and typeof juvenile justice facility. Results indicate that on average: (a) girls manifest greater pathology than boyson almost all MAYSI –2 scales; (b) younger adolescents score higher on anger and lower on alcohol/druguse 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 youthslowest; and (d) levels of symptoms on average decrease as one moves from pretrial institutions to postadjudicativeinstitutional settings.94.3. Surviving the Challenges of Juvenile Corrections: Suicide Prevention StrategiesJoseph V. Penn, Brown University (jpenn@lifespan.org)There is a high prevalence of suicidal and self-mutilative behaviors among incarcerated juveniles. Recentstudies suggest, there is an average of 17,000 incidents of suicidal behavior in U.S. juvenile correctionalfacilities each year, and that youth suicide in U.S. juvenile detention facilities is more than four timesgreater than in the general population. Intake screening, timely clinical referral, and ongoing assessment ofall confined youth are critical to suicide prevention efforts by correctional staff. Two essential componentsof a successful suicide prevention program are properly trained staff, and ongoing communication amongcorrectional and clinical staff.This paper will present the existing literature on suicide attempts and suicidal behavior in the juvenilejustice population. It will review new guidelines for the identification of high-risk periods, systematicscreening, clinical assessment, and management of youth presenting with self-mutilative behaviors andsuicide attempts. Finally, it will review unique challenges in juvenile correctional settings, such as how tointerface more effectively with juvenile and family courts, medico-legal liability issues, strategies fordetection, and management of malingering, future challenges for effective staff training, and theimplementation of suicide prevention programs.94.4. Practice Parameter for the Assessment and Treatment of Youth in CorrectionalFacilitiesChristopher R. Thomas, University of Texas (crthomas@utmb.edu)Over the past decade, the number of youth held in correctional facilities in the United States has grownconsiderably. Up to 75% of these youth have a diagnosable mental disorder according to some estimates,but many do not have access to adequate mental health services. In addition, psychiatrists providingtreatment for these youth face a myriad of challenges and pitfalls: potential role conflicts; confidentialityissues; working with families, social services, law enforcement, and courts; negative perceptions ofdelinquents; and the complex, multiple needs of these youth. In response to the lack of standards and

277guidance in addressing these problems, the American Academy of Child and Adolescent Psychiatrydeveloped 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 healthcare, including initial evaluation, ongoing monitoring of mental health problems, assessment of violent orsuicidal youth, and use of medications. Particular attention focused on the difficulties encountered intreatment planning and implementation for these youth. The research on which the recommendations arebased, 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 andleaders.94.5. Quality of Juvenile Forensic Diagnostic Assessment in the NetherlandsNils Duits, Ministry of Justice, Amsterdam, The Netherlands (NDuits@planet.nl)Juvenile forensic diagnostic assessment and decisions of the court can have far reaching consequences forjuvenile 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 organizationalframework of the juvenile forensic diagnostic system. In the Netherlands, we developed a unique qualityframework for the juvenile forensic diagnostic assessment. It has typical ‘polder model’ characteristics,such as cooperation and networking with forensic partners. Organizational and practical aspects will bepresented in the light of the Dutch juvenile juridical context. Empirical research stood at the basis of thisunique quality framework. In the perspective of Dutch juvenile penal law, the concept of quality has beeninvestigated by means of concept mapping among ‘users’ and ‘makers’ of juvenile forensic diagnosticassessment. Methodology and results will be presented, and consequences on quality management will bediscussed.95. Juvenile Sex Delinquency95.1. Juvenile and Adult Sexual Offenders Compared: Psychiatric Characteristics andRecidivism RiskMichael Günter, University of Tübingen (michael.guenter@med.uni-tuebingen.de)Susanne Leutz, University of TübingenSimone Vees, University of TübingenKlaus Foerster, University of TübingenThere is not enough empirical knowledge about the differences between adult and juvenile sexualoffenders. This study aimed at acquiring more data about the differences between these two groups withrespect to psychiatric status, developmental problems, and recidivism risk.

278The study included all juvenile and adult offenders charged with sexual offences who received a forensicpsychiatric assessment in our department or in the adult psychiatric department, between 1983 and 1994.We compared characteristics from the intensive forensic psychiatric assessment after the index offencebetween the two groups and with later recidivism taken from the criminal records. Forensic reports wereevaluated systematically with an evaluation form.N = 60 subjects could be evaluated in each group. Clear differences between the groups with respect to theindex offences were found. Recidivism with sexual offences was significantly lower in the adolescentgroup, especially in the sub-group of developmentally retarded adolescents. It was difficult to detect furtherrisk factors for re-offending sexually from the forensic reports.Adolescent sexual offenders show clear differences from adult offenders, and have a better prognosis.Prospectively, only a small sub-group, which is difficult to identify, seems to account for the retrospectivefinding from other studies, that a considerable proportion of adult sexual offenders already have recordsback to adolescence.95.2. Young Sex Offenders: Assessment and Treatment ModelsVera Cuzzocrea, University of Modena and Reggio EmiliaGian Luigi Lepri, University of Modena and Reggio EmiliaThe literature review revealed that between 20-30 per cent of sexually abusive behaviour was committed bypersons under 18 years; over 50% of incarcerated adult offenders had offended before the age of 20 years,and over 10,000 children were sexually abused by another child or young person. Young sex offendersdiffer from adult sex offenders. The majority of young sex offenders are adolescent males, while between 5and 15 per cent of these offences are committed by women. Half the sample of young offenders reported ahistory of physical or sexual abuse, and a home environment characterized by overcrowding, alcohol abuse,and domestic violence; A significant male relative was likely to have committed a criminal offence; and, inhis community, he regularly witnessed violence and sexual activity. The sex offences were usually carriedout with a co-offender in a variety of venues. The victim was usually known and younger than the offender.Despite the introduction of intervention programmes internationally (over 300 in the USA), assessment ofsuccess has been lacking. Establishing the success of these interventions is made difficult by the lack ofcontrol groups. However, some studies of established programmes over five-year periods show thatrecidivism rates are between 5% and 14%. Offenders appear to respond to cognitive behaviour and relapseprevention interventions. Intervention should begin with an assessment of the child, to determine childrenat 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 bedelivered within the framework of a forensic clinical approach.95.3. The ASOAP-D as an Instrument for Personality Assessment and Measurement ofEffect of Therapy in Juvenile Sex OffendersRon van Outsem (info@dewaag-denhaag.nl)The ASOAP-D is a multidimensional personality assessment questionnaire. It focuses onthose personality characteristics which, in literature, are generally considered relevant to

the development and perpetuation of sexually abusive behaviour in juveniles. In thispresentation, the instrument will first be introduced. After this, the preliminary resultsfrom comparative research between several categories of juvenile sex offenders, juvenileviolent offenders, and non-delinquent youth will be presented. Lastly, the measuredchanges in relevant personality characteristics of a group of juvenile sex offenders whofollowed specialised treatment will be assessed.27995.4. A developmental approach to psychopathology in adolescent offenders: subtypingsex offenders and assaultive offendersPeter Hummel, Klinik für Kinder, Arnsdorf, Germany (Peter.Hummel@skhar.sms.sachsen.de)Research in Germany concerning juvenile sexual delinquency is mainly done by medical professionals, ie.,by assessing case histories. In Canada, Great Britain, and the USA this research is mainly done bypsychologists, ie., by means of psychometric assessment. The purpose of this study is to compareadolescent 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 whosevictim/s was/were (a) child/ren of both sexes, called victims children, n = 36; adolescent assaultiveoffenders, whose victim/s was/were male adolescent/s or adults, called victims men, n=33. All malesubjects were matched as follows (to restrain confounding variables): German nationality, averageintelligence, only hands-on offences, single perpetrators, age at the time of the offence between 14 and 20years.Development of the individual, his family, his sexuality (case histories), and his personality (psychometricinventories) was examined. Reclassification was done after factor analysis and subsequent discriminateanalysis.The victims-women subject group were best predicted by the sexual development (63%), respective byindividual, familial, and sexual development (71%). The victims-children subject group were best predictedby the individual development (78%), no combination was better. The victims-men subject group were bestpredicted 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 methodto describe the profile of the respective offender group. Items of the case histories seemed to be morepowerful than psychometric inventories. Limitations of the study concern the choice of the psychometricinstruments, the possibility of concealed offences not going with the respective group, and other aspects ofdevelopmental psychopathology within the respective group (e. g. impulsivity).

28095.5. The Adolescent Sex Offender Assessment Pack – useful applications in Germanspeaking CountriesRichard Beckett, Forensisches Institut Ostschweiz, Weinfelden, Switzerland (monika.egli-alge@forio.ch)Constanze Gerhold , Forensisches Institut Ostschweiz, Weinfelden, SwitzerlandMatthias Schmelzle, Forensisches Institut Ostschweiz, Weinfelden, SwitzerlandMonika Egli-Alge, Forensisches Institut Ostschweiz, Weinfelden, SwitzerlandLieselotte Türkmen-Barta, Forensisches Institut Ostschweiz, Weinfelden, SwitzerlandUlrich Preuss, Forensisches Institut Ostschweiz, Weinfelden, SwitzerlandObjective: To describe a current research project, founded by Richard Beckett in the UK for the assessmentof juvenile sex offenders. The Adolescent Sex offender Assessment Pack – ASAP – will be described, interms of its psychometric construction, and the current use in some European Countries, such asSwitzerland, Germany, and Austria.Method: The prediction of sexual abusing behaviour is quite difficult, and the object of this internationalresearch project. Because of the sparse records of sexual abusing juveniles in several countries, it isnecessary to promote an international cooperation. The ASAP has been used in some countries—Switzerland, Germany, and Austria—for some years, and has now been adapted and improved. For themeasurements of treatment outcome, the ASAP is a useful instrument. In this study with 11 – 12questionnaires, personality-profiles of the juvenile sex offenders are established; for example: self-esteem,emotional loneliness, anger management, general empathy, delictoriented marks as attitudes to children andsex, cognitive distortions, and sexual deviancy. The questionnaires are partially known and validated,partially newly developed and revised in the frame of this project on N=479 juvenile sex offenders at theage 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, focusingthe personality structures of the juvenile sex offenders. A cluster analysis showed some effects and especialfactors of the personality and typology of the offenders. Also some risk factors and determinations can bedescribed.96. Legal Consciousness: I96.1. Tortured Women in Seneca the ElderVictoria Pagán, University of Wisconsin-Madison (vepagan@wisc.edu)Seneca the Elder heard the best orators of the last years of the Roman republic; in his old age, his sonspersuaded him to write down his recollections of these great speakers. The result is a collection of

281controversiae, in which an invented legal case was argued on both sides before an imagined jury. Thecases 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 Romanrhetoric, education, and law; however, because they are fiction, they also have much to teach us about therelationship between narrative and law.Because the cases are imaginary and the speakers are guided by their professors of rhetoric, controversiaeprovide a safe place for Romans to discuss disturbing social and moral transgressions—a comfortable placeto speak the unspeakable—with rules and regulations that keep both speaker and audience from the perilsof 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 ofdeclamation creates and sustains authority. Gunderson rightly forces the conclusion that the elaborateartifice, the playfulness, and the artistry that define declamation are niether harmless nor insignificant.Rather, they are implicated in the creation and maintenance of the psycho-social system of inequality at thefoot of Roman socio-economic institutions.Absent from Gunderson's analysis are the tortured women of declamation. This paper argues that theexplicit descriptions of the torture women suffer, besides bearing witness to the institutionalization ofviolence toward women, provide stock 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 themore disturbing possibility of female autonomy. The fictional legal cases are thus implicated in sustaininga particular-male dominated-reality. While fictional controversiae demonstrate that law is deeplyembedded in narrative forms, this case opens up the possibility that the particular narrative form of thecontroversiae creates and sustains not legal practice, but legal consciousness.96.2. Manumission and the Assimilation of Freedmen in the Roman WorldMarc Kleijwegt, University of Wisconsin-Madison (mkleijwegt@wisc.edu)The process of manumission in the Roman world, in crude terms, entailed the social and legalmetamorphosis of a being devoid of all human rights into a Roman citizen. The frequency with whichRoman 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 recognizingthat in the ancient world the Roman willingness to free their slaves and to grant them certain rights, whichbrought them on a par with citizens, was without parallel. The Roman custom stood in strong contrast tothe procedure adopted in the Greek world, where slaves became ‘metics’, that is, foreigners, rather thancitizens. Furthermore, the level of manumission in the Roman world is assumed to have been the highest ofall slave societies in world. Because of their lack of free birth, however, ex-slaves had very few routes forsocial advancement. All status-groups as well as the most prestigious state priesthoods were closed tometics. They were prohibited from serving in the Roman army and could only enlist with the vigiles, thefire-brigades of seven thousand men formed in AD 6 by the emperor Augustus. In the communities of theRoman 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 propertyand transferring it intact to their freeborn off-spring. The latter encountered no legal impediments to socialmobility, even though the social codes made the rapid rise of freedman’s sons undesirable.

28296.3. Regulation of Memory in Classical and Early Christian RomeCharles Hedrick, University of California Santa Cruz (hedrick@ucsc.edu)Conversion is among the most striking ideas in the history of Christian culture, and it has never suffered forlack of attention. Almost without exception, modern scholars have dealt with it as an "actuality," that is, asan event, something that happens at a particular time and place to particular people. In the earlier part ofthe 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 socialvalue 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 itsimportance in its effects – the new enlightenment or status that results. If we think of conversion as a value,however, then its importance is abiding. For example, in the course of the first four centuries of our eramillions of inhabitants of the Roman world converted to Christianity: these are events, and have aggregateimportant 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 akin to 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 aconflicting past identity. For the upright Christian convert there is a paradoxical virtue in having once beentruly wicked. The ideal of conversion introduces an inconsistency or fissure into the sense of self, which isnegotiated through memory. This inconsistency is at the heart of much Christian thought in Late Antiquity.96.4. Personal Freedom and Social Constraint: Athenian Democracy and the ModernLiberal StateRobert Wallace, Northwestern University (rwallace@northwestern.edu)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 lawsprohibited, e.g., prostitution, drunkenness, or homosexuality. Coarse, libellous, impious language filled thestage. Brilliant politicians lived unconventional lives and were reelected. On core liberal values, Athenswas far more tolerant than modern liberal states.However, Athens offered no guarantees of freedom, like our rights. What guarded freedoms? Also, nomodern 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 bypowerful ideologies that maintained no one tell another how to live. Principles, ideologies, and mentalitiesare positive promoters of freedom; rights are passive and weak.Athens cohered because Athenians also accepted the ideology that the community's material interests camebefore the pleasure of any person. Furthermore, unlike modern capitalist societies, self-control was acentral virtue. Enslavement to passions was seen not to yield happiness. Personal freedoms were selfregulated;hence social regulation was superfluous.

28396.5. The People’s Justice: Law, Litigation, and the Jury in Ancient AthensAndrew Wolpert, University of Wisconsin-Madison (awolpert@wisc.edu)In contrast to modern representative democracies, ancient Athens had neither a professional class of judgesand jurists nor a system of precedent and appeal. The ordinary citizens selected by lot, in the thousands, toserve as jurors had, therefore, enormous discretionary powers. Unfortunately, they did not leave writtenrecords about the cases that they heard. Hence, their silence is a serious obstacle for the study of Athenianlaw and society. This paper seeks to resolve this problem by examining the framework that litigants usedto present their cases.Although few Greek historians insist on a strict dichotomy between legal arguments and rhetorical appealsthat appear in Athenian court speeches, they tend to prioritize one over the other. Some suggest that jurorstended 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 distinctionsbetween the types of proofs and appeals seriously distort their use in the courts and their reception byjurors.All arguments had the same purpose, to prove that the litigant’s case was just and that the jury shouldtherefore vote in his favor. To ask whether the litigant depended more upon legal or rhetorical arguments topersuade the jury is simply the wrong question. Each litigant used whichever arguments he thought wouldhelp his case, and no litigant dared to lay his claim solely on matters of law or exclusively on emotional andethical appeals. We can better appreciate Greek forensic oratory if we apply theories from the law andnarrative school as well as theories on trial advocacy to the workings of the Athenian courts. Litigantssought to persuade the jury to believe their particular story about the dispute and its impact on the widerAthenian community, in order to justify the resolution that they proposed. They then selected whicheverlaws, whichever proofs, whichever appeals, and whichever facts about the events would fit within thatparticular framework.97. Legal Consciousness: II97.1. The Development of the Jural Perspective in the Ancient WorldGabriel R. Ricci, Elizabethtown College (riccigr@etown.edu)(This paper explores the development of the jural perspective in Greek literature from the jurisdictionaldivisions in Hesiod’s Theogony, in which the concept of Fate receives a spatial and topologicalinterpretation, to the dialectical method for which Socrates is renowned. The general argument is that theGreek literary tradition, whether it be the epic genre, tragedy, the religious cosmologies, or themetaphysical tradition originating with the pre-Socratics, is a concerted effort to articulate the legalfoundations of existence. In some cases this developing perspective appears as a detail, as in the case of thejudicial setting depicted on the shield made for Achilles, or in more dramatic form, as in theinstitutionalization of the jury system by Athena at the Areopagus in Aeschylus’s Oresteia, or in the legal

284conflict between Creon and Antigone in Sophocles’s Antigone. Along the way, there is the emergence ofthe 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 bythe phyusis and nomos controversy that occupied natural philosophy as well as political and moralspeculation.97.2. Examination of Contemporary and Historical Manipulation of Religious andLegal IconographyGeorge Robert Ash, Madison, Wisconsin (Grash2@gmail.com)The history of law and history of religion both have visual and symbolic representations. This paper willexplore the enduring nature of some these images, and trace their use and evolution through time. Thepaper will consider variations of the primary iconography of the three major Abrahamic religions, and theirrelationship to the iconography of law. Often law and religion were aspects of the same entity and, attimes, 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 toappropriate symbols and icons. These images draw on often unconscious historic weight to lend prestige totheir 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 thatthe 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. The accompanyingsense of quasi-divine authority of the flag, as used in contemporary American politics, evidences the battlebetween the primary political parties to be viewed as the legitimate heir to that power and legacy. One canalso trace the migration of use and authority of this symbol from one group and ideology to another. Thestates currently associated with the Democratic party are the states that composed the Union, and wererepresented by the American flag during the civil war. Today the American flag is closely associated withthe Republican Party, which is strongest in the southern states that made up the Confederacy. Thisexample, the American flag, illustrates the durability and historic power of icons, and the continuing battleto appropriate them to further and validate radically different agendas.97.3. From Anarchy to Monarchy: King Saul and the Shaping of Legal ConsciousnessJames A. Diamond, University of Waterloo (jdiamond@uwaterloo.ca)The Old Testament book of Judges covers a period characterized by a legal consciousness that is identifiedby its final verse "In those days there was no king in Israel; everyone did as he pleased". The lack of acentralized governmental authority encouraged an anarchic tribalism associated with the rampantlawlessness of its concluding narrative involving rape, civil war, genocide, and kidnapping. The book ofSamuel marks a transition to a monarchic autocracy with its implicit rejection of prophetic authority, whichconcedes 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 firstexpression in the reign of King Saul, a figure whose external perfection (handsomest, tallest) isincongruous with his internal instability where he is prone to periodic bouts of manic depression (e.g. “anevil spirit from the Lord began to terrify him" 16:14) and possibly schizophrenia ("Then he stripped off his

285clothes, spoke in ecstasy and lay naked all day and night" 19:24). A royal administration that isdistinguished by legal incapacity culminates in suicide, an act that ironically, may have been the king'smost lucid moment. Although ancient Israel's initial experiment with monarchy may have been a dismalfailure, its literary account is a superb portrayal of the challenges faced by radical changes in legalconsciousness. This paper will explore the hermeneutics of a biblical narrative intended to shape popularlegal consciousness.97.4. Legal Primitivism and Its DiscontentsSteven Wilf, University of Connecticut (swilf@law.uconn.edu)How do we interpret the continuing preoccupation among Anglo-American jurists with primitive law, andmore particularly with lex non scripta, from Henry Maine’s Ancient Law (1861) to Bronislaw Malinowksi’sCrime and Custom in Savage Society (1926)? In the second half of the nineteenth century and through theearly twentieth century, an immense literature was created which charts the evolution of legal systemsparallel 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 CoolidgeCarter, 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 legalprimitivism is valorized–as is the case in celebrations of Teutonic forests as the birthplace of republicanlegalism; at other times, it is portrayed as barbaric or totemic. Nevertheless, despite its vastness, andvariety, 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 racialassumptions embedded in these works.But my interest in legal primitivism is not a venture of antiquarian cultural recovery. For these nineteenthand early-twentieth century thinkers, their fascination with legal primitivism betrayed their need for alaboratory of ideas. Legal primitivism is the doppelgänger of legal modernism, the place where legalmodernists, caught between an increasingly formal common law and an increasingly insistent thrusttowards codification, shunted their own anxieties. It was unease with legal modernism’s focus on writtentext, for example, that animated the identification of orality as a core characteristic of the savage legalmind. James Coolidge Carter mined legal primitivism as a focal point of dealing with the troublesomeproblem of competing and contradictory legal precedent. Primitive law presented rudimentary legalsystems–ideas, in the words of Henry Maine, which are to the jurist what the primary crusts of the earth areto 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 theorigins of legal modernism with the rise of the surety of social science. Others, notably Critical LegalStudies scholars, have pointed to the modernist impulse of grappling with indeterminacy in a disenchantedworld. My paper focuses upon the anxiety of legal change. It seeks to situate legal modernism withincultural modernism as a whole, and, more particularly, within the scope of the larger cultural project ofidentifying 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 desperatelysought to see as its other.

28697.5. Before a Boundary: A First Essay in AntiquityJonathan Boyarin, University of Kansas (jonathanboyarin@yahoo.com)This speculative paper seeks out possible resources in late antiquity, to again attempt to overcome theperception that law in society and culture is inescapably dogged by a split between letter and spirit, orbetween doxa and reality. It does so by attempting to reach “behind” the complimentary formation, duringthe first Christian centuries, of rabbinic Judaism as an orthodoxy of the “letter” and Patristic Christianity asan 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 Christianand Jewish groups [was] rational decision-making processes through dialectical investigation." He furthersuggests that this habitus drew on the tradition of Sophist discourse, a movement that was in some validsense devoted to a disinterested search for truth, while enjoying some measure of social authority. AsSusan Jarratt earlier explained, in her Rereading the Sophists,With the sophists, nomos, a self-conscious arrangement of discourse to create politically and sociallysignificant knowledge, enters as a middle term between mythos and logos. This addition to classicalrhetorical terminology might be used to displace the Aristotelian focus on rhetorical arguments withheightened attention to narrative structure, changing dramatically the status of arrangement and collapsingthe discrete categories of logos and pathos.Accordingly, this paper begins by explaining the split between letter and spirit as an effect of thedichotomization 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 opensfinally 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 thata nomos can be both powerful and at the same time a conscious, responsible human production.98. Legal Consciousness: III98.1. American Law and Native American Indigenous Peoples: Equivocal slippagesBetween Consciousness and ConscienceRichard A. Monette, University of Wisconsin-Madison (rmonette@wisc.edu)Perhaps the greatest human rights abuse of all is to subjugate an entire people, incorporate them withoutnorm or logic, suppress their outward cultural attributes, tear apart their cultures, sear the seams of theirvalues and beliefs, and keep them alive to systemically suffer. When Felix Cohen wrote The LegalConscience, speaking truth to American law, he chose Native Americans as his benchmark. If democraticlaw is indeed based upon the norms and values of the collective, then Cohen was speaking truth to anAmerican collective consciousness. In the slippages, equivocal and unequivocal, between the American

287conscience and an American collective consciousness, between American law and justice, reside the humanrights abuses of the Native American.In a recent case concerning the US Supreme Court’s position on the powers and authority of AmericanNative Nations (Lara), US Supreme Court Justice Clarence Thomas referred to the Court’s jurisprudence inthis area as “schizophrenic”, an accurate assessment of the collective consciousness of the Court and itsjurisprudence. This talk will illustrate the historically divergent and increasingly diverging doctrinesleading to Justice Thomas’ label of “schizophrenia”. One development is founded upon and would adhereto America’s highest ideals, the other to America’s worst practices. In light of this American human rightsabuse, one is left with questions for American Native Nations: can we survive with two Americas? Or,which path of the divergent jurisprudence will America and the US Supreme Court choose to provide thecure for its “schizophrenia”?98.2. The Problems of Legal Consciousness in Russian Culture: Past and PresentGary Rosenshield, University of Wisconsin-Madison (grosen@slavic.wisc.edu)Almost immediately after the fall of communism in 1991, the Russians began showing an interest inreforming the judicial system and reviving the jury trial for criminal cases. It has been a slow and arduousprocess. Russia cannot just resume from where it left off in 1917, when the jury trial was abolished by theBolsheviks. Much of the culture and tradition of the pre-Revolutionary legal system has been lost in the lasteight decades. It is not only a matter of reviving old institutions but of developing a legal consciousnessamong 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 becamecompletely independent of the administration, trained counsel represented defendants and clients, evidencewas presented in court, proceedings were public, and juries responsibly deliberated the fate of their peers.Nevertheless, before the reforms were enacted there were skeptics who doubted that the jury trial couldsucceed in Russia. The country, they argued, was unprepared for it; the Russian people had not developedthe necessary legal consciousness for the reforms to work. Writing in 1850, fourteen years before theenactment of the judicial reforms, the English philosopher, Herbert Spencer, scouted the possibility of asuccessful jury system in Russia: "[i]t is not trial by jury that produces justice," he argued, "but it issentiment of justice that produces trial by jury, as the organ through which it is to act; and the organ will beinert unless the sentiment is there." Most would argue that the relative success of the jury system provedSpencer wrong. Yet Russian political theorists throughout the nineteenth century, despite judicial reforms,worried that the absence of a true legal consciousness, especially among the intellectual elite, wouldprevent Russia from developing the democratic institutions of Western Europe. The same worries existtoday. In this paper, I shall discuss the problem of legal consciousness in pre-revolutionary Russia andattempt to show how the same problems of undeveloped legal consciousness that existed in the nineteenthcentury are making the task of modernizing and democratizing the legal system especially difficult in ourown time; a task made even more difficult with the government's turn to more authoritarian rule as a meansof dealing with political terror.

28898.3. Legal Consciousness in Western CultureDavid N. Weisstub, University of Montreal (admin@ialmh.org)Given the central place given to law in the foundational cultures of the West, the emergence of a legalconsciousness naturally followed. Legal consciousness, thereafter, took on a force of its own in thedevelopment of both common law and constitutional regimes. Most recently, the idea of a mainstreamlegal consciousness has been challenged by two major critiques: feminism and multi-culturalism. Despitethe many transformations of the concept of legal consciousness, the question is posed whether there is asustained content that remains.98.4. On Crime and the Scottish EnlightenmentLeonard Kaplan, University of Wisconsin-Madison (lvkaplan@wisc.edu)The Scottish Enlightenment constituted a particularly lucid moment in the history of political philosophyand law. Figures like Adam Smith, Francis Hutcheson, Adam Ferguson, Thomas Reid, Dugald Stewart,David Hume, and others reduced natural law sentiments to rational and empirical consideration. Withoutdenying God, they removed God from the discourse, thereby promoting that through reason humanitywould make sense of and constitute politics, jurisprudence, economics, and psychology.Post modern consciousness and theory has lost the confidence in reason shared by that significantmovement situated in Edinburgh, where capitalism was seen as a political economy that could effectuateconsiderable wealth without too much economic impoverishment. In fact, the thinkers within this rhetoricaland actual space had a grasp on the limits, as well as the possibilities, of man as maker through reasoneddiscourse. These Enlightened thinkers are, in fact, the enemy of many who resurrect old, frequently flawed,ideological metaphysics for interest group gain against Enlightenment optimism.In recent years crime writers, found throughout the world, have established a rich body of work incontemporary Scotland. These writers are sophisticated about their enlightenment heritage. Their workconstitutes a rich narrative critique of the gap between Enlightenment hope and current cultural corruptionand despair. The gap between the stories told in these representations present the difference between liberaljurisprudential longing, aspiration, and current reality. This paper will consider that gap and the constraints,both theological and jurisprudential, from the attainment theorized by the Scottish thinkers.The paper will summarize the Scottish thought aspirations. Several Scottish crime novelists will beconsidered, e.g., Paul Johnston, Christopher Brookmyre, Ian Rankin, Val McDermid, Denis Mina, andAgnes Owen.98.5. An Ethical Rip CurrentWilliam King, Pastor Emeritus, Covenant Presbyterian Church (Lurgana@aol.com)I will be telling the story of a collision of cultures, ecclesiastical and civil law, and organized religion withthe innate assumptions of its followers.

289A minister of a Korean Presbyterian Church was the subject of a formal complaint signed by 38 of hisparishioners. The complaint was submitted to the Presbytery (the organization consisting of all theministers and an equal number of laypeople [elders] in the geographical area that includes the KoreanPresbyterian Church); the Presbytery holds much of the same authority as does a bishop in an Episcopalordered denomination.The complaint was investigated by a Presbytery task force, 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 thePermanent Judicial Commission.The minister was found guilty of spousal abuse, sexual misconduct, and financial misconduct; he wasremoved 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 he was justified in hitting her, and that the Presbyteryand Church members who filed the complaints were acting under the influence of Satan. The victims ofsexual misconduct did not wish to bring these acts to the attention of the law. The church board has takenno action to inform the Internal Revenue Service that the minister misrepresented his income in order toavoid 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 fearby some because he is a Shaman who claims the power to curse. The church is embarrassed, feelsobligated, full of anger, and certain that the American Church has not well comprehended the Christianityof the Korean Church.A westernized Near Eastern religion that meets the far Eastern understanding of the same denomination hascreated an ethical rip current which is fascinating and complex.98.6. Cruel and Unusual Places: The Death of the PrisonPatricia Likos Ricci, Elizabethtown College, U.S.A. (riccipl@etown.edu)After two centuries of progressive ideals and innovative designs, the American prison has been found guiltyof 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 PrisonAbolition), maintains that prisons have not only proved incapable of their mission to deter crime andrehabilitate criminals, in the last twenty years, their proliferation and privatization have produced a “prisonindustrialcomplex” with minority convict labour. Recently the California-based Architects, Designers andPlanners for Social Responsibility (ADPSR) have called for a national boycott on prison design as a protestagainst the highest rates of incarceration in the world. Drawing on the insights of Alexis de Tocquevilleand 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 analysesthe goals and results of three influential prison models constructed in the United States from the 19 th to the21 st century: the Panopticon plan designed by British philosopher Jeremy Bentham and interpreted byarchitect John Haviland at Eastern State Penitentiary (1823) in Philadelphia; the “telephone pole” plandesigned by French architect Francisque-Henri Poussin for the prison at Fresnes (1898) and adopted by theAmerican architect Alfred Hopkins at Lewisburg Federal Prison (1932) in Pennsylvania; and the latetwentieth-century “podular” plan represented by Pelican Bay Security Housing Unit in California.

29099. Legal Consciousness: IV99.1. Rights: Heteronomy not AutonomyDavid Novak, University of Toronto (david.novak@utoronto.ca)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 alegal context.One, autonomy means “the capacity to command oneself.” That is, I am only obligated to do what I havecommanded myself to do. Contracts presuppose this: a contract obligates me because I have obligatedmyself to the contract. Since the most persistent justification of democracy and its law has been that it isfounded in a social contract among its citizens, I am thus obligated to the legal system in its particularsbecause I have obligated myself to the system in general. In this sense, legal consciousness is consciousnessof 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 elseprior to their making the contract. These rights are “inalienable.” No one may revoke them from anyoneelse — even from oneself.Two, autonomy is the idea of law itself (nomos - autos), for example: Justice is fairness (John Rawls). Itprecedes the actual institution of law that emerges from the social contract as a political agreement. It is theright 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 overallmovement towards that ideal. However, it is extremely doubtful whether I can derive legal consciousnessfrom my ideal trajectory. For if, at times, law necessitates the coercion of others, how can I justify coercionof 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. Aright is justified if it is exercised by someone entitled to that right, and it is justified when that right-holderis 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 toexercise autonomy in many public and private acts, autonomy itself is not the foundation of that right orany other right. Hence legal consciousness is the consciousness of heteronomy, viz., that which entitles oneto have a right. But can fundamental heteronomy be justifiably exercised by anyone less than the CreatorGod who has given moral law to humans as an integral part of his governance of the universe.99.2. Statutory Interpretation in the EU: The Augustinian ApproachLawrence M. Solan, Brooklyn Law School (larry.solan@brooklaw.edu)The European Union now has 25 members and 20 official languages. Directives enacted by the EU arepromulgated in all 20 official languages, and each version is authoritative. This creates a seemingly

291unmanageable 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 inargument in any dispute before it, whether or not any of the parties to the dispute speak that language. Inthis paper, I call this practice “the Augustinian approach” to statutory interpretation, and defend it assensible.In On Christian Doctrine, Augustine, an essentialist, advocated for examining all translations of the Bibleto determine God’s actual message. By searching for differences among the translations, it becamepossible to infer just where human language has interceded. When that happened, triangulating among thevarious 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 interpretmultilingual statutes. The success of this approach depends largely upon the extent to which word meaningis similar across languages and cultures. The paper looks at advances in linguistic lexical semantics and thepsychology of concepts to argue that this Augustinian approach has a strong underlying basis incontemporary learning.99.3. Legal Consciousness and Ricoeur’s Theory of ImaginationGeorge Taylor, University of Pittsburgh, (taylor@law.pitt.edu)One of the most striking conclusions of the United States’ September 11 Commission Report is that theattack that day revealed a failure of imagination by members of the U.S. government. Indeed, theExecutive Summary to that report states that the failure of imagination was the government’sA ‘mostimportant failure’. My paper seeks to assess the nature of that failure as an issue of legal consciousness andoffers some possible remedies. I take as my primary text a set of lectures on imagination by philosopherPaul Ricoeur that I am currently editing for potential publication.For Ricoeur, too much of the history of philosophy and psychology reflects the predominance ofreproductive imagination. Reproductive imagination identifies the mental impression or image as a replicaof an outer reality. David Hume’s theory is representative. Building in part on Kant, Ricoeur insteademphasizes the role of productive imagination, where the mind creatively opens new vistas of reality, as inliterary fiction.My argument is that the differentiation between reproductive and productive imagination can be fruitfullyapplied to legal consciousness. All too frequently legal consciousness, at least in the United States, isreproductive, 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 governmentalactors. The September 11 Commission concludes that it is ‘crucial to find a way of routinizing, evenbureaucratizing, the exercise of imagination’.I will show how Ricoeur develops his theory of productive imagination as applied to fictions. Then I willpursue, as both a philosophical and psychological matter, how a productive imagination may be inculcatedas a matter of legal consciousness. How is a productive legal imagination possibly different from thehermeneutic concept of application, where meaning changes in B is open to the new experience supplied byB 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 comparativepsychology by Richard Nisbett help us determine how to overcome the perdurance of legal categories andcategorization?

29299.4. Feminist Consciousness and Mental HealthCandice Hoke, Cleveland State University (shoke@law.csuohio.edu)In light of the theoretical divisions among feminist scholars generated over the past two decades, is itpossible to speak of “feminist consciousness”? Although the term may have had a generally agreed contentduring the 1960s and 70s, the epistemological divide occurring during the past two decades betweenessentialist and postmodern feminists (as well as other theoretical strands) can be argued to have obstructeda unitary conception of feminist consciousness. That feminist political activists transnationally espousewidely divergent perspectives and political programs traceable in part to the vectors of race, class, andculture, underscores an arguable lack of common conceptual or political ground that can be characterized asfeminist consciousness.This paper argues that despite the theoretical, practical and political differences among feminists, somecommon ground can be identified. I draw predominantly upon feminist economic development scholarshipand classic feminist psychological theory to establish this argument. Transnationally, feminist scholarsworking on economic development issues in concrete cultural situations offer empirically grounded insightsinto elements of feminist consciousness. These scholars have catalogued as effects of feministconsciousness (and of the structures supporting economic empowerment of women) a positive sense of selfand self-possibilities as well as an enlarged perception of acceptable social, familial, economic and politicalroles. Transculturally, commonalities emerge that can be typed feminist consciousness despite the range ofsocial differences between communities and individuals.This economic development scholarship supports theoretical insights offered by classic feministpsychological 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, andachieve healthy psychological positions, rest in self conceptions and gender conceptions that we can term“feminist.” Additionally, certain psychological pathologies have been identified in those possessingexcesses of power (manifesting a tendency toward physical and psychological abuse) which arguably canbe allayed by feminist consciousness and practice by men.99.5. Practicing Psychiatry in the Shadow of the LawGuy Lord, Medical College of Wisconsin (grlord@execpc.com)Legal issues can be considered a sixth axis in a multiaxial diagnostic system. In each clinical encounter, apracticing physician must place himself or herself, the patient and other aspects of the situation within amatrix of legal concerns. The patient is also aware of a legal context to this clinical encounter. In my ownspeciality of child psychiatry, considerations may include: informed consent, custody and placementmatters, malpractice worries, and the legal minefield of psychopharmacology. Traditional forensicpsychiatric topics such as legal insanity and competency are less common concerns. The sources ofinformation are not usually professional journals, but newsletters, communications from professionalsocieties and from one’s own attorney or malpractice carrier. Can all of this be distilled into a single legalconsciousness? This can be viewed in the context of the current American sense that we are continuallybeing taught to live in fear. One’s legal consciousness can be seen as the mixture of dread and reassurancethat 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 alicensed 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.

293Knowledge serves mostly to allay fears. The consciousness also has a dramatic quality. At many points inclinical decision making, the image arises of oneself in court defending the step one is taking. These andother aspects of legal consciousness in the treatment setting will be discussed.99.6. Legislating the ReformationLee Palmer Wandel, University of Wisconsin (lpwandel@wisc.edu)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 abroad nineteenth-century interest in publishing the sources of the Reformation, of which the CorpusReformatorum and the Weimar Ausgabe of Martin Luther’s works are the most famous products. Like somany of these publishing projects, Richter’s gathered from dispersed local archives documents which werethen arranged according to categories of primary interest: in the case of the volume, geography andchronology. Richter’s earlier work had been on canon law and Gratian; he envisioned this as an extensionof what he then termed Protestant ecclesiastical law.Richter’s volume, along with those Emil Sehling edited beginning in 1902, brought together what had beenlocal documents, promulgated by either Free Imperial Cities, such as Nuremberg or Augsburg, orPrincipalities, such as Brandenburg. Together, these volumes speak to a stunning innovation: the use ofcivil law to define and institute religion. Prior to the sixteenth century, local bishops and the papal curiahad jurisdiction over the practice of worship—liturgy, the sacraments, forms of prayer. In the fourteenthand fifteenth centuries, increasingly, various secular authorities had moved to take over the regulation ofmorals. But with these Church Ordinances, secular authorities—those authorities explicitly notecclesiastical—extended their jurisdiction and legislated “religion”: the form of the liturgy, the number ofsacraments, 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.100. Legal Consciousness: V100.1. Scare You to Death, Work You to Death, Bore You to Death: The Developmentof Legal Consciousness in American Law SchoolsKatherine Lord, Valparaiso, Indiana (katherinelord@1stcounsel.com)In order to make effective conclusions or predictions about “The Law” as it relates to various other aspectsof society, it is crucial to examine how future lawyers and lawmakers are taught to view the law. Thispresentation will investigate factors and influences in the cultivation of legal consciousness in Americanlaw schools today. I will discuss what impact the teaching philosophies of professors can have, as well asthe availability of extra-curricular influences, such as clinical experience, internships and studentorganizations. As a case study, I will describe the process of founding a new student group on my law

294school campus, the experience of working with the administration to make the organization successful andhow members of the organization feel it has shaped their outlook on the study and practice of law.100.2. The Legal Rights of Individuals Seeking Assistance from the Government: Doesthe Perception Reflect Reality?Paul M. Schmidt, Attorney-at-Law, Madison, Wisconsin (pschmidt@boardmanlawfirm.com)This paper discusses our current legal consciousness concerning the existence and importance of individuallegal rights in situations where a mentally impaired individual encounters governmental controls andprocedures. Specifically, this paper explores specific areas where individual rights are tested byinstitutional objectives:1) qualifying for entitlement benefits, such as Social Security Disability benefits; 2) qualifying for welfarepayments, such as Supplemental Security Income payments; and 3) appointing a legal guardian for anincompetent individual. This paper compares the current societal beliefs and attitudes about the rights ofindividuals in these situations, with the realities and shortcomings of the system. As a higher percentage ofour population (the “Baby-Boomers”) ages, and suffers afflictions of old age, such as dementia andAlzheimer’s disease, a shift in emphasis may occur: there will be increased demand on institutionalresources, and society may not have the ability to respond to this demand. The pressures tocompartmentalize and streamline the process will increase, further jeopardizing individual legal rights inthe process. This paper explores how our legal consciousness may evolve in the near future as a result ofthese pressures, and suggests some alternatives for addressing the current and potential future shortcomingsin the “system.”100.3. Law Enacted & Law in Action – The Case of Internet “Spam”Gerald J. Thain, University of Wisconsin-Madison (gjthain@wisc.edu)It is uncontroverted that unsolicited commercial e-mail messages (spam) are a major concern for efficientoperating of e-mail on the internet. The belief that this is a problem that can be addressed satisfactorilythrough enactment and enforcement of laws serves as wide-spread, notwithstanding, significant evidencethat law cannot be effective in dealing with this issue. The classic example of this is the so-called ‘CanSpam’ legislation adopted in the United States, with great attendant publicity.This issue will be addressed as follows:• Summarization of the problems created by Aspam@ e-mail, noting the very low cost of usingthis medium for the senders and the heavy burden that the abundance of such messages hasplaced on internet communications;• Reviewing the provisions of the ACan Spam@ act recently enacted with considerable publicitythat it will be essentially effective in combating the spread of spam;• Noting the reasons why the act cannot be effective to any noticeable degree, including thelimitations of the reach of the law (much spam is allowed under it so long as it is notdeceptive nor pornographic) and the ease with which present technology can over-come thelaw easily by such means as masking the sender’s address;

295• Considering some suggested alternative approaches to the problem of spam, especially inother countries, and noting that none so far overcome the technological methods of evadinglegal controls or the problems of international enforcement;• Treating the way this situation illustrates a common mentality in the U.S. that enacting a lawwill solve a social problem, with the impact that this concept has on the legal process, whenenforcement is unlikely;• Noting how the approach to this problem illustrates the “Athere-ought-to-be-a-law” mentalityof many in the U.S. that view law as a primary solution to social problems;• Considering this failure of the general public to divide law enacted from law in action in termsof legal consciousness.100.4. Temporality and Jewish Legal ConsciousnessJonathan W Schofer, University of Wisconsin Madison (jwschofer@wisc.edu)This paper examines the formation of consciousness through law and legal imagery according to classicalJewish sources. In the late ancient rabbinic communities, that in many ways created the canons of Judaismas it has developed to the present day, study of legal materials and practice according to legal norms notonly were central to religious ideals, but they were seen as crucial to the creation of ideal selves. Suchideals were conveyed through the teachings and models of early sages; the cumulative tradition of thistransmitted instruction was known as Torah; and rabbinic practice was ultimately framed as the appropriateway to orient towards their deity.Specifically, in my presentation I will focus on temporal elements in this process of self-formation. Inparticular, 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 consciousnessthrough study and practice of Torah, and (c) the theology of divine justice, according to which the deity is ajudge who in the future will enact decisive judgment upon each human, based on assessment of characterand action, that will determine existence after death. I will examine specific literary materials showing thecomplex ways that these frameworks are intertwined, and then I will reflect upon the broader implicationsof this descriptive study for our understandings of temporality, law, and consciousness.101. Legal Consciousness: VI101.1. Media Violence: Entertainment, Art, or ThreatThomas D. Barton, California Western School of Law (tbarton@cwsl.edu)Dozens of empirical studies over several decades have warned about seriously harmful effects–especiallyon children–of violence in the media. Yet little has changed, and the prospects remain dim. We possess

296the legal authority to regulate. We lack the political will. In the face of such serious risks, why are wedoing this to ourselves?The answer may be that portrayals of violence are often socially classified in ways that insulate theportrayals from serious regulatory scrutiny. Violent images often win labels that suggest they pose littledanger to mental health or to social stability. Crucially, these labels do not correlate well with how graphicthe images are, or how densely they appear in a portrayal. Works employing the same levels of violencemay 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 tolegally 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 thelabelling is the underlying social message th at accompanies the violent images. Where the context of theviolence 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, butdoes so in a way that most people regard as thoughtful, legitimate, or controllable, then the work as a wholeis regarded as “art.” Where violence appears in a work that seeks social change, but does so in a manner ortoward particular ends that many people regard as uncontrollable, disruptive, reckless, morally offensive, ordis-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 neglectsthe impact of these images on children whose understanding of the contexts may not be well developed.101.2. Legal Consciousness and Contractual ObligationKojo Yelpaala, University of the Pacific (kyelpaala@pacific.edu)The paper on “Legal Consciousness and Contractual Obligations” will explore the origins of contractualobligations. 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. Viewedwithin this broad conceptual framework, where do human beings get the idea that they must keep theirword or perform their promises? Is it, as utilitarian theorists might suggest, simply a matter of carefulburdens and benefits calculus for breach? Or, might our consciousness in contractual obligations havedeeper roots in religion, theology or the centrality of the supernatural in the ordering of human socialorganizations? In the specific case of Judeo-Christian religions, might the sources of contractual obligationbe located in the “Covenant with God”? But the origins of contractual obligations might be less a questionof religion but more a question of evolved social norms of reciprocity or human biological need forcollaboration and cooperation. In a world of “efficient breach” and shifting moods in internationalrelations, the investigation of this question is both timely and important.

297101.3. Some Implications of the New Brain Science for Fault in Criminal LawWalter Dickey, University of Wisconsin - Madison (wjdickey@wisc.edu)Recent developments in brain science, particularly regarding consciousness, raise serious questions aboutchoice and free will. The criminal law in the United States is based on the idea of free will and choice. Thisis 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 tryto establish that the desire of the actor was not as it appeared from his actions, from which inferences aboutmental state and choice were made. This paper will explore new findings from brain imaging and theirimplications for the expression of fault, based on free will. I will argue that this new science casts furtherdoubt on these concepts. This may merely suggest that we abandon them, in favour of morestraightforward expressions of impulse control, or not.101.4. Tort, torsion, tortureJacques Lezra, University of Wisconsin (lezra@facstaff.wisc.edu)On what grounds can a "case for torture" be proposed? This was the matter of debate following thepublication in 1982 of Michael Levin's article of the same name; a spate of columns in the US pressfollowing the World Trade Center attacks in 2001 took up Levin’s brief argument again, and it lies behindthe so-called « torture memoranda » and associated opinions drafted by the United States’ Department ofJustice 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 ofU.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 intentionallyinflicted 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, orintimidating or coercing him or a third person, or for any reason based on discrimination of any kind, whensuch pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a publicofficial or other person acting in an official capacity”) hangs on the so-called “ticking-bomb” scenario. ForLevin, and for the Bush administration, the circumstance of impending, certain, and preventablecatastrophe justifies the use of torture, and the suspension of the “rights” of the subject who undergoestorture. My presentation examines the specifically literary aspects of the "ticking bomb" argument (forinstance, the normativization of extreme or « representative » cases, anecdotal rhetoric of different sorts),and suggests that a problematical and tendentious understanding of temporality vitiates efforts to convertsuch hypothetical arguments into justifications for this or that juridical procedure ("torture warrants," forinstance). This brief talk works between Henri Alleg’s La Question, Gillo Pontecorvo's film The Battle ofAlgiers, a brief excerpt from Dante's Purgatorio, Jay S. Bybee’s “Aug. 1, 2002: Justice Department Memoto the White House Counsel,” and Levin's essay.

298101.5. Insanity Cycles: the regular misunderstandings of science and lawVictoria Nourse, University of Wisconsin (vfnourse@wisc.edu)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, whenthe law deems the defendant insane. The law’s insanity defense has traditionally characterized the loss ofself-control quite literally as a measure of legal consciousness – whether the defendant knew whether hisconduct was right or wrong. This notion of consciousness has, in turn, been subject to relentless attackfrom experts in science, medicine and psychology as an unrealistic portrait of the mind. Indeed, thepurpose of this paper is to put battles between the science of mind and the criminal law in some historicalperspective. It will turn out, for example, that the great debates of today are far from new, but haveimportant historical analogues in the 19 th century. Law has embraced scientific definitions of mind, morethan once, only to be met by popular rebuke, leading to retrenchment and reinvigoration of seemingly crudeand legalistic ideals of mind. If this is right, then we must entertain the possibility that the law’s mind andscience’s mind are really rather different ideas.101.6. Instrumentalism and Northeast Asian Legal ConsciousnessJohn Ohnesorge, University of Wisconsin (jkohnesorge@wisc.edu)Legal consciousness and culture have been at the center of political, economic and social interactionsbetween the West and Northeast Asia, meaning China, Japan and Korea, for at least 150 years. Differencesin legal culture were used by the West to justify imperialism in Asia in the Nineteenth and early TwentiethCenturies, and differences in legal consciousness and culture are still cited by both sides when conflictsarise in trade and economic relations, as well as in disputes over politics and human rights. Morefundamentally, both East and West continue to define themselves, to some extent, in terms of how theirlegal cultures differ from those of the other.Recent changes to the legal systems of Northeast Asia have cast doubt on the validity of some longstandingassertions about legal consciousness and culture in the region. For example, the argument thatNortheast Asians are culturally averse to litigation has been undercut by evidence that traditionally lowlocal 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 rightsassertion and litigation, the evidence suggests that legal consciousness as reflected in legal systemperformance is guided by its own logic, which can be understood in the universally applicable language ofindividual self-interest.Reformers in Northeast Asia appear to have taken this message to heart, and are seeking to encourage rightsassertion and litigiousness in their societies in order to bring about broad social change. After providing ananalysis of the ways in which legal culture and consciousness have been used in various East-Westinteractions, this paper will explore the motives and assumptions behind the attempts of reformers inNortheast Asia to remake local legal consciousness in the pursuit of specific instrumental goals.

299102. Legal Consciousness: VII102.1. Families and the New Legal ConsciousnessNina Carmic, University of Wisconsin-Madison (nlcamic@wisc.edu)It is no secret that the law has overshadowed customary practices and religious traditions in the vastmajority of societies, in setting parameters of legitimacy for both family formation (through marriage), aswell 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, anincreasing number of families are drawn to the legal process in solidifying their family relationships. Thereis, of course, no better example of this than in the U.S., where the laws no longer seek to criminalize privateconsensual sexual relationships, yet neither do they support it between couples of the same sex. A primarygoal for same sex couples has been in the past year, the legalization of marriage – as if the conferring of thelegal label grants the much desired legitimacy to this form of family life. The desire by same sex couples tolegitimize a relationship through entry into marriage has certainly been met with greater resistance thansupport within the legal establishment, even as it remains a coveted legal status for the vast majority ofsame sex couples in stable, enduring relationships. In my essay, I explore the vastly complicatedrelationship between family formation and dissolution and jurisprudence. I note that families resolve thevast majority of their conflicts outside of the legal system. I raise the question of why marriage and divorceremain so firmly entrenched within our legal consciousness, given the law’s more capricious attitudetoward regulating family behaviors in general. Why has the state retained command of this ultimatelyprivate sphere of relational formation/dissolution? Is the goal of protecting individual family memberssubservient to a political motivation, whereby the state is seeking to exert influence for reasons having lessto do with stabilizing family life and more to do with maintaining its coercive (rarely channeled intoprogressive reform) hold on this vital institution? If that is the case, then are the interests of individualfamily members, especially the less powerful within the family unit, likely to be well served? I addressthese questions in the context of American family law, as well as with references to legal systems in othernation states.102.2. The Sympathetic Discriminator: Mental Illness and the Americans withDisabilities ActElizabeth Emens, University of Chicago Law School (eemens@law.uchicago.edu)While animus and stereotyping are common responses to mental illness, discrimination against people withmental illness also occurs in part because of how those with mental illness may make other people feel. Aperson suffering from psychosis may make others feel agitated or afraid, for example, or a depressed personmay make others feel sad or frustrated. One basis for discrimination in this context is therefore a desire toavoid negative emotion. More pointedly, the phenomenon of emotional contagion—the largelyunconscious process by which we absorb the emotions of nearby others—may form a peculiarly intractablebasis for discrimination against people with mental illness. Research on emotional contagion indicates thatthe emotions of people with mental illness are likely to be absorbed by those around them, and thatemotional contagion increases the more we like someone. These data suggest certain limitations to theapplication of the much-vaunted contact hypothesis to the context of mental illness discrimination. The

300contact hypothesis posits that workplace integration increases liking and decreases discriminatory animusand stereotyping, which are both much-needed interventions in the highly stigmatized area of mentalillness. But the literature on emotional contagion suggests that contact may never completely eraseoutsiders’ impulse to exclude people with mental illness from the workplace. Instead, even if contact couldeliminate animus and stereotyping, coworkers who come to know and like their colleagues with mentalillness may still have a reason to want to avoid or exclude them: a desire to avoid negative emotionalcontagion. This thesis has implications for doctrinal debates about the meaning and scope of theemployment 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 ofjobs to involve effecting certain emotions in others; who must bear the burden of effective accommodationnegotiations; how the “regarded as” prong of the definition of disability should be interpreted; and whetherinteracting with others is a major life activity for purposes of the definition of disability under the ADA.102.3. Colonial Madness, Legal Consciousness, and the Poetics of Suffering: StructuralViolence in Algerian LiteratureRichard C. Keller, University of Wisconsin-Madison (rkeller@med.wisc.edu)Social scientists and humanists have exhaustively explored the production of biopolitical knowledge and itsimplications. 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 ofthe colonial situation. The intention is to explore the ways in which the medical and psychiatric clinic oftenoperated as a literal theater for colonial conflict and for the marginalization of indigenous subjects. ForAlgerian author Kateb Yacine, psychiatry operates as a biopolitical machine for the regulation of a colonialorder in which citizenship was the privilege of the European settler. Kateb’s poetry, drama, and novelsprovide crucial sources for exploring literature as a site of resistance to a psychiatric paradigm that cast theAlgerian 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 medicalizedlanguage. The paper thus explores the possibilities of applying methodologies borrowed from the socialhistory of medicine and medical anthropology to literary works with the goal of shedding light on therelationship between health, citizenship, and consciousness. By reading Kateb’s work alongside criticaldocuments in the history of colonial medicine, the paper points to the multiple axes of oppression thatshape suffering, disenfranchise populations, and preclude “healing.” By drawing on recent anthropologicalwork on suffering and structural violence, the paper argues that Kateb’s uses of medical language toreinscribe social experience are highly relevant in a world in which legal citizenship and the right to healthremain closely entwined.102.4. The Concept of Evil: A New Look at Evil from the Vantage Points of Theology,Philosophy, and Forensic PsychiatryMichael H Stone, Columbia University (mstonemd@aol.com)The concept of Evil has long been considered relevant only to the domains of theology and philosophy, asthough the Deity alone is privileged to make judgments regarding Good vs. Evil. The term “evil” has littlecurrency 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.

301This presentation will review the evolution of the concept from ancient times to the 20 th century, focusingon conceptions stemming from religion and philosophy. The theodicies of Leibniz and those that came afterwill be addressed. In addition, the parallels between contemporary notions about Evil and its forensic orjurisprudential 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 orthe 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 (goodnessor 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 aboutgroups. In wars each side sees the other as “evil”; only occasionally is there universal condemnation of oneside, even by those not directly involved – as in the case of the Nazis or of Cambodia’s Pol Pot. As forindividuals, we also distinguish between those who commit a criminal and cruel (or “evil”) act once in alifetime, that seemed uncharacteristic of their usual self – versus those who habitually commit depravedacts (and who thus seem “evil” in general). Serial rapists and serial killers would fall into the lattercategory. Many such persons are diagnosed as “psychopaths.” In recent years psychopaths and other typesof antisocial persons have been studied by imaging and other neurophysiological techniques, and have beenfound 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 thatcontributes to subsequent behavior of a kind that we identify later on as “evil.” This area will also bediscussed in the presentation – as part of the complex set of interactions that underlie the uniquely humanphenomenon of Evil. The ways in which ordinary people caught in extraordinary circumstances can end upcommitting evil acts – with bland indifference and seeming unawareness (à la Hannah Arendt’s “Banalityof Evil”) – will also be touched on.102.5. Legal Primitivism and its DiscontentsSteven Wilf, University of Connecticut (swilf@law.uconn.edu)How do we interpret the continuing preoccupation among Anglo-American jurists with primitive law, andmore particularly with lex non scripta, from Henry Maine’s Ancient Law (1861) to Bronislaw Malinowksi’sCrime and Custom in Savage Society (1926)? In the second half of the nineteenth century and through theearly twentieth century, an immense literature was created which charts the evolution of legal systemsparallel 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 CoolidgeCarter, 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 legalprimitivism is valorized, as is the case in celebrations of Teutonic forests as the birthplace of republicanlegalism; at other times, it is portrayed as barbaric or totemic. Nevertheless, despite its vastness andvariety, 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 racialassumptions embedded in these works.But my interest in legal primitivism is not a venture of antiquarian cultural recovery. For these nineteenand early-twentieth century thinkers, their fascination with legal primitivism betrayed their need for alaboratory of ideas. Legal primitivism is the doppelgänger of legal modernism, the place where legalmodernists, caught between an increasingly formal common law and an increasingly insistent thrusttowards codification, shunted their own anxieties. It was unease with legal modernism’s focus on writtentext, for example, that animated the identification of orality as a core characteristic of the savage legalmind. James Coolidge Carter mined legal primitivism as a focal point of dealing with the troublesomeproblem of competing and contradictory legal precedent. Primitive law presented rudimentary legal

302systems; ideas, in the words of Henry Maine, which are to the jurist what the primary crusts of the earth areto 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 theorigins of legal modernism with the rise of the surety of social science. Others, notably Critical LegalStudies scholars, have pointed to the modernist impulse of grappling with indeterminacy in a disenchantedworld. My paper focuses upon the anxiety of legal change. It seeks to situate legal modernism withincultural modernism as a whole, and more particularly, within the scope of the larger cultural project ofidentifying 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 desperatelysought to see as its other.102.6. 'Lies Lawyers Live'Richard B. Jacobson, University of Wisconsin-Madison (jmsc@itis.com)The pragmatics of lawyer-client relationships and lawyer-court relationships involve a number of partlyrepressedhypocrisies. Those this paper examines include:1. The Lawyer-Client Relationship is RationalA version of traditional Freudian transference underlies the relationship, profoudly affecting thedisinteredness of the lawyer and the capacity of the client for consultation, autonomy and informedconsent.2. Always Believe the VictimDevelopment and pragmatics of United States’ law relating to sexual abuseThe Expert is Always Right and Abdication of Judicial Responsibility3. Best Interests of the Child Guide the Divorce CourtRole of the Guardian ad litem and Abdication of Judicial ResponsibilityRole of the independent expert: the same4. The Victim Must Always be ConsultedState and federal laws requiring consultation with the Victim Deny the Fundamental Role of the Courtsin Criminal Cases5. Nine of ten victims demand harsh punishmentThis section deals with the delights of being a victim.

303103. Legal Representation of Mental Health Patients in Israel103.1. Legal Representation of Mental Health Patients before Regional PsychiatricBoards in IsraelArie Bauer, Ministry of Health, Jerusalem, Israel (arye.bauer@moh.health.gov.il)Paola Rosca, Ministry of Health, Jerusalem, IsraelRazek Haled, Ministry of Health, Jerusalem, IsraelAlexander Grinshpoon, Ministry of Health, Jerusalem, IsraelThe Treatment of Mental Patients Law was issued in Israel in 1991 and includes paragraphs dealing withhearings of patients at the Regional Psychiatric Boards. These Boards are statutorily empowered to decidefor the continuation of compulsory hospitalizations (whether the hospitalization order has been issued by aDistrict Psychiatrist or by a court of law) or for the release of patients. One of the major criticisms in thepast few years was that mental patients, due to their illness, are frequently incapable of representingthemselves in front of the Boards and claiming their rights for liberty. Moreover, the Boards tended toagree 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 IsraeliBook of Laws (N.5) stating that mental patients under compulsory hospitalization order and their familiesshould be informed of their right to be legally represented in front of the Regional Psychiatric Boards at theexpense of the State of Israel.Our purpose is to illustrate this project and its process, which finally brought about the desired change: thatis free legal representation of mental patients. The paper will also discuss the pros and cons of this project,and its implications concerning the time perspective, the financial aspect, and the improvement in mentalpatients rights implementation.103.2. Representation of Mentally Ill Clients at the Regional Psychiatric CommitteesYona Haier Levi, Office of the Public Defender, Tel-Aviv, Israel (Yonah@justice.gov.il)Dorit Nachmany Albeck, Office of the Public Defender, Tel-Aviv, Israel (Doritn@justice.gov.il)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; therepresentation was conducted at hearings held before the regional psychiatric committees, authorized togrant vacations and release patients from psychiatric hospitals.Up to that time, in most cases, the patients had not been represented before the committees, and theprovision of representation proved that without the presence of a lawyer the patient’s rights areunprotected: the rules of natural justice are not observed, the hearing is short and laconic, no reasons aregiven for the committee’s decisions, etc.This paper will present the principles of a report prepared by the Public Defender’s Office, summarizingthe ramifications of the legal representation with respect to the committees’ work, and the rights of the

304mentally ill. The report’s findings proved that the chances of a person who has been forcibly hospitalizedto be released from hospital or go on vacation are higher when he is represented at the committee by alawyer. In addition, it was clarified that the presence of a lawyer at the committee favourably affects theproceedings and decisions of the committee.In addition, this paper will present the legislative changes that have recently occurred in Israel in thismatter.103.3. Mental Patients’ Legal Representation before District Psychiatric Committees inIsrael: Justification and CriticJacob Margolin, Eitanim Psychiatric Hospital, Israel (kfrjacob@matat.health.gov.il)Eliezer Witztum, Ben-Gurion University of the NegevThe Israeli District Psychiatric Committee, acting on behalf of the Israel "Treatment of Mental PatientsLaw" of 1991, is provided with ample authority in the domain of civil commitment of the mentally ill. Thiscommittee has a quasi-legal status. Recently, the Israeli Knesset (Parliament) has added the obligation ofinforming these patients of the option of having the right to legal representation before the committeehearings. This presentation will discuss the issue of legal representation of the mentally ill, its essence, andits problematic aspects. Two case studies will demonstrate some of the problematic issues concerning thisnew rule. The first concerns an earlier and premature release from hospitalization due to formal and legalprocedures, in spite of medical opinion. The second case study deals with the possibility of forming aconflict between the psychiatric opinion, as represented by the attending physician, and the patient and hislegal adviser. Such a conflict may cause significant damage to the therapeutic alliance, and reduce patientcompliance. Some possible solutions will also be suggested.103.4. Study and Follow-up of the Use of Legal Representation of Psychiatric Patientsin Regional Psychiatric Boards in IsraelRoberto Mester, Ministry of Health, Jerusalem, Israel (rmester@netvision.net.il)Yair Barel, Ministry of Health, Jerusalem, IsraelAlexander Grinshpoon, Ministry of Health, Jerusalem, IsraelArie Bauer, Ministry of Health, Jerusalem, IsraelThe Israel Mental Health Act of 1991, which is still current today, states that a patient may be legallyrepresented by a lawyer when he appears before a regional mental health board convened to deal with theextension 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 detrimentaleffect of enforced hospitalisation has led the Ministry of Health to implement two pilot projects centred ongranting patients appearing before regional courts the services of lawyers paid by the government. Theresults of these projects convinced the legislators that the procedure should be formalised and, as aconsequence, at the beginning of 2004 a law was passed granting all patients appearing before the regionalboards in these issues the services of a government-paid lawyer. The unit for Evaluation and Auditing ofPsychiatric Services of the Israel Ministry of Health carried out a follow up study to determine the fate of

305patients discharged by the regional psychiatric boards, against the recommendation of their treatingprofessional teams. The study, carried out over a period of three years, included patients using the servicesof lawyers and those that did not use this service. Following the new legislation, the study now includes allpatients discharged by the regional psychiatric boards in Israel.This presentation analyses and discusses the results of the first stages of the study.103.5. Trends in Involuntary Psychiatric Hospitalization in Israel 1991-2000Alexander M. Ponizovsky, Ministry of Health, Jerusalem, Israel(alexander.ponizovsky@moh.health.gov.il)Arie Bauer, Ministry of Health, Jerusalem, IsraelPaula Rosca, Ministry of Health, Jerusalem, IsraelAlexander Grinshpoon, Ministry of Health, Jerusalem, IsraelBackground: Involuntary Psychiatric Hospitalization (IPH) is defined as a restrictive intervention aimingat treating the dangerous psychotic patient at a critical time. The legislative criteria for involuntarycommitment in Israel are: 1. acute psychotic state; 2. physical danger to self or others, and 3. a causativelink between the psychiatric disorder and the dangerous behavior. Thorough information about involuntarypsychiatric hospitalizations (IPH) is crucial for the planning of national mental health care policy and up todate 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. Thepredictors identified in the literature include: male gender, young age, diagnosis of schizophrenia or othermajor 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. Werestricted 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 theinvoluntarily 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 andcommunity services, and for preparing specific guidelines to extend the use of involuntary ambulatorytreatment orders.

306104. Lethal Violence by Women104.1. Maternal Filicide Offenders and Their VictimsKristen R. Beyer, FBI’s National Center for the Analysis of Violent Crime, Washington, USA(kbeyer@fbiacademy.edu)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 toBureau of Justice Statistics (1999), it is reported that 57% of child homicide victims under age five arekilled by their parents or stepparents. Of those child homicides, a significant number (approximately halfin 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 birththrough 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 biologicalmothers who have killed their children. The inclusion criteria include the victim being under 18 years ofage and the biological child of the offender. Women who have committed neonaticide, infanticide, and/orfilicide have been included in the study. Offenders were identified from FBI case files, VICAP, state andlocal law enforcement agencies, prosecutor’s offices, and public source data. Case materials includinginvestigative reports, psychological reports, autopsy reports, and/or confessions were requested fromvarious agencies. Data was extracted from the files and recorded onto a protocol that was developed by theFBI’s National Center for the Analysis of Violent Crime (NCAVC) and reviewed by the NCAVC’sextramural Research Advisory Board. The protocol consists of questions relating to 1) offenderdemographics, 2) victim demographics, and 3) offence 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 toexpand the study to increase generalizability, reliability, and validity. Case examples may be included todemonstrate research findings.104.2. Involuntary Outpatient Treatment in NorwayKjetil Hustoft, Stavanger University Hospital, Norway (KHU2@SIR.NO)Terje Houeland, Stavanger University Hospital, Norway (THO@SIR.NO)This presentation will address the Norwegian Law of Psychiatry (Mental Health Act) especially as it relatesto involuntary out-patient treatment. The general aspects of involuntary in-patient admission—whichinclude observation for up to 10 days and admission for an unlimited numbers of day—will be discussed inrelation to the criteria that are necessary for patient admission. In addition, a main focus of this presentationwill include the criteria for involuntary out-patient follow-up, based on the Mental Health Act. A number of

307issues including practical arrangements for involuntary out-patient follow up, necessary treatment plans,and the frequency of use of involuntary out-patient follow up in Norway will be discussed.104.3. Moving Beyond the Stereotypes: Women’s Subjective Accounts of Their ViolentCrimesCandace Kruttschnitt, University of Minnesota (kruttsch@atlas.socsci.umn.edu)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 rangeof violent acts, this paper shows they justify their actions and the degree to which these justifications reifyor deny common popular, legal, and feminist depictions of them. Most often, these depictions assume thatwomen's violent offending is a result of past or current victimizations or underlying pathologies. Yet, asMorrissey (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 areincarcerated in the Hennepin County Adult Detention Facility (Minneapolis, Minnesota). A life eventscalendar was used to assess women's involvement as both victims and offenders in violent and near-violentcrimes over the 36 months prior to their incarceration. This sample permits a comparison of narratives ofviolence from different racial groups (white, African-American, and Native American). Further, itcontextualizes 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 refine ourunderstanding of women's subjective experiences of violence and the degree to which these subjectivitiesreproduce various social constructs of violence.104.4. Female Homicide Offenders – Psychotic or Personality Disordered?Hanna Putkonen, University of Helsinki (Hanna.putkonen@hus.fi)The aim of this study was to examine what differences would emerge grouping the offenders by thepresence of a psychotic or personality disorder. The study group comprised Finnish female homicideoffenders, 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 moreoften a quarrel (p

308104.5. Understanding the Risk Factors for Violence and Criminality in Women: TheConcurrent Validity of the PCL-R and HCR-20Janet I. Warren, University of Virginia (jiw@virginia.edu)This study explores the performance of 132 female maximum-security inmates on the PsychopathyChecklist-Revised (PCL-R) and the HCR-20 (Historical, Clinical and Risk Management Scheme) toexamine the concordance between these two risk assessment instruments, and to assess their potentialusefulness in determining level of risk for violent behavior and other forms of criminality. The twoinstruments 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 predictviolent and non-violent crime, the HCR-20 did not add to the variance explained by the PCL-R. Theseresults confirm earlier research that suggests there is little or no difference between these two riskassessment instruments in their relationship to community or institutional violence. Further, ReceiverOperating Characteristics (ROC) analyses show that both instruments demonstrated an inverse ability topredict convictions for murder, a close to chance ability to predict violent crime, but a shared ability topredict property and minor crime. Broadly, these results suggest that psychopathic women are involved inchronic patterns of non-violent criminality, while women charged and convicted of murder generally do nothave elevated scores on the PCL-R or HCR-20.105. Liberty or Beneficence in the Care of the Mentally Ill?105.1. Treatment Non-Adherence in Mental Health: Freedom at What Cost?Steve Abdool, Regional Centre for Excellence in Ethics, Guelph, Canada (abdostev@homewood.org)Treatment compliance is an extremely complex phenomenon, and a wide range of factors contribute to thisimportant dimension of patient care. No matter how much effort, time and other resources - limitedresources one might add - are spent on health care delivery, if treatment compliance is sporadic or deficient,then the primary goals of medical intervention are not fulfilled. Consequently, severely ill patients remainuntreated and manifest florid symptomatology, may pose risks of harm to themselves and others, distress totheir families, and finite resources are practically wasted. A recent review of the literature by Cramer andRosenheck (1998) showed that the mean compliance rate for patients with physical disorders is 76% and58% for patients with psychiatric disorders. One review in the US estimated that the annual cost incurredbecause of poor compliance is at least one hundred billion dollars (Reston, 1992). This is due to a largevariety of factors that include unnecessary hospital or nursing home admissions, lost productivity (byreason of exacerbation of illness and premature deaths), and cost for outpatient care.In this segment of the symposium, participants will critically examine the notion of ‘compliance’, itsmultifaceted basis, and clinical, social and ethical ramifications involving all major stakeholders (patients,families, health care professionals and society in general). In doing so, participants will appraise a widerange of influential factors relating to therapy resistance, reluctance and adherence. These include patientrelated,disorder-related, clinician-related, environment-related, and treatment-related determinants. The

309symposium will be interactive, use real case scenarios, and draw on the knowledge and experiences of allparticipants.105.2. Complexity and Pitfalls in the Admission and Treatment of Psychiatric Patients ina Large Inner-City HospitalKen Balderson, St. Michael’s Hospital, Toronto, Canada (baldersonk@smh.toronto.on.ca)Psychiatrists and other health care professionals frequently make decisions which restrict the liberty ofpatients through forced detention and evaluation in hospital emergency rooms, involuntary committal andtreatment. These decisions may be affected by many factors, including but not limited to patient age,gender and class, whether family are involved, diagnosis, resource availability, and the weather. Thephilosophy and amount of experience of the clinician are also important.Some clinicians may use the mental health act as their guide, sparing them from making ethical choices thatthey find onerous. Certification is more palatable than coercion. However, mental health legislation and itsinterpretation by review boards and courts may leave clinicians feeling frustrated and disillusioned as theyfeel blocked from acting in patients' best interests and making, what they see, as ethical choices.For patients, the expectation of compliance with their physician's treatment recommendations bringsconnotations of submission and obedience. They frequently feel angry, demoralized and disempoweredwhen their liberty is restricted by certification; their right to make treatment decisions is taken away whenthey are declared incapable to consent. They may be faced with a difficult decision: should they "comply"with the treatment in order to regain their freedom as quickly as possible? If they disagree with theirdoctor and request an appeal, will they be punished or forced to stay in hospital longer?This paper will look at case vignettes from an inner-city emergency room and inpatient mental health unit,including input from patients, to examine the complexity and some pitfalls involved in making ethicalclinical decisions.105.3. Stigma and Labelling of the Mentally Ill in a Culturally Diverse Society:Implications for Everyday PracticeHazel Markwell, St. Joseph’s Health Centre, Toronto, Canada (markwellh@smh.toronto.on.ca)There are numerous sources of stigma and labelling of ‘mental illness’ and the ‘mentally ill’. First, thesubstantial socio-cultural dimension to stigma and labelling clearly influences patients’, families’, healthcare professionals’ and society’s perception, conceptualization and treatment of ‘mental illness’. This posesspecial challenges for all stakeholders with regard to illness identification, care and recovery, especiallywhen there is an aggregation of diverse cultures, such as exist in Canadian society. Second, the media is acommon source of stigma and stereotyping of the ‘mentally ill’ within practically all societies. The public’sassociation of mental illness with violence, for example, is a major cause of stigma against the mentally illin the Western world, and some studies show that stigma has intensified over the past few decades despiteincreased public knowledge. A third element of stigma and labels in mental health is the use of psychiatricdiagnosis in the West as a solution to human problems, such as explanation, mitigation and absolution forunacceptable behaviours. On the other hand, the common practice of pejoratively using labels, such as‘borderline’, serves to exclude and repudiate difficult-to-treat patients.

310105.4. ‘Over-Diagnosis’, ‘Mis-Diagnosis’, and Changing Diagnoses in Psychiatry:Critical Issues with Extensive ImplicationsEdgardo Perez, Homewood Health Centre, Guelph, Canada (pereedga@homewood.org)Patients today may present a psychiatrist or other clinician with an extensive list of past diagnoses. Due tochanges in the Canadian health care system, we now have layers of physicians through which a patient mayfilter. The perspective of each clinician may well lead to a variety of diagnoses for any given patient. Inpsychiatry, the DSM and other diagnostic tools guide us, but their degree of validity raises significantquestions and concerns. It can be very challenging for the clinician and confusing for the patient when aclinician determines the need to change a previously given diagnosis. In other areas of medicine, theclinician is taught how to manage a comparable situation in the "false-positive" result. The clinician mustmaintain an objective perspective in the presence of a well-respected colleague's previous opinion, that is,the potential “false-positive.”This presentation will review the extent to which diagnostic tools in psychiatry have been validated, and theimpact of the clinician’s own perspective and framework on diagnostic label and outcome. This symposiumwill also appraise an approach to “challenging” a previously given diagnosis. Case examples will be used toreview how to effectively elicit from the patient and the family the meaning and function of the diagnoses.105.5. Distractors in Civil Commitment Decision-MakingIan Freckelton, Monash University (Freckelton@latrobe.edu.au)A series of emotive considerations that are extra-legislative frequently play a potent role in decisionmakingabout whether patients should be subject to mandated in-patient or out-patient treatment. Thelanguage employed can be pejorative, counter-therapeutic and inaccurate.Such terms include that a patient: (1) is insightless; (2) is non-compliant; (3) is an “absconder”; (4) issexually disinhibited or promiscuous; (5) is violent; and (6) is suicidal.Avoiding labelling theory and post-modernist considerations, the paper will draw upon real case examplesfrom the Victorian Mental Health Review Board in Australia to argue that such terms are often employeduncritically and dangerously by clinicians and review tribunal bodies alike to determine whether patientsshould be detained. It will contend that the essence of such terms, when evidence-based and contemporary,has relevance to the decision-making process. However, it will argue that great care needs to be employedin the adoption of terminology that can be distressing and counter-therapeutic for patients, as well asprejudicing for clinicians and review tribunal decision-makers.105.6. Schizophrenia: History of Treatment and OutcomeSabry Attia, Professional Counseling PC, Grosse Pointe Farms, U.S.A. (attia@comcast.net)Schizophrenia ia a devastating illness that affects about 1.0 % of the world population. Presently in theUSA, an estimated 2.5 million individuals are diagnosed with schizophrenia. In 1980 the loss of

311productivity as a result of schizophrenia was estimated at $20 billion. The National Institute of Healthreported the cost of this disease ranges from $30 to $ 60 billion annually. The author will defineSchizophrenia according to DSM IV, the diagnostic criteria, and how it is perceived by the community andthe treating personnel. He will present historic treatment methods utilized before the modern psychotherapyor modern medication were known and implemented. The current treatment policies include medicationsand electric shock treatments. The presenter will discuss researches conducted in Finland, Denmark and theUSA and will emphasize the importance of social skill training evidenced with the outcome of a skilltraining project conducted in Michigan that focused on improving the schizophrenic patients’ quality oflife.106. Lifelong Internment in Switzerland106.1. Forensic-Psychiatric Criteria for the Indefinite Safe Custody of DangerousPerpetrators. A Retrospective AnalysisAndreas Frei, Psychiatrische Klinik, Lucerne, Switzerland (andreas.frei@ksl.ch)Marc Graf, Universitäre Psychiatrische Kliniken, Basel, SwitzerlandVolker Dittman, Universitäre Psychiatrische Kliniken, Basel, SwitzerlandAt the beginning of the nineties, a series of spectacular crimes, committed by repeat offenders, weredisturbing the public mind. As a consequence, serious doubts about the competence of forensic-psychiatricexperts arose. Also, as a consequence, an initiative to change the constitution was launched by somecitizens, mainly by relatives of victims. They wanted the introduction of a form of life-long safe custodywithout the possibility for a revision; up until that point, a revision of this measure had to be done regularly.However, in February 2004, this change to the constitution was accepted by the Swiss voters; thetransformation of this decision, through the creation of a new law, resulted insurmountable difficulties inrespect to delays of the European Convention of Human Rights. The authors of this paper feel thatthe initiative passed due to poor knowledge of the public mind in connection with the decision making offorensic-psychiatric experts. Between 1989 and 1998, 112 spectacular cases of attempted, performed orcompleted murder or manslaughter have been assessed by the forensic-psychiatric department of thePsychiatric University Clinic (PUK) of Basle. The aim of this paper is to highlight the significance ofcareful statistical criteria in the decision-making process. Analyses, such as sociodemographic data,psychiatric diagnosis, and/or PCL-R, make the decision making far more transparent, and direct the expertto a more found conclusion. To be discussed in this paper are six such cases, in which the perpetrator wassuch a public danger that he had to be locked away indefinitely.

312106.2. Forensic Psychotherapy with Detainees Under Art. 43 fig. 1, sect. 2 Swiss PenalCode (Timely Unlimited Safe Custody)Ronald Gramingna, Interkantonale Strafanstalt Bostadel, Menzingen, Switzerland(Ronald.Gramigna@Bostadel.ch)The unlimited safe custody according to Art. 43 fig. 1, sect. 2 p. c. in Switzerland concerns two forms: thecustody for dangerous perpetrators who are neither treatable nor require care and perpetrators, and thecustody for those who are treatable in principle, though the prognosis of such a treatment however, remainsstill very insecure. Perpetrators under Art. 43 fig. 1, sect. 2 p. c. must have been judged as mentallyabnormal by the court. At the end of 2003, 134 people were held, under Art. 43 fig. 1, in Switzerland. Theforensic-psychotherapeutic management of such people is difficult, of course. Basically, each detaineeunder unlimited safe-custody has a right to psychotherapeutic treatment. Their motive for treatment,however, may be questionable; seeking psychotherapy is a means some detainees use to obtain a looserdetainment. The authorities, on the other hand might ask the detainees to undergo treatment before grantinggratification. In this collusive netting, therapists are placed in a very delicate position, because they mustact objectively in a typically subjective scenario.106.3. Lifelong Internment in Switzerland: Legal Issues and ConsiderationsMarianne Heer, Supreme Court of Lucerne, Switzerland (Marianne.Heer@lu.ch)Since the introduction of the Swiss penal code, lifelong internment was an option, but was of minorrelevance until the beginning of the nineties. This measure has since become increasingly important mainlyin connecting two spectacular crimes of two perpetrators on parole. The number of new defendants whowere faced with this penalty has not increased; however, is the option of life-long internment is now afrequent issue amongst forensic-psychiatric expertises and in inditements. The number of detainees underthis order has increased since they are no longer discharged. Having life-long detainees places theauthorities in charge 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 will take effect in the near future. Theprinciple that only mentally disturbed perpetrators could be the object lifelong internment has beenabandoned. Lifelong internment is possible for first time offenders who possess certain personality traits,according to an expertise, and in cases where the circumstances of their crime and their biography as awhole suggest possibility for repeat offences. According to this notion, the conditions for release havebecome stricter; detainees cannot be released in order to attempt to prove themselves outside custody;rather, a proof of non-existing danger of recidivism is required.The discussion about lifelong internment has become even more specific, following an initiative to changethe constitution regarding the lifelong internment of so called extremely dangerous perpetrators without theoption of reassessment unless there are "scientifically proven" successful new methods of treatment. It isobvious that there is a general deep mistrust of the population towards judges and forensic psychiatrists.Most legal experts think this change of the constitution is not in accordance with the European Conventionof Human Rights.Apart from the implementation of this new law, increasing strict legislation should be carried out. Forexample, the additional lifelong internment should be implemented if a convicted detainee displaysdangerous characteristics; the judgement can be altered and a timely limited penalty can be changed intolifelong internment. According to the present legislation, only a measure (and not a timely limited penalty)can, if it is not successful, be additionally changed into lifelong internment. By implementing this practice

313of altering legal decree, important basic principles of legislation would be seriously violated, for example"ne bis in idem" or the principle of final judgement.Another important issue is the question of what would become the index-crime for the consideration or theruling of lifelong internment. According to the first proposition of the revision of the penal code, the indexcrimewould have had to have been a capital crime. As a consequence, recidivistic paedophile perpetratorscould not qualify for lifelong internment. This would be not approved by the public opinion. The indexcrimeshould be deemed according to the latest legal discussions, and be defined more openly. It is not thecrime as such which necessarily proves the dangerousness of the perpetrator, rather it is his state of mindwhich becomes apparent through the crime that matters most in cases of determining lifelong internment.107. Memory under High Stress107.1. Impact of Stress on Memory for Complex, Impersonal InformationGary Hazlett, U.S. Army, Sanford, USA (hazlettg@soc.mil)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 assessedmilitary performance) and marked inaccuracies in memory (as measured by eyewitness identification). Thepresent investigation was designed to better define and characterize these stress-induced alterations. Anenhanced understanding of the way stress affects perception, cognition and memory is important becausemany battlefield errors (e.g., friendly fire incidents, collateral damage, etc.) have been linked to a decline incognitive operations.184 active duty military personnel enrolled in Survival School Training were the subjects of this study. Allsubjects completed pre-stress and post-stress measures of dissociation; all subjects completed pre-stresstrauma history questionnaires. Subjects were randomized to one of three groups (Pre-Stress; Stress andPost-Stress groups) and were administered the Rey-Osterreith Complex Figure (ROCF) test. Subjectscompleted the copy section and one minute recall phases of the test.ROCF copy and recall scores were normal for the Pre-Stress and Post-Stress Groups. ROCF copy andrecall scores were significantly altered in the Stress group. In the Stress Group, the copy procedure shiftedfrom configurational to piecemeal in all but 4 subjects. ROCF recall scores for the Stress group weresignificantly lower and in a range normally seen in individuals suffering from brain injury. A significantand negative relationship was observed between symptoms of Stress-Induced dissociation and ROCF recallscores in the Stress Group; in addition, a significant, negative association was observed between Pre-stressdissociation scores and ROCF recall in the Stress Group. Finally a significant, negative relationship wasobserved between history of traumatic stress and ROCF performance during stress.These data enhance our understanding of stress induced cognitive deficits. The alteration in the ROCFcopy and recall tasks is consistent with stress induced impairment of pre-frontal cortex functioning. Inaddition the discovery of a relationship between baseline variables (dissociation and history of trauma) andsubsequent performance under stress suggests that these may be used to predict real world difficulties andalso assist in the development of countermeasures. Such interventions might reduce error on the battlefield.

314107.2. Accuracy of Memory for Voices of People Encountered during Conditions ofHigh StressHeather Hazlett, University of North Carolina (garyheather@hotmail.com)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 personthey encountered during a high stress, compared to a low stress, interrogation. Recognition was assessedusing a series of voice recordings of the various interrogators. Subjects were given the opportunity to listento each and rate their selection and confidence levels of their selection. Accuracy rates were poor. Only20% of subjects were able to correctly identify the voice of the person who had conducted theirinterrogation. However, unlike the data from our eyewitness studies, we found a significant, positiverelationship between subjective ratings of confidence and accuracy. The ability to recognize a person’svoice that subjects encountered during realistic, highly personal, threatening stress was extremely poor.Additional research evaluating neuro-biological contributions to accuracy may enhance our understandingas to why some individuals are accurate in voice recognition and others not. Forensic examiners areadvised 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.107.3. Eyewitness Identification for People Encountered Under Conditions of AcuteStressCharles A. Morgan III, Yale University (charles.a.morgan@yale.edu)This study was designed to extend the findings of our previous research in eyewitness memory for peopleencountered during acute stress. We tested whether multiple exposures to a person would enhanceeyewitness memory. In addition, we tested whether people who are given a second chance to identify aperson were more likely to change their response to a correct or incorrect identification. These questionsare 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 interrogationstress. 24 hours after stress exposure subjects were asked to identify the one interrogator who theyencountered 48 hours earlier during stress exposure. After making their selection, subjects were given anadditional opportunity to make a second identification.As in our previous studies, when presented a photograph taken at the time of stress exposure, only 58% ofsubjects were able to correctly identify their interrogator. When given a second opportunity to view theserial photo line-up, 50% of subjects who had been wrong in their initial identification, switched to acorrect ID. Of the subjects who had been initially correct 40% switched to an incorrect response.Study Two: 58 U.S. Navy personnel enrolled in Survival School were exposed to interrogation stress. Onehour later, they were re-exposed to the same person who interrogated them. 24 hours after this, subjectswere asked to perform eyewitness identification of the interrogator.Eyewitness identification accuracy improved from 60% to 80% when subjects were re-exposed to theirinterrogator.The data from study one suggests that many people who are given the opportunity to make a secondeyewitness ID change their answers. Because none of the demographic variables predicted which subjectswere more likely to switch from correct to incorrect responses or vice versa, it is unlikely that asking

315witnesses to make a second guess will clarify evidence in the absence of other objective information. Thedata from study two demonstrates that memory is better if people have increased exposure to a personduring stress. This must be taken into consideration when evaluating the credibility of eyewitnessidentifications in court.107.4. Memory for People, Places and Events Encountered during Exposure to AcuteStressSteven Southwick, Yale University (Steven.Southwick@med.va.gov)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 wasdesigned 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 formore 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 theirstressful 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 comparedperformance 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 thescores from the standardized memory test and will also present the data from the debriefings. We willexplore whether accuracy of memory on the two separate tasks is related and also present the overallaccuracy of memory.The data from this study are highly relevant to forensic evaluations and to eyewitness testimony. Humanmemory is not a uniform construct and it is possible that memory for faces is not the same as memory forevents, 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 theirassessments.108. Mental Disability I: Exploring the Intersection betweenMental Disability Law and International Human Rights Law108.1. Exploring the Intersection Between Mental Disability Law and InternationalHuman RightsHenry Dlugacz, St. John’s University (hdlugacz@gis.net)In this presentation, the author will explore the emerging connection between mental disability law in theUnited States, and evolving international human rights principles in related areas. The notion of

316fundamental rights, which underlie U.S. mental disability law, have been primarily developed by FederalCourts in landmark constitutional jurisprudence beginning in the early 1970’s and extending to the presenttime. While attempts to effectuate the concepts of dignity and self-determination which animated thesedecisions have been uneven in practice, they articulate conceptions of human rights for the mentallydisabled which have greatly influenced international standards in the field. The author will compare andcontrast two professional experiences to illustrate this formulation: (1) his work in assisting to develop andlater serving as court-appointed monitor of a federal class action lawsuit challenging, on constitutionalgrounds related to freedom from harm and the right to adequate treatment, the conditions in a forensichospital; 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 intersectionbetween these U.S. constitutional principles and the international approach to human rights for the mentallydisabled. At the end of the presentation, the audience will be able to identify the fundamental constitutionalrights articulated in federal mental disability cases and see how they influence international human rightslaw in this area.108.2. Advocating for the Rights of Individuals with Mental Disabilities in the KyrgyzRepublicDebbie Dorfman, Washington Protection and Advocacy System, Seattle, USA (debbied@wpas-rights.org)Craig Awmiller, Washington Protection and Advocacy System, Seattle, USA (craiga@wpas-rights.org)The presenters will be speaking about their experience working on advocating the rights of individuals withmental disabilities in the Kyrgyz Republic. We will discuss the vast differences between the rightsguaranteed for individuals with mental disabilities that are written on paper and the actual implementationof these rights, as what is written is not necessarily reality. Additionally, we will discuss barriers toimplementation of these rights and advocacy strategies that can be used internationally to ensure that theserights are implemented. In discussing these issues, we will use our experience in the Kyrgyz Republic as arepresentative example.108.3. Developments in English Mental Health Law Since the Incorporation of theEuropean Convention on Human RightsKris Gledhill, Barrister-at-law, London, England (krisgledhill@aol.com)The English legal system follows a dualist approach and so the European Convention on Human Rightswas not part of the domestic legal regime until incorporated into domestic law by the Human Rights Act1998: this requires the domestic courts to interpret the law so as to comply with the Convention as far aspossible (including adopting a strained interpretation of language), and allows them to declare the law to beincompatible with the Convention if the language of the relevant statute cannot be interpreted in a mannerconsistent with the Convention.Following the 1998 Act, there have been a large number of test cases which have lead to reinterpretationsof the Mental Health Act 1983 in order to seek to comply with the requirements of the EuropeanConvention, and (as at the present time) three occasions in which the domestic courts have declared the1983 Act to be incompatible with the Convention.

317The presentation will outline the main developments, which demonstrate how the mental disability law of asupposedly advanced nation was in breach of the Convention in a number of respects and how, inconsequence, the incorporation of an international human rights instrumented was needed in order toprovide the protection reflected in that international human rights instrument.108.4. Incorporating Therapeutic Jurisprudence into a New International Human RightsLaw ExternshipKeri K. Gould, St. John’s University (gouldk@stjohns.edu)I am the Assistant Dean for Externships at St. John's University School of Law. In that capacity, I overseethe creation and curriculum of all the externship programs. I have recently created a new InternationalHuman Rights Law Externship. In this externship, students will be focusing on Trafficking of HumanBeings, Child Protection, Peacekeeping Operations, and the United Nations System. The students will work12 – 15 hours a week in not-for-profit organizations in this field.In working with the adjunct professor who will be the classroom teacher, I am teaching the teacher abouttherapeutic jurisprudence and its application to clinical legal education, and the importance of including aTJ approach to the work the students are doing in their placements and to the substantive areas of law thatthey will be learning.108.5. Took a Stranger to Teach Me to Look into Justice's Beautiful Face: MentalDisability Law, International Human Rights Law, and Distanced LearningMichael L. Perlin, New York Law School (mperlin@nyls.edu)The past thirty years have seen a remarkable revolution in all aspects of constitutional “mental disabilitylaw” in the United States (civil commitment, institutional rights, the right to refuse treatment, issues ofpatient sexuality, the interplay between mental disability, and the criminal trial process). For a variety ofreasons (economic, social, legal), this revolution has largely not been replicated in nations with developingeconomies. Through the technology of the Internet-based education, the author (a professor at New YorkLaw School) has created an on-line mental disability law course for attorneys, activists, advocates, mentalhealth professionals, and governmental officials in such nations, in an effort to both teach participants thebases of American constitutional mental disability law (principles that, by and large, form the basis ofinternational human rights law in this area), and to encourage and support the creation and expansion ofgrass-roots advocacy movements that may optimally lead to lasting, progressive change in this area. Thispaper will discuss this course, report on courses taught in Nicaragua and Japan, and consider plans toreplicate (in modified form) these experiences throughout other nations with developing economies inCentral America, Central and Eastern Europe, and Asia.

318108.6. Human Rights and Procedural Safeguards Under Mental Health Legislation: TheOntario ExperienceJoaquin Zuckerberg, Consent and Capacity Board, Toronto, Canada (joaquin.zuckerberg@moh.gov.on.ca)Federico Allodi, Consent and Capacity Board, Toronto, Canada (fallodi@pobox.com)This paper assesses Ontario's mental health legislation and practice vis-à-vis international human rightsstandards and describes the main legal, administrative, and clinical issues presented in the implementationof the newly amended provincial legislation. As a legal framework, it focuses on essential proceduralsafeguards 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 Conventionon Human Rights as interpreted by the European Human Rights Court, and briefly the Inter-Americansystem of legislation of the Organization American States. Against this background, the paper analyzes thecompliance of the mental health legislation of the province of Ontario with international standards, andsome 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 thecounsel (J. Z.) of the Consent and Capacity Board of Ontario. As a method, all calls and consultationsduring 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 whenpossible, the paper will make brief references to and discuss the way other domestic legal systems havedealt with the implementation of specific standards. The paper aims to generate discussion for potentialreforms in domestic legal systems and provide a methodology to be used as a tool to assess similar mentallegislation in other local contexts.109. Mental Disability II: Mental Disability and Human Rights:The Domestic and Regional Context109.1. Commemorating and Preserving Psychiatric Patients' History to Promote HumanRights TodayGeoffrey Reaume, York University (greaume@yorku.ca)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 horribleconditions, to exploitation of patients' labour, to numerous physical and sexual abuses inflicted upon men,women, and children confined in mental institutions. Along with these human rights violations withinpsychiatric facilities, there is a long history of abuse and discrimination in the community towards peoplecategorized and identified as mentally disabled.One of the many ways that can aid in improving the human rights of people categorized as mentallydisabled today is to acknowledge their history in public venues, so that more people are made aware of thispast. This public education will serve as a long overdue commemoration of the people whose lives have so

319often been hidden behind walls of silence. It will also offer a very public reminder to learn from the lessonsof past abuses, by making connections between historical human rights violations and the contemporarystruggle for people's human rights today. History can be used as a forum for promoting social justice amongthe 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 psychiatricpatients' history, and why this is relevant to promoting their human rights now and in the future. Themes tobe discussed include historical memory, anti-discriminatory practice, historical conservancy, and involvesthe people who have lived this history in the preservation and interpretation of their collective past. Themain point of this presentation will be to discuss how public historical preservation and commemorationcan help to bring down walls of silence about the lives of psychiatric patients from the past, while at thesame time contributing to the fight against discrimination experienced by people in the mental healthsystem today.109.2. A European Code of Practice for the Protection of the Human Rights and Dignityof Persons with Mental Disorder?Mary Keys, National University of Ireland (mary.keys@nuigalway.ie)The very essence of the European Convention on Human Rights and Fundamental Freedoms is respect forhuman dignity and human freedom; the Court of Human Rights considers that it is under Article 8 thatnotions of the quality of life take on significance. Article 8 provides that everyone has the right to respectfor his private and family life, his home and his correspondence, and any interference with such rights mustbe justified by reference to specified limitations outlined in Article 8(2). The right to autonomy is expressedas a fundamental human right and recognised by Article 8; in Pretty v United Kingdom (2002) the Courtconsidered the notion of personal autonomy as an important principle underlying the interpretation of itsguarantees. The growing recognition of this right to autonomy and self-determination for all personsrequires that those with mental disabilities have procedures that will ensure fair and just decision-making inconjunction with or on behalf or such persons. This paper will address the approach of the Council ofEurope and the Court of Human Right to the protection of vulnerable adults. The paper will refer to theConvention on Human Rights and Biomedicine 1997 along with the recently published Recommendation(2004) concerning the protection of the human rights and dignity of persons with mental disorder asoffering valuable guidance for law reform.109.3. The Case of HL v United Kingdom: When can a Non-dissenting but IncompetentPatient be Admitted to Hospital Informally and Without Legal Safeguards?Paul Bowen, Barrister-at-law, London, England (p.bowen@doughtystreet.co.uk)In 1999 the House of Lords of England and Wales rejected a claim for habeas corpus brought by a learningdisabled adult, HL (through his carers as litigation friends), in respect to his ‘informal’ admission to apsychiatric 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 hisadmission 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 Act1983. They reached these conclusions notwithstanding the fact that L lacked capacity either to consent ordissent to his admission and that his carers, who did object to the hospital admission, had been barred from

320visiting 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 byan independent judicial body.L took his case to the European Court of Human Rights, claiming he had been ‘deprived of his liberty’ inviolation of his rights under Article 5 of the European Convention on Human Rights (HL v UnitedKingdom). 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 ofState parties to the European Convention. All State parties have a significant population of adults who lackcapacity to make decisions for themselves, but have adopted different legal approaches in seeking to strikethe right balance between the provision of care to such individuals and the proper respect for theirfundamental rights.109.4. Canada’s ‘Beautiful Mind’ Case: Will the Supreme Court of Canada's Decision inStarson v. Swayze Really Make a Difference?Aaron Dhir, University of Windsor (aad265@nyu.edu)In June of 2003, the Supreme Court of Canada delivered its much anticipated decision in the case ofStarson v. Swayze. This marked the first time that Canada’s highest court dealt with an appeal originatingfrom a civil mental health tribunal. The case has been referred to by the media as “Canada’s ‘BeautifulMind’ Case”, given arguable parallels to the life of famed mathematics genius John Forbes Nash, who wasdiagnosed with schizophrenia. Indeed, Scott Starson is an extraordinarily intelligent man, who has excelledin 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 physicistsin 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 Boardafter being found not criminally responsible on two charges of uttering death threats. His attendingpsychiatrist found him incapable of consenting to treatments such as anti-psychotic medication, moodstabilizers, and anti-anxiety medication. Starson rejected the proposed treatment, feeling that it hamperedhis ability to do scholarly work. Although he was unsuccessful before the Ontario Consent and CapacityBoard, both the Ontario Superior Court of Justice and Court of Appeal concluded that the Board's findingof incapacity was unreasonable and set it aside. In a decision that has been lauded by mental healthconsumer/survivor groups and denounced by members of the psychiatric community, the Supreme Court ofCanada ruled in Starson’s favour.While the Supreme Court of Canada's decision is in some ways a step forward for the rights of psychiatricpatients, I will argue that in other ways it will have little effect on the lives of patients who are foundincapable of consenting to treatment. Drawing on my experience as co-counsel for two intervener groupsbefore the Supreme Court of Canada in this case, I will provide a critical analysis of the legal test forcapacity under Ontario’s Health Care Consent Act, which the Supreme Court of Canada was asked tointerpret in Starson v. Swayze. As per the legislation, an individual lacks capacity if he/she does not meettwo criteria. First, a person must be able to understand the information that is relevant to making atreatment decision. Second, a person must be able to appreciate the reasonably foreseeable consequencesof the decision or lack of one.I intend to argue that the test for incapacity inherently places patients in an impossible position. TheStarson decision theoretically stands for the proposition that an individual should not fail the first branch ofthe test simply because he/she denies having a mental illness. However, the fact that the second branch ofthe 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 mustnevertheless concede that he/she could be aided by anti-psychotic medication. Thus, patients are subtly

321forced to agree with their psychiatrist’s diagnosis. My discussion of this absurdity will be informed bysocial science evidence, calling into question the efficacy of anti-psychotic treatment modalities andarticulating 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 ofCanada's decision to avoid relying on relevant international human rights instruments submitted by theinterveners.109.5. The Legal Construction of the Disabled Person: Locating the Nexus ofConstructions of Disability and Theories of EqualityMarcia Rioux, York University (mrioux@yorku.ca)Issues of disability are issues of justice and equality. People with disabilities are both the most marginal ofthe marginalized and are disproportionately unemployed and living in poverty. When one views howsociety understands people with disabilities, one opens the window on how society understands itself. Theextremes 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 siteof the disability (medical and legal models) and one grounded in the environment (service and socialmodels). It argues that models based on concepts of equal treatment not only create inequality butrationalize the reduction of entitlements for people with disabilities. The limiting of care and treatment arejustified by the way in which both disability and equality are understood as the responsibility of theindividual both in cause and effect. The inherent biases in limited notions of equality and in presumptionsof disability as an individual pathology undercut the enjoyment of the fundamental rights of citizenship andparticipation. Models based on concepts of equal outcome compel states to provide services and care thatinclude people in their communities.110. Mental Disability III: Rights of People with IntellectualDisabilities within Europe110.1. The Protection of Rights of People with Intellectual Disabilities by the EuropeanSocial Charter: Autism Europe Collective ComplaintEvelyne Friedel, Attorney, Paris, France (efriedel@jonesday.com)The fundamental rights of people with disabilities are, in particular, defined in the Treaties andRecommendations of the Council of Europe, and in the Treaties and the Charter of Fundamental Rights ofthe European Union. In order to guarantee the respect of the rights of people with disabilities, severalactions 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, collectivecomplaints can be lodged with the Committee of Social Rights of the Council of Europe.

322The European Social Charter of 1961, revised in 1996, sets out rights and freedoms, and establishes asupervisory mechanism guaranteeing their respect by the States parties. Under a protocol which came intoforce in 1998, collective complaints of violations of the Charter may be lodged with the EuropeanCommittee of Social Rights.See for more information:http://www.coe.int/T/E/Human_Rights/Esc/2_General_Presentation/SocialCharterGlance_may04%20.asp#TopOfPageIn this respect, Autism Europe filed a collective complaint in July 2002 with the Committee, allegingFrance’s failure to comply with its obligation to provide an education to people with autism. AutismEurope's complaint highlights the discriminatory treatment suffered by people with autism, and denouncesFrance’s failure to comply with articles 15, 17 and E of the European Social Charter (to be distinguishedfrom the Charter of Fundamental Rights of the European Union). Under these provisions of the EuropeanSocial Charter, States undertake to apply the necessary, adequate, and sufficient measures, in order toprovide children and adults with disabilities an education in the ordinary system wherever possible, orwhere such integration is impossible, through specialised public or private institutions. Autism Europe'scomplaint is the first collective complaint in Europe targeted to defend the rights of handicapped people.On March 10, 2004, the Council of Europe rendered its decision regarding the collective complaint ofAutism Europe. The Council of Europe concluded that the situation of people with autism constitutes aviolation of the European Social Charter.110.2. Access to Justice for People with Mental Disabilities in Central and EasternEuropeOliver Lewis, Mental Disability Advocacy Center, Budapest, Hungary (olewis@mdac.info)This paper focuses on the practical and legal obstacles of litigating human rights cases in mental disabilitysystems, in central and Eastern Europe. Since the fall of the communist regime, there has been low politicalwill to implement much needed systemic reform. The Mental Disability Advocacy Center (MDAC) is aninternational organization which protects and promotes human rights of people with mental healthproblems and intellectual disabilities, in central and eastern Europe and central Asia. One of MDAC’s coreactivities is strategic litigation in domestic and international courts which challenges inadequate law or thelack of implementation of law.To bring cases to courts, lawyers and advocacy organizations need to proactively educate potential clientsabout their rights, as well as find clients willing to litigate important human rights issues, and supportclients through the stressful and lengthy process. For people with mental disabilities in the central andeastern European region, there are numerous obstacles in seeking justice through the courts. These hurdlesinclude isolated institutions far from urban centers, low awareness of rights in mental disability serviceproviders, legal professionals, legal incapacity, retribution by staff, as well as any mental health problem orintellectual disability which a client might have. MDAC’s approach to these difficulties will be outlined, aswill examples from current cases.

323110.3. Guardianship and Decision-Making Laws: A Comparison of the National Law ofFive Countries to Internationally Recognized Human Rights StandardsMarit Andrea Rasmussen, Mental Disability Advocacy Center, Budapest, Hungary(mrasmussen@mdac.info, mdac@mdac.info)The project examines guardianship processes affecting thousands of adults with mental disabilities acrossEurope. Guardianship laws are the legal framework within which important personal and financialdecisions are made on behalf of adults adjudged to have reduced decision-making capacity. While somemeasures may be necessary to protect vulnerable individuals, only human rights compliant laws promoteand 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 internationalnorms, including the Council of Europe’s Recommendation (99)4, “Principles Concerning the LegalProtection of Incapable Adults.” The template also incorporates elements of “best practice” alternatives toguardianship, such as supported decision-making.Results will highlight areas in national guardianship legislation of target countries which fail to conform tointernationally recognized human rights standards. These legislative weaknesses indicate areas of the lawripe for reform, and will provide guidance to governmental leaders and legislatures. Findings will alsosupport the efforts of non-governmental organizations and inter-governmental agencies involved inadvocacy on behalf of users of guardianship processes, to raise public awareness and will bolster litigationefforts on behalf of individual users and survivors of guardianship practices.110.4. Rights and IncapacityPeter Bartlett, University of Nottingham (peter.bartlett@nottingham.ac.uk)Increasingly in recent years, there have been trends to bring people lacking capacity into the scope offormalised legal régimes. The clearest example is perhaps HL v UK (Appl. 45508/99, decision 5 October2004), where the European Court of Human Rights accorded article 5 rights to compliant but incompetentpatients admitted informally to psychiatric facilities. There is cause for celebration, in the fact that theneeds of this marginalised group were addressed by the Court; at the same time, a ‘rights’ model createstheoretical difficulties in application to this group. Is a right to legal representation, for example, theappropriate 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. Thispaper will instead explore the theoretical difficulties of applying a rights model to people lacking capacity.

324110.5. Anti-Discrimination Legislation and Persons with Disability: A NorwegianPerspective in a Comparative ContextAslak Syse, University of Oslo (aslak.syse@jus.uio.no)In November 2003, the Norwegian Government appointed a legal Commission to draft a new bill and/orproposals to amend existing legislation in order to strengthen the protection accorded by the law against thediscrimination of disabled persons. The object is to promote full participation in society and equalitybetween disabled persons and other citizens. The Commission’s proposals should aim to provide a genuinestrengthening 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 beawarded to disabled individuals in more areas than is the case in currently applicable legislation. TheCommission should discuss possible sanctions and take a stand on rules concerning the burden of proof andforms of responsibility in the event of sanctions in civil law, and consider whether special bodies should beresponsible for effective following up of the body of rules. The Commission should ensure that theproposed 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 ofHuman Rights, Articles 2 and 26 of the United Nations International Covenant on Civil and PoliticalRights, Article 2 of the United Nations International Covenant on Economic, Social and Cultural Rightsand relevant rules within the European Economic Area. The Commission should also review antidiscriminationlegislation in other countries, and the work carried out in this field in internationalorganisations, including work on a United Nations Convention on the Rights of Disabled Persons. TheCommission’s report to the Government is to be delivered April 2005. In this paper I will, as the chair ofthis commission, give a short presentation of the findings and assessments in the report. The Commissionvisited 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 thesubtitle: A Norwegian perspective in a comparative context.111. Mental Disability IV: Mental Illness and CommunityIntegration111.1. The Perils of Disclosure: Implications of the Americans with Disabilities Act onthe Work Experiences of People with Psychiatric DisabilitiesSusan G. Goldberg, CESSI, McLean, USA (gsusan@earthlink.net)People recovering from psychiatric disabilities face a number of challenges in the employment arena, manyof which are related to the Americans with Disabilities Act (ADA). A particularly thorny issue involves thenotice provision of the ADA, which requires that employees disclose their disabilities to their employers inorder to claim certain ADA rights. But whether or not an employee chooses to disclose a disability is still adifficult question for many people with psychiatric disabilities. In addition to the ADA protections, thereare professional, personal, and policy considerations that strongly favor disclosure. For these reasons, most

325social service providers, who work with people with psychiatric disabilities, encourage them to disclosetheir disability at work.Yet, there are equally -- and sometimes more -- compelling reasons not to disclose. A person who disclosesa psychiatric diagnosis may experience isolation, discrimination, and prejudice at work. These importantconsiderations are usually not addressed by social service professionals. The ADA provides some optionsfor handling disclosure, but the range of options is rarely known by people with psychiatric disabilities orthe counselors and advisors who work with them.This presentation will discuss the findings from two research studies funded by the National Institute onDisability and Rehabilitation Research (NIDRR). The studies explored, in depth, the experiences of peoplewith psychiatric disabilities around employment and disclosure. I will discuss various approaches to theproblems of disclosure that were used by participants, including “selective disclosure” of time, person,place, and content.111.2. Does U.S. Federal Policy Support Employment and Recovery for People withPsychiatric Disabilities?Mary Killeen, CESSI, McLean, USA (mkilleen@cox.net)Evidence suggests that the majority of people with psychiatric disabilities recover over time; they developsupport 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 apsychiatric disability are actually employed, and most of those who are employed work only part-time atbarely 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, weconducted a qualitative study of 16 unemployed and 16 employed individuals with psychiatric disabilities.All of the participants had disabilities severe enough to qualify for Social Security Disability benefits.We found that federal policy is still based upon the discredited notion of a downward trajectory for allindividuals with a psychiatric disability. Interviews, regarding the impact of federal policies and programson the lives of study participants, revealed a deep-seated assumption within these policies and programsthat the participants would never recover, or would recover from their illnesses only marginally. Federalprograms played a crucial role for the participants directly after the onset of their illnesses, and for thosewhose symptoms were so unmanageable that they were unable to work. However, these same programsoften hindered participants as they began to recover. Rather than offering a “hand up” to those who wereready to improve their situations, federal policies and programs often placed roadblocks in the paths ofthose who wished to earn more than marginal incomes. These roadblocks take the form of income andmedical benefit loss, denial of funding for education, and placement in the most menial jobs without regardfor the individual’s work history and capabilities.We found that current federal policies and practices encouraged employment and integration of only a fewparticipants, in a particular stage of recovery, and placed significant barriers in the employment path ofothers. This presentation will discuss the results of this study and the barriers that current federal policiesand 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 Statesfederal disability policy had a tremendous impact upon participants’ lives. U.S. policies and programs sentcontradictory and confusing messages to participants about their ability to work, the kind of work theycould do, and how much income they could earn. Overcoming the hurdles necessary to become eligible forSocial Security income benefits, obtaining appropriate training from the state Vocational Rehabilitation

326agencies, understanding and using the Social Security work incentives, finding and maintaining medicalbenefits, and obtaining assistance from mental health agencies was daunting.111.3. To Sue or Not to Sue: Implications for Plaintiffs who Allege Serious MentalHealth Impacts in Civil SuitsSandra B. McPherson, Fielding Graduate Institute, Santa Barbara, USA (smcpher1@earthlink.net)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 societycontinues to be one where significant prejudice may pertain. Where the individual is overstating orinaccurately presenting mental health symptomology, he or she then may face the onerousness of beingidentified as a malingerer. Further, the process may result in shame and humiliation, since it documents, inthe most public of ways, a condition that is a basis for the lack of positive regard by other members ofsociety. 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 thatthe process involves. A sample of civil suit records was conducted to determine the categories ofinformation, the evaluative procedures involved, and the types of data that appeared in the expert reportand/or other phases of the case. Anonymized samples of testimony were reviewed and analyzed, asdemonstrations of the process and its potential for destructive impact. While the option of suit actionrepresents a corrective to unwarranted injury, the introduction of the mental health aspect may or may notbe of benefit to a plaintiff who is seeking redress for some grievance. From the perspective of therapeuticjurisprudence, decisions involving mental health and civil litigation involve complex cost benefitconsiderations.111.4. Disability Civil Rights Law and PolicyPeter Blanck, University of Iowa (peter-blanck@uiowa.edu)This paper examines civil rights laws and policies affecting persons with mental and physical disabilities,focusing on the Americans with Disabilities Act (ADA) of 1990. The paper discusses, based on historicaland contemporary studies, the ways in which public acceptance and inclusion of persons with mentaldisabilities into society is at least as driven by political, economic, and attitudinal factors regardingconceptions 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 ofChicago economist, and Nobel laureate, Dr. Robert Fogel. The research examines a massive amount ofdata, 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 thatmany 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. SeeBlanck, 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 Nativeand 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 mayhave influenced pension awards more than previously documented.

327The paper then discusses the relevance of the historical studies to contemporary society. Scepticism towardpersons with mental disabilities, and related criticisms of the ADA, have perpetuated attitudinal barriersand unjustified prejudice. The analysis illustrates how these negative attitudes influence development oflaws and policies toward Americans with mental disabilities, which, in turn, affect the social constructionof disability.111.5. Employment Prospects for People with Serious Mental Illness within the Contextof the U.S. National Labor Market: National Workforce Development PolicyImplicationsRichard C. Baron, OMG Center for Collaborative Learning, Philadelphia, USA (rick@omgcenter.org)Based on qualitative research for the U.S. National Institute on Disability and Rehabilitation Research andthe University of Pennsylvania's Collaborative on Community Integration for People with PsychiatricDisabilities, this presentation assesses the employment status of people with mental illness in the context ofthe 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 seriouspsychiatric disabilities have been able to find jobs that pay better than or offer medical coveragecomparable 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 themanufacturing sector in the past, that paid well and included adequate medical benefits have all butdisappeared, and the absence of part-time or seasonal jobs that provide an adequate income or medicalcoverage.Nonetheless, there is no general push at the policy level to revise U.S. labor policy, even though those withmental illness are joined by an increasing number of low-wage Americans with a modest or unsuccessfulacademic record (e.g. welfare clients), looking for or toiling at entry-level or low-skills jobs (e.g., exoffenders),and dealing with significant barriers to full-time long-term work (e.g., those with literacylimitations).The proposed presentation seeks to raise awareness that the labor market for people with mental illness isthe 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 employerdiscrimination against people with serious mental illness; improving the effectiveness of training,placement, and retention programs for this population) with public policy initiatives focused on laborpolicies more broadly: income supplements; heightened minimum wage standards, improved educationalprogramming, national health care, job creation strategies, etc.

328112. The Role of Specialized Courts: Mental Health andAddiction I112.1. A Three Year Comparative Study of Behavioral and Criminal Justice Outcomesfor Mentally Ill Offenders Seen in a Mental Health CourtGary Bess, California State University (bess@sunset.net)Jim Myers, California State UniversityStephen Benson, Superior Court Judge for State of California, USAThe intersection between individuals with mental illness and their involvement in California’s criminaljustice system is well documented. According to Ditton’s (1999) review of federal Bureau of JusticeStatistics data, 16 percent of local jail populations, 16 percent of probationers, and 16 percent of the stateprison population have been diagnosed with a mental illness. Although there is a high population of thementally ill who are incarcerated, there are even greater numbers that are arrested, jailed, and released, onlyto re-offend in a seemingly unstoppable cycle. Research shows that approximately one-half of individualswho have a mental illness will be arrested at least once while suffering symptomsIn Butte County, a rural California county (population 210,000) located between California’s north-easternSacramento Valley and the Sierra Nevada Mountains, there was a 50 percent growth in the average dailyjail population between 1991 and 1999. During this period within the jail medical unit alone, on whichinmates with a mental illness are assigned, there was greater than a 200 percent increase in the averagedaily 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 illoffenders, and utilized a multidisciplinary intervention team, composed of representatives from theCounty’s Sheriff’s Office, Probation Department, Behavioural Health Department, District Attorney’sOffice, Public Defender’s Office, and Judicial Court. One hundred (100) mentally ill offenders wererandomly 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 ajudge who mandated the defendant’s receipt of supportive services provided by the team, as a condition ofprobation. Those assigned to the treatment group, while appearing before the same judge, received thecommunity’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 withalcohol and/or drug problems, and nearly one-third (32.3%) were diagnosed with a Bipolar Disordersclassification. An additional one-quarter (24.7%) was diagnosed with a Schizophrenia and Other PsychoticDisorders classification. There additionally was an escalation in arrests for the three-year period beforeentry into the program. Slightly greater than 40 percent (42.9%) had at least one arrest three year’s prior toprogram entry, and 76.9 percent were arrested at least once within 12-months of having committed anoffence qualifying them for enrolment in the program.As a result of this intervention, it appears that enhanced treatment participants were booked into jail a fewernumber 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.

329112.2. Mental Health Services in Toronto CourtsSteve Lurie, Centre for Mental Health Association (CMHA), Toronto, Canada (slurie@cmha-toronto.net)Mental health services have been available in the courts in Toronto Ontario Canada since 1997. Aspecialized mental health court was developed in one of the five courts, while court support workers wereplaced in the four regular courts. 2,300 people with mental disorders appear before Toronto courts eachyear. The experience providing mental health service in the courts will be reviewed, using findings from aprogram review (Macfarlane 2002). The workshop will describe the history of court-based mental healthservices in five criminal court settings throughout the city of Toronto, and the results of a formal programreview 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 thesedata. Second, the broader and longer term effects of the review are described, in terms of the developmentof the mental health services themselves, the impact on the courts, the effect on the quality and timelinessof mental health services provided to the mentally disordered accused persons in the courts in Toronto.Finally, the subsequent work of the court support consortium developed following the review will bediscussed.112.3. Court Outcomes for Clients of a Mental Health Court Liaison (MHCL) Service:The First Six YearsJohn Sharples, University of Newcastle, Australia (John.Sharples@hunter.health.nsw.gov.au)At the last conference, we reported on a 3-year service audit of clients seen by the Newcastle MHCLservice, which documented client characteristics, service patterns, and associated relationships. This paperexamines 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 wereapproximately 1,773 clients involved in 2,246 service episodes. For each service episode, basic sociodemographic,clinical, service contact, and criminal charge details were collected. Court outcomes recordedincluded: punishment received; charges dismissed; Apprehended Violence Orders (AVOs) received; andwarrants 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% hadtheir charges dismissed (61.3% under S32 of the MH Act).Previous studies have identified relationships between gender, diagnosis, patterns of offending, and courtoutcome. By examining such relationships in the court liaison data, we may be better equipped to identifyservice needs and improved intervention strategies for our clients. We need to continue to strengthen linksalready forged between the mental health and criminal justice systems.

330112.4. Establishing a Mental Health DocketMelissa A. Knopp, Supreme Court of Ohio (knoppm@sconet.state.oh.us)A revolving door problem has developed in the United States of America. Jails and prisons have becomethe de facto mental health system of our day. The number of mentally ill offenders has been increasingsteadily in the Ohio court system. Specialized Dockets, defined as a therapeutically oriented judicialapproach to provide court supervision and appropriate treatment for offenders, has been the solution toalleviating this problem.Ohio has served as the United States leader in the specialized dockets area with the most drug courts percapita than any other state in the country. Currently the state boasts over 57 drug courts, 20 mental healthcourts, 3 re-entry courts, and one domestic violence court. Much of Ohio’s success in this field isattributable 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 inOhio trial courts. The Court has promoted the creation of these dockets primarily through offering directtechnical assistance, provided by staff of the Supreme Court of Ohio. In addition, the Supreme Court hasdeveloped, funded, and hosted training events throughout the state of Ohio and in individual communitiesfor vital individuals involved with specialized docket programs. The key to the Supreme Court’s success inthis 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. Inaddition, this session will outline the underlying policies created and advocated by the Supreme Court ofOhio, and the processes developed by the Specialized Dockets Section of the Supreme Court of Ohio toplan, implement, and operate a mental health court program.112.5. Creating a Community Mental Health Court: From Crisis Intervention Training(CIT) to the Mental Health Court DocketKaren E. Woods, Twin Valley Behavioral Healthcare, Columbus, USA (krnewds@aol.com)Creating a mental health court docket is a process that starts with the development of a community taskforce, the training of Crisis Intervention Teams (CIT), composed of police officers who respond to callsidentified as involving a mentally ill individual, and the development of a treatment team of professionalswho work with mentally ill defendants in developing a diversionary treatment plan. This presentation willfocus on developing a task force, that includes community leaders and agencies, to work on issuesassociated with Jail Assessment and Referral; CIT training; Common Pleas Drug Court Processes andProcedures; Municipal Mental Health Court Processes and Procedures; Availability of CommunityResources; Funding and Grant Writing; and Publicity and Public Awareness. The process of developing atraining curriculum and the training of CIT officers will be outlined. The benefits of CIT to the communitywill be discussed. Such benefits would be that the defendant or potential defendant receives mental healthservices from which he/she would benefit; local jails and lock ups do not receive mentally ill offenders thatare difficult to manage, and who may be disruptive to the usual institutional order; and defendants aremonitored and managed in the community, in an appropriately restrictive environment which is costeffective, humane, and more effective overall compared to purely incarceration based programs. Thebenefits, positive outcomes, and obstacles to developing a task force and in training of CIT officers will beexplored.

331113. The Role of Specialized Courts: Mental Health andAddiction II113.1. Strategies for Addressing Co-occurring Disorders in a Drug Court Setting:«Treatment is Essential to Success» (TIES) Program for felony offenders,Columbus, Ohio USAJennifer L. Brunner, Judge, Franklin County Court of Common Pleas, Ohio(Jennifer_Brunner@fccourts.org)There are approximately 1000 drug courts in the United States, and specialized court dockets have beenused outside of the U.S. Since their inception, there has been a dichotomy in the development ofspecialized court dockets between substance abuse and mental illness, with many such courts including onediagnosis 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 apilot program of the Franklin County Court of Common Pleas in Columbus, Ohio USA, developed toassess participants for co-occurring disorders from the outset, connect them with appropriate andcoordinated drug, alcohol, and mental health treatment, along with comprehensive community services toreduce the risk of relapse or non-compliance. It is a post-conviction program developed within an existingcourt and probation program setting. This presentation will focus on a variety of assessments used in theprogram; sharing of them between multiple treatment and service providers in an urban setting of a 1million population; developing and implementing memoranda of understanding with multiple treatmentproviders; imposing sanctions and awarding incentives for participants in the program; operation of thecourt and treatment team, including staffing; strategies for managing participants’ appearances at court; andcase flow management and program integration, within an existing court docket system.113.2. The Adult Drug Court Model: The Effect of Structural Differences on ProgramRetention RatesNatasha H. Williams, Morgan State University (natwilliams@att.net)Drug courts are a major innovation in penal responses to drug crime, and the first successful rehabilitationmovement since the mid-1970s. Drug courts are judicially supervised programs that place the drug-abusingoffender in an intensive community-based drug treatment program, that not only provides treatment butother rehabilitative services such as job training, parenting classes, and GED assistance. Upon programcompletion, 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 structuraldifferences 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 AssistanceProject (DCCTAP). The survey was mailed to 210 adult drug courts that were in operation as of December31, 1999. The sample used for data analysis consisted of 141 adult drug courts that had been in operationfor at least twelve months. The data analysis involved factor analysis and regression analysis.

332Due to limitations of the drug courts’ various theoretical models and outcome measures, the research designwas unable to explain the interaction among the structural variables.This research exposes inadequacies in current research, and provides a basis upon which to develop morepragmatically focused evaluation designs built upon theoretical models that better explain drug courtfunctions, as well as generating a policy agenda that links research to policy development.113.3. Behavior Modification in Drug Courts: A Normative Alternative to TherapeuticUnderstandingsEric Miller, Western New England College (emiller@law.wnec.edu)Social norms theory challenges the dominant justification of drug courts as a means of treating non-rationaladdicts charged with drug offences. Drug courts utilize a form of behavior modification to keep the addictfrom re-offending. The court’s explicit goal is to reconfigure the addict’s internalization of acceptablenorms of conduct; it accomplishes this task by replacing the addictive community with the judge as anauthoritative source of norms.There are various points of overlap between social norms theory and the therapeutic paradigm underlyingdrug court procedure. Drug courts are presented, often uncritically, as a form of “therapeutic,” “problemsolving”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 thebasis of this therapeutic goal. The expressed goal of drug courts is to instil a sense of “self-esteem” inotherwise 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 notassociated 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 institutionalchecks on police and prosecutorial discretion, drug courts risk justifying increasingly invasive and broadsweepingpolice 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 theoversight of the criminal justice system. This counter-intuitive result, suggests some re-evaluation of drugcourt process is urgently required.113.4. Long Term Outcome of Patients participating in Mental Health Court in SaintJohn New Brunswick, CanadaVinod Joshi, Community Mental Health Services, Saint John, Canada (Vinod.joshi@gnb.ca)Increased criminalization of mentally ill offenders has become a serious issue in most communities in thewestern world.Various studies have found 10 to 15% of Prison inmates have serious mental illness. Many jails, withinadequate mental health care, are becoming crowded by patients with serious mental illness.

333Mental Health Courts (MHC) are becoming increasingly popular as a way of addressing people withserious mental illnesses. Mental Health Courts are attempting to divert people with serious mental illnessfrom the criminal justice system into a treatment program. This approach is based on TherapeuticJurisprudence and Drug Treatment Courts.So far, there are over 100 operational MHCs, mainly in the United States.Even though all these courts are called Mental Health Courts, there are a lot of differences among MentalHealth Courts.In Canada there are two such courts, one in Toronto and the other in Saint John, New Brunswick. TheMental Health Court in Saint John was established in November 2000, by Judge Alfred H. Brien. Itoperates on alternate Friday afternoons. So far, almost 100 accused individuals, with serious mentalillnesses, have participated in Mental Health Court. The Mental Health Court consists of a presiding Judge,and a Court team: consisting of a Crown prosecutor, a Defence counsel, a Psychiatrist, a Psychologist, aPsychiatric nurse, a Probation officer, and a Member of the community. On average, a participant isfollowed for 10 to 12 months, following the initial Court appearance, and makes multiple appearances incourt. Despite the growing popularity of Mental Health Court, questions have remained: if they areeffective and if the benefits are long term.We will present the results of ongoing research being conducted in Saint John, to provide some answers tothese questions.The presentation will compare data from two groups: the first group is those accused with serious mentalillnesses participating in Mental Health Court (25 participants); and the other group is those accused withserious mental illness participating in regular court (21 participates). Data from both groups will becompared including demographic data, psychiatric data, psychiatric services utilization data, criminaljustice and emergency service utilization data.Findings of this data will be presented and discussed.114. Mental Health, Human Rights and Social Justice114.1. Mental Health and Human Rights – A Social Justice AnalysisKwame Akuffo, Thames Valley University (Kwame.Akuffo@tvu.ac.uk)Professor Gostin has pointed out that “despite its rhetoric of ‘voluntarism’ and noncoercion, mental healthpolicy quintessentially involves the exercise of governmental power - the power to restrain, to treat, anddeprive of basic rights of citizenship.” This fact, along with the recognition that severe human rightsviolations adversely affect the mental health of victims, means that mental health and human rights have anecessary 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 disparategroups. But, what does the subjugation of mental health law regimes to this dominant phenomenon ofhuman rights, in Western democratic states, for example, mean and what is its practical result? If thefabrication of mental health law in the new language of rights is adjudged to have largely failed to securethe protection of the millions across the world who suffer mental ill health, then the high claims made in thename of human rights require a serious questioning of the human rights concept itself. Meanwhile, in many

334parts of the world, particularly in much of the developing world, discourse around mental health rarelyengages issues of human rights.This paper offers a critique of human rights as they apply to mental health matters, primarily in Europe andNorth America, and questions whether the dominant conception of human rights in the western worldshould provide the model for the global evolution of mental health law. The paper will also seek tounderstand how the protection of the human rights of people with mental illness in typical developingnations is conceived and implemented. The paper will argue, as its conclusion, that dominant rights-basedconception of human rights is too narrow and fails to reflect social justice as the true test of the applicationof human rights114.2. Mental Health and Social Justice in Contemporary BritainR. Balarajan, National Institute of Ethnic Studies in Health (NIESH), London, England(profbalarajan@aol.com)Mental Health presents one of the greatest disease burdens in modern Britain and, consequentially, asignificant challenge to the NHS. It is a domain where measures of outcome are not robust, thus eludingthe careful scrutiny of the structures and processes involved. It is also a domain that is susceptible tohuman rights issues, not only because of the intrinsic nature of the underlying condition, but also becauseof 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 theprofessions and the medico-legal system of the country in which certain circumstances arguably may notpresent the optimal setting for care and outcome. Further negative influences, such as discrimination andprejudice could very well come into play affecting pathways to care, from recognition of ill health to accessto care to outcome. Mental health in the NHS of contemporary Britain thus would be taken as a case studyto explore the challenges faced by society in delivering equitable care and support for all its citizens.114.3. The Psychiatrist as an Agent of Social Control or an Advocate of Social Justice?(In America, Three Strikes and You’re OutPaul G. Organ,PsychiatryConfidential.com, California, USA (poganmd@aol.com)This presentation addresses the role of the psychiatrist as the primary medical-legal "gate-keeper" to thecriminal 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 primarydeterminant of how individuals in society are admitted, treated, or sentenced into one of the three systemsof social justice/ social control: individuals are diagnosed and categorized as "patients," to be treated withinthe mental health system; "inmates," to be incarcerated in the criminal justice system; or "addicts," to berehabilitated in a drug abuse treatment program.Involvement in any of these systems creates permanent problems, limitations, and obstacles for theindividual and their families that can have devastating and irreversible personal, financial, legal, and socialconsequences. In many cases, individuals are relegated to more than one of these systems and face alifetime of exclusion, marginalization, and oppression.

335In particular, the arbitrary and pernicious use of psychiatric evaluations and recommendations to removemembers of racial and ethnic minority groups from society (especially the male population) and confinethem for extended periods of time, is being used to effectively neutralize large numbers of individuals andtargeted 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, ever-increasing, threat to theintegrity of psychiatry as a healing profession. In many areas of American society and culture, psychiatryfunctions 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 psychiatryand psychiatrists as agents of social control and injustice, or as advocates for social justice and progress.114.4. Mental Health: From a Medical to a Human Rights and Equitable DevelopmentalModelZonke Majodina, South African Human Rights Commission, Johannesburg, South Africa(zmajodina@sahrc.org.za)The paper advocates a paradigm shift in the approach to issues of people with mental health problems. Byadopting a human rights model, it envisions societies that encompass human diversity and the developmentof all human potential. In this regard, the paper will make reference to the United Nations Standard Ruleson the Equalisation of Opportunities for People with Disabilities, as well as the political and moralfoundations of the Rules as articulated in the International Bill of Rights comprising the UniversalDeclaration of Human Rights and other international human rights instruments. A full expose of the rangeof civil and political rights, as well as social and economic rights and how they impact on the lives ofpeople with mental health problems will be given. In all societies, there are still major obstacles preventingpersons with mental health problems from exercising these rights and freedoms, thus making it difficult forthem to participate in the activities of their societies. It will be argued, that States have a responsibility totake appropriate action to remove such obstacles.114.5. The Canadian Federal System: Challenges to Mental Health Law ReformGilbert Sharpe, McMaster University (gsharpe@goodmancarr.com)The challenge for Canadian mental health legislation is to link the concept of universal health care to thecontext of provincial jurisdiction where the priorities of health care, including mental health, areimplemented. The current Canadian Senate Kirby Report follows a cycle of earlier Canadian attempts toprovide the basis for analysis to determine the authority of the federal government to encourage thosedelivering provincial mental health services to resist prioritizing other health care demands at the expenseof the mentally ill. Beyond facilitating improved health care within federally mandated institutions it isimperative that creative inroads be located to obligate provincial authorities to protect vulnerablepsychiatric populations. Even where protecting envelopes have been put into place to prevent hospitalsfrom balancing their budget at the expense of psychiatric care, many hospitals in Canada ignore suchrequirements when faced with stronger pressure from physical disease lobbies. The Canadian federal modelwill be compared to other jurisdictions in the attempt to construct a federal structure to realise the optimumdelivery of psychiatric services.

336114.6. What Universities are Doing to Accommodate Students With DisabilitiesDonald Stone, University of Baltimore (dstone@ubalt.edu)American universities have the responsibility of providing reasonable accommodations in their educationalprograms to physically and mentally disabled students. The Americans with Disabilities Act, a landmarkcivil 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 seekingadmission and reasonable accommodations in the educational program of universities. Examples ofaccommodations 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 accommodationsinclude extending the exam period, waiver or substitution of course requirements for graduation, extensionof time for submission of written assignments, waiver or substitution of class-work assignments, priority incourse registration, authorization to tape lectures, modification of the add/drop policy, auxiliary aids, tapedtexts, interpreters, readers and note takers, and modified class schedules. The law mandates the provisionof reasonable accommodations to disabled students to level the playing field to fairly compete with nondisabledstudents but not to provide an unfair advantage. Discussions on establishing university polices onaddressing needs of disabled students will be highlighted. Implications for the employment arena are alsodiscussed. Focus on law students for illustrative purposed. School Discipline and Suspension, SafetyIssues, and Confidentiality in Student Records will also be explored.114.7. A Thing Called Prisoner – The Potential of Punitive Coma for PrisonManagementRegina E. Rauxloh, University of Surrey (R.Rauxloh@surrey.ac.uk)In his article “The Punitive Coma” (90 California Law Review May 2002, 829) J.C. Oleson describes therepugnant and violent conditions of American warehouse prisons, with frequent torture and rape, high ratesof suicide, and even killings committed or initiated not only by prisoners but also by prison guards. Despitethese poor conditions prisons become increasing expensive.To the well documented burning issues of overcrowded, violent and expensive prisons Oleson presents aradical solution. He suggests putting prisoners into a narcotic coma for the duration of their sentencesclaiming that: “the punitive coma is an enlightened form of punishment, as it is more efficient andcompassionate than the legitimised methods of punishment currently in use.”I argue that even if it were possible to maintain a large number of human beings for years and years inartificial comas without damaging them physically nor psychologically (which is quite questionable), thereare number of compelling legal and moral obstacles which make Oleson’s proposal unacceptable. In thispresentation I will systematically explore the range of arguments against punitive coma. I argue that thistreatment is an unusual and cruel punishment that not only violates most of the constitutional rights ofprisoners but most of all deprives them of their human dignity. Furthermore, it would have considerablenegative impacts on the Criminal Justice system and broader society and therefore must never be allowed tobe introduced.

337115. Mental Healthcare Financing in the USA115.1. Historical and Philosophical Context of Mental Healthcare Financing in the USAWynne Korr, University of Illinois at Urbana-Champaign (wkorr@uiuc.edu)John Encandela, ORC Macro, Atlanta, USA (John.A.Encandela@orcmacro.com)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 type and extent of care and treatment that people receive may be both a benefitand hindrance. For example, a focus on financial mechanisms may be “prudent” and, therefore,advantageous, insofar as it may assure adequate funding is available for the types of services promised. Onthe other hand, this focus may introduce problems if the economic interests of groups with power takeprecedence over the needs of people with SMI.This paper provides an historical and philosophical overview of systems of financing mental health care inthe U.S. since the early 1900s through the current time. We explore the relationship between philosophiesof caring, legal policy, and systems of financing, and raise the question of if and how the balance in thisrelationship has shifted over the last century. This question lays the groundwork for the remaining papersin this panel and provides the context for discussion at the end of the panel.115.2. Financing Mental Health Services for Children with Serious EmotionalDisturbanceRobert Stephens, ORC Macro, Atlanta, USA (Robert.L.Stephens@atlanta.orcmacro.com)Anna Kriveloya, ORC Macro, Atlanta, USA (Anna.Krivelyova@atlanta.orcmacro.com)In 2003, the Report of the President’s New Freedom Commission on Mental Health explicated the need fora fundamental transformation of the fragmented, disconnected children’s mental health service deliverysystem 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 servicesdesigned to address the specific needs of each child and family served—placing an emphasis on thestrengths of the child and family in developing an individualized service plan. Families will need to partnerwith 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 theneeds and preferences of families and their children, and systems of care must elicit the help of families indefining and running these systems.A database exists with information that should aid policy makers and community planners in improving thefunctioning of systems of care. This paper focuses on services and cost data from the national evaluation ofthe 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 ServicesAdministration. The program provides grants to states, communities, territories, and American Indiantribes to improve and expand their systems of care to meet the needs of children and adolescents withserious emotional disturbance and their families. The grant communities are required to develop

338comprehensive community-based services that include diagnosis and evaluation, case management,outpatient services, intensive day treatment, respite care, therapeutic foster care, transition and familysupport services. To ensure program sustainability, the amount of matching non-federal funds mustincrease over the course of the grant. Data from the national evaluation will be used to address thefollowing questions: What are the various funding sources communities use to implement the program’sinnovative service array? To what extent does service utilization vary among children and acrosscommunities? And what are the costs associated with the implementation of a system of care? Results willbe employed to develop recommendations for policy makers and community planners to improve thefunctioning of systems of care.115.3. Medicaid, Mental Health Service Delivery, and Managed CareRobert Rich, University of Illinois at Urbana-Champaign (rrich@law.uiuc.edu)This paper/presentation focuses on the financing of mental health services and policy at the state level inthe United States. It focuses particularly on Medicaid as a program and its limitations. In this context, theanalysis includes the use of mental health carve outs in managed care settings. The Managed CareOrganization is particularly important because of its dominance in health and mental health servicedelivery.In addition, the paper examines the use of Medicaid financing to support mental health service delivery inthe 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 inresponse 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 healthservices—both the federal statute and the different state statutes.115.4. Strategies for Ensuring Continuity of Care for Persons in IMDs and CorrectionalFacilitiesJohn Encandela, ORC Macro, Atlanta, USA (John.A.Encandela@orcmacro.com)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) mentalhealth services for inmates in correctional facilities. The rationale is that these services are theresponsibility of states rather than the federal government. Critics have claimed the Medicaid exclusion hascompromised the ability of states to provide integrated systems and continuity of care for individuals withsevere mental illness (ISMI), isolated ISMI from other Medicaid-eligible populations, and relegates theseindividuals to “second-rate,” lower-cost care and severe lapses in care and treatment. Critics have addedthat this is a recipe for interruption of pharmacological treatment, increase in relapse, and rehospitalization.Others have shown that Medicaid has funded an increasing share of the operations ofpublic psychiatric hospitals, but the real problem is states’ misunderstanding or lack of knowledge abouthow they may best access and use such Medicaid support.Strategies to address the above problems have been implemented. For instance, some states have begun tosee the importance of assisting IMD inpatients and correctional facility inmates to obtain SupplementalSecurity Income benefits before they leave their respective institutions, and some IMDs and correctional

339institutions are beginning to give higher priority to re-establishing Medicaid eligibility of individuals beforethey leave the facility. A few states have begun to offer incentives to increase the number of peoplescreened for Medicaid eligibility and reinstatement, when they are being discharged from IMDs andcorrectional facilities into the community. This paper provides a review of states’ experiences indeveloping strategies and incentives to address the service gaps faced by patients and inmates when theyenter and are discharged from IMDs and correctional facilities.115.5. Implementing Evidence-Based Practice: Legal and Economic ConsiderationsKraig Knudsen, George Warren Brown School of Social Work (kknudsen@gwbmail.wustl.edu)Legal precedent and healthcare financing in the United States has influenced the implementation anddissemination of evidence-based practices for persons with severe mental illness (SMI). Although there area number of evidence-based practices available for use, they have been disseminated slowly across theUnited States due to restrictive laws and financing. This presenter will report several findings from a studyinvestigating factors that influenced two states in their decisions to adopt and disseminate one suchevidence-based practice, the Assertive Community Treatment (ACT).Using a multiple case study design, the study examined two state mental health systems, one a high adopterof ACT and one a low adopter. Over a period of eight months, interviews were conducted with 22stakeholders (e.g., state administrators, family and consumer advocates, and academicians) in the twostates. Using semi-structured interviews, participants were asked to explore their experiences indisseminating ACT. The presenter will report findings that suggest that differing legal precedent andfinancing of mental health care in these two states directly contributed to the decision to adopt anddisseminate ACT. Specifically, the presenter will discuss how differences between the two state’sregulatory systems were related to the adaptation of state Medicaid policy to include ACT, as areimbursable service, and the use of managed care principles to encourage the use of community treatmentalternatives over hospital care. In addition, the presenter will discuss why the high adopter state perceivedACT as a cost-effective way to reduce state mental health expenditures, while the low adopter state foundACT to be cost prohibitive.116. Multiculturalism and Minorities I116.1. Racial Double Binds in American Legal DiscourseReginald Oh, Appalachian School of Law (Roh@asl.edu)The thesis of this presentation is that legal and political racial discourse, by placing subordinated racialgroups in “racial double bind” situations, actively works to inflict psychological and psychic harm onmembers of subordinated racial groups and to reinforcing dominant racial structures in society. Thispresentation 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).

340According to psychologists, a “double bind” situation is one in which a person cannot “win,” no matterwhat that person tries to do. In short, 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. In a “racialdouble bind” situation the dominant racial group engages in meta-communication with the subordinateracial group, in which the dominant group denies that it is treating a subordinate group in a racial/racistmanner at a literal-level of communication, while simultaneously communicating at a meta-level in whichit believes that the racial minority is indeed inferior and is, in fact, treating the group in a racial/racistmanner.A “racial double bind” puts the subordinate racial group in a no-win situation. If the subordinate groupaccepts the truth of the literal message (that it is not being treated in a racist manner), then it must acceptthat its unequal and inferior socioeconomic position is a result of its own doing and making. On the otherhand, if the subordinate group challenges the meta-level communication as racist, the dominant group willdeny that it sent out any meta-level message. Moreover, the dominant group will then raise accusations ofracism against the subordinate group, by, for example, accusing the subordinate group of “playing the racecard” or of engaging in racism herself by raising unwarranted accusations of racism. The end result is adenial of racism, an assertion that it is “all in their heads;” thus, the conclusion that follows is thesubordinated racial group’s inferiority is a result of its own doing and making—a no-win situation.116.2. Antagonistic Cultural Ideology and the Protection of Mental HealthRichard Harvey, Saint Louis University (HarveyR@slu.edu)This research reflects the current zeitgeist within social stigma literature that attempts to identify andexplain the various phenomena that victims of prejudice and discrimination employ to defend againstmental health deficits (i.e., self-esteem, stress, etc.). A new model that seeks to encompass a range of “selfprotective”strategies, the “Antagonistic Cultural Ideology model,” is discussed. The major premise of themodel 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: oppositionalthinking, distrust/threat of dominant group members, and rejection of dominant group values. Feltstigmatization, rather than mere stigmatized group membership, is considered the main antecedent to theendorsement of an Antagonistic cultural ideology. The Antagonistic Cultural Ideology functions as a twoedgedsword. On the one hand, the primary function of an Antagonistic Cultural Ideology is to protect andenhance social identity; increased self-esteem is a bi-product of increased identity. On the other hand, theendorsement 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 especiallylinked to diversity, and how victims cope with perceived racial/sexual harassment within organizations.116.3. The Legal and Behavioral Implications of the Term “Majority Minority”Derek Humphries, Attorney-at-law, Washington, USA (dhumphries@hblawyers.com)The term "majority minority" has been applied to localities where Latinos are the majority of thepopulation. Recently, the term has been applied to describe population areas where Black Americans arethe majority of the population. A consultant's report submitted to the City Council in the city of Detroit,Michigan recently described the Black population there as a "majority minority". I plan to explore the legaland behavioral implications for leaders of all cultures in a community where this term is used to apply to

341Black Americans. How do "leaders" respond? Do the leadership paradigms change? Indeed, how would wedescribe the current leadership paradigms for Black American, Black West Indian, Black African, BlackNative American, and Black Latino leaders?What are the implications for legal definitions which are based on customs, practices, and privilegesderived from a white master/black slave culture? What are some of the self-affirming and self-destructiveelements of current governance models? Do they change in a community where the Black Americanpopulation is now characterized as the "majority minority"? There are a lot of questions, and, probably, alot of different answers.116.4. Cultural Application of the Profile Mood States with Arab Muslim Immigrant andRefugee WomenAnahid Kulwicki, Wayne County Department of Public Health,Michigan USA (Kulwicki@oakland.edu)Karen Aroian, Wayne State UniversityThe purpose of this study is to determine the cultural applicability of the Profile of Mood States (POMS) ina sample of Muslim Arab immigrants and refugee women in the metropolitan area of Detroit. As a result ofpolitical 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 experienceshas been a challenge to many American health professionals. Specifically, health care professionals havebecome more aware of the benefits of using common psychological measures which assess mental healthwell being of clients across cultures. A valid and reliable tool that measures mood states in diversepopulations is imperative for the development of culturally appropriate mental health services for clientsexperiencing disturbances in mood states. A POM has 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 confusionbewilderment(McNair, Lorr & Droppelman, 1992). POMS was reviewed and modified for culturalrelevance independently by five experts on Arab culture. After modification, the measures were translatedinto Arabic and back translated into English as a validity check by people who shared the samecharacteristics as the five experts. The measures were administered to 30 Muslim immigrant or refugeewomen to assess for comprehension, cultural applicability, and completeness. The internal consistencyreliability of the total POMS with Arab women was 0.93, and ranged from 0.61 for the Confusion-Bewilderment subscale to 0.90 for the Fatigue-Inertia subscale. The next lowest internal consistencyreliability was 0.78 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 internalconsistency reliability of the subscale increased to 0.74. The adapted Arabic version of the POMS wasfound to be an appropriate measure for use with Arab immigrant women. The tool is being used to measuremood states with a convenience sample of 650 Muslim Arab women as part of a larger by NIH fundedstudy.

342117. Multiculturalism and Minorities II117.1. Responding to Black Children’s Mental Health Needs in the Juvenile JusticeSystem: A Reparations PerspectiveAngela Olivia Burton, City University of New York (burton@mail.law.cuny.edu)Mental health is paramount to personal well-being, family relationships, community cohesiveness, andsuccessful contributions to society. Focusing specifically on the mental health needs of Black Americanchildren, this presentation will document the prevalence of racial disparities in the incarceration of Blackchildren and the unwarranted diagnosis of many of these children with mental illness and/or behaviourdisorders. The presentation will explore the consequences of this phenomenon, including thedisproportionate use on Black children of more severe forms of treatment such as psychotropicmedications, restraints, and other highly intrusive and restrictive approaches. Labelled as mentally illcriminals, many of these children are subjected to inappropriate, unnecessarily harmful, and oppressivetreatment under the guise of mental health care.This maltreatment of Black children in the juvenile justice system has serious consequences, not only forthe individual children who are subject to these gross abuses, but also negatively affects the families andcommunities from which they come. For instance, the unwarranted or erroneous administration ofpowerful, mind-altering psychotropic drugs can lead to long-term and sometimes irreversible damage to thechild’s mental and physical health, and negatively impact their future life prospects. From a communitarianperspective, the criminal pathologization and displacement of large numbers of children away from theirfamilies and communities and into detention facilities under state supervision, undermines the Blackcommunity’s ability to address the children’s needs with reference to our unique history and culture, andresults in the loss of opportunities to shape what is perhaps our most important means of eventual selfdetermination—ourfuture generations.Central to the presentation, is the premise that institutional racism and the absence of culturally competentdiagnosis and treatment Black children are major contributors to this problem. It is argued, that thesituation of Black children in the juvenile justice system described here, represents a group-based harm thatmust be placed at the forefront of the agenda of those advocating reparations on behalf of African-Americans. As long as Black children are subjected to these shocking abuses within the juvenile justicesystem under the guise of mental health treatment, a healthy, productive, self-determined Black communitywill remain elusive. To counteract this trend toward increasing state control over the mental health of ourchildren, members of the Black community must take control of developing policies and managingprograms and procedures for addressing the mental health needs of our children, with emphasis on enablingand empowering communities and families based on principles of self-determination and extendedcommunity and family based care.117.2. Reducing Disparities of Care for Severely Mentally Ill African AmericansTrevor Hadley, University of Pennsylvania (thadley@mail.med.upenn.edu)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

343Pennsylvania and Lincoln University which make up the Philadelphia Consortium on PsychiatricDisparities. The intent is for members of the PCPD to continue to collaborate on mutually beneficialprojects in the future that will ultimately improve the health and well-being of the populations served bythese agencies. The vast majority of patients with serious mental illness are cared for in the public mentalhealth system. Despite the great advances in state of the art care and excellent treatment guidelines forsuch patients, there still exist documented racial disparities in the quality of care and engagement ofAfrican American patients. This presentation will report on a major intervention to improve the quality ofcare, by training and engaging psychiatrists and patients in a process to follow these treatment guidelinesThe four main components of the current project are:Evaluating the process and impact of implementing automated prescription systems in mental healthagencies. This includes a pre- and post-automation chart review.Using “academic detailing” to assist psychiatrists to better understand prescription patterns and choices,especially as this relates to standardizing care across ethnic/racial groups.Providing social skills training to clients (diagnosed with major depressive disorder or schizophrenia) tofacilitate improved client-clinician communication and client adherence to treatment plans.Conducting a systems-level evaluation of organizational change, to better understand the barriers to andpotentials of automated prescription systems, as well as getting a more in depth understanding of how eachagency has adapted to respond to the needs of its clients.117.3. Ethnic Issues in Diagnosing and Treating Mental DisordersWilliam B. Lawson, Howard University Hospital (wblawson@howard.edu)Misdiagnosis and underdiagnosis is common in some ethnic minorities in the United States. This persistingphenomenon has important legal implications. First, ethnic minorities, especially African Americans areoverrepresented in the criminal justice system. The mentally ill are overrepresented and could probably bediverted to other settings for optimal treatment. Second, a large percentage of these individuals may havevariants of bipolar and anxiety disorders, such as post traumatic stress disorder. Specialized mental healthtreatment is often required. Pharmacotherapy is often inappropriate, as a result of misdiagnosis. Excessiveuse of antipsychotics and excessive dosing is often seen. Pharmacological findings, however, suggest thatminorities should receive lower doses of many psychotropic medications. Side effects of olderantipsychotic medications, such as tardive dyskinesia, and emerging risks associated with newermedications, such as diabetes mellitus, increase litigation risk for the treating physician unfamiliar withcultural and biological issues in ethnic pharmacotherapy.

344117.4. Situation and Treatment Requirements of Refugees of the Caucasian Region inAustriaLutz Reinfried, University of ViennaJ. Scharfetter, University of Vienna (joachim.scharfetter@meduniwien.ac.at)R. Frey, University of ViennaE. Resinger, University of ViennaS. Kasper, University of ViennaIn recent years, the number of migrants from countries of the former Soviet Union, especially from theCaucasian region (Georgia, Tchetcheny, Ossetia, Karabach), is rising in Austria. The European Union playsan important role as a destination for migrants from different politically instable regions. These asylumseekers or refugees are a socially isolated fringe group – uprooted of their native culture, their nativelanguage, often even traumatised by experiences of violence. Coping with this pressure, migrants fare arelatively high risk to develop drug (i.e. heroine) addictive behaviours in addition to post-traumatic stressdisorder and major depression, especially if they have a history of drug consumption. The exposure todrugs extracted from poppy seed (in Russian called “mag” or “cocnar”) is very common in the Caucasianregion; drugs are quite easily available there compared to Austria or to other countries of the EuropeanUnion.Georgian migrants in Austria suffering from drug addiction are confronted with three main problems: insocial and medical concerns and in communication. Due to these problems the rate of committed crimes,imprisonment and conviction is high in this group. The outcome is additional discrimination, less chancesof integration and a lack of future prospects in the countries of the European Union as well as in theCaucasian region.The capacities to deal with these people are limited. Missing linguistic, cultural andpolitical-historical knowledge makes even well meant helpfulness and all medicalpsychiatricapproaches difficult. Moreover, one of the main problems is the lack ofsufficient information about psycho-demographic data of this region. As an attempt toestimate the amount of necessary treatment of psychiatric patients among migrants of theCaucasian region, especially of those suffering from drug addiction, we will describepsycho-social and forensic problems as well as psychiatric disorders of people from theCaucasian region and of those seeking refuge in Austria.117.5. Of Eggshells and Thin-skulls: A Consideration of Racism-Related Mental IllnessImpacting Black WomenCamille Nelson, Saint Louis University (nelsonca@slu.edu)Recent research has indicated that the prevalence of mental disorders is estimated to be higher amongBlacks than among Whites, most likely due to the nexus of race and socioeconomic disparity. Blacks areunder-represented in in-patient populations, and more likely than Whites to use the emergency rooms formental health treatment. Numerous studies confirm that Blacks drop out of mental health services at asignificantly higher rate than Whites, and use fewer treatment sessions for mental health issues.

345Furthermore, Blacks enter mental health treatment at a later, more advanced, stage than Whites, underconsumecommunity mental health services of all kinds, are misdiagnosed more often than Whites, and aremore often diagnosed with a severe mental illness than Whites. People from diverse ethnic backgrounds areoften prevented from receiving adequate mental health treatment, due to misdiagnoses and lack of access tothe services they need. Factors contributing to this disparity include a general mistrust of medical healthprofessionals, cultural barriers, co-occurring disorders, socioeconomic factors, and primary reliance onfamily and the religious community during times of distress.Unfortunately, the traditional institutions of racialized research largely ignore the disparate social andpolitical exposures confronting people of color, such as residential and occupational segregation, racialprofiling, tokenism, discrimination, racism, and the consequential physiological and psychological effectsflowing from the macro and micro effects of such interactions and intersectionalities. This article exploresthese issues, and proposes civil law legal frameworks for addressing these disparities especially as womenof color are impacted. In particular, it is suggested that renewed consideration be made of the Thin-Skulland Eggshell doctrines in the United States and comparable traditional international doctrine.118. Munchausen Syndrome by Proxy118.1. DisscussantBernard Starkman, Ottawa118.2. The Disciplinary Committee and the Judge in Munchausen by ProxyWilma Duijst, Radboud University (w.duyst@jur.ru.nl)In this investigation, we looked at the judgments of disciplinary committees on the way a physician or anurse handled a Munchausen by proxy case. Also, we looked at the judgments given by criminal judges incases of Munchausen by proxy. In the judgments, an indication is given about how a physician or a nursehas to act when a suspicion of Munchausen by proxy arises. We compared the indication given in thejudgements with the policy of the AMK (Advies an Meldpunt Kindermishandeling, An institution wherechild abuse can be reported and advice can be given).118.3. The Dutch Child Protection Board and the Munchhausen by Proxy SyndromeMargot Pot, Child Protection Board, Utrecht, The Netherlands (m.pot@rvdk.minjus.nl)This paper examines how the Dutch systems (and especially the Child Protection Board) are structuredaround child protection and the Munchhausen by Proxy Syndrome (MBPS).

346In the Netherlands the Child Protection Board is a so-called second-line organisation. This implies that onlya limited number of organisations are authorised to make direct contact with the board, such as the BureauJuvenile Care (or a section of it, the Advice and Registration Point Child Battery) and the Court. Only inextremely grave situations, other agencies and persons are permitted to directly call the Board’s assistance.The Child Protection Board does not have a special policy for cases where there is suspicion of theMunchhausen by Proxy Syndrome.There is one case of MBPS in the Netherlands; Venema vs. the Netherlands is important for the way inwhich the Child Protection Board acts.In 2002, the European Court of Human Rights proffered their judgment.In this case, there was nothing physically wrong with the daughter of the family, so there was a suspect thatMrs. V was suffering from MBPS. The Child Protection Board acted immediately, and went to the court fora supervision order and an order for the little girl to be removed from her family. The parents started aprocedure to regain custody of their daughter and also claimed compensation for non-pecuniary andpecuniary damage. Finally, the European Court of Human Rights in Strasbourg, determined that there hadbeen a violation of art. 8 (violation of family life) of the Convention on Human Rights.118.4. Munchausen Syndrome by Proxy: Bibliographical Update and Signalizing of TwoCasesSara Sabatasso, University of PaviaFabio Buzzi, University of Pavia (fabuzzi@unipv.it)The Munchausen Syndrome by proxy (MbPS) was identified in the second half of the Seventies; hence,several aspects of the nosological definition or the mechanisms of the abusers’ behaviour remainundetermined. This prevents an univocal definition of the MbPS, one which describes all aspects of theabuse, those which are dissimilar from other forms of child abuse, inherent in the syndrome. For thisreason, an analytical description of all the clinical manifestations of MbPS is required.The incidences of MbPS are unknown, because a large number of studies do not give a commondenominator. Yet, in recent years, there are numerous reported cases of MbPS, probably because of thegreater attention being given to child abuse cases. Between 1998 and 2003, 250 cases were described inliterature. Among them, poisoning cases are very frequent; they involve a great variety of substances, oftendrugs used by relatives at home. This study will present two reports falling into this category, observed atthe hospital (S.Matteo) of Pavia, between 2002 and 2003.The first case involves a 14 year old male, C.D. The Authorities of Protection and Justice were alerted byC.D.’s teachers, following the adolescent’s unexplained year and a half absence from school. In 2002, the120 kilogramme teenager, was ordered, by judges, to undergo hospitalization. The Department of Pediatrydiagnosed C.D. with iatrogenic Cushing Syndrome.. During his hospitalization, C.D. underwent a largenumber of chemical and instrumental examinations. Based on the test results, physicians suspected theadministration of non-prescription drugs by his mother. This suspicion was confirmed when, on twooccasions, nurses found C.D.’s mother administering her son cortisones (prevalently) and laxatives. Uponinvestigation, this situation had been going on for nearly two years, immobilizing the boy on a sofa due tohis weight and bone-articular pain. C.D.’s clinical situation rapidly improved once contact with his motherwas eliminated, parental authority was limited, and C.D. was entrusted to Communal Service.The second case is that of R.A., another patient in the Department of Pediatry. Although R.A. washospitalized at the age of 11, paediatricians had been following the boy’s case since 1999; hishospitalization was ordered by the “Tribunale Per i Minorenni” (Court discussing cases involvingjuveniles) of Milan, who had been alerted by the paediatricians themselves and by the infantile

347neuropsychiatrist who was treating R.A.’s cephalalgia. At the beginning of the hospitalization in theDepartment of Pediatry the child presented a clinical condition highly similar to that of C.D., with theexception of his weight, which was only 34.4 kilograms. Following examination, physicians diagnosedprobable iatrogenic cushing syndrome and cortical suprarenal gland secondary insufficiency. Unable todiscern a reasonable explanation for his progressive weight gain and increased hairiness, physicianssuspected MbPS. However, in the case of R.A., neither the abuser nor any evidence of abuse wasidentified. An improvement in his clinical condition was observed after first controlling the parents andthen separating the boy from his parents (especially the mother).In both cases, the parents (especially the mother) hindered physicians’ actions and built barriers, especiallywhen they felt under suspicion. These “barriers” are one of the many difficulties met in managing MbPScases. Other difficulties arise from the need to individualize, as soon as possible. MbPS diagnosis is up topaediatricians, not to psychiatrists. However, psychiatrists play an important role in approaching the abuser.A close monitoring of the parent-child relationship—by close supervision and then video surveillance—isneeded 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. Inthis area, welfare workers as well as physicians are important. The expert has to evaluate how the abuse isconducted, 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, including administering medicines or active drugs, usually causesvery serious physical damage. The “perverse” parent-child relationship could also cause psychologicaldamage. It is more difficult to value psychological damage and its long-term effects than that physicaldamage.118.5. Management of MBPS in Clinical PracticeR. Vecht-van den Bergh, Practicing Psychiatrist, Oegstgeest, The Netherlands (rvecht@planet.nl)MBPS maltreatment is real. Though MBPS is no longer considered rare, it is still under-identified.If MBPS is diagnosed, it becomes important to apply the MBPS label in order to provide the victim withprotection. Presentation of MBPS is various; many different diseases can be fabricated, such as diabetes,infections, anaemia, fever, and epilepsy. There is generally a two year period between the identification ofthe first symptoms in hospital, and the diagnosis. It is very important to try to shorten this period.Because MBPS is a disease in disguise, where the illness of the mother/perpetrator is inflicted on the child,it takes time to recognise the abusive patron. An additional difficulty, is the psychology of themothers/perpetrators, who are very good liars and strongly manipulative, Healthcare workers, especiallypaediatricians, can profit from knowledge about personality disorders. Despite being often perceived asdevoted parents, it is assumed that the motivation of the perpetrator, manifest through abusive behaviour, isself-serving psychological needs. Some perpetrators seem to be motivated by the need to manipulate anddeceive authority figures like doctors, policemen, or teachers. The abuse mostly involves more than onechild in a family, and may include children in other families; it may look like a serial crime. There is a highrecidivism 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 undersurveillance. Apprehended Mothers stress that the child cannot cope without her. This presentation willfocus on the experience with MBPS cases in the Netherlands. Covert video surveillance is sometimesrequired to make a definitive and timely diagnosis; otherwise cases go undetected, placing children atcontinued risk. In the Netherlands, this method has been used in hospitals in cooptation with police to get alegal proof.

348118.6. Munchausen by Proxy Syndrome and InterventionsJolande Schoonberg, Advice and Report Centre for Child Abuse, Amsterdam, The Netherlands(jschoonenberg@xs4all.nl)The Advice and Report Centres for Child Abuse in the Netherlands, established in 1972, are organization inwhich suspects of child abuse and also of Munchausen by proxy syndrome (MBPS) can be reported; thesecentres are staffed by social workers and confidential doctors. The confidential doctors are instrumental indiagnosing cases of child abuse, especially those with complex medical aspect, as with MBPS. Following asuspicion of MBPS, the confidential doctor can do an investigation. Important are the parents, the child andthe doctors who are involved in the treatment of the child. We must answer the question if there isprobably a case of MBPS. After the investigation the interventions that follows can be a further diagnosticprocedure with police Video-registration, protection of the child by separating from the parent(s), or/andtreatment of the child and the parents. MBPS always poses a great danger for the development, or the life,of the child. H.Schreier most recent definition is helpful: MBPS is PCF (Paediatric condition falsification)and FDP (factitious disorder by proxy). Both aspects of Schreier’s definition should been recognised for anMBPS diagnosis. We see a lot of cases that seem to be MBPS, but are, in fact, very similar to or look likean MBPS case.118.7. Munchausen Syndrome by Proxy: Contestable and Contested AssumptionsFiona Raitt, University of Dundee (f.e.raitt@dundee.ac.uk)Munchausen Syndrome by Proxy is a psychiatric construct “discovered” in 1977. It refers to a psychiatriccondition, whereby a parent figure, almost invariably a mother, is compelled to cause deliberate harm totheir child as a means of gaining attention from others. The present paper seeks to unveil the assumptionsabout mothering that underlie this association, and the role that expert witnesses play in the courtroom inreinforcing those assumptions. In common law jurisdictions many prosecutions for alleged maltreatment ofchildren have been successful on the basis of expert testimony offered in regard to the syndrome. In theUK, a diagnosis of Munchausen Syndrome by Proxy will often result in the public authorities seeking anorder from the civil courts to remove any children from the care of the mother. Such prosecutions and civilproceedings will be underpinned by many of the same cultural assumptions concerning motherhood thatunderlie the construction of the syndrome itself, including innateness of the maternal instinct andexpectations about mothering capabilities. The paper explores the emergence of this syndrome in lawthrough the testimony of experts in the courtroom, and will illuminate the contestable assumptions uponwhich the syndrome and its application in law are founded.

349119. Narcissism and its Relationship to Civil and Criminal Law119.1. Narcissism and the CourtsFrank Herrmann, Boston College Law School (francis.herrmann@bc.edu)Narcissism is a frequent factor in a variety of disputes that are submitted to courts for judicialdetermination. The diagnosis appears in employment and disability cases, parental rights issues, criminalsentencing, 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 askwhether the approaches are consistent with one another.119.2. Narcissistic Character Pathology and Criminal and Civil Law: An OverviewGerald E. Kochansky, Harvard Medical School (dr.k@rcn.com)This session will focus on some of the ways an understanding of narcissistic character pathology can helpto explain certain phenomena that emerge in civil and criminal legal contexts. Underlying narcissisticvulnerabilities and resulting injuries, along with narcissistic traits or defenses, may contribute to theemotional injuries which litigants allege in various tort actions. Narcissistic character traits may presentcomplex challenges in employment situations, which in turn may end up in the legal system, and can leadto criminal behaviors in individuals who are not fundamentally anti-social, as in recent corporate scandalslike those allegedly involving executives of Enron.Narcissistic traits—such as grandiosity, sense of entitlement (recently measurable by a newly developedscale), lack of empathy, vulnerability to experiencing shame and humiliation, and inability to bear andconstructively use criticism—can also enter into intellectual property disputes, slander actions, attorneyefforts 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) indealing with individuals with narcissistic character pathology and the challenges they present as employees,clients, or potential litigants.119.3. Dealing with Narcissists in Employment Litigation: Traps for the UnwaryDavid Wolowitz, Harvard Law School (david.wolowitz@mclane.com)Employers and lawyers who advise them are often unprepared to deal with problem employees who havenarcissistic character pathology. Typically, employers utilize progressive discipline to improve employeebehavior and performance. Employees with strong narcissistic traits will likely respond to such efforts as ifattacked. If the employer responds with discipline or termination, the narcissistic employee is likely tolitigate. Human resources professionals and employment lawyers would be well advised to obtaining

350training in recognizing narcissistic traits in problem employees. By consulting with forensic mental healthprofessionals in advance of intervention, human resource professionals and lawyers may be able to reducethe likelihood of protracted litigation.Employment litigation with a narcissistic employee presents special problems. Their vulnerabilitycontributes 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 theparties, prolonged litigation, and further obstacles to settlement. Their grandiosity and lack of insight makeit extremely difficult for them to follow the advice of their counsel or evaluate the merits of the opponent'scase.To complicate matters, a narcissistic employee who has been disciplined or terminated may suffersignificant narcissistic trauma in circumstances which would not traumatize another employee who doesnot have these traits. The narcissistic employee will likely blame the trauma on the perceived unfairtreatment and make the asserted emotional distress a part of the damages claim. In most jurisdictions, thelaw does not support emotional distress claims when the distress exceeds that which a reasonable personwould exceed under the circumstances, unless it results from a susceptibility of which the accused hasknowledge. Therefore, it is crucial that the employer and its counsel utilize a forensic mental healthprofessional 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 employmentlawyers of utilizing knowledgeable mental health professionals to advise them on risk managementstrategies when dealing with difficult employees with narcissistic character pathology both pre-litigationand during the litigation process.119.4. Sexual Misconduct in Professional Relationships: What’s Narcissism Got To DoWith It?Andrea Celenza, Harvard Medical School (acelenza@aol.com)There is widespread concern about the problem of sexual misconduct in professional relationships. This isespecially true for the therapist-patient relationship but is, in some measure, also true for any fiduciaryrelationship or any relationship with a professional providing a service to a layperson in need. Amongmental health professionals, sexual misconduct is recognized as unethical, due to the power imbalanceinherent in the structure of the therapist-patient dyad. In the mental health arena, the relationship isfounded on an asymmetric distribution of attention, wherein the professional learns a great deal about thepatient and not vice versa. This type of relationship encourages transference-based illusions derived fromearly childhood, rendering the patient particularly vulnerable to exploitation. The problem is intensified forany professional relationship that continues over time.Eight precursors to sexual misconduct have been identified, many of which are features of the character ofthe professional. Most of these are related to narcissistic pathology and bear on the professional’stemptation to exploit the power imbalance inherent in the asymmetric structure of the professionalrelationship. These risk factors will be highlighted in order that the professional may be aware ofvulnerabilities and potential blind spots to consider throughout his/her professional life.

351120. Neuro-biology and Mental Health: Jurisprudential Issues120.1. Neuro-Jurisprudence: The Brain and the LawRicardo Weinstein, Psychologist, Encinitas, USA (rweins@pacbell.net)The last two decades have witnessed a convergence of the disciplines of brain science that has majorimplications for understanding human behaviour. The neurosciences, including brain physiology,neurobiology, brain chemistry, neuropsychology and techniques in brain imaging, have evolved at a rapidpace allowing for new understanding of brain development and functions. Mental health and the law havealways been difficult partners, and many have questioned if psychology has any place in the courts. Withnew and better understanding of brain/behaviour relationships, the neurosciences now have solidcontributions 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 generallycomes about very slowly. The most recent developments in neuropsychology, however, raise questionsabout whether the law can actually promote justice if it does not consider new understandings of the brain.It has become evident, many psychological concepts have become obsolete and philosophical questionsregarding human behaviour need to be re-examined.This presentation will offer a review of brain development as it relates to legal issues. It will discussconcerns relating to insanity, legal responsibility, and competency, as well as issues of intent and the role ofemotions. The concept of free will, in light of the present knowledge of brain function, will also beexamined. The assumption of free will underlies most Western law; the presentation will include adiscussion of free will as a relative, rather than an absolute, concept. Finally, it will provide examples ofhow all of these issues become integrated in death penalty cases in the United States by presenting a modelof comprehensive evaluations of brain function, including neuropsychological and neurophysiologicalmeasures.120.2. Conceptualisation of Violence as a Neuropsychiatric DisorderThomas C. Thompson, Thompson, Sak and Associates, Las Cruces, USA (tctmjs@zianet.com)The premise of this paper that individuals who engage in violence suffer from a neuropsychiatric syndrome,that is largely ignored at the level of judicial and treatment decision making. This is conceptualized as adevelopmental syndrome associated with abnormalities and atypical organization and development of thebrain. Violent offending is perceived as the end product of brain development, in which higher-levelcognitive/executive and emotional regulatory systems have malfunction as a result of both neurochemicaland structural deficits. These deficits are believed to be the result of genetic, prenatal, and perinatal factorsthat can be magnified by the interaction of early non-normative experiences of abuse and neglect. In olderadolescents and adults this leads to a high prevalence of affective dysregulation, substance abuse, andimpulsive violence.The author proposes that we begin to systematically gather neuropsychological, psychophysiological, andelectroencephalographic data in order to establish databases. Databases would allow for the developmentof standardized assessments that could be available at the level of community programs and practitioners,thereby allowing for the more accurate identification of those individuals who are higher risk for serious

352repetitive long-term violent behaviour. Further, the development of databases and standardizedassessments will begin to delineate alternative treatment models, which emphasize violence as aneuropsychiatric syndrome. It is anticipated that such a project would inform both treatment and judicialsystems where there is a need for comprehensive differential diagnosis and the development of differentialtreatment programming. The development of the database and its ability to inform treatment and judicialsources will lead to earlier and more successful intervention reducing the high personal, familial, andsocietal costs of violence.120.3. The Brain, Emotions, and Family Law: High Conflict Custody Disputes SeenThrough the New Lens of Neuro-JurisprudenceJanet Weinstein, California Western School of Law (jweinstein@cwsl.edu)High conflict child custody and visitation disputes are problematic for professionals involved in the legalsystem, for the parties, and for the children who are the subjects of the disputes. The legal system expectspeople to behave rationally, but people in the midst of intense conflicts, particularly when they arefundamentally personal as these conflicts are, may not be able to overcome their emotions in order tobehave the way the courts expect. There have been a variety of approaches to this problem, some moresuccessful than others. Attempts to reduce the problem have included unified family courts, parenting anddivorce education programs, special masters, and other counselling programs. The law and associatedprofessions, particularly mental health, have examined the problem from many perspectives including thepsychology of these disputes, the economic burden it imposes upon the courts and the families, and thedevelopmental consequences to children.This paper examines these difficult disputes from the perspective of the brain—what the brain does inreaction to particular stimuli. From this perspective, the paper discusses possible explanations for thebehaviour exhibited by these parents, and suggests possible approaches to reducing conflict by usinginformation about the brain. Looking at the problem through the new lens of neuro-jurisprudence providesthe opportunity to develop new approaches or lend support to approaches that seem to be working.120.4. The Biology of Money: Legal ImplicationsLaurence R. Tancredi, New York University (lrtancredi@yahoo.com)The relationship of the brain to how we handle money has become an area of interest in recent years. Partsof the brain generate fear and anxiety over changes in monetary status. Other areas are concerned withrepetitive and alternating patterns and, therefore, engage in forecasting. Still other areas of the brain—dueprimarily 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 inpathological gambling. This presentation will examine the biological features of the brain that affectmoney, examine when our need for money and risk gets out of control, and finally review the implicationsof impulsivity and compulsion with regard to money as they apply to legal responsibility.

353120.5. Lie Detection and Neuroscience: Historical and Practical ImplicationsElizabeth Ford, New York University (forde01@med.nyu.edu)Lying and deception have been discussed extensively in studies of ethics and morality, but the accurate andreliable detection of such activity has haunted the scientific and legal communities for centuries. Liedetection techniques have advanced considerably since the days of hot coals and witch trials, but therecontinues to be great difficulty identifying a liar in the psychiatric and/or criminal population. Mostprofessionals, including judges and psychiatrists, perform no better than chance when attempting to identifya liar. This is an important issue because legal decisions and psychiatric treatment recommendations areoften 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 afoolproof test for the courts? Can this technique offer enough conclusive evidence about a defendant’shonesty? While the few studies that have been done indicate that there may indeed be a role for thistechnique, the literature remains sparse and limited. These issues, along with provocative questions aboutsociety’s preoccupation with lying, will be discussed.121. Personality Disorders I121.1. Developing a new Spectrum of Services for People with Personality DisordersEddie Kane, UK Government Expert Advisory Group on Personality Disorder, London, England(eddie.kane2@btinternet.com)Personality disorders are common and often disabling conditions. Whilst many people with personalitydisorders 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 onfamily, friends, and those who provide them with services and care. The stated objective of recent UKpolicy interventions in these services is to:• assist people with personality disorders access appropriate clinical care and management fromspecialist services• ensure that offenders with a personality disorder receive appropriate care form services andinterventions, designed to both provide treatment and to address their offending behaviour• establish education and training to equip staff across the wide range of agencies who deliverservices specifically or, by default, to people with a diagnosis of personality disorderFollowing 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 peoplewith a diagnosis of personality disorder. In January 2001, national guidance on type, level, and quality ofservices was published in a document entitled ‘Personality Disorder: no longer a diagnosis of exclusion’.

354This was followed by further national guidance on training and skills development for people from allagencies offering services to individuals with personality disorder entitled ‘Breaking the Cycle ofRejection: the PD capabilities framework’. This paper examines the impact of these policy initiatives,their impact on the development of new services, and the creation of a workforce capable of revitalisingservices for this socially excluded group.121.2. Personality Disorder: From Diagnostic Category to Service Delivery—aSociological PerspectiveNick Manning, University of Nottingham (Nick.Manning@notthingham.ac.uk)'Personality disorder' has been a rapidly moving diagnostic category, but one which has attracted a range ofnew service developments in the UK. In this paper, some reflections are offered on the way such diagnosticcategories have evolved and on the development of services based upon them. These will be presented andanalysed from the perspective of the sociology of knowledge. Conditions that underlie the stabilisation ofsuch categories, and the policy and political consequences of basing services on them, will be reviewed.121.3. To Move or not to Move—That is the Question! Some reflections on MakingCritical Decisions in the face of Uncertainty.Conor Duggan, University of Leicester (conor.duggan@nottshc.nhs.uk)Although the introduction of DSPD in Britain has been criticized, one major advantage is that it attemptedto make explicit much of what has heretofore been implicit in psychiatric practice. For instance, in thefuture, 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 affordprotection against inappropriate detention for the individual assessed. This focus on entry criteria to theservice, while it is to be welcomed, is unfortunately not matched by a similar attention to exit criteria. If thepurpose of the intervention is to reduce risk, then how much does this risk have to be reduced to allow anindividual to progress from one level of security to another? This is a critical area as, without suchmovement, the system will inevitably silt up, and thereby fail to meet the expectations of service providerand user alike.These decisions will inevitably be problematic, given the lack of a proper evidence base that might justifythem. For instance, the evidence that interventions designed to reduce risk in those with a personalitydisorder (particularly those who are most severely affected) or those who sexually offend, is almost nonexistent.Given our current state of knowledge, I argue that these decisions on transfer will inevitably beconjectural and seemingly arbitrary. One consequence of this uncertainty is that the system will behaveconservatively, so that it is likely to detain more than is necessary. This setting of the transitional bar at avery 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 securetier can sensibly demand from the higher secure setting, so that the patient can progress sensibly and safelyfrom one tier to another? One condition is that this lower tier will itself require an exit strategy of its ownthat, in turn, will influence (and be influenced) by the tier below it and so on, until the patient reaches thecommunity. With each reduction in security, the demands are likely to become more stringent (as security

355decreases), thereby making the individual’s journey increasingly problematic. How are we to overcomethese barriers, and thereby avoid the mistakes of the past with silos of unwanted and unmanageablepatients?One consideration is that the traditional demarcation of services into autonomous tiers is unlikely to workwithin such a system, and a whole systems approach will be essential if the DSPD proposal is to besuccessful. To date, mental health professionals have resisted this integrationist approach, and this will be amajor challenge to service development in the future. In addition, a more explicit set of criteria need to beproduced by lower tiers, again ideally anchored by some evidence, that both patient and service providersare aware of from the outset, and will need to be attained in order for the individual to progress. If this istaken to its logical conclusion, it will result in the community provision setting the pace (a bottom-upapproach), rather than the reverse. However, the Government’s attention (wrongly in my view) has been tofocus resources on the highest level of security, rather than that which is proposed here. Nestlinguncomfortably between high and low security (i.e. in a medium secure facility), is a useful position toreflect upon these tensions; this will be the focus of this presentation.121.4. Developing New Services for People with Personality Disorders: UK experiencesNick Benefield, Department of Health, Manchester, England (Nick.Benefield@dh.gsi.gov.uk)Implementation of the UK’s Personality Disorder service development and training programmes, has seenthe establishment of 17 new pilot services. These projects cover a range of service models for adolescentsand adults, in the Forensic and non-forensic populations. Independent evaluation of these different serviceswill be completed in 2006. Progress and preliminary findings will be described and key issues for learningdiscussed. The implications for future strategic service planning in Personality Disorder services will beidentified.121.5. Readiness for Treatment, Engagement and Outcomes in the Treatment ofPersonality Disordered OffendersKevin Howells, University of Nottingham (kevin.howells@notthc.nhs.uk)It is increasingly accepted that psychological therapies have an important role to play in the managementand treatment of personality disordered offenders. There is some evidence to suggest that therapy can beeffective in bringing about significant change, for at least some offenders, although there are clearly alsosome 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 tooccur. It is proposed that the concept of "readiness for treatment" is a useful one, and that future researchand clinical practice should focus on the identification and modification of the various dimensions ofreadiness.

356122. Personality Disorders II122.1. A Multi-disciplinary Team Approach to Assessment and Individualised TreatmentInterventions of Personality Disordered Offenders Within a High Security PrisonCaroline Doyle, Prison Service, Durham, England (Caroline.doyle@hmps.gsi.gov.uk)Dave Matthews, Prison Service, Durham, England (Dave.matthews02@hmps.gsi.gov.uk)HMP Frankland is one of eight High Secure Establishments within the High Security Directorate, and isone of two Prison Service DSPD Pilot sites. The Westgate Unit is a newly constructed, 80 bedded unitwithin the establishment; that will deliver a structured DSPD assessment, treatment needs analysis, riskmanagement package, and a variety of psychodynamic therapeutic individual based treatment plans toprisoners meeting the DSPD Criteria.The DSPD assessment and treatment phases will be supported by a complementary regime delivered by arange of multi-disciplinary team members. This regime is individually designed to address the personalitydisorder traits and risk needs identified.Each prisoner will have an individualised designed timetable, incorporating formalised therapy with thecomplementary supplementary regime. Prisoners will also have optional sessions that will be discussed andintegrated into their treatment plans and targets. The complementary regime includes activities such ashorticulture, 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 optimumlevels of communications. This team will be responsible and accountable for all decisions and negotiationswithin the unit.Training on care and treatment of the personality-disordered prisoner within the DSPD Service will beprovided and delivered to all staff. The emphasis of recruiting staff through a structured, core competencyframework allows for individual training analyses and appropriate skills utilisation.The DSPD Service has developed intensive academic and clinical links with PCTs, mental health services,and universities. Joint appointment and secondment opportunities enhance both the quality of staffs’ skillsand care of prisoners.122.2. Research and Development: Plans and ProgressMatt Erikson, Dangerous and Severe Personality Disorder Programme, London, England(Matt.erikson@homeoffice.gsi.gov.uk)The DSPD pilot programme is aimed at providing protection for the public from some of the mostdangerous individuals in society, specifically those who present a high risk of sexual or violent offendingand in whom a severe disorder of personality is present. The DSPD programme also seeks to improve thehealth outcomes for this, often neglected group, and work towards successful re-integration into society.To support this ambitious and complex programme of work, a large raft of research has been initiated. Theresearch programme has been determined through consultation with a group of experts drawn from

357Psychiatry, Psychology, and Sociology. This group provides invaluable assistance in a complex anddeveloping field.The research programme can be broadly divided into the following areas: the relationship betweenpersonality disorders and serious offending; the aetiology and development of personality disorder; and thevalidity and reliability of assessment systems used in the programme. Dangerousness and personalitydisorders are complex areas. Improved understanding of the relationship between the two will be importantto the effective treatment and management of this group. Regarding the second area, this work is importantin terms of the potential to prevent the development of severe personality disorder and the behavioursassociated with it. Additionally, greater understanding may offer the potential to improve approaches totreatment. Regarding the third area, it is essential that the instruments that are used to identify this group areboth valid and reliable across different age groups, gender, and ethnicity. The development and evaluationof treatments for this often difficult group, is central to the aims of the programme. Due to the challengingnature of this group, they have often been neglected or excluded from treatment. Evidence suggests that theefficacy of treatment for this group remains an open question. Robust evaluation of treatment forms a largepart of the research agenda. This presentation will provide an overview of current projects in these areas,and what will be delivered by them. Some recent results from this programme of work will also bepresented.122.3. Developing Services for Dangerous Offenders with Severe Personality DisorderSavas Hadjipavlou, Dangerous and Severe Personality Disorder Programme, London, England(Savas.hadjipavlou@homeoffice.gsi.gov.uk)This paper will discuss the background, recent developments, and future directions of the Dangerous andSevere Personality Disorder Programme (DSPD). The Programme's aims are to create, within the Prisonand Health systems in England and Wales, the capacity to assess and treat dangerous offenders with a highrisk of reoffending, and whose offending is linked to severe forms of personality disorder. This groupposes severe challenges for prisons, secure hospitals, and in the management of risks in the community.The focus will be on the lessons about the organisational challenges in implementing such a programme, interms of cross-agency working, multiprofessional services, and evaluation/research.122.4. Attitudes, Training and Effectiveness in Working with Personality DisorderedOffendersTodd Hogue, Rampton Hospital, Nottinghamshire, England (todd.hogue@nottshc.nhs.uk)Karen D’Silva, Rampton Hospital, Nottinghamshire, England (karen.d’silva@nottshc.nhs.uk)Within clinical settings, there is an increasing recognition that the training and development of staff is animportant part of ensuring a competent workforce. However, beyond the development of the appropriateskills to undertake relevant tasks, training also has an impact on the attitudes that individual hold to boththeir job and client group. Such attitudes are likely to be particularly important when working with difficultclient groups, such as individuals with personality disorder or those thought to be dangerous and severelypersonality disordered (DSPD). This paper overviews the possible effect that different attitudes towardspersonality 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 disorderedindividuals, based on previous work relating to attitudes towards sexual offenders. This measure was used

358as 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 aspecialised staff training and development programme had on attitude change. As expected, staff attitudestowards working with a personality disordered population became more positive with training. The paperdiscusses the implications of measuring attitudes towards a specific client group, both in terms ofmeasuring the effects of training but also the possible effects those different attitudinal sets have for thedevelopment of therapeutic alliance and patient change. The paper also discusses how these types ofattitude measures might be used to examine the general approach that clinicians, across the health system,take to working with personality disordered patients.122.5. Integrating Psychological Need and Public Protection in a Community Model forPersonality Disordered OffendersRob Leiper, Invicta Community Care NHS Trust, Kent, EnglandJackie Craissati, Oxleas NHS Trust, Kent, England (Jackie.craissati@oxleas.nhs.uk)The Department of Health has initiated a number of projects in the UK to develop medium secure andcommunity services for personality disordered offenders. These developments are independent of, butintended to complement, the development of high secure services for Dangerous and Severely PersonalityDisordered offenders.DHP—a six bedded hostel project with attached outreach team in southeast London—was specificallydesigned to bridge the gap between community mental health services, criminal justice services, and thevoluntary housing sector. Its aim is to target high risk, severely personality disordered offenders whoalready have a track record of failing within the community, and who are rejected from or not suitable forother community provision.Existing models of care or agency co-ordination—for example, probation and police risk managementprocedures, or the care programme approach—do not address the full range of difficulties with which suchoffenders struggle, and thus expose services to the possibility of splits and rivalries. Furthermore, thecurrent climate of public protection and associated media interest has meant that risk assessment hasdominated 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 personalitydisordered offenders which integrates consideration of offending behaviour (and risk), mental health issuesand psychological need, and social adaptation and functioning. At the core of such a model lies individualformulation: informed by actuarial assessments of risk, a clinical understanding of psychologicalfunctioning, and a physical and staff structure which addresses interpersonal difficulties and socialexclusion.High risk personality disordered offenders often feel overwhelmed and disheartened when constrained byrestrictive avoidance strategies; their psychological difficulties often trigger a paradoxical effect in that riskunexpectedly rises in response to external measures of containment. The DHP model reframes risk andneed 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 a mutuallyagreed goal.

359123. Personality Disorders III123.1. The Occupational Therapist’s Role in DSPDMark Spybey, St. George’s Hospital, Northumberland, England (mark.spybey@nmht.nhs.uk)Kimberley Pollard, St. George’s Hospital, Northumberland, EnglandNicola Seddon, St. George’s Hospital, Northumberland, EnglandThe DSPD programme is a joint initiative between the Department of Health, Home Office, and PrisonService. 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 deliveryof 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 singletreatment approach has a monopoly of success. Whilst a variety of psychological therapies and drugtreatments are utilised, other treatment models may be of use. Bateman and Tyrer (2001) suggest, that it isovertly simplistic to believe that personality disordered patients will respond to one particular form oftherapy. Clients struggle to cope with chaotic lifestyles, painful interpersonal functioning, socialdifficulties, vulnerability to self-destructive behaviours, and the complicating effects of beinginstitutionalised.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. OccupationalTherapy 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 occupationaldysfunction, 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 performanceand volitional deficits that may complicate sustained engagement in treatment (Whiteford, 2000). Throughengagement in appropriate activity, it is possible to assess and address some of these factors. This paperwill highlight how Occupational Therapists may contribute towards the assessment of risk and theidentification of strengths and needs; it will highlight some of the consequences of being able to accessactivities that give structure and purpose to the lives of inmates and, by doing so, contribute towards thedelivery of a robust assessment and treatment programme.123.2. High Security Services for Dangerous Severe and Personality Disorder—AComparison of English and Canadian ApproachesTony Maden, Imperial College London (a.maden@ic.ac.uk)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.

360The RPC applies cognitive behavioural techniques to reduce recidivism, and current evidence suggests thesame approach should form the core of the treatment regime in DSPD units. The key to success is the strictmanagement of programme integrity, to deliver intensive treatment tailored to the individual’s abilities andreadiness 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, byproviding an objective measure of success within a reasonable time frame. The DSPD service will requireeffective 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 ordinaryprison whenever they wish, and the average length of stay is about two years. The DSPD service will haveto guard against beds becoming blocked by long-stay patients, who have no way out of the service. Longterm incarceration in hospital is an expensive and inefficient way of protecting the public, and a unit with ahigh proportion of long-stay patients would find it hard to sustain a therapeutic ethos, with a consequentthreat to staff morale.123.3. Dangerous and Severe Personality Disorder Unit (DSPD) in a High SecurityHospital: The First Two YearsJose Romero Urcelay, Broadmoor Hospital, Berkshire, UKBicester Ward at Broadmoor Hospital was the first operational DSPD pilot unit in the NHS. Thispresentation will give an open, honest, and realistic account of the process of developing the unit in aclimate of professional and political controversy regarding the new concept of DSPD. It will describe thechallenges we have encountered, the lessons learnt from mistakes, and the successes that we believe wehave achieved. It will address the different components of the process:• Recruitment, Training, Support, and Retention of Staff• Interaction with the rest of the Hospital• Patient characteristics• Treatment models and overall Therapeutic Programme• Future Challenges123.4. Violence and Personality—Personality Types in Forensic Patient with ViolentCrimesAlexandra Stupperich, University of Regensburg (Alexandra.stupperich@medbo.de)Concerning the discussion about the connection of personality traits and personality disorders, the studytested the relationship between delinquency (non violent, violent, and sadistic), personality disorder, andpersonality. We used the Trierer Integrated Personality Inventory (TIPI Becker 2004), which is based onthe 4PX factor model of personality traits (Neuroticism, Extraversion / Openness, Agreeableness, andConscientiousness). In addition, 34 facet scales are measured. The TIPI was designed for the normal anddisordered personality, and was almost employed in examination of perpetrators (Becker 2002).We tested 94 male forensic patients with different criminal backgrounds, who were all sentenced to long orlifelong imprisonments (medium age 36; diagnosis categories: 49 Personality disorders, 33 mentallyhandicapped, 13 psychosis; crimes: 46 sexual offenders, 37 battery, 12 others; violence during crimes: 23

361hands off, 57 hands on, 15 sadism). 104 conscript army soldiers serve as a control group (male, mediumage 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 38scales Chi2(76)=94,3 p=.08, 91% c.cl., kappa =.85). No differences between the groups hands on andhands 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 did not differ (Big Four Chi2(8)= 5,5 p=.69; 58% c.cl., kappa =.06; 38scales Chi2(76)=68,7 p=.71, 80% c.cl., kappa =.65). Logistic regression analysis shows 13 of the 34 facetscales as valuable predictors for group separation. Using Cluster analysis for these selected scales, fourpersonality subgroups are identified. Cluster 1 and 2 are dominated by patients with personality disorders(81 / 71 %) and patients who were sentenced because of murder or battery. Cluster 2 and 4 were dominatedby patients with intellectual disabilities (ID) (52 / 100%) which had committed sexual crimes, such aspaedophilia, as well as murder or battery.Forensic patients present neuroticism, conscientious, and a lack of agreeableness. However, this mostlyholds for the mentally handicapped; patients with personality disorders, as well as psychotic patients are notas outstanding. Violence types are hart to peg, at least in the special patient group under study (high riskpatients). Sadism relates to a lack of companionability, self–confidence, and self-assertion, low zest foraction, and empathy, like almost described in literature (Baumeister et al., 1999, Osterheider 2004).123.5. The Ripple Effect: The Evolving Alienation of Men with Disordered PersonalityStructureTom Gorman, Forensic Assessment and Community Services, Edmonton, Canada (tomgorman@cha.ab.ca)While the treatment of abusive men has largely been conducted from a feminist or psychoeducationalframework, little attention has been paid to the fact that many abusive men, particularly those seen inforensic settings, have personality disorders. Clinical experience suggests that men with differentpersonality disorders show significant differences in the nature, pattern, and rationalization of their abusivebehavior. Mr. Gorman will briefly review how specific patterns of abuse are linked to specific personalitydisorders, in particular antisocial, narcissistic, and borderline personality disorders. He will also discussways to address these individual patterns within the group context, without losing the feminist andpsychoeducational frameworks of family violence treatment. The goal is to help men recognize andunderstand their particular personality characteristics and relationship patterns, and how thesecharacteristics 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 familyviolence 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 situationsdepicting 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 ofcognitive skills, use of social skills, evidence of responsibility, evidence of empathy, and other factors. Themen’s behavioural and cognitive responses will reflect the above-mentioned link between specificpersonality disorders and specific behavioural patterns. Results of the post-treatment tests highlight whichinterventions are most likely to be effective in helping these men discover and use alternatives to violentand abusive behaviours.

362124. Police and Mental Health124.1. Alberta’s Provincial Diversion ProgramLaurie Beverley, Alberta Mental Health Board, Calgary, Canada (laurie.beverley@amhb.ab.ca)The Mental Health and Justice Partnering Deputies Committee is the accountability structure for AlbertaMental Health Board’s cross-ministerial initiatives related to individuals with mental illness who are inconflict 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, HumanResources and Employment, Community Development, and the Chief Executive Officers from the AlbertaMental Health Board (AMHB) and Alberta Alcohol and Drug Abuse Commission (AADAC). Alberta’sProvincial Diversion Program, amongst other initiatives, has been developed with cross-ministerialinvolvement and support. This has fostered an integrated approach to improving service delivery toindividuals 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 withmental illness who are in conflict with the law receive appropriate care, support and treatment from mentalhealth, 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 DiversionCommittee—consisting of numerous ministry and agency representatives—was formed to develop theProvincial Diversion Framework (2001). Specifically, the framework was designed to guide thedevelopment 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 setof provincial standards and guidelines for Alberta’s communities involved in the diversion of individualswith mental illness who are in conflict with the law. The intent is to capitalize on the existing resources andexpertise within communities, and, if necessary, to augment resources as needed. AMHB co-chaired thecommittee along with the 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 ProgramAdvisory Committee with representation from current partners, regional health authorities, communitystakeholders, and consumer groups. The author, as co-chair of this committee and initiative, will present anoverview of the process incorporated, work completed, and activities currently in progress.124.2. Learning the Hard Way: Inquest Findings from Police Shootings of Mentally IllIndividualsTerry Coleman, Moose Jaw Police Service, Moose Jaw, Canada (tcoleman@city.moose-jaw.sk.ca)One of the inevitable consequences of deinstitutionalization has been a significant increase in the numberof interactions between the police and individuals with mental illnesses. While the vast majority of theseincidents are minor and may not even involve any type of criminal activity, there are a few instances inwhich a mental health crisis develops into something much more significant, with tragic outcomes. Duringthe 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

363factors 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 suggeststhat remedies are complicated and entail much more than simple training or service provision. This paperwill review the inquest findings over the ten year period, and look at the themes that have emerged andtheir implications for both police services and mental health services, both as individual agencies and asunexpected partners in the care of mentally ill individuals living in the community.124.3. Police Interactions with Individuals with Mental Illnesses: Canadian SolutionsDorothy Cotton, Correctional Service Canada, Kingston, Canada (cottondh@csc-scc.gc.ca)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 nottraditionally been viewed as mental health care providers. But what constitutes an appropriate policeresponse when individuals with a mental illness are involved? This paper will provide an overview of thecomponents of a comprehensive police response to situations involving a person with mental illness inCanada. Much attention has been paid to the development of crisis response models—these include modelsthat involved intensive officer training, joint mental health/police response, and other cooperative andcollaborative models. Examples of how these models are used in Canada will be presented and how eachdifferent model suits different geographic needs, depending on population composition and size, policingstyle, availability of mental health services, and other local characteristics.But crisis response is only one component of police response. Other essential components which will bediscussed include:• the need of formal management level coordination between systems (e.g. clear policydevelopment 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 ofcrime or may be the subject of interrogation• educational needs (including education at the student/recruit level and continuing educationfor senior personnel; and the need for both professional specific and joint training initiatives)• diversion alternatives (including pre and post charge diversion as well informal alternatives)• linkages between correctional facilities, police and mental health agencies including forensichospital settings in order to minimize recidivism and maximize community integration• applied research and evaluation• mental health legislation needsThe goal of the presentation is to provide a blueprint for police services, correctional/forensic services, andmental health agencies to work cooperatively in providing a comprehensive community response toindividuals with mental health problems who come in contact with the criminal justice system.

364124.4. Towards an Integrated Psychiatric Emergency Service at the Ottawa Hospital:Integrating Emergency Psychiatry, Mobile Crisis, Police Mental Health Unit andEarly Intervention ProgramsColleen MacPhee, The Ottawa Hospital, Ottawa, Canada cmacphee@ottawahospital.on.caClaudia Hampel, The Ottawa Hospital, Ottawa, CanadaBruce Kennedy, The Ottawa Hospital, Ottawa, CanadaPeter Linegar, Ottawa Police Services – Mental Health Unit, Ottawa, CanadaLouis Soucy, The Ottawa Hospital, Ottawa, CanadaPaul Roy, The Ottawa Hospital, Ottawa, CanadaThe TOH is a 1,060 bed academic Health Sciences centre. TOH has 3 campuses, and provides health careservices in French and English to over 1.5 million residents of Eastern Ontario. Through the process ofMental Health Reform, TOH has received dedicated funding for first-line mental Health services including:psychiatric emergency services (PES), Mobile crisis team (MCT), and First Episode Psychosis program(FEPP).These programs have been designed to form an integrated model of emergency mental Health response forthe Ottawa area. The ability to provide a patient focused, integrated response is enhanced by serviceagreements and liaison with the Ottawa Police Mental Health Unit.The goals of this integrated model (RAPID) are to:Reduce reliance on in-pt hospital treatment providing services in the least costly and least restrictiveenvironment.Facilitate Access to high quality/rapid emergency care for those patients who require that intensity ofservice.Preserve independent functioning and promotion of rapid stabilization.Intervene as early as possible during the course of a new illness or new acute episode to reduce symptomsand duration of illness.Decrease barriers to referral/inappropriate referral by promoting community re-integration and appropriatecommunity links.The presentation will review the services and how they are integrated. Key aspects will include patientflow, standardization of patient information, access to hospital and community services, privacy and legalissues with the Police Mental Health Unit, patient outcomes, and potential for further future mental healthservice links. We will also review the impact these programs have had on Ottawa Police Services (e.g.decreased time spend in the Emergency Department) as well as current challenges and lessons we havelearned.

365124.5. Police Service Utilization of Psychological Services in CanadaJohn Tivendell, University of Moncton (tivendj@umoncton.ca)Reacting to the media's new interest in forensics and psychological profiling, Dr Jennifer Brown, directorof the graduate program in Forensic Psychology at Sussex University, recommended clarifying the role andstatus of psychologists working with Police services (Brown, 1998). She argued that such a clarificationwas needed in order to (continue to) protect the interests of the public, and that Police services could do soby ensuring that the services rendered by these psychologists meet all the codes of professionalaccreditation. Unlike the status of professional chartering of forensic psychologists in England, in Canadamost police services are in fact aware of the licensing requirements facing the professional psychologistswith whom they work. However, they may not know of the psychologist's moral obligation to also be at "lafine point" of his or her science. While the majority of police services in Canada make some use ofpsychological services, the field occupies a curious position between Clinical psychology on the one hand,and Industrial/Organisational psychology on the other. This paper will report on the results of a nationalsurvey of police utilization of psychological services. In this the first step in understanding the current stateof police psychology in Canada, we obtained information about the use of psychology in personalityscreening at the pre-employment and specialty assignment levels, for both police and civilian staff; inEmployee Assistance Programs; in fitness for duty, crisis intervention and crisis negotiation services; andin a variety of management development and consulting roles. Both police and psychologists report theneed for increased training and orientation for each system in making the best use of each others skills.124.6. 7x24hr Crisis Intervention at a Police StationRob van den Brink, University Medical Center Groningen (R.H.S.van.den.Brink@med.umcg.nl)Fons TholenWim WinthorstJan BroerErna BerendsenDurk WiersmaMore people with serious mental health problems are living in the community. The police are called uponto provide 24-hour crisis intervention for this group. Arranging adequate assessment and care, however, isexperienced by the police as both very time-consuming and not a police task.Therefore, the city of Groningen, in the Netherlands, began an experiment to assess police response topeople with mental health problems. In light of this, a screening room (Front Office) was established insidea police station, where the police can take the person. Furthermore, it was agreed, that either a public healthphysician or a mental health services psychiatric nurse would be on the spot within 30 minutes to take overthe responsibility for the person, thus making it possible for the police to return to their duties on the street.We registered the nature and cause of the crisis situation and the need for (immediate) care, as assessed bythe Front Office. In addition, data were collected on any care provided by the Back Office (mental health,social, and addiction services) in the year prior to and the month following the crisis. Finally, two expertpsychiatrists evaluated the adequacy of the crisis assessment and care provided. The calls upon the FrontOffice will be interpreted in the light of all reports of public mental health problems found in the policeregistration system for the pilot year, and the way the police dealt with these problems.

366125. Polygraphy with Sex Offenders125.1. Post-conviction Polygraphy with Sex Offenders in England: Issues of Utility andImplementationShay Addison, University of Newcastle-upon-Tyne (shayaddison@hotmail.com)Proponents of post-conviction polygraphy, make a persuasive case for its introduction in the managementof sex offenders. When used in this context, the polygraph has the potential to overcome limitations incurrent supervision practices, as well as generally improving the assessment and treatment of sex offenders.Its use in such a capacity has increased markedly over the last decade in the US. This expansion is likely tocontinue, as professional organisations and leading sex offender practitioners endorse its utility. Whileenthusiasm to polygraph sex offenders is perhaps understandable, the research evidence demonstrating itsvalue in these settings is, at best, limited. Much of this research has been complicated by methodologicalproblems, such as small sample sizes, retrospective methodologies, lack of comparison groups, and socialdesirability biases. This presentation explores data from an on-going large-scale research project beingconducted throughout England investigating the application of polygraphy to the treatment and supervisionof community-based sex offenders. Comparing probation areas with and without polygraph, allows us toevaluate the impact that the procedure has upon what is known about offenders in regards to offendinghistory. Furthermore, we investigate the impact that the polygraph has upon risk assessment and moregeneral treatment. Data will also be presented regarding its perceived helpfulness in treatment andsupervision from probation officers and other treatment professionals. Finally, a number of case exampleswill be presented and the obstacles to implementing polygraphy in such settings are discussed.125.2. Post-conviction Polygraphy: The Issue of AccuracyLars Madsen, University of Newcastle-upon-Tyne (Lars.Madsen@nmht.nhs.uk)Post-conviction polygraph testing is becoming more widely used throughout the United States in thetreatment and management of sex offenders. More recently, in the UK, the polygraph has also beenseriously considered as an adjunct to treatment and supervision. Many studies have demonstrated that thepolygraph improves the quality and quantity of information obtained during treatment. While such researchdemonstrates the utility of post-conviction polygraph testing with sex offenders, it provides littleinformation about the likely accuracy. Numerous studies have shown high accuracy rates, however, othershave criticised these findings by highlighting methodological problems. At the core of this debate is theutility of the different research methodologies used—field (i.e. actual ‘real-life’ polygraph tests) andlaboratory (i.e. polygraph tests conducted in a controlled laboratory setting) studies. Broadly speaking, fieldstudies are complicated by the difficulty of knowing who is really lying, whilst it is unclear whetherlaboratory studies can be generalised to non-research settings. In addition, much of this research has tendedto focus on pre-conviction uses of the polygraph, such as used in criminal investigations or for employeescreening; the extent to which the results from these studies are applicable to post-conviction settings withsex offenders is also unclear.A good understanding of the accuracy of post-conviction polygraph tests is vital for professionals to knowhow best to respond to the different test outcomes (i.e. pass, fail or inconclusive). Indeed, if the polygraph

367does not display a reasonable level of accuracy, then its long-term value as a treatment and supervision toolis highly questionable.In the present study, we utilised a unique methodology to investigate the accuracy of post-convictionpolygraph tests with adult sex offenders, in the US, mandated to take polygraph tests. By incorporating aquestion on drug use in the participant’s regular test, and immediately afterwards following-up with a drugtest,we compared the objective drug test result with information provided during the polygraph regardingdrug usage. In this methodology, therefore, it is possible to objectively establish who is lying and truthful(regarding drug use). Since these participants were required to take regular polygraph tests and have aconsiderable investment in passing these tests, we are able to investigate the accuracy of the polygraph in a‘real-life’ context. We further provide information about the impact of personality factors, intelligence, andother demographic variables on false-positive (i.e. offenders accused of lying when telling truth) and -negative rates (i.e. offenders lying and not getting caught by polygraph).125.3. Training Polygraph Examiners to Work with Sex OffendersLou Crisilla, Deception Control Services, Fort Lauderdale, USA (Lars.Madsen@nmht.nhs.uk)This presentation discusses the necessary training and supervision requirements of polygraph examinersworking with sex offenders. Traditionally, the polygraph has been used in pre-conviction contexts for theinvestigation of a specific crime. In these circumstances, the examiner is typically part of a policedepartment who is recruited to determine a suspect’s veracity. With the development of post-convictionpolygraphy, the role of the examiner has changed. In such contexts, the examiner is part of a therapeuticand supervision team with the goal of preventing recidivism and reducing an offenders risk. In this regard,there has been a shift in the focus of the examination, from the outcome (i.e. deception versus nondeceptionindicated) to what information is disclosed about offending behaviours. The examiner thereforeneeds to have not only a good understanding of sexual offending and risk, and also needs to able tonegotiate between the sometimes competing demands of probation/parole officers and therapists. To reflectthese developments, the training of polygraph examiners has developed considerably in recent years. Thepurpose of this presentation is to discuss these developments. Specifically, it will outline the importantdifference in the role of the examiner in a pre versus post conviction context. It will also focus upon thewide variety of challenges involved in supervising sex offenders in the community, particularly the ways inwhich they differ from other populations under supervision. The importance of the examiner adopting atherapeutic focus and developing a collaborative relationship with other professionals involved in thetreatment and supervision of such offenders is also discussed.125.4. The Impact of Personality and Other Variables upon Accuracy and Disclosure inPost-conviction Polygraphy with Sex OffendersShaun Parsons, University of Newcastle-upon-Tyne (s.parsons@ncl.ac.uk)The polygraph has been increasingly applied to the treatment and supervision of community-based sexoffenders in the United States. Here, proponents argue that the polygraph assists with gaining importantinformation and deterring such offenders from engaging in risk behaviour. The limited amount ofempirical evidence supporting this proposition, makes the impact that personality has on this aspect poorlyunderstood. This presentation will review research findings and present data on the impact of personalityand other characteristics on the accuracy of polygraph outcomes. Specifically, it will attempt to address the

368impact that psychopathy and antisocial features may have upon such outcomes. The presentation will alsoaddress how such factors may affect the nature (i.e. false confessors) and time of admissions.125.5. Clinical Applications of the Polygraph in Sex Offender Work—Pre versus PostConviction PolygraphyDaniel T Wilcox, University of Birmingham (s.parsons@ncl.ac.uk)Over the last several years, the use of the polygraph in the community management of sex offenders inEngland has increased. This has largely been a result of the promising early results of Home Office,supported polygraph research trials that have been conducted in several UK locations. The studies havedemonstrated the benefits of the polygraph, in terms of supervising sex offenders who are on Probation orLicence as well as gaining valuable information for assessment and treatment purposes. Offenders areadministered Maintenance and Monitoring tests to determine whether they are complying with conditionsof their Orders or requirements of treatment. They may also be given Sexual History DisclosureExaminations or Specific Incident tests. SHDEs are employed to gain more extensive information aboutany past sexual abuse history beyond the index sexual offence. Research reveals considerably morecrossover into other areas of sexual offending than has previously been recognised. The Specific Incidentpolygraph examination is designed to gain information about the index offence and, as such, ordinarilyfocuses on addressing the denial and minimisation that can have an unhelpful effect on the group treatmentprocess.This presentation focuses on clinical applications of these types of Post-Conviction polygraph tests. Itrefers to specific case studies in respect of containing behaviour, identifying risk, and assessing change.Specific consideration is also given to the pre and post-conviction use of the polygraph with sex offenders.Similarities and differences in format, application, and interpretation are discussed.126. Post-traumatic Stress Disorder and the Law I126.1. Secondary Victimization of Traumatized Asylum Seekers in The Netherlands:Where Law Does Not Listen to ScienceBoris Drozdek, GGz 's-Hertogenbosch Outpatient and Day Treatment Centre for Refugees, Vught, TheNetherlands (drozdek@worldonline.nl)The legal issues surrounding asylum seeking and becoming a bona fide legal alien in the Netherlands andelsewhere has become both politically and psychologically sensitive as a cultural issue. Thousands ofasylum seekers, in various states of desperation and traumatization, seek refuge from the horrors anduncertainties of political tyranny, war, and the attendant traumas they bring to the lives of innocent people.The overriding question of legal and moral justice is imperative, especially in attempting to provideadequate mental health care to this very traumatized population, which has rates of PTSD in the 80 th and90 th percentile. The procedure of obtaining asylum in the Netherlands and several other European countries

369became very difficult in the last decennium. The political and legal blocks to becoming a legal alien, havecreated a set of secondary stressors which overlay the ones encountered in the process of being an asylumseeker. The so called trauma policy within the Dutch system law lacks the needed subtlety, and is notcompletely based on scientific knowledge of chronic and complex posttraumatic stress disorders. The focusof this presentation is to explain the nature of the complex interface between government policies and therealities of providing necessary and mandated mental health care to asylum seekers and refugees.126.2. Post-war Problems of Reparation, Compensation and Justice for War Victims andFormer Military Veterans: Where Psychiatry Meets Legal Roadblocks and SystemFailuresRudolf Gregurek, University of Zagreb (gregurek@mef.hr)The war in the Balkans, 1990-1995, was characterized by ethnic genocide and many episodes of ethniccleansing between Serbians, Croatians, and Bosnians. The wide spread incidence of these forms of ethniccleansing produced unique and difficult problems of readjustment for the survivors and their families. InCroatia, there are today tens of thousands of displaced war victims, especially in persons that formallyresided near the old national boundaries of Croatia, Bosnia, and Serbia. Particularly problematic, was theVukovar Region of Croatia, where there were bloody battles and ethnic cleansing that occurred in 1991 andafterwards, as ethnically mixed families and neighborhoods turned against one another as the war raged onuntil 1995. After the Dayton accords for peace in 1995, many survivors sought mental health services fromthe Croatian government due to being victims of war crimes, war atrocities, and personal episodes of ethniccleansing perpetrated by persons known to them as former citizens or neighbors. This presentation willhighlight examples of ethnic cleansing and war crimes in the region of Vukovar, and the posttraumaticsequels in patients with PTSD and minimal or no resources. The presentation will illustrate how theabsence of government funded programs and allocations of resources create complex moral dilemmas interms of providing proper care and gaining access to more benefits and legal rights within the postwarculture itself.126.3. The Relative Influence of Rules and Laws on the Influx of Asylum SeekersHans Hovens, Delta Bouman Psychiatric Teaching Hospital, Portugal, The Netherlands(Hans.hovens@deltabouman.nl)This paper will focus on the interrelationship between governmental rules and laws, used to justify theadmission or exclusion of asylum seekers and refugees to the Netherlands and other countries throughoutthe world. It will be shown, that politically based rules and policies can be a tool for systematicdiscrimination of those whom government may which to exclude from potential asylum seeking forpurposes motivated by economics or racial prejudice. The paper will highlight how streams of refugees,throughout the ages, have been adversely affected by such policies, leading to the continued need to flee,from country to country, to avoid returning to a homeland torn apart by war or political change. The natureof specific laws and their exclusionary criteria will be reviewed, and shown how they can exacerbate thepresence of severe cases of PTSD, and in turn, create even more mental health problems for a profoundlyvulnerable population.

370126.4. Mental Health Work with Refugees and Asylum Seekers with PTSD: Legal andMoral Dilemmas from the War in Former YugoslaviaSilvana Turkovic, Dagbehandeling voor vluchtelinge, Vught, The Netherlands (silvanaturko@freeler.nl)This presentation will summarize mental health field work and the provision of care to a wide spectrum ofwar victim in the former Yugoslavia. The presenter has worked with numerous NGOs and GOs in helpingto create needed mental health programs for asylum seekers, refugees, and war victims in Croatia, Bosnia,and other parts of the world. The presentation will highlight the enormous difficulties in establishingadequate mental health programs because of legal and governmental factors: first, the absence of prosocialand dedicated long term programs to assist the victims of war crimes, ethnic cleansing, and war atrocities;second, the legal obstacles to providing necessary psychosocial assistance to families and widows whowere the victims of rape and torture; third, the difficulties in pressing legal charges and allegations againstknow war criminals due to threats of reprisal and death to mental health and other aid workers; fourth, thenon responsiveness and slowness of existing governmental and international agencies, to recognize andassist victims of war crimes, especially women and children, who were raped and tortured for politicalpurposes. The presentation will exam specific cases to illustrate the interface between the role of the mentalhealth worker and the legal system, in attempts to bring justice and healing.126.5. PTSD and the Law: The Intersection of Civil and Criminal Law in the Pursuit ofJusticeJohn P. Wilson, Cleveland State University (J.P.Wilson@csuohio.edu)The use of posttraumatic stress disorder in legal determinations has shown a parallel growth to theexpansion of knowledge about the disorder. Today, there are over 25,000 published articles on PTSD inprofessional journals and books, a fact which documents the rapid and exponential growth of research inthe field of traumatology.As knowledge of the disorder has grown, it has seen application to many areas of mental health andtreatment, as well as to the interface between the nature of post traumatic injuries and legal issue, rangingfrom criminal proceeding to civil adjudications for compensation of damages caused by trauma fromvarious traumas; negligence; war trauma; torture; terrorism; war crimes; industrial accidents and naturaldisasters, to name a few types of events. Recently, Wilson&Moran(2004) reviewed the literature on PTSDand the law and found five distinct areas in which legal proceedings and scientific research has beenconducted: (1) criminal litigation, where PTSD has been used as a complete defense, partial defense, or asmitigation; (2) civil litigation, where PTSD has been used to verify personal injury cases; (3) in disability orpension claims for persons who suffer at work or in the line of duty; (4) courts of common pleas, regardingdomestic and familial matters; (5) in religious tribunals and Cannon Law regarding standing in good steedwith Church authorities. This presentation will discuss precedent setting cases and the legal issues theyraise in terms of mental health considerations and the nature of scientific evidence about PTSD as adiagnostic entity.

371126.6. The development of an Effective Legal Team in Capital Cases with DeeplyTraumatized ClientsJackie Walsh, Attorney, Roberson & Walsh, Seattle, USA (jackie@robersonwalshlaw.com)When a deeply traumatized client is facing the death penalty, it is imperative to identify the necessaryexperts who will be able to assist in developing the case and later testify concerning mitigating evidence.Experts must also be able to put the client’s mental disease and social history in the context of the crime, sothat it may be addressed in the case prior to reaching a potential penalty phase.With a deeply traumatized client, it may be necessary to retain experts in developmental paediatrics,neuropsychiatry, psychology, and neuropsychology. Medical experts with clinical experience in treatingclients with PTSD, are also essential. The development of the legal team begins with a highly qualifiedmitigation specialist. The role of the mitigation specialist is to gather information concerning the client’slife. This information includes, but is not limited to, a collection of and review of medical, psychological,mental health clinic, psychiatric, social services, school, juvenile facility, department of corrections, jail,public defender, prosecution, police and sheriff, obituary, hospital, newspaper, birth and death certificates,funeral, court, marriage and divorce, census bureau, assisted living, and discovery records spanning at leastthree generations of the client’s life. The corroborating documentation of a client’s life will serve as thebackdrop to each expert’s opinion.In my presentation, I will discuss the attorney’s decision of which experts to utilize, the relationshipbetween the attorney and the experts, as well as the role the client plays as part of the legal team.127. Post-traumatic Stress Disorder and the Law II127.1. Posttraumatic Stress Disorder and Executive Cognitive Functioning in ChildrenSuffering From Domestic Violence or Separation ExperiencesSabine Völkl-Kernstock, Medical University of Vienna (sabine.voelkl-kernstock@meduniwien.ac.at)Petra Fennesz, Medical University of ViennaHeidrun Eichberger, Medical University of ViennaMax H. Friedrich, Medical University of ViennaThe study focuses on posttraumatic stress disorder (PTSD) and executive cognitive functioning in childrenwho have experienced separation or have become victims of sexual or physical abuse. Possible correlationsbetween the experience of separation or domestic violence and posttraumatic stress disorder (PTSD), aswell as PTSD’s impact on executive cognitive functioning are examined. Ehlers (1999) found that anumber of PTSD symptoms are similar to those associated with brain injury. The study of Diamond et al.(2001) points to a relationship between cognitive functioning and symptoms of PTSD. In the studypresented here, a representative sample of 80 patients between 10 and 18 years of age from the ViennaMedical University—Department of Neuropsychiatry for Children and Adolescents—is examined. The

372sample is divided into two subsamples, consisting of children who have suffered from separation and thosewho have suffered from violence. Executive cognitive functions are assessed using a neuropsychologicaltest battery. PTSD is diagnosed in accordance with DSM- IV criteria and the “Impact of Event Scale-Revised (IES-R)” by Maercker & Schützwohl (1998). Demographic data are assessed by a semi-structuredinterview.First, results show no significant correlation between PTSD and child experience of separation, but indicatethat there is a tendency towards a positive correlation between PTSD and child experience of domesticviolence. Results concerning the relationship between PTSD and executive cognitive functions are inpreparation.127.2. PTSD in Forensic Setting: Recent Trends in JapanKyoko Hashizume, University of Tsukuba (kyoko@cool.email.ne.jp)In Japan, the number of occurrences of forensic psychiatric evaluation (F.P.E.) for PTSD (post traumaticstress disorder) claimants is increasing. We have assessed many victims of crimes and accidents, most ofwhom are involved in civil cases, but recently we have had an increase in criminal cases. In this article, weexamine 4 cases (3 rape victims and 1 stalking victim), focusing on how F.P.E. should be applied to victimsof crime.In 4 cases, the point of F.P.E. in time (before or during trial), the agencies that requested F.P.E., and theobjective of the request were various. In three cases, F.P.E. was requested by the prosecutor, and in onecase, by police. In all cases, F.P.E. was requested in order to demonstrate the victim’s mental state duringand following the event, with purpose of obtaining more severe sentence for the offender. In case 1, theclient requested F.P.E. to prove victim’s PTSD as evidence of bodily injury. In case 2, the client aimed todemonstrate the occurrence of rape, retrospectively based on PTSD symptoms. In case 3, the clientexpected therapeutic effects of F.P.E., thereby confusing two different roles: therapist and evaluator withthat of psychiatrist. In case 4, the client requested F.P.E. for the victim to obtain information about harmfuleffect of stalking.Using case examples, the problem of F.P.E. for victims of crime in Japan can be pointed out. The intentionof client requesting F.P.E. tends to be inconsistent, with some cases of inappropriate use of F.P.E.. Thesystem of F.P.E. for rape victims leaves much room for improvement, in Japan.127.3. A Conceptual and Developmental Framework for Understanding Trauma and itsComplex EffectsJulie A. Kriegler, National Institute of Post Traumatic Stress, USA (jakphd@batnet.com)Trauma puts individuals at risk, not only for disorders officially designated as trauma-based disorders butfor other major disorders and dysfunctional behaviors. Thus, to focus on the diagnosis of PTSD alone maylead to a misunderstanding and a misrepresentation of our clients.Trauma disrupts the necessary attachment and safety needed for neuropsychiatric development, and leads todysregulation and dysfunction at multiple levels of development and functioning. The alterations andadaptations made in the development of our brains and selves caused by these experiences lead tocognitive, affective, behavioral, and interpersonal disabilities that then lead to problems in learning,relating, and functioning in expected or productive ways. While the ultimate intervention into thisdamaging cycle is prevention; currently, the multigenerational cycle of trauma, broken attachments, and the

373resulting mental impairments lead many individuals into cycles of violence and “acting out;” that inevitablylead to incarceration, Death Row, and execution. Due to these outcomes and because trauma is a risk factorfor and creates symptoms similar to those of other disorders, and may often be a more parsimonious andaccurate description of the etiology of the disordered behavior presented, the differentiation and clearidentification of trauma’s impact is crucial.127.4. Evaluation and Treatment of Emotional TraumaRoy Lubit, Mount Sinai School of Medicine (Roylubit@rcn.com)Enormous numbers of people suffer emotional trauma and significant disability as a result of war, sexualabuse, assaults, and accidents. The number of people who suffer significant psychological damage is oftenconsiderably greater than the number who suffer serious physical damage. The forensic evaluation ofemotional trauma requires an understanding of the psychological and neuropsychological processes ofemotional trauma, and the options and outcomes of new treatment options. Emotional trauma can lead to acombination of new images of the world and oneself, neuropsychological changes, and conditioned learnedresponses, which together can have profound and enduring effects on the individual’s ability to function inthe world. Nevertheless, new treatments hold out considerable hope to help many of those who have beentraumatized.127.5. Instinctual Trauma ResponseLee Norton, Norton and Moody, Inc., Tallahassee, USA (leenorton@earthlink.net)The study of trauma has evolved through several phases over the past 100 years. Recent decades have leftresearchers and clinicians stymied as to the best means by which to resolve the myriad symptoms inherentto 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 notonly the more common intrusive, avoidant and arousal symptoms but, more important, the dissociation thatoften 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 Gant, developed a uniqueintervention that is remarkably effective in resolving symptoms of traumatic stressconditions and dissociation. It is based on seven components of what Dr. Tinnin has termed the InstinctualTrauma Response: startle response, thwarted intention, freeze state, altered state of consciousness,emotional response, body/somatic response and self repair. Treatment consists of four modalities: nonabreactivelinear narrative of the event (video taped), review with client of video narrative, art work ofevent emphasizing each component of the instinctual trauma response, and “video dialogue”, a powerfultechnique consisting of a “dialogue” between conflicted parts of the wounded ego that resolves the “victimmythology” inherent to severe or chronic trauma.This presentation will define and describe the Instinctual Trauma Response and the intervention developedand employed by Dr. Tinnin and his wife at their clinic, the Trauma Recovery Institute, in Morgantown,West Virginia.

374The study of trauma has evolved through several phases over the past 100 years. Recent decades have leftresearchers and clinicians stymied as to the best means by which to resolve the myriad symptoms inherentto 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 notonly the more common intrusive, avoidant, and arousal symptoms but, more important, the dissociation thatoften 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 inresolving symptoms of traumatic stress conditions and dissociation. It is based on seven components,which Dr. Tinnin has termed the Instinctual Trauma Response: startle response, thwarted intention, freezestate, altered state of consciousness, emotional response, body/somatic response, and self repair. Treatmentconsists of four modalities: non-abreactive linear narrative of the event (video taped), review with client ofvideo 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 woundedego that resolves the “victim mythology” inherent to severe or chronic trauma.This presentation will define and describe the Instinctual Trauma Response and the intervention developedand employed by Dr. Tinnin and his wife at their clinic, the Trauma Recovery Institute, in Morgantown,West Virginia.128. Psychiatric Morbidity in Corrections I128.1. Addiction and Personality Disorders (co morbidity) within TBS: EvaluationJ.M. de Jonge, FPC Veldzicht, Balkbrug, The Netherlands (m.d.jonge@veldzicht.dji.minjus.nl)People, who have committed a severe offence while being unaccountable, can be sentenced to TBS (oftenin combination with a jail sentence). TBS stands for ‘TerBeschikkingStelling’ translating to ‘placing at thedisposal of’’ namely, the government. TBS is a non-punitive sentence in which a person undergoespsychiatric and/or psychological treatment in a TBS-clinic, as opposed to a punitive sentence (in jail).With non-punitive sentences, the issue is not reprisal, but protection. Society has to be protected from theoffender; a repetition of the offence must be prevented. The main goal of treatment in a TBS-clinic is areduction of danger (and chance of recidivism). Research numbers tell us that recidivism after treatment ina TBS-clinic is about 20%, compared to 80% recidivism after jail sentence.Research numbers showed that about 80 % of all patients in TBS are known to suffer from substance abuse.This is the reason why specialized addiction wards had to be developed. On these wards, each of thepatients has to go through a treatment program. Our goal is to offer a 24-hour addiction-treatmentenvironmentin which not only the multidisciplinary team, but also the peer patients play an important role.Hoeve Boschoord, Dr. S van Mesdagkliniek and FPC Veldzicht are three of the TBS-clinics in theNetherlands.FPC Veldzicht is, like Hoeve Boschoord, based on a behavioural approach. All patients are placed inVeldzicht with a TBS measure, no patient is placed on a voluntary basis.

375Two wards were established, in 1999, with 10-12 patients each. Analysing the diagnoses of the patients onthe wards, it soon became obvious that all of the patients also had personality disorders; anxiety disorders,depressive disorders, ADHD and PTSD were also diagnosed. Each of these patients go through anapproximately three-year program.The first cohort of patients has completed the whole programme and has moved into the re-socialisationphase. They are on the last steps leading them back into society again. Some relapsed into using drugsand/or alcohol. As soon as that happened, the patients were placed back on the closed addiction ward for atime-out and some booster sessions of the addiction module. Regular evaluation and learning fromexperience keeps us developing our ward further and further, and can hopefully help other TBS-clinicsdevelop such wards.The last update of results will be presented.128.2. Addiction and Personality Disorders (Co Morbidity) within TBS: TreatmentDr. J.M. de Jonge, FPC Veldzicht, Balkbrug, The Netherlands (m.d.jonge@veldzicht.dji.minjus.nl)Of the people staying in the Dutch TBS-system, many ( 70 %) committed a crime which was related tosubstance abuse. Many patients have a history of alcohol and/or drug abuse, mostly combined withpathology on axis I and/or II of the DSM-IV.Although being under the influence of alcohol or drugs is not acknowledged as a reason forunaccountability or innocence in the Dutch legal system (the ´´culpa in cause principle´´), in the criminaloffences that brought people into the TBS-system, a relationship with the use of alcohol and drugs can beassumed. These relationships can be defined in different ways:• Under the influence of drugs or alcohol people may lose their normal inhibitions and commita severe aggressive offence• Aggression may be used to obtain drugs. This may be instrumental aggression to finance thedrugs ( e.g. armed robbery or rip deals) but also impulsive when an action to obtain drugsescalates• Aggression is an very normal phenomenon in the drugs scene and makes people used to itMany times these causes are intertwined.In this session, the treatment of patients with personality disorders (mostly antisocial, borderline ornarcissistic) and severe addictionproblems will be discussed. A treatment that aims to reduce the re-offencerisk by making the patient stop the drug-taking behaviour, but that also tries to treat the other problems thatare related to the cluster-B personality disorder (like aggression, impulsive behavior, poor maintenance ofrelationships, instability of mood and affect) will be assessed.The program that is designed in the Van Mesdagkliniek in Groningen in the Netherlands will be presented.It consists of a structured daily program and of different kinds of training such as drug training, but alsoGoldstein training or other social skill training, Dialectical Behavioural Therapy, aggression management,vocational training, Psychotherapy can also be included in the treatment process.Special attention will be paid to the parts of the treatment directly deal with the drug abuse. Certain aspectsof the treatment of addiction in a forced setting will be highlighted, the benefits as well as the problems ofsuch institutios will be discussed.

376128.3. The Prevalence of Mental Disorders in a Population of Juvenile IncarceratedOffendersG. Hinrichs, Clinic for Children and Adolescent Pscychiatry, Kiel, Germany (g.hinrichs@kiju-psych.unikiel.de)Denis Köhler, Clinic for Children and Adolescent Pscychiatry, Kiel, Germany(Denis.koehler@forensischepsychologie.de)Within English-speaking countries several studies exist on the prevalence of mental disorders amongincarcerated offenders, however, we still have a lack of such studies in Germany. Until now no comparableresearch was published.In the present study, 149 young male inmates were investigated with the structured clinical interview(SKID- I and II) and the Psychopathy-Checklist: Screening Version (PCL-SV). Additionally, psychologicaltests were administered and socio-demographic and forensic variables explored.The results show a huge amount of mental disorders, in general. The most prevalent diagnoses weresubstance use disorders (abuse and addiction) and personality disorders.The findings indicate that the spectrum of mental disorders among incarcerated young offenders is quitedifferent from that of clinical populations. Therefore, psychological and especially psychotherapy should bemodified for forensic populations.128.4. Prevalence of Mental Disorders among Juvenile PrisonersBettina Reinhold-Hurley, Georg-Elias-Mueller Institute of Psychology, Goettingen, Germany(breinhold2000@yahoo.de)Stefan Jacobs, Georg-Elias-Mueller Institute of Psychology, Goettingen, Germany (sjacobs@unigoettingen.de)As part of the study 40 male inmates of the open juvenile prison Rosdorf/Goettingen (Germany), betweenthe ages 18 and 23 years, underwent a psychological assessment to determine possible mental disorders.The obtained results were compared to the prevalence rates of a community male sample taken from theGerman National Health Interview and Examination Survey 1998/99-Mental Health Supplement. The aimof this study was to determine whether inmates experienced a significant (1-month and lifetime prevalence)increase in substance-related, affective and anxiety disorders, compared to that of the general malepopulation.Two clinical interviews (SCID-I and –II) were administered to the inmates. Furthermore, asociodemographic questionnaire and the Symptom-Checklist SCL-90-R were used.As expected, the inmates showed a higher rate of substance-related disorders with a lifetime-prevalence of63.5%. Similar results were obtained concerning affective disorders. 17.5% of the subjects met the criteriafor an affective disorder, at the time of assessment. 27.5% had a history of at least one affective disorder, atsome point in their lives. It is evident, that the young inmates do not actually show different psychiatricdisorders, but significantly higher rates than the community male population of the same age. Nevertheless,the inmates showed no significant higher rate of current substance-related or anxiety disorders, but it shouldbe assumed that a reliable assessment of current alcohol- and drug consumption can not be obtained withinprison environment.

377Evidence of a personality disorder was found in 65% of the subjects, with a majority (52.5%) showingsymptoms of an antisocial personality disorder. Furthermore, co-occurring disorders were present in 87.5%of the sample.At the time of assessment, 60% of those examined revealed evidence of at least one mental disorder. Basedon the total life span, 90% of the same group fulfilled the criteria of a psychiatric disorder. The high overallprevalence rates indicate the need for further research within this field, showing also a necessity forspecialized assessment upon entry to a penitential facility with adequate multiprofessional treatment,focussing mainly on substance-related disorders.128.5. Development of a Treatment Program for Violent Offenders in a German PrisonChristian Huchzermeier, Clinic for Psychiatry and Psychotherapy, Kiel, Germany(huchzermeier@psychiatry.uni-kiel.de)In 1999, a programme for the treatment of violent offenders was established at Neumünster Prison by theUniversity Psychiatric Department. The prison’s main concern, at the start of the programme, was to takeaccount of the requirements made by a new law to combat sexual offences and other dangerous crimes(Gesetz zur Bekämpfung von Sexualdelikten und anderen gefährlichen Straftaten) passed in 1998, while theintention of the psychiatrists and psychologists was to develop psychotherapy with a scientific basis. Ourgoal was to design treatment for violent offenders, which took account of the principles for thedevelopment of adequate programmes. These include a theoretical basis for the genesis of violentdelinquency and also dynamic diagnostics and systematic evaluation of effectiveness. They also include astructured therapeutic approach, with close supervision of the therapists and consistent ambulatoryaftercare.We report, first, on our experience up to now with the application of these principles, which relates both tofinancial and staff limitations and to the different points of view of the clinical therapists and themultiprofessional prison staff.The preliminary results of the accompanying research are then presented. These contain mainlysociobiographic and psychometric data on comorbidity and therapy motivation in the offenders whom wetreated. Selection criteria for patients, and ideas for interventions leading to changes, can be derived fromthese findings. These are intended for use in both individual and group therapy.128.6. Bad or mad? – From a Criminological Point of ViewMartin Weinrich, University of Hamburg (m-weinrich@jura.uni-hamburg.de)Criminology deals with the question of how crime works. To tackle this problem, criminologists want tofind out, in particular, which factors determine the genesis of delinquent behaviour, both on the individualand social level.Thinking of “bad or mad” from a criminological point of view therefore also means asking whichpsychological factors—and, among these, which psychiatric disorders—could be relevant as reason forspecific criminal behaviour. Do some criminals act delinquently because they are mentally disordered? Arethey then ‘really’ responsible for their delinquency and to what extent? Or is it ‘beyond their control’?

378On the one hand, psychiatric diagnosis seems to generate a feeling of security. In giving scientificexplanations why some people break core penal laws, forensic medicine provides answers for the highlydisturbing question: why some individuals act in such an antisocial and destructive manner. However, onthe other hand, is diagnosis already treatment? What about the purpose of imprisonment, what about thepurpose of therapy? And what about the way society deals with crime perpetrated by mentally disorderedpersons?How are we to weigh up the factors of safety in society and those of individualised treatment of delinquent,mentally disordered individuals and financial resources?The following presentations, in this symposium, will discuss data on the prevalence of particularpsychiatric disorders causally linked with delinquency in regular prisoners. Furthermore, the authors willalso deal with the issue that, as yet, there is no study demonstrating significant proof of reasonablysuccessful treatment.This presentation will provide perspectives to integrate these findings and thoughts within a criminologicaland sociological context.128.7. Legal Responsibility in Personality Disordered Offenders – Should People with(Antisocial) Personality Disorders go to Prison or to a Hospital?Christian Huchzermeier, Clinic for Psychiatry und Psychotherapy, Kiel, Germany(huchzermeier@psychiatry.uni-kiel.de)Although criminal acts are not necessarily the result of personality disorders, a high rate of personalitydisorders and psychopathy is found among criminal offenders: The Kiel Prison Study on prevalence ofmental disorders was the first representative study to examine the frequency of mental abnormalities anddisturbances among sexual and violent offenders in a German prison. It showed that 82% of the offendersinvestigated had at least one personality disorder. Of these, antisocial personality disorder was by far themost frequently diagnosed at about 42%. While a single personality disorder was diagnosed for 47.5%,comorbidity of different personality disorders was present in 35.0%. Only 17.5% of the offenders showedno personality disorders. Psychopathy, as defined by Hare, was probably present in 10% of thoseinvestigated, with 27% seen as having psychopathic features. These findings are in line with the results ofdifferent international studies, and raise the question of how to deal with personality disordered offenders—either as criminals or as persons with a mental disorder. This incorporates the problem of what to do withthese offenders and, in particular, where antisocial personality disordered persons should be sent—to prisonor to a hospital.This presentation focuses on the German situation for criminal responsibility of offenders who have apersonality disorder. Under German criminal law, personality disordered offenders can be sent to aforensic-psychiatric hospital for an indeterminate period of time, if they are found to have acted with“diminished” criminal responsibility and still be dangerous. The problems in forensic- psychiatricassessments of persons with personality disorders are pointed out, under consideration not only of thepsychiatric point of view but also of sociological and criminological explanations for antisocial andcriminal conduct.

379129. Psychiatric Morbidity in Corrections ll: ‘The Irish PrisonPopulation’129.1. Affective Illness in Sentenced, Remanded and Newly Committed Males in IrishPrisonsKatharine Curtin, Donegal Mental Health Services, Donegal, Ireland (ktcurtin@eircom.net)Brenda Wright, Central Mental Hospital, Dundrum, IrelandStephen Monks, Beaumont Hospital, Beaumont, IrelandDearbhla Duffy, Naas General Hospital, Naas, IrelandSally Linehan, Naas General Hospital, Naas, IrelandHarry Kennedy, Central Mental Hospital, Dundrum, IrelandObjectives: To describe the prevalence of affective mental illness and co-morbidity amongst sentenced,remanded, and newly committed males in Irish Prisons.Method: We interviewed three distinct prisoner samples: a stratified random cross sectional sample ofprisoners in the main remand prisons in Ireland (n=615); a stratified random cross sectional sample ofprisoners, in the main sentenced prisons in Ireland (n=438); and a consecutive committal sample ofsentenced and remanded prisoners who were interviewed within seventy two hours of committal (n=232).Those who refused to be interviewed did not cause any detectable bias. We used the SADS-L (Endicott andSpitzer 1978), SOD-Q (Philips et al), and a semi-structured standardised interview to elicit furtherdemographic and personal details. Limited information was collected on decliners. We have calculatedpoint prevalence, six month, one year, and lifetime prevalence for all major affective diagnoses (ICD 10:F10-F44 inclusive)Results: Respective six month rates of depressive illness (ICD-10 mild, moderate and severe categories) inthe committal, remanded, and sentenced samples were 6.3% (95% CI=4.7-8.6%), 10% (weighted mean),and 11.6% (weighted mean). Six month Prevalence rates of Anxiety Disorders were 5.4% (95% CI=3.9-7.5%), 6.8% (weighted mean), and 14.1% (weighted mean). Lifetime co-morbidity rates for substancemisuse were in excess of 70% in those committals with a diagnosis of depression or anxiety. Lifetimeprevalence of Deliberate Self Harm was 19.4% in the committal sample, 32.1% in the cross sectionalsample of remanded males, and 28.3% in the cross sectional sample of sentenced males.Conclusion: There are high rates of affective illness in Irish Prisoners, as they pass through the judicialsystem from committals to sentenced prisoners. This is a highly legitimate focus of psychiatric and publichealth concern because of the notably high prevalence rates, and links with prison suicide.

380129.2. Prevalence of Mental Disorder in the Irish Sentenced Prison PopulationDearbhla M. Duffy, Central Medical Hospital, Dundrum Ireland (dearbhladuffy@hotmail.com)Sally A. Linehan, Central Medical Hospital, Dundrum IrelandHarry Kennedy, Central Medical Hospital, Dundrum IrelandStudies in other jurisdictions have demonstrated increased rates of mental illness in both remanded andsentenced prisoners. A recent metanalysis, by Fazel and Danesh (Lancet 2002), found that 3.5% ofsentenced males had a psychotic illness and 10.8% a major depressive illness. We set out to perform thefirst systematic survey of a representative sample of all sentenced prisoners in Ireland.We surveyed 438 sentenced male prisoners (representing 15% of the total sentenced male population),drawn from the 15 Irish Prisons for sentenced males. Subjects were randomly selected for interview from alist stratified according to age and sentence length. We approached all life-sentenced prisoners andinterviewed 98 (82%).The Schedule for Schizophrenia and Affective Disorders, Lifetime Version (SADS-L), was administered todetect lifetime and 12-month prevalence of major mental illness. Substance misuse was measured using theSADS for alcohol and the Severity of Dependence Questionnaire (SODQ) other intoxicants. We also used asemi-structured interview to collect demographic details including ethnicity, history of self-harm,psychiatric history, and an extensive drug and alcohol history. Diagnoses were made using ICD-10Research Criteria from collected data.20 of those interviewed had a lifetime history of psychosis. The six-month prevalence of psychosis was1.8% (95% CI 0.8 – 3.8%) for non-life sentenced prisoners and 6.1% (95% CI 2.8 to 12.7%) for lifesentenced prisoners. This extrapolates to 61 sentenced prisoners in Irish prisons with a severe mental illnesswho would require treatment in a secure hospital setting. Co-morbidy levels were high, only 10% of thosewith a history of psychosis had no drug or alcohol problem.The sampling method ensured that the sample was representative of the general sentenced prisonpopulation. Our study identified higher rates of severe mental illness, than would be expected in the generalcommunity. Service innovations in community and secure hospital care as well as reform of CriminalJustice Mental Health legislation will be required to provide appropriate mental health services for suchpatients.129.3. An Ethnic Profile of the Irish Prison PopulationSally Linehan, Central Mental Hospital, Dundrum, Ireland (slinehan@iol.ie)Dearbhla M. Duffy, Central Mental Hospital, Dundrum, IrelandBrenda Wright, Central Mental Hospital, Dundrum, IrelandKathrine Curtin, Central Mental Hospital, Dundrum, IrelandStephen Monks, Central Mental Hospital, Dundrum, IrelandHarry Kennedy, Central Mental Hospital, Dundrum, IrelandResearch has demonstrated differential representation of ethnic subgroups in the criminal justice system.Irish Travellers are a small indigenous ethnic minority group who are widely acknowledged as one of themost marginalised and disadvantaged groups in Irish society. They represent less than 1% of the Irish

381population. We hypothesised that Irish Travellers would be over-represented among committals to IrishPrisons and that they would differ from other committals in psychiatric morbidity.We interviewed a stratified random sample of 340 male prisoners serving fixed sentences, representing15% of the total male sentenced population in Ireland. We also interviewed 232 remand prisoners (42% ofall remands at the time of the survey) and 615 incident remanded prisoners interviewed within 48 hours ofcommittal. The Schedule for Schizophrenia and Affective Disorders, Lifetime Version (SADS-L) wasadministered to detect lifetime and 6-month prevalence of major mental illness. Substance misuse wasmeasured using the SADS for alcohol and the Severity of Dependence Scale for other intoxicants.Diagnosis was made according to ICD-10 research diagnostic criteria. Population statistics for both theTravelling community and general population were obtained from Census 2002 data.Travellers accounted for 10.9% of the sentenced population and 5.4% of new committals on remand. MaleTravellers had a relative risk of imprisonment, compared with the settled community of 12.3 (95% CI 5.0-30.1). Within the sentenced group, Travellers were no more likely to be detained for a violent or alcoholrelatedoffence than other ethnic groups. Lifetime and 6-month rates of psychosis were high, but did notdiffer significantly, between ethnic groups. The lifetime prevalence of psychosis was 6.2% (95% CI 4.9-7.9%) for Caucasians and 7.1% (95%CI 3.3-14.7%) for Travellers. The 6-month prevalence of psychosiswas 2.9% (95% CI 2.0-4.1%) for Caucasians and 4.8% (95% CI 1.9-11.6%) for Travellers. Substancemisuse was common in all ethnic groups but Travellers were more likely than other ethnic minorities tohave a lifetime history of harmful use of alcohol or alcohol dependence (chi 2 12.8, p

382Psychiatric Association, 2000). We also obtained demographic, ethnic, and personal details using a semistructuredstandardised interview. Data was analysed using SPSS 12.0.For the cross-sectional study, we interviewed 24 remanded and 68 sentenced female prisoners. In oursurvey of female committals, 57 remand and 37 sentenced prisoners were interviewed within 72 hours ofreception to prison.5 (5.4%) of the committal and 5 (5.4%) of the cross-sectional sample had a psychotic illness within theprevious 6-months. 13 (14%) of the committals and 19 (20.7%) of the women in the cross-sectional samplehad an affective disorder. 8 (8.6%) of committals and 14 (15.2%) in the cross-sectional sample had ananxiety disorder within the last 6-months. 61 (65.6%) of the women interviewed at committal and 61(65.2%) of the cross-sectional sample had a substance misuse problem in the last 6-months.Comments: We have demonstrated a high prevalence of mental illness and substance misuse problemsamongst women in prison in Ireland. Our findings highlight the need for the integration of community andforensic psychiatric services, and for ongoing collaboration with drug services.129.5. Co-morbid Mental Illness and Substance Use Disorders in Irish Prison InmatesStephen Monks, Central Mental Hospital, Dundrum, Ireland (smonks@rcsi.ie)Co-morbidity of mental illness and substance misuse has been associated with increased utilisation ofpsychiatric services, violence, suicidal behaviour, and excessive service costs. High rates of co-morbidityhave been found in the UK prison population (Singleton et al 1998). Association of cannabis and cocainedependence, and higher rates of psychosis in UK prisoners have also been found (Farrell M et al 2002). Theaetiological relationship between substance misuse and mental illness has not been well elucidated. Weaimed to estimate rates of co-morbidity in the Irish prison inmates on committal to prison, and looked at therelationship between substance misuse and psychosis in this population. 615 male prisoners (313 remandand 302 sentenced committals) and 94 females (57 remand and 37 sentenced) were interviewed oncommittal to prison. This represents the largest prison survey of its kind in Ireland to date, and one of thelargest committal studies in any jurisdiction. Psychiatric illness was assessed using the Schedule forAffective Disorders and Schizophrenia (SADS-lifetime version, Endicott and Spitzer, 1978), modified togenerate current, six month, and lifetime rates. We used the Severity of Dependence Questionnaire (SODQ)to quantify psychological dependence measures (Phillips et al, 1987), and took detailed supplementary drughistories for individual substances to clarify levels of use, abuse, and dependence. Diagnoses were madeaccording to ICD-10. 60.6% of males and 65.6% of women had some substance use disorder at time ofcommittal to prison. Alcohol (39.3%), cannabis (31.4%), opiates (25.8%), and cocaine (12.2%) were themost frequent substances of abuse/dependence in the year prior to committal. Lifetime prevalence ofsubstance use disorders was not significantly (0.053) more common in those with history of mental illnessthan those without ( 75.8% vs 67.5%). The difference was significant (p=0.016) when looking specificallyat those with a history of psychosis and those without (85.7% vs 68.0%). However, the rate of currentsubstance misuse in the 2.1% of prisoners who were psychotic at time of interview did not greatly differfrom those with no psychosis (69.2% vs 60.4%). We found that substance misusing psychotics were nomore likely to be imprisoned for violent offences, than their non-psychotic substance misusing counterparts(9.1% vs 14.9%). Opiate dependent individuals on methadone maintenance prior to committal were tothose not attending community drug treatment services: the relative risk of imprisonment for those onmethadone maintenance was 0.5. Substance misuse is a risk factor for imprisonment and have similar ratesin both mentally ill and non-mentally ill individuals. Treatment for substance use disorders can reduce therisk of imprisonment. Dual stigma for co-morbidity cases leads to rejection from services.

383130. The Psychology of Terrorism130.1. The Worried Well: Considerations for Military Base CommandersFran Pilch, United States Air Force Academy, Colorado Springs, USA (Frances.pilch@usafa.af.mil)This study on the worried well includes sections on the biological weapons threat.The idea of the worried well and mental health consequences of a terrorist event involving biologicalweapons, disease detection systems, problems of patient surges and the relationship of surge to personneland facilities, triage, engaging the public to mitigate the problem of the worried well and otherpsychological trauma, insights into risk communications, lessons learned from natural disease outbreaks,simulations and exercises, quarantine, shielding, preparedness and mental health, multiple actors inemergency response, preparedness as it relates to the interaction between military bases and surroundingcommunities, strategies for effectively engaging the public, and the role that leadership plays in crisismanagement.The study relies heavily on interviews conducted at the Monterey Center for Non-Proliferation Studies andin El Paso County, Colorado, in which four military bases are located. Each section concludes withrecommendations to base commanders concerning appropriate actions they should consider takingconcerning biological weapons attacks in order to minimize damaging mental health consequences, toaddress the problem of the worried well, and to better integrate emergency management systems with thoseof the community.The most important conclusions reached by this study are that the worried well needs respectful attentionduring the triage process; that the problem of the worried well can be partially addressed by simple, timely,non-contradictory information from trusted leaders; that education, information and preparedness are toolsof empowerment for the public that may themselves mitigate the problem; that integration of emergencyresponse teams into county and local networks is highly desirable; that participation in joint exercises isextremely useful; and that military leadership needs to be visible in a time of crisis. Public trust inleadership is important to public response, and is best built over time. The new concept of shielding and itsapplicability to a biological weapons crisis is analyzed and endorsed. Finally, the importance ofpsychological consequences of such a crisis is highlighted, and military leadership is urged not to minimizethe mental health issues both during and after crises.130.2. The Psychology of a Community under Attack from a Campaign of Terrorism -Lessons from the Northern Ireland ExperienceJ. Alderdice, House of Lords at Westminster, England (alderdicej@parliament.uk)Northern Ireland is a well-known example of a community that lived under threat of terrorism for thirtyyears and is now making progress towards stability and an end to terrorism. Using his experience as apsychiatrist and psychotherapist, but also as a leader of a political party and subsequently Speaker of theNorthern Ireland Assembly, Lord Alderdice explores the psychology of the community under attack. Heexamines the elements leading to splitting, division, and violence pointing up that the usual politicalscience and economic models do not satisfactorily explain the facts without an added communalpsychological dimension. In particular, he identifies ‘humiliation’ as a key factor in the stimulus for

384political violence, analogous to James Gilligan’s observations in cases of individual criminal insanity in theUSA. Attention to its obverse - ‘respect’ – is identified as a key component in the style of politicalleadership necessary to create community cohesion and successfully address terrorism. He examines thedifference in acute terrorism, (as in a number of single attacks) where the population responds with anxietyand uncertainty, as distinct from chronic terrorism which has different phases, and to which the response ofthe community changes in order to survive psychologically. Land and place in communal violence alsohave psychological as well as social, cultural and economic significance, and this is related to communalhistory and myth. The application of these Northern Irish insights to the issue of Terrorism as it affects theworld more generally now, but especially in the Middle East, suggests new, more psychologicallysophisticated ways of addressing the causes and outcome of terrorism in the communities from which itemerges.130.3. Redefining Readiness: Terrorism Planning Through the Eyes of the PublicRoz D. Lasker, The New York Academy of Medicine, New York, USA (rlasker@nyam.org)This presentation will report the findings of a research study that gave the American people their firstopportunity to describe how they would react to two kinds of terrorist attacks: a smallpox outbreak and adirty bomb explosion. The work involved in-depth conversations with government and private sectorplanners, 14 group discussions with diverse community residents around the country, and a telephonesurvey of 2,545 randomly selected adults in the continental United States. Our research documents thatcurrent plans to safeguard the American public are destined to fail because they do not account for howpeople would actually behave in these situations or for all of the risks and concerns that would drivepeople’s actions. We also show that if planners know what people would face, they can developbehaviourally realistic response strategies that would make it much easier for people to follow protectiveinstructions. To do this, planners and policymakers will need to focus not only on educating the public, butalso on learning from the public. Effective techniques for engaging the public in this work – and thepsychological implications of these techniques – will be discussed. The full report of the study is availableonline at http://www.cacsh.org/eptpp.html.130.4. Public and Private Sector Collaboration: A model Approach to Addressing theThreat of TerrorismDavid Levenberg, General Growth Properties Inc., Chicago, USA (David.Levenberg@generalgrowth.com)This session will explore the challenges and public health opportunities of interaction between the privateand public sectors with time critical issues. Balancing the business and financial needs of the industryagainst the Government role of acting in the best interest of the citizens at large, the Shopping Centerindustry’s voluntary provision of distributing to the public amber alert information and installation ofdefibrillators serves as a foundation for more comprehensive strategies to minimize the insecurity related tocurrent terrorist threats.The use of the Shopping Center property in times of crisis (hurricanes, floods, riots) has becomecommonplace. The public now recognizes the connection between these properties and “crisismanagement”. The logical progression for the use of these facilities is to begin offering resources to thepublic related to the threat of terrorism.

385In this context, we will examine the role of the shopping center as a “community anchor” for communityshielding in times of crisis, and how that message can effectively be distributed and customized to entirecommunities in order to enhance public trust and cohesion.Other areas of discussion will include:An examination of the model of cooperation built by shopping center security professionals. In anextremely competitive business environment, this group has managed to collaborate for over 12 yearswithout the bureaucratic hurdles that have been the demise of other groups. An understanding of the threatsposed by crime, or, in more recent years, terrorism, to the well-being of an entire industry has driven thisgroup to share best practices without regard to competitive advantage.The realistic development of safety goals and security measures that promote a positive perception by theconsumer while mitigating the effects of potential attacks. Post 9-11 the challenge became how to operatea business that invites the public in without restriction and yet has in place safeguards against an attack.This ever-evolving blend of procedures, policies, people, and technology has resulted in a robust andflexible security operation.Liability and legislation: are these the real drivers behind quality improvement? What has really motivatedthese corporations to increase spending and focus more than ever on the operation and effectiveness of theirsecurity departments? The threat of legislation that could financially cripple these companies is certainlyone of the driving forces. Another is the potential that they will be held liable to those injured during anattack.However, those are not the only reasons. An understanding that being a good neighbor in thesecommunities translates into longer stays, more frequent visits, and more dollars spent.A new marketing strategy is evolving. Instead of bright lights and lots of glitz, it may be defibrillators,training, and information on family emergency planning, child fingerprinting and DNA collection, and aprofessional and visible security force that attracts customers.130.5. Measuring ‘Terror’: Proving Crimes of Terrorism Through the Use of ExpertPsychiatric and Psychological Evidence in CourtBen Saul, Faculty of Law, The University of New South Wales (b.saul@law.ox.ac.uk)Since the 1920s, the international community has often attempted to define international terrorism,particularly for prosecuting terrorism as an international crime. Those efforts continue today in the UNGeneral Assembly, which has been negotiating a Comprehensive Terrorism Convention since 2000. Mostproposed definitions of terrorism require, as an element of the criminal offence, that certain violent acts areintended or calculated to put a person, group of people, or civilian population in a state of terror or gravefear. Indeed, it is the essence of terrorism that someone feels or experiences terror. This novel andsubjective element raises significant evidentiary difficulties for national and international criminal laws,which are explored in this paper. What is “terror” and how is it measured? What kinds of acts are capableof causing “terror” in individuals or whole populations? Is “terror” a temporary and transient state, or is itmore enduring or permanent? Does everyone experience “terror” in the same way, do different peoplehave different thresholds of fear, and if so, what sorts of factors make individuals more susceptible orresistant to feelings of “terror”? How is “terror” proved in a criminal trial, and what role is there for expertpsychiatric, psychological, or medical testimony? Some of these questions were confronted by theInternational Criminal Tribunal for the former Yugoslavia in the Galic case of December 2003, and insubsequent prosecutions brought in the Sierra Leone Special Court. In international humanitarian law,there are specific prohibitions on “acts of terror” and “terrorism” in the 1949 Geneva Conventions and the1977 Geneva Protocols. The Galic case involved the first ever war crimes prosecution for breaches ofthese prohibitions, resulting in the conviction of Serbian fighters for the sniping and shelling of civilians in

386Sarajevo, which was intended to terrorize the city’s inhabitants. Expert psychiatric evidence was adducedto prove the likelihood and existence of terror flowing from such acts. As more States enact terroristcrimes in their national laws, and as international law moves closer to adopting an international crime ofterrorism (additional to the war crime of terror in armed conflict), consideration of what constitutes “terror”and “terrorism” becomes vitally important, not least to ensure that persons accused of terrorism receive fairtrials and are not unjustly convicted.131. Psychopathy and Justice: Critical Perspectives131.1. Psychopathy as an Incapacity to Answer for One’s ActionsAntony Duff, University of Stirling (r.a.duff@stir.ac.uk)The label ‘psychopath’ lacks any clear and agreed meaning; it is too often misused to label those who areunusual, rebellious, or wicked as mentally disordered. Such a label can then be used to justify thepreventive detention or incapacitation of those who are judged to be ‘dangerous’, which deprive those whoare detained the civic rights and standing that are their due.However, we can, as I have previously argued (‘Psychopathy and Moral Understanding’, AmericanPhilosophical Quarterly 1977), specify a plausible meaning for the term—one that picks out a distinctivekind of responsibility-negating mental disorder. A new definition would concern the agent’s ability tounderstand the moral dimensions of his actions, and to grasp the reasons for action that morality (and thelaw) provide.In this paper, I will revive that argument, and connect it more closely to a conception of responsibility asanswerability. To be responsible, on this conception, is to be responsible for something (in this case, one’swrongful actions), to some person or body who has the standing to call one to account; it is a matter ofbeing able, and liable, to answer for one’s actions to others. In moral contexts, I must answer for the moralwrongs I have committed to those who have a proper interest in them. In the context of the criminal law, Imust answer (at a criminal trial) to the whole polity for the criminal wrongs that I have committed.Nevertheless, if someone cannot understand the moral dimensions of his wrongful actions, he cannotanswer for them to his moral fellows or in a criminal court: he cannot be held responsible for them.131.2. Accommodation of Psychopathy as a Validity Criterion for Theories of theSubjectWilliam Watson, University of Toronto (williamwatson@sympatico.ca)It is widely recognized that psychological and psychiatric theories rely on an underlying conception of thehuman subject, which is at odds with the rationalist conception of the subject underlying legal theory.Medico-legal constructs such as 'insanity' are thus metaphysical hybrids, and can be challenged for theirincoherence, or at least seen as requiring careful philosophical justification. Similarly, the

387psychological/psychiatric conception of the subject is at odds with conceptions of the subject underlyingthe social sciences, and thus socio-legal studies. However, a broadly psychological conception of thesubject will be shown to be metaphysically defensible, and to preserve insights relevant to both law and tosocio-legal studies. Psychopathy will be presented as a flawed but exemplary psychological construct; thatis, one consistent with the conception of the subject underlying psychological and psychiatric thinking.From this perspective, the plausibility and potential utility of psychopathy as a significant medico-legalcategory, i.e. as relevant to blameworthiness and disposition, is defensible. Linguistic constructionistframeworks used in critical socio-legal analyses of medico-legal categories such as psychopathy are forcedto model language use as 'apsychological', or at least to leave the psychological mechanisms facilitatinglanguage use not theorized. This is because accepting the significance of such psychological mechanismswould weaken the claim that psychological and psychiatric theories are 'mere linguistic constructions'.Contemporary research on language processing by psychopaths highlights the weakness of this viewprecisely because it suggests that psychological mechanisms facilitating language use can be both abnormaland even potentially medico-legally relevant. The inherent plausibility of psychological insights, includingpsychological insights regarding language use, must be accommodated in legal and socio-legal reasoning.Critical legal and socio-legal analyses of 'psychopathy', vital at a time when the diagnosis can be highlydamaging to an individual's rights, should not render it inherently implausible, or its plausibility irrelevant.131.3. Psychopathy and the Framing of Remorse: Judicial Use of Forensic Assessmentsto Construct the Criminal OffenderRichard Weisman, York University (rweisman@yorku.ca)The attribution of remorsefulness or remorselessness is one of the most significant determinations thatcourts make regarding both the characterization and disposition of criminal offenders. Whereas forcontemporary forensic psychiatry and psychology, attributing remorse may constitute but one item on anindex, in the Canadian judicial context, in communications with juries, in sentencing, in deciding on parole,long-term offender or dangerous offender status, defining a person as remorseful or not may be the mostweighty decision for a court after a finding of guilt. Using judgements in Canada from 2000-2003, thispaper will show how forensic expertise in diagnosing psychopathy and antisocial personality is used forlegitimate designations of persons as remorseful or not, how expert designations are used both to supportand to invalidate lay designations of persons as remorseful or not, and how these designations becomefrequent sites of contestation in the adversarial context of the court. The paper concludes with a discussionof some of the methodological and epistemological problems for both lay and expert witnesses in decidingwhether remorse is genuine or insincere, spontaneous or strategic, deep or superficial.131.4. Psychopathy and Moral ResponsibilityMatt Matravers, University of York (mdm3@york.ac.uk)Psychopathic offenders have often attracted the interest of moral philosophers. One influential account hasit that the critical question is whether psychopaths possess “participant reactive attitudes” (that is, whetherthey can properly grasp what it is to feel shame, resentment, guilt, gratitude, and so on). The underlyingtheory of responsibility here is owed to Peter Strawson, who argued that such reactive attitudes were crucialto moral responsibility. Strawson’s account has been hugely influential in moral and legal philosophy.Recently, a different approach to moral responsibility, one based on the capacity of the agent to respond toreasons, has challenged the dominant Strawsonian orthodoxy. In this paper, I consider the moral

388responsibility of psychopathic offenders from the “reason-responsiveness” perspective; concentrating onthe problems created by people who have the general capacity to respond to reasons, but who seem not tohave the capacity to respond to a particular sub-set of reasons, namely moral reasons. Having done so, Ithen briefly consider the relationship of moral and legal responsibility.131.5. Moral Death RevisitedJeffrie Murphy, Arizona State University (jeffrie.murphy@asu.edu)I will revisit my widely cited and anthologized 1972 essay “Moral Death—A Kantian Essay onPsychopathy”. In that essay I drew on Gabriel de Tarde’s theory of responsibility as based on socialsimilarity and reciprocity to argue that the psychopath is generally not properly held responsible for hiswrongful conduct. I argued that this comes with a price, however—namely, that there are no principledreasons (though some practical ones) for not regarding the psychopath as a non-human, without rights.132. Psychopathy in Juveniles I132.1. Predictive Validity of the SAVRY (Structured Assessment of Violence in Youth)in a Dutch Population of Young OffendersHenny Lodewijks, Rentray Judicial Juvenile Institute, Lelystad, The Netherlands (hlodewijks@rentray.nl)Objective: To gain information about reliable predictive information for institutional violence and violenceafter release and other rule breaking in order to develop a risk management policy.Method: The prospective study includes all juvenile offenders charged with violence or with other crimesbut with a violent history. We follow two separate cohorts of both 100 juveniles during their stay and aftertheir release. We compare the SAVRY results with official ratings of crimes and rule breaking to determinethe predictive validity of the instrument.Results: Will be available in June 2005.

389132.2. Phenomenology of Psychopathy in GirlsH.S. Backer, Practicing Psychiatrist, Den Helder, The Netherlands (hilmar@worldmail.nl)E.J. van Maren, Practicing Psychologist, Den Helder, The Netherlands (e.van.maren@dji.minjus.nl)Available data shows that the prevalence of psychopathy in girls is low compared to boys. Evidence alsosuggests that psychopathy synonymous with Conduct Disorder, although there is overlap: Almost allpsychopaths will meet the criteria for Conduct Disorder, but a minority of juveniles with Conduct disorderwill also meet criteria for Psychopathy. DSM-IV criteria are specific but not sensitive for ConductDisorder in girls. Antisocial lifestyle items predominate in the criteria. Psychopathy in girls is moredifficult to detect because the PCL-YV is unreliable, probably because the typical female items are moresensitive to subjective interpretation and may not detected during face-to-face contact. They may appearmore clearly psychopathic through group observation. In clinical practice, psychopathy in (pre-) adolescentgirls has a different expression. It may be less evident in face-to-face contact, as girls are more apt to investin social contacts than boys are. Psychopathy in girls is seen in their way of relating to people, andbehavioural problems are less specific. The common factors for boys and girls are the dimensions: lack ofemotion, callousness, lack of conscience and lack of empathy.132.3. Adolescent Psychopathy and Risk AssessmentPatricia Bijttebier, Catholic University of Leuven (Patricia.Bijttebier@psy.kuleuven.ac.be)Stef Decoene, Catholic University of LeuvenPsychopathy is generally considered the best single predictor for recidivism risk with adult delinquents.Both psychopathy and risk assessment procedures are well developed for adult offenders, and research issteadily progressing.Societal, clinical, and scientific reasons place much importance on diagnosing psychopathy as early aspossible. Measures such as the PCL: Youth Version (Forth, Kosson, & Hare, 2003), Antisocial ProcessScreening Device (Frick & Hare, 2001), and the Childhood Psychopathy Scale (Lynam, 1997) have beendeveloped. Equally, risk assessment procedures are currently under development.We will discuss these developments, but will also examine how far views about risk assessment with adultoffenders can be applied to risk assessment with adolescents. Potential problems in diagnosingpsychopathy will also be discussed. Finally, preliminary results of our research on adolescent psychopathyand risk assessment will be presented.

390132.4. Psychopathy in Youths: Pitfalls and PossibilitiesJacqueline Das, Practicing Psychologist, Harreveldm, The NetherlandsTheo Doreleijers, Free University of Amsterdam 7Henny Lodewijks, Rentray Judicial Juvenile Institute, Lelystad, The NetherlandsThe concept of psychopathy as measured with Robert Hare’s Psychopathy Checklist-Revised (PCL-R) hasbecome very important in forensic psychiatry during the past decade. Psychopathy can be characterized asa personality disorder characterized by an unstable, impulsive lifestyle, lack of empathy and guilt feelings,and a manipulative and grandiose interpersonal style. Most research with the PCL-R has been conducted inadult male forensic samples. Results show that psychopathy is diagnosed in about 25% of forensic subjectsand that it is a strong predictor of general and violent re-offending.The study of psychopathic traits in children and adolescents is a next step in the study of psychopathy togain more insight into the etiology and persistence of the disorder to allow early intervention. However,there are some ethical concerns about diagnosing psychopathic traits in children. First, diagnosingpsychopathy in children and adolescents can be in conflict with the DSM-IV criterion that personalitydisorders cannot be diagnosed before the age of 18. Second, the term psychopathy has a pejorativeconnotation because it gives rise to associations of dangerousness and untreatability. Third, certaindefining psychopathic traits may be at least partially related to the phase of adolescence, for instance,impersonal sexual relationships and lack of long-term goals. This may lead to false positive diagnoses.In this presentation, the value of the concept of psychopathy will be discussed based on the extant empiricalliterature. Part of the presentation will focus on the findings from research with the Psychopathy Checklist:Youth Version in adolescent offenders in a Dutch juvenile justice treatment institution.132.5. Clinical Aspects of Violence Risk AssessmentNils Duits, Ministry of Justice, Amsterdam, The Netherlands (NDuits@planet.nl)Violence risk assessment for juvenile court as a basis for decisions becomes more and more important.Structured Instruments of Assessment of Violence Risk in Youth are introduced (SAVRY). These areinstruments based on treatment settings and not on the setting of the pre-trial diagnostic assessment forjuvenile court. To determine which factors correlate most with clinical judgment on violence risk in pretrialassessment, research was conducted on diagnostic assessment files for juvenile court of 100 juvenilesbetween 12 and 18 years old, who were suspected of violent crimes. Research was also conducted onrelevant clinical risk factors by using a concept mapping consensus method among 50 leading senior‘makers’ of these diagnostic assessments.Results of this research will be presented and consequences for violence risk assessment for juvenile courtin the pre-trial phase will be stated.

391133. Psychopathy in Juveniles II133.1. Personality Dimensions and Traumatization in Delinquent Juveniles with a HighScore on the PCL-YVM. Krischer, University of Cologne (mkrischer@uk-koeln.de)K. Sevecke, University of CologneM. Doepfner, University of CologneG. Lehmkuhl, University of CologneIn this study, we focused on a sample of delinquent juveniles who scored high on the PCL-YV (Forth,Kosson & Hare, 2003) in order to look for gender differences regarding early childhood traumatization andpersonality dimensions, using the DAPP (Dimensional assessment of personality pathology, Livesley &Jackson. 2003). The leading question is whether an association between scoring high on the PCL-YV andan early experience of traumatic incidents can be found.A group of 40 male and 30 female incarcerated juveniles (age 14 to 19 years) scoring over 20 on the PCL-YV were included into the study and compared with a control school sample of similar size. TheChildhood Trauma Questionnaire (CTQ, Bernstein & Fink 1998) was used to investigate the severity ofsexual or physical abuse, emotional or physical neglect, and emotional abuse. Using t-tests and varianceanalyses, we looked for differences in girls and boys with respect to having experienced traumatic eventsduring their childhood.Although in relation to traumatic experiences, delinquent boys and girls do not differ significantly there is atrend of more traumatic experiences in girls than in boys scoring high on the PCL-YV. In addition, wefound a different profile of personality dimensions in delinquent boys than girls, correlating with differenttraumatic incidents. Final results will be presented during the conference.Conclusively, our results show that compared with a control group there is a higher number of delinquentjuveniles (scoring high on the PCL-YV) reporting traumatic incidents in their childhood. Furthermore, wecan prove gender differences in reference to personality dimensions and the severity of traumaticexperience.

392133.2. Gender Difference of Psychopathy in Youth: Delinquent Girls & Boys Comparedwith a Control School Sample - Factor Structure, ADHD, Temperament andBehavior ProblemsM. Krischer, University of Cologne (mkrischer@uk-koeln.de)K. Sevecke, University of CologneM. Doepfner, University of CologneG. Lehmkuhl, University of CologneThis study (the Cologne GAP-Study) focuses on psychopathy in female and male delinquent adolescents,using the PCL-YV (Forth, Kosson, Hare 2003) for the first time in Germany. Gender differences in thispopulation are often mentioned in literature, but rarely empirically analyzed with similar samples. Theleading questions are whether we can identify psychopathy in delinquent girls and boys, whether we canidentify gender differences, and whether there is an association with ADHD, temperament, and behaviourproblems.A group of 70 female and 80 male incarcerated juveniles between 14 and 19 years of age were includedinto this study and compared with a control school sample. Beside the PCL-YV, a ADHD self rating scale(Döpfner et al.), the JTCI (Cloninger et al.) and the YSR (Achenbach et al.) were used to investigate theseverity of ADHD symptoms and behavior problems.Factor analyses were conducted in order to study the different factor structure in boys and girls.Furthermore, using t-tests, the gender differences were analyzed.A different factor structure was found in boys than in girls. ADHD self-rating problems in delinquent boysand girls do not differ significantly. Temperament and behavior problems correlate with differentpsychopathy dimensions.Final results will be presented during the conference.Conclusively, the results show that the PCL-YV can be used as a valid instrument for assessingpsychopathic traits in a German adolescent jail population. Furthermore, we can prove gender differencesin reference to the psychopathy concept and regarding the impact of temperament and behaviouralproblems.133.3. Self-Injurious and Antisocial Behaviour in Adolescents: Psychopathology andLifestyleLaura Dalla Ragione, Department of Mental Health, Perugia, Italy (dallaragione@tiscali.it)Letizia Drappo, Department of Mental Health, Perugia, ItalyThis is a reflection on the role of disturbed regulatory function in teenagers, and an attempt to formulate thedynamics of the group of adolescents involved in self-injurious and antisocial behavior. Certain aspects ofthe lifestyle and behavior patterns of these young people display striking similarities. In particular, theirbehavior evidences the presence of a central self-destructive moiety that can be likened to a negative egoideal; this acts to shape and to direct their lives. Early negative events during infancy appear to instil aninner presence that functions as a negative ideal. This in turn makes for a driven pattern of punishmentseeking,self-injurious behavior including self-mutilation, drug addiction, and antisocial acts. This element

393in the character structure of these patients is discussed in clinical and theoretical (developmental) terms,with special address to a chronic low-grade sense of inner malaise, a tendency to self-blame for whatevergoes wrong for family and close friends, feelings of alienation from the larger society around them,behavioral provocativeness in the service of seeking the relief that punishment brings, recurrent gestures ofself-mutilation, frequent involvement with cults of symbol worship, a record of multiple antisocial acts, andsometimes suicidal gestures and attempts. The origins of the negative regulatory superego elements thatmake for this type of psychopathology are explored.133.4. Predictors for Recidivism in Delinquent Youth According to the PCL-YVPia Niklaus, Institute for Forensic Child and Youth Psychology and Psychiatry, Bern, Switzerland(pia.niklaus@ifkjb.ch)Daniel Gutschner, Institute for Forensic Child and Youth Psychology and Psychiatry, Bern, SwitzerlandObjective: To examine the predictors for recidivism in delinquent youth according to the PCL-YV.Methods: 85 young delinquents (75 boys and 10 girls) referred to us by juvenile court for assessment had torun through a standardised test-battery for intelligence, attention, personality, and a list of otherquestionnaires. In addition, structured interviews were held to gain information about socio-economic dataand the psychopathology. Finally, the PCL-YV was rated for each individual. The actual recidivism wasdetermined by questionnaires that were sent to the responsible juvenile courts.Results: High scores in the PCL-YV could best be explained by the variables “aggression against others”,“contact with the justice of the father”, “exaggerated opinion of oneself” and “problems in school andwork”. Psychopaths/ non-psychopaths did not differ significantly regarding the test diagnostic results. Itcould be shown that juvenile offenders who are defined as psychopaths carry significantly more often ICD-10 diagnoses than juvenile offenders without a psychopathy do. An identifiable tendency is thatpsychopaths commit more offences and different kinds of offences than non-psychopaths do.Conclusion: Juveniles who show aggression against others, have a father with a criminal background, havean exaggerated opinion of themselves and problems at school or work score higher on the PCL-YV andtherefore carry a higher risk for recidivism.133.5. Psychopathic Disorder in the UK: Early Case Studies of Women and YouthGhislaine du Planty, Cambridge University (ghislaineduplanty@yahoo.com)In the UK, the 1959 Mental Health Act established legal grounds for hospital admission of patients underthe age of twenty-one years suffering from psychopathic disorder (Part IV, 26 (2a)) or if "it is necessary inthe interests of the patient's health or safety or for the protection of other persons that the patient should beso detained" (Part IV, 26 (2b)). In addition to providing for the confinement of those suffering from mentalillness, the 1959 legislation provided for the detention of young patients, and dangerous patients, neither ofwhom could be classified as mentally ill. This provision was prepared by more than twenty years ofparliamentary papers addressing the issue of crime and juvenile delinquency and their possible treatmentsby scientific medicine. Provisions for the confinement in psychiatric hospitals of children and youth werelinked with crime, and for girls, with sexual behaviour. It has frequently been asserted that psychopathicdisorders are a legal, not a medical category, although examinations of case histories at Broadmoor SpecialHospital show psychopathy to have been used and understood as a legitimate diagnostic category before the

3941959 legislation, along with related ideas of "aggressive psychopath", psychopathic personality, and"inadequate" psychopath”. It was often recorded under the heading "Diagnosis" or "Supposed cause", andpatients were widely referred to as psychopaths. As such it may be seen as a medical category that becamea legal category, the effect of which was to considerably restrict its usage, initially. This paper reviewsadmissions of women to a secure psychiatric hospital who were assessed with psychopathic disorder beforeand after the 1959 legislation that introduced this legal category.134. Rap, Hip-Hop, and Pop: The Impact of Popular Culture andAdolescent Behavior in the USA and in Latin AmericanSocieties134.1. I See You, But Do You Really See Me? The Effect of Media Literacy onTeaching AdolescentsKaren E. Simms, Indiana University Southeast (ksimms@ius.edu)In the United States, the popular media (i.e. television, music, video, and print etc.) is often recognized asthe major form of entertainment and, at times, information. However, the impact of television and othermedia on adolescent development has vastly changed since the 1970’s. The role of television in general hasevolved into a series of projections focused on today’s youth, underscoring that only certain images,behaviors, language, etc. are acceptable. The vernacular, clothes, attitudes and styles promoted by MTV,BET, VH-1 and other media encourage youth to claim something that is distinctively their own and notsomething that was developed by their parents. Although the change in media has dramatically impactedAmerican society in general, the perceptions that are marketed specifically to African Americanadolescents via television and video have impacted African American adolescent literacy development andachievement. For most African American adolescents, media reinforces an approach to life by using aconstant barrage of negative imagery that is demeaning to themselves, and other populations. In thissession, the author of the chapter, “I See You but Do You Really See Me? The Effect of Media Images onAdolescent Development and Teacher Practices.“ from Language, Literacy, and the African AmericanExperience: Defining Moments (Roman and Littlefield Publishers, spring 2004) examines the impact ofmedia, correlating aspects of this cultural phenomenon to achievement and literacy. Faced with the nationalissue of an ever-widening academic achievement gap among African American students, this presentationalso highlights strategies that can improve literacy while using media as an instructional tool rather thandismissing media as a popular icon.

395134.2. Teenage Boys: Perspectives on Kohlberg and Hip-HopGloria Murray, Indiana University Southeast (glomurra@ius.edu)American popular culture is riddled with the influences of hip-hop music and the products of hip-hop.Sounding like a child’s innocent game, hip-hop was created by young black men and co-opted andsuccessfully marketed by corporate America. Its’ melodies and some of its’ lyrics are used in televisioncommercials selling items from detergents to back-to- school clothes. The hip-hop players, who are mostlymen, have demonstrated their ability to influence language, clothing styles and the media since theinception of this artistic form of communication. It is also music that degrades women and promotesviolence, according to some. Negative hip-hop artists are accused of infecting and devastating AfricanAmerican communities, in particular, with lyrics, images and products that promote immorality andviolence.Adolescents are believed to be particularly vulnerable to the negative and positive aspects of hip-hopculture. Adolescence is a period within the life span when a person’s physical, psychological and socialcharacteristics are in transition. With a newly emerging cognitive structure, adolescence is a time a ofquestioning and identity confusion. It is also a time, according to Erickson, of formulating values.Kohlberg sees this time in life as building a sense of personal mastery and development of mature decisionmakingin ethical and moral matters. Considering the influence hip-hop has on the American culture,understanding the relationship between the events in one environment and making decisions, is critical forthe young adolescent as he/she determines their moral character and identity. This presentation discusseswhat the young adolescent believes and thinks about hip-hop culture and its influence on their judgmentand decision-making. After all, it is the young who are so often the target of marketing campaigns,promoting the products of hip-hop and the selling of everyday goods and products. The findings of fourcase studies of young black make adolescents who shared their thoughts and opinions on how hip-hop hasinfluenced their lives and their decisions will be examined.134.3. Impact of Media Literacy on the Mental Health of AdolescentsTeesue H. Fields, Indiana University Southeast (thfields@ius.edu)It has long been recognized that popular culture has an impact on the social and emotional development ofadolescents in the United States. However, of increasing concern to mental health professionals is thecontribution of rap, hip-hop and pop in influencing the more serious mental disorders prevalent amongadolescents. Some of the negative, nihilistic messages of popular culture may be able to sway adolescents,especially those who are already emotionally vulnerable, toward self-defeating approaches to theirproblems.Of particular concern is the possible increase in adolescent violence, depression, self-mutilation, conductdisorder and suicide as a result of identifying with popular culture. Of course these issues have alwaysbeen a concern by adults with regard to the youth culture, no matter what that culture contains, because theadult generation is concerned by the rejection of their own values. However, there is some evidence toshow that the violence, racial slurs and negative attitude toward women that is part of the current popularculture is having an impact on the levels of violence in schools and communities in the United States.This presentation will look at current research in the prevalence of violence, depression, self-mutilation,conduct disorder and suicide in various cultures and subgroups within the United States. The presentationwill also examine programs in school settings that try to deal with these issues and will report on theirsuccess. Finally, there will be recommendations for future research in this area with an emphasis on

396prevention activities. Certainly it is not possible for mental health professionals to banish popular culture,no matter what its provocation. However, it might be possible for adults to find ways to live with theculture while learning the skills needed to guide adolescents toward better cultural evaluation and selfknowledge.134.4. Impact of the USA Pop Culture Beyond Its BoundariesMagdalena Herdoiza-Estevez, Indiana University Southeast (mherdoiz@ius.edu)While co-presenters address different aspects of the topic with references related to research based in theUSA, this paper analyzes the ways in which the USA pop-culture is affecting the development of culturalexpressions and consumer patterns of the youth in Latin American societies. Particular topics addressedare:Role of TV and Internet in the development of global trends among adolescents concerning behavior andcreative musical work.Ways in which the pop culture is adopted by and adapted to the local cultures.Use of pop culture to expand the market.These topics are approached from a comparative perspective that includes the evolution of culturalvariables and the standards “exported”, in the past and today, by dominant cultures. USA standards ofmusical forms, content, techniques and aesthetics as well as verbal content standards (lyrics) have varieddramatically in the past decade and have reached global audiences influencing musical and culturalexpressions especially among the youth. Indeed, young adolescents are the main target of marketingcampaigns promoting the products and images of USA hip-hop culture to the world. Cable and Internethave become powerful dissemination venues where new paradigms and new products are promoted,especially among the youth. This phenomenon is clearly expressed in Latin America. USA marketing andmarket of hip-hop and pop related products have indeed become important parts of the Latin Americanurban landscape, particularly among the middle and upper social classes.However, the interaction of the youth with the new musical and cultural elements is multifaceted anddialectic, and should not be seen as a unilateral influence where the Latin American youth is merely arecipient, follower and consumer. The Ecuadorian case presents a complex set of facts that show a broadarray of responses from the youth to the USA pop culture. These responses vary from the adoption of itsstandards to the creative adaptation of it. The active and creative “dialogue” with the local culture(especially urban) has produced uncountable and identifiable musical expressions. This phenomenon putsforward the complexities of the intercultural relations and the intrinsic contradictions that define them.Having said that, no matter what the characteristics of the contradictory relations between the LatinAmerican youth and the USA hip-hop and pop music may be, the market for these new tangible andintangible products has dramatically expanded along with the influence of the new dominant paradigms.

135. Recent Developments in the Treatment and Care of ChronicOffenders in Germany and the Netherlands397135.1. Long-term Dangerous Forensic Patients: Numbers and Needs for Security,Supervision, and Mental HealthcareKaty de Kogel, Ministry of Justice, The Hague, The Netherlands (c.h.kogel@minjus.nl)During the last 10-15 years there has been a serious a lack of treatment capacity for patients with a TBSorder.TBS is a hospital order which can be imposed by the court on offenders who committed a seriousoffense and are considered not responsible or partially responsible for their offenses. TBS serves to protectsociety and can only be imposed when the risk of criminal recidivism is considered unacceptably high. TBSconvicts have nearly always committed (sexually) violent offences.One of the strategies to deal with shortage of treatment capacity in the TBS-hospitals is to allocate thescarce facilities to patients with positive treatment perspectives. Patients who do not profit from treatmentand are considered still dangerous would no longer receive intensive treatment directed at resocialization.Two national TBS long stay units for untreatable patients are already in function in The Netherlands. Nonjudicialmental health facilities also have to deal with chronically dangerous patients. Development of new,possibly more differentiated facilities suitable for long stay dangerous patients is intended both in thejudicial TBS-sector and in the non-judicial mental health field.In this presentation the concept and possible operationalisations of ‘chronic’ or ‘long-term dangerousness’will be discussed. Subsequently numbers of long-term dangerous forensic patients will be presented, aswell as supervision/security needs and need for mental health care.135.2. The Development and Evaluation of a Unit for Chronic Mentally DisorderedOffendersEmmo Doddemma, Forensic Psychiatric Hospital Veldzicht, The Netherlands(info@veldzicht.dji.minjus.nl)In the Netherlands people suffering from mental illness who commit serious crimes can be adjudicated(partially) not criminally responsible by the judge. They can be confined to a forensic facility to receivemandated treatment. This is called TBS. During the mid-nineties it became increasingly clear that in theNetherlands, a certain group of TBS patients did not improve despite of treatment, and still imposed athreat to society. These TBS-patients congested the clinic and occupied expensive places where otherpatients could not get treatment. In Forensic Psychiatric Center Veldzicht, a special forensic ward was setup: the long-stay facility. On April 1st 1999, the long-stay started with 20 occupants (two wards, each with10 patients). The emphasis no longer rests on reducing the risk of re-offending, but on providing care andsupport in a closed setting. The main objective is enhancing the quality of life within the confinement of theTBS facility. Initially some people feared all kinds of problems on this ward, such as aggression, hostagesituations and suicide. After five years, Veldzicht research concludes that these escalations have notoccurred. The number of incidents, certainly compared to certain regular wards, can be considered low.Though the occupants find the idea of a very long stay on this ward - for most of them, probably lifelong -difficult to accept, most occupants are relieved because they no longer have to answer to the demands of

398mandatory treatment. These patients are no longer confronted with continuous setbacks or failure. In factthere are little demands upon the patients on the long-stay ward. Most of them function well; some, evenbetter than compared to the regular wards where they used to receive treatment. Some of them do so wellthat it confuses the issue of them being a threat to society. It’s the expectation of Veldzicht that in thefuture, more facilities like the long-stay will be built. After five years we clearly see a difference between(every combination of) need for care and the necessity of security. So Veldzicht expects that adifferentiation will be implemented in order to continue to provide the best care for subgroups of long-staypatients.135.3. On the Necessity of the Discriminating Accommodation of Forensic Patients WhoHave Only Little Dismissal ProspectsUwe Dönisch-Seidel, Forensic Psychiatry/ Ministry of Health, Düsseldorf, Germany (uwe.doenischseidel@lbmrv.nrw.de)In Germany there is a growing lack of capacity for violent and dangerous offenders who do not benefitfrom intensive inpatient treatment. Previous examinations on these so-called longstay patients havedemonstrated large heterogeneity of this group concerning diagnosis, crime and safety demands. This raisesthe question whether, analogous to usual forensic treatment programs against deviance and crime,distinctions in ways of accommodation and care are to be aimed at; as well, group heterogeneity raisesissues regarding the rules for execution patients who are difficult to release and constitute a danger forsociety. Various alternatives are shown and discussed which are going to be tested as part of a Dutch-German evaluation project for these offenders.135.4. The Growing Number of Dangerous Mentally Disordered Offenders in TheNetherlandsPeter G.J. Greeven, Expertise Centre for Forensic Psychiatry, Utrecht, The Netherlands (pgreeven@efp.nl)In the last 25 years, the Netherlands has been confronted with an enormous rise in the amount of dangerousmentally disordered offenders. Many of these offenders are detained in prison services or treated inforensic psychiatric hospitals (under a Dutch entrustment act). Despite the fact that the number of inpatientbeds has almost tripled, offenders still have to wait for at least a year before they can be transferred to aproper facility. Along with this development a ‘new’ type of offender was referred to the hospitals. Manyof them were severely disturbed and considered permanently dangerous to society. These offenders showedno substantial improvement despite many years of intensive treatment and forced the ministry of justice todevelop so-called ‘longstay-units’. The aims of these facilities are threefold: 1) to protect society from therisk of criminal offences by these patients, 2) to provide care for the patients in order to optimize theirquality of life, and 3) to provide care at lower costs.The background of these developments will be discussed in the presentation.

399135.5. The ‘Kempehuis’: A Dutch Forensic Long-stay Unit – Safe Enough to Live In?Ed Schutgens, Pompe Mental Hospital, Nijmegen, The Netherlands (e.schutgens@Pompestichting.nl)The ‘Kempehuis’ is a forensic psychiatric unit specialized in the treatment and care of chronic forensicpsychiatric patients. The unit accommodates about 40 patients (aged between 29 – 66) who have thefollowing features in common: they have committed severe offences (48 % sexual such as rape andpaedophile acts) in the past; they suffer from a sever personality disorder; intensive treatment in the pasthad insufficient results; the inpatient treatment in the past consisted of at minimum 6 years stay in one ortwo forensic psychiatric hospitals; the risk of new offences is estimated to be very high in case of return tosociety. Therefore these patients have to stay at the specialized longstay unit, as part of our maximumsecurity hospital treatment.The question then becomes one of duration: how long are these patients expected to stay in the ward - untildeath do us part? This is an unfortunate possibility for some. But that is not our final option. We have aserious obligation to these patients. They have already been punished for their crimes, but remain atpsychological risk; our knowledge has so far proved to be insufficient in treating their mental illness. Thepatients ‘pay’ for the lack of approtiate care, with their precious civil rights of freedom and selfdetermination.Within our assignment to protect society against criminal acts of our patients, we have the duty:• to guarantee for each patient a quality of life, which is as good as possible, within therestrictions of the necessary deprivation of freedom• to provide a safe place to live their lives between companions in misfortune (we call it: theright to be ‘disturbed undisturbed’)• to take care that they are deprived of their freedom as little as possible without endangeringsociety's safety (including allowing facility leaves under supervision)• to continue investigating new treatment possibilities for each patient• to keep updating risk assessment for each patient (which changes are necessary)• to develop a range of differentiations between institutionalization in a high secure unit on theone hand, and living in an open house under permanent supervision on the other hand.Our manifestos are: to provide as much care as needed, to not deprive the patient of more freedom than isnecessary, and (last but not least) to provide only the imprisonment time that safety requires!This paper presents our approach in this specific field of forensic work.

400136. Recidivism136.1. Investigating Risk Factors for Sex Offense Recidivism among Child MolestersPre and Post TreatmentScott Aylwin, Alberta Hospital Edmonton, Edmonton, Canada (scott.aylwin@amhb.ab.ca)This study examines three possible static risk factors for sexual offense recidivism among a sample of 420convicted adult male child molesters, and the role of treatment in mediating the influence of thesevariables. Having male victims is commonly considered a risk factor for sexual offense recidivismaccording to actuarially based risk prediction instruments. Similarly, an offender's own childhood sexualabuse has been implicated as a static risk factor, and serum testosterone has recently been considered as arisk factor for re-offense among sex offenders. Using a lengthy follow-up period (mean = 9 yrs.) treatmentcompleters and non-completers of the Phoenix Program at Alberta Hospital in Edmonton were comparedon these variables. It was found that having male victims per se was not associated with recidivism, buthaving male victims exclusively was correlated with recidivism among patients who did not completetreatment (r = .19, p < .01). The severity of sexual abuse experienced by offenders in childhood was alsocorrelated with recidivism (r = .20, p < .01) among treatment non-completers. After controlling for age,serum testosterone levels too, were associated with sexual offense recidivism among non-completers (r= .20, p < .01). However, among patients who completed treatment, none of these variables werepredictive of sexual re-offense. This study indicates that successful completion of treatment can amelioratethe ability of static risk factors to predict sexual recidivism. Findings further suggest that actuarial riskprediction instruments may be improved by including treatment completion as a variable.136.2. Back into Society: Rehabilitation and ResocialisationH.A. Feringa, Groningen, The Netherlands (leidaferinga@home.nl)The Dr. S. van Mesdagkliniek is the largest forensic psychiatric hospital in the Netherlands. Because of itssize and broad expertise, the clinic can offer a patient-oriented and on a small scale organised treatment,also to very complicated patients.The goal of getting the patient to actively take responsibility for his treatment, his actions and the meaningof his actions for the victim is a central component of institutionalization. Such institutionalizationprograms show statistical evidence of substantially reducing the risk of recidivism.By intensive co-operation with other organisations within the (mental) health care system, the forensic fieldin tandem with education and research organisations, allows the clinic to further enhance the progress ofthe patients, thus developing interdisciplinary knowledge and experience.An important part of the treatment of patients who suffer from addiction is exposure during therehabilitation/resocialisation-phase. Treatment without exposure is akin to practicing as a doctor withouthaving finished medical school. Parts of the exposure-period are comparable to behaviour-experiments incognitive behaviour therapy.

401In addition to exposure, other domains should be analysed before actually considering patient reintegrationinto society. Another condition is that there needs to be an agreement with the patient (or his carers) on theimportance of: the social network, spending the daytime, medication, and finances.Central items at (re)integrating patients with addiction problems appear to be: working out the individualdomains, cognitive behavioural therapy, and relapse prevention plans (including monitoring).A major focus in this presentation is the fact that a patient becomes aware of his/her actions and has theopportunity to choose between positive and negative stimulus. This also seems to be an importantforecaster of recidivism. “People produce their own recidivism”.136.3. Recidivism of Insanity Acquittees in New ZealandJeremy Skipworth, Ministry of Health, Wellington, New Zealand (jeremy_skipworth@moh.govt.nz)David G. Chaplow, Ministry of Health, Wellington, New ZealandPhil M.J. Brinded, Ministry of Health, Wellington, New ZealandNew Zealand law continues to use a McNaughten type test of insanity, with post acquittal care usuallycoordinated by Forensic Mental Health services as a Special Patient. Special Patients have a high degree ofadministrative structure overseeing their care (substantially in excess of civil committed patients), and maynot be discharged or reclassified without Ministerial assent. This reflects the high degree of public interestand concern over the risk that these patients present to the community. However, very little is known aboutthe actual risk of recidivism that this population presents to the community in New Zealand.This study describes the demographic, clinical and criminological characteristics of special patientsacquitted by reason of insanity in New Zealand over the last 40 years (n=300), and examines key outcomesincluding duration of institutional care, duration of Special Status, and criminal recidivism post release intothe community, as well as following reclassification from Special Status.Results will be placed in the international context, with a view to commenting on the ability of differenttreatment programmes (such as the inherent difference between special status and civil status in NewZealand) to influence recidivism.137. Refugees and Asylum Seekers137.1. Points of Intersection: Refugee Determination Procedures, the TraumatisedApplicant and the Mental Health ProfessionalNaomi Frommer, University of New South Wales (n.frommer@unsw.edu.au)As a consequence of the traumatic histories of many asylum seekers, the refugee determination processrepresents a point at which psychological factors and legal decision-making intersect. Substantial numbers

402of asylum seekers presenting before refugee decision-makers are likely to be suffering from complexpsychiatric disturbances, and yet in Australia, there are currently no clear guidelines for determiningofficers to follow in interpreting the ways in which psychological symptoms manifest or affect thepresentation of an applicant. This paper will consider the complexity of presenting and assessingpsychological evidence within this forensic setting, based on recent longitudinal research with a group ofasylum seekers involving the provision of psychological assessments and analysis of refugee decisionoutcomes. Drawing on examples from the research, discussion will focus, first on the influence ofpsychological factors on the presentation of asylum seekers’ accounts of their traumatic experiences, withspecific reference to the impact of trauma on memory functions, recounting of trauma experiences, and theeffects of such disclosures on symptoms of psychological distress. Next, it will consider the potential roleof expert psychological evidence in assisting decision-makers in the assessment of applicants. Finally, thepaper will examine the dilemmas faced by clinicians working with asylum seekers in a context whereforensic demands can outweigh usual clinical practice regarding the cautious exploration of traumaticmaterial, and set out guidelines to assist mental health professionals involved in the provision ofpsychological assessments for asylum seekers and refugees.137.2. Is Australia adhering to its International Human Rights Obligations in respect toUnacompanied Minors Seeking Asylum?Fiona Martin, Queensland University of Technology (f.martin@qut.edu.au)Terry Hutchinson, Queensland University of Technology (t.hutchinson@qut.edu.au)Research indicates that unaccompanied refugee children seeking asylum are in an especially vulnerableposition. As a result, there are several international agreements and statements directed towards securingtheir rights and protection. Consequentially, medical research has pointed to the long-term detrimentaleffects if such standards for their treatment are not followed.This paper analyses the issues surrounding Australia’s agreement with international human rights law, andthe reality of Australia’s political policy, as underpinned by the provisions of Australian legislationembodied in the Migration Act 1958.More specifically, international covenants protecting the rights of children impose an obligation on memberstates to use detention of children as a last resort. The Australian government, it will be argued is usingdetention of refugee children as its first option, and not where all other options have failed. This argumentis supported by the 2004 Report of the Australian Human Rights and Equal Opportunity Commission “ALast Resort?: National Inquiry into Children in Immigration Detention”.In addition to this, the authors will discuss the existing mental health research on unaccompanied childrefugees to point to strong evidence of the high risk to long term mental health of unaccompanied childrenas a consequence of their detention. In particular, the very fact of detention it will be argued - with theconsequent deprivation of liberty, having no caregiver in the same family or cultural group, and the processof asylum seeking - is exacerbating the mental ill-health of already damaged and vulnerable children.

403137.3. Status Anxiety: Refugees in Legal LimboJane McAdam, University of Oxford (jane.mcadam@law.ox.ac.uk)This paper considers the psychological effects that gaps in the international legal protection regime have onrefugees and other persons in need of protection. It examines the legal limbo created by States’ failure togrant a formal legal status to certain individuals—from ‘prima facie refugees’ left in refugee campsfollowing situations of mass displacement, to persons in western countries who are admitted to the Stateterritory but denied a formal legal status and access to rights.In mass influx situations, the price that States demand for admitting large numbers of refugees and asylumseekers is a de facto suspension of all but the most immediate and compelling Convention rights. Thoughpersons are prevented from being returned to persecution and serious harm, they are frequently left withonly a minimum of basic subsistence rights. A similar quality–quantity trade-off can be observed withrespect to ‘complementary protection’. While States generally acknowledge their extended nonrefoulementobligations under human rights law not to remove certain persons from their territories, such aspersons at risk of torture, they are reluctant to grant formal rights, particularly at an equivalent level toConvention status.Though the creation of codified regimes such as ‘subsidiary protection’ in the EU has partially remediedthis situation, new problems have emerged. By defining who should benefit from subsidiary protection,States have simultaneously ‘defined out’ other potential beneficiaries. Although States are entitled to limitthe application of subsidiary protection status to particular groups, they cannot override their internationalnon-refoulement obligations. Accordingly, they must still refrain from removing persons who face a realrisk of inhuman treatment, even where such persons are ineligible for subsidiary protection. The result is aprotection gap that creates a fragile legal and psychological predicament for excluded non-removablepersons.137.4. The Mental Health of Child Asylum Seekers in Australia: Legal, Ethical andClinical Challenges to the Policy of Mandatory DetentionLouise Newman, NSW Institute of Psychiatry, New South Wales, Australia(louise.newman@nswiop.nsw.edu.au)The policy of arbitrary indefinite detention of all unauthorised arrivals to Australia has been applied to over2000 infants and children including unaccompanied minors. Psychiatrists and mental health professionalshave been involved in assessing and documenting the psychological and emotional implications ofprolonged detention in depriving conditions and have urged the release of all children and their primarycaretakers into the community on the grounds of significant degrees of developmental compromise andmental disorder. Children have been exposed to riots, self harm and suicidal behaviour and show features ofacute and chronic post-traumatic disorders. There are major difficulties for parents in these environmentsand minimal ability to ensure child protection.Clinicians face ethical dilemmas when they attempt to support and treat mental disorders in the detentionenvironment and must consider their professional response in the face of government policy which isjudged to have harmful effects on mental health and development. Current legal challenges to detentionfocus on the punitive potential of this system and the concept of ‘psychological torture’ of long-termdetainees and children.

404137.5. Psychological Aspects of Caring after Human Rights ViolationsCornelia Seidl, Aspis Treatment Centre, Klagenfurt, Austria (aspis@uni-klu.ac.at)Refugees face multiple stressors and challenges after escaping from human rights violations in theirrespective countries of origin. Support and treatment share important aspects of interaction, that requirespecial care to avoid traumatizing or “re”traumatising feelings of helplessness in both the client and thehelper. Building “safe places” can be instrumental in the support of this vulnerable and frequently severelytraumatized group in different settings. The concept and “implementation” of such “safe places” isdiscussed with a special focus on transcultural aspects of the relationship.138. Rehabilitation of Forensic Patients138.1. Psycho-Forming Training As A Means Of Social Adaptaion Of OffendersMalkin Valeriy, Ural State University, Russia (Malkin@mail.lyceum.usu.ru)Usage of ordinary methods of psychic self-regulation (mental, psychological and self- training) in workwith offenders proves effective in the regulation of emotional states (decreasing anxiety and psychicstresses and increasing of emotional steadiness). Positive changes to personality over a long period of timeis possible, provided that such emotional alterations include a utlization of regulatory psychic mechanisms– systems of mental (motivating) purpose and emotional arrangements (they cannot be approached underthe circumstances of self- and mental trainings).Under such conditions, professionals can alter and form psychological characteristics such as: adequateself-assessment, self–confidence, ability to accept positive reflection, and overall decrease ofaggressiveness and conflicts.These psychological characteristics could provide offenders with social adaptation in their future life. Inorder to encourage development of these adaptive processes, we used psycho-forming trainings thatincluded psycho-technical exercises, and games and mental rehearsals of different psychic situations.Professional suggestions and self-suggestions were used to create the image of a self-confident person,ready to overcome able to fight for his/her goals. The most important and obligatory factor of increasing ofpsycho-forming training is the consolidation of goal formation in areas pertaining to labour, sport, creativeoutlets, and other spheres of activities.Our research revealed a great effectiveness of psycho-forming training; namely, our investigation revealedwhy it is very useful to use the process of formation in using such psychic qualities as adequate selfassessment,increasing of self –confidence, and preference of motivation, in order to reach success overavoiding failures, decrease fear of loneliness, and develop communicative qualities and purposefulness.Comparison of two groups of offenders, one of which was treated with psycho-forming training, revealedthat this group had better social adaptation than the group did not deal with psycho-forming training.

405138.2. Measurement Instruments for the Evaluation of Criminal Law PolicyEric Blaauw, Erasmus University (ericblaauw@hotmail.com)The Crown Council Rotterdam (The Netherlands) has recently decided to pay extra attention to theprevention of recidivism in four groups of offenders: (1) juvenile repeated offenders with at least oneviolent offence, (2) juvenile nuisance offenders, (3) adult repeated violent offenders and (4) adult repeatedoffenders with substance dependence. In the project, that is called the person-oriented approach; offendersare subjected to a prison sentence and to a conditional sentence during which, a treatment program starts.When offenders drop out of the treatment program or otherwise discontinue treatment, they are sent back toprison. Treatment consists of drug treatment, resocialisation projects, and/or mental health care. In theproject, cooperation exists between the Crown Council, parole organizations, and addiction careorganizations; these organizations assign a case manager to each offender in the project. The project isbeing evaluated by the Department of Forensic Psychiatry of the University Erasmus Medical Centre. Forthe evaluation, attention is given to the prevalence of general recidivism, specific recidivism as well as toreduction of nuisance, improvements in (mental) health functioning and decrements in criminogenicfactors. In the presentation, the project will be described as well as the instrument that was designed toevaluate the efficacy of the project.138.3. Violence in Dutch PrisonsErik Bulten, Dutch Prison Service, Vught, The Netherlands (E.Bulten@dji.minjus.nl)Prison guards are often confronted with violence. Compared with other professions, the prevalence ofincidents is third in line. This general picture will be evaluated. Misconduct, in terms of disruptivebehaviour during detention, is a serious problem. Besides some general issues about research in this matter,the situation seems to be worsening, in and outside the Netherlands. Some facts will be presented about thisworrying situation.Differentiation in regime (special units) is one of the answers for the question how to deal with prisonerswith mental disorders and prisoners with behavioural problems. Some data will be shown about prisoners inspecial units with regard to aggressive, violent behaviour. Because violence is also of growing concern tosociety, the potential of prisoner re-offence is a significant issue. A lot of prisoners re-offend. Based on newassessment procedures more programs will be developed to reduce the possibility of recidivism, accordingto the "what works" principles. ART will be one of the programs provided during detention.At the end of the presentation the connection between inside-oriented (prison misconduct) measures, andpolicy and out-side oriented (reducing recidivism) goals and policy will be discussed.

406138.4. Public Policy Regarding Forensic Psychiatric InpatientsJacqueline Kuyvenhoven, Custodial Institutions Service, Den Haag, The Netherlands(j.kuyvenhoven@dji.minjus.nl)Judicial interventions have to make society safer. Recidivism must be reduced, and preferably abolished.That is the political context in which detention under hospital orders (TBS) in the Netherlands is takingshape. Recent violent recidivism of forensic psychiatric inpatients has increased discussions in the lowerhouse and has put the TBS-system under pressure. The minister of Justice has to make very clear whatcontribution he makes to safety in society; that prescribes which activities are on the policy agenda duringthe next years. Risk assessment, risk management, leave arrangements and supervision during the gradualstages of returning to society are the current issues of major concern. In this presentation, I will give anoutline of the political context we experience and the package of measures we take to reduce the risk ofviolent recidivism.138.5. Community Based Forensic Mental Health Programs in the Netherlands: TheIntroductionHjalmar van Marle, Erasmus University (h.j.c.vanmarle@erasmusmc.nl)The developments in the Dutch maximum security hospitals, engaged in the provision of security, care andcure according to the Entrustment Act (TBS), have lead to the augmentation of their services. There arenowadays several forensic out-patient clinics for ambulatory treatment. The introduction of professionalpsychiatric and psychotherapeutic treatment in prison for a broad spectre of patients’ needs has beencompleted. Conditional release from prison and conditional sentences are agreed upon, that they shouldserve a mental health goal next to the one of security for society.An alarming finding is that 70% of all the TBS-detainees (1400 in total) have had an earlier career withinthe general mental health system. Most of them have co-morbid disorders as schizophrenia, drug addiction,and personality disorders. For many, the interventions of the general health system did not succeed inpreventing a down drift to criminality, drug addiction and violence. On the other hand TBS-detainees, whowere in need of care while no longer assessed as a danger to society, did not get a bed in a general mentalhospital. The fear for former offences to occur again overshadowed the whole clinical picture. So themaximum security hospitals were left with a population of psychiatric patients to whom they could offeronly a prolonged incarceration, but not the necessary extended treatment.This state of affairs, included both the ministries of the mental health system and the criminal justicesystem, with efforts having been undertaken to work together on a quid pro quo basis. The maximumsecurity hospitals should also take in violent psychiatric patients from the general health system, and thegeneral psychiatric hospital should arrange for more beds to be allotted to the rehabilitation of formerdangerous patients. Currently, this propsed blue print is implemented in the individual facilities accordingto different local histories (e.g. former co-operation) and situations (e.g. a nearby colleague), with no hurryfrom the government.From the forensic psychiatric field itself, the endeavour to integrate care and information is of growingsignificance, in tandem with the general urge to do so being offered every day in clinical practice.Psychiatric patients, who commit offences with violence like robbery, were sent with a treatment order to ahospital because of the risk they caused, and returned after a few days to the place of the offence, oroffended again. This is because, after only a few days, the hospital did not diagnose these individuals asdangerous enough for an involuntary stay or treatment, or the offered ambulatory treatment went astray

407because the patient did not show up at the follow-up contact. The mental health system was heldresponsible for a solution by the authorities. A co-operation between certain civil institutes (mentalhospitals, outpatient clinics, probation services, care for addicts, police, city health authority, youth care,social work and rehabilitation) was founded, and chaired by the Prosecution Counsel. This is called theForensic Psychiatric Circuit (FPC).A forensic psychiatric patient has the right to be in any of these institutions; all are responsible by a writtenagreement. Some institutions form a closer co-operation by multilateral covenants, to reach for a slidingscale of services (e.g. in-patient, out-patient, assertive community treatment, rehabilitation). A RegionalInstitute for Indications (RIO) therefore has a forensic psychiatric chamber to discriminate between theforensic institutions. An exception has been made for the TBS-maximum security hospitals, to which thepatient has been sent by the criminal court, and for the out-patient clinics that are totally financed by thehealth system.Detailed arrangements from the different care systems will be the subject of the other presentations in thissession.139. Relational Ethics in Forensic Settings139.1. Forensic Psychiatric Settings: A Crucible for Relational EthicsWendy Austin, University of Alberta (wendy.austin@ualberta.ca)Forensic psychiatry has been aptly described as a moral minefield. The competing obligations that lie at theinterface of the justice and healthcare systems raise questions about the very viability of a forensic ethic.The explicit need for security and detention and the implicit “untrustworthiness” of forensic patients shapethe everyday reality of forensic settings. Suspicion can color client-practitioner relationships withscepticism regarding motives and actions existing as the basic stance of both members. Fundamental careconcepts, such as patient advocacy, take on a different nuance in this milieu and may even seem alien to it.Despite the complex ethical demands of forensic psychiatric settings, they receive little attention withinmainstream bioethics. There is, however, a growing imperative to find a theory of ethics for the specialty. Ithas been argued that a set of principles (e.g. truth-telling and respect) be used to resolve conflicts inforensic settings. Others note that the socio-political aspects of forensic work require attention to thecontext of patients’ illness and life situation if practice is to be genuinely ethical. The use of narrative ethicsto augment principlism has been suggested. In this paper, a case is made for a different ethical frameworkfor forensic practice, that of relational ethics. Relational ethics is a developing ethic that emphasizesattentiveness and responsiveness to the practice environment and to the particular perspective and lifecircumstances of those involved. It makes room for the reality of competing demands (i.e., custody andcaring) to be addressed. Described are the elements of relational ethics (engagement, mutual respect,interdependent environment, vulnerability and embodiment) as they relate to forensic practice. It iscontended that forensic settings are the very place to test the validity of this applied ethic.

408139.2. What We Can Learn from the Story of "Typhoid Mary": Using the Framework ofRelational Ethics in an Exploration of Treatment Strategies When Working withHigh Risk Offenders in the CommunityTom Gorman, Forensic Assessment and Community Services, Edmonton, Canada (tomgorman@cha.ab.ca)Mary Mallon was an Irish cook who worked in New York State in the early 1900s. She was identified byepidemiologist, Dr. George Soper, as a healthy typhoid carrier. Mary Mallon did not believe she wascarrying typhoid and reacted angrily to Dr. Soper’s and later Dr. Baker’s approach; with the help of thepolice she was taken to a local hospital and reluctantly gave samples that confirmed typhoid. From 1907until 1910 The Board of Health placed Mary on North Brother Island and during that time the press labelledher as “Typhoid Mary.” Mary was released on the understanding that she would report to the Board ofHealth every three months and never cook again. In 1912 she disappeared. In 1915 typhoid broke out in amaternity hospital. Mary was discovered to be a cook there. Apprehended by the Health Department shewas returned to the island. Mary Mallon always resented the label “ Typhoid Mary” and never believedshe carried typhoid; she died on the island in 1938. 53 cases of typhoid and 3 deaths were attributed toMary Mallon. Dr. Baker said Mary’s “bad behaviour inevitably led to her doom.”As a therapist, Mr. Gorman works in collaboration with the police and probation services in themanagement of high-risk offenders in the community. Professionals have identified these clients asdangerous, as almost certain to re-offend and to be untreatable. They have been diagnosed as psychopaths,anti-social personality disorders, paedophiles, and sadists and on occasion “evil”. On their release to thecommunity, the media has labelled them as “High-risk Perverts,” “Predators,” “Dangerous to The Public,”“Deviants” etc. These clients are angry, resentful, do not trust the therapist, rarely take responsibility fortheir offences and have no empathy. They are a very real risk to society. Drawing comparisons with thestory of "Typhoid Mary", Mr. Gorman will explore treatment strategies using the core elements ofrelational ethics: mutual respect, attention to the environment, and engagement. He will discuss using theframework of relational ethics as beneficial in balancing the needs of these clients and those of society atlarge.139.3. Establishing Ethical Relationships within an Adolescent Sex Offender TreatmentProgramBrendan Walsh, Forensic Assessment and Community Services, Edmonton, Canada(brendanwalsh@cha.ab.ca)At Counterpoint, youths who have become closed and distrusting are expected to become honest and selfdisclosing.Youths who have been disrespected are expected to be respectful. Therapists must demonstratetrust and respect to youths with a history of deceit and deviance.In this 8-bed facility, youths convicted of sexual offences receive specialized treatment while serving acourt-mandated custodial sentence. Staff must establish and maintain a therapeutic relationship with theseyouths. This relationship is an intense one; youths reside in the program for at least 6 months, andparticipate in group work, individual counselling, school, life skills programming, and recreationalprogramming. Staff must be therapists, role models, and mentors, while simultaneously attending tosecurity concerns and behavioural issues. A youth failing to comply with therapeutic or behaviouralexpectations may be removed from this “open custody”, community-based programme to a secure facility.

409Can an effective, ethical, therapeutic relationship, based on trust and respect, be established and maintainedin such an environment? How will you know if and when you have one? Can youths ever be consideredwilling participants in treatment when onerous sanctions can be levied for non-participation? Can stafftruly consider themselves therapeutic rather than coercive when they clearly have such power at theirdisposal? What guides ethical decision-making?Within the context of relational ethics, and based on personal experience and conversations withcolleagues, Mr. Walsh will attempt to answer the above questions. He will discuss effective engagement ofhard to reach young people, and attempt to uncover what constitutes and guides an ethical therapeuticrelationship. He will argue that the relationship established between staff and youth is the key to thatyouth’s successful completion of the programme, and, consequently, to that youth making and maintainingsignificant life changes.139.4. Ward Atmosphere and ViolenceBert van der Werf, De Geestgronden Psychiatric Centre, Bennebroek, The Netherlands(b.vd.werf@geestgronden.nl)Aggression and violence, but also the subsequent constraint by nursing staff can easily contribute to ahostile ward atmosphere, not to mention the sometimes demolishing impact of long-lasting threats on teammorale. Based on research it is clear that aggression and violence have something to do with patientcharacteristics, but it is also evident that there is no one to one relationship, or with specific psychoticsymptoms such as hearing command voices, there is no clear cut blue print for treatment.Ward atmosphere has insufficiently been researched, because it is hard to sharply define and measurereliably. However, ward atmosphere is a feeling that experienced nurses notice at once, when they enter award.In this contribution, I want to go into the concrete and stable aspects of ward atmosphere, approaching it asa ward culture, with values, norms, coping strategies, beliefs on the crucial aspects of care, expectations onhow aggression is provoked and what stops it, and as a regimen, legal as well as informal. I will discusssome typical examples of a condensed form of ward culture, in relation to: early warning plans, the impacton coping strategies, and possible consequences when teams are faced with really difficult, aggressive andthreatening patients. I will end this contribution with some practical guidelines for team behaviour incomplex threatening situations.139.5. Relevance of Mental Health Issues and Mitigation in International Human RightsTrials (Pre-Conference)Scharlette Holdman, Institute for Human Rights Investigation, San Francisco, USAGeorge W. Woods, University of WashingtonThis is a proposal for developing a training, education, and skills acquisition program for attorneys, humanrights advocates, and mental health professions on the relevance of psychiatric issues to human rights asaddressed by state and international tribunals, governments and corporations, non-governmentalorganizations, and advocacy groups. Understanding mental health is especially critical for defense counsel,prosecutors, and jurists in state and international tribunals that conduct criminal proceedings against those

410charged with war crimes, crimes against humanity, and crimes that violate international law. Mental healthis relevant to all stages of defending persons accused of serious human rights violations, includingcompetency to aid and assist counsel, reliability and voluntariness of statements, waivers of any rights,ability to withstand conditions of pretrial confinement, culpability, factual innocence, mental state at thetime of the offense, and mitigating factors that explain otherwise inexplicable actions.Standard of CareThe foundation of any mental health legal claim is a reliable determination of the presence, severity andeffect of psychiatric illness on an individual. The reliability of the determination or diagnosis in turn restson three critical factors: the training, skill, and experience of the evaluating mental health professionals, thereliability and thoroughness of a social and medical history, and appropriate medical, neurologic, andcognitive diagnostic tests.The standard of care for defense counsel places on them the burden of investigating, preparing, andpresenting appropriate mental health issues to the trier of fact and sentencer. Protocol for investigating anddetermining the presence, severity and effect of mental illness on behavior has been developed throughaggressive litigation strategies by defense counsel in capital cases in the United States and codified in caselaw and guidelines by professional organizations such as the American Bar Association. The standard ofcare and protocol can be imported to the standard of care for counsel in litigation that involves humanrights issues.TrainingThe training program will be designed and conducted by a multidisciplinary and international team ofattorneys, mental health professionals, human rights advocates, and investigators with experience in capitallitigation and international or state tribunals that hear human rights cases. Training will cover the protocolfor investigating mental health issues, relevance of mental health issues to criminal proceedings, and lawand strategy of admissibility.140. Research Ethics I: Research Ethics and Clinical Practice140.1. Challenges for Governance of Human Genetic Databases and Implications forProspective Genetic Research in Mental HealthJennifer Fleming, University of Queensland (j.fleming@imb.uq.edu.au)The potential for prospective genetic mental health research (often referred to as “future/unspecified”research) in contributing to our understanding complex genetic diseases such as schizophrenia & treatmentregimes such as pharmacogenomics in behavioural disorders, mental health is inextricably linked to sound(ethical and legal) governance. Acknowledging that the international development of human geneticdatabases present new challenges to the legal, ethical and regulatory frameworks for human geneticresearch; a fundamental question we should ask is: to what extent? Collections of genetic biologicalspecimens, human DNA samples, tissue or other cell collections linked with related medical informationand other material to provide genetic data and thereby: (i) offer the promise of new knowledge andunderstanding in the way our genes interact with the environment along with advances in new diagnosticand treatment regimes and (ii) add a new dimension to traditional governance issues. This paper willprovide a brief overview of some of these challenges with the global emergence of human genetic

411databases (“genebanks” and “biobanks” as often termed) in the international and Australian context and theimpact on associated prospective genetic mental health research.140.2. Placebo-controlled Clinical Trials in SchizophreniaYuval Melamed, Lev Hasharon Mental Health Center, Israel (yuvalm@lev-hasharon.co.il)Avi Bleich, Lev-Hasharon Mental Health Center, IsraelClinical trials involving human subjects give rise to ethical and medico-legal dilemmas. Essential researchof new drugs may potentially expose patients to ineffective medications or to placebo. The complexity ofthe problem increases when dealing with mentally ill patients, for whom, on the one hand there is no knowncure for their disease, and on the other hand, it is sometimes questionable whether or not they are able toprovide informed consent to participate in clinical trials.The Israel Psychiatric Association decided to develop a position paper on the subject of placebo-controlledclinical trials in schizophrenia patients.Discussion groups were established, and the available material in the professional literature was examined,with an emphasis on recent developments. The Declaration of Helsinki and its amendments were analyzed,and experts in the field were consulted.Clinical drug trials for development of new medications are essential in all fields of medicine, especially inpsychiatry. The requirement for a placebo arm in pharmaceutical trials presents ethical and clinicaldilemmas that are especially complicated with regard to mentally ill persons whose free choice and abilityto provide informed consent may be questionable. On the other hand, we do not believe that thispredicament justifies unconditional rejection of placebo use in psychiatry, when it may provide substantialbenefit for some patients. At the same time it is our duty to provide stringent restrictions that will enablestrict supervision over the scientific, clinical and ethical aspects of the trials. The principle investigatorshould have formal training for conducting clinical trials. Qualifications for trial investigators are clearlystated in internationally recognized guidelines (ICH-topic E6, Guideline for GCP, Section 4.1,Investigator’s Qualifications and Agreements) as follows: The investigator(s) should be qualified byeducation, training and experience to assume responsibility for the proper conduct of the trial, should meetall the qualifications specified by the applicable regulatory requirement(s), and should provide evidence ofsuch qualifications through up-to-date curriculum vitae and/or other relevant documentation requested bythe sponsor, the IRB/IEC and/or the regulatory authority(ies).We propose the following criteria for approval of pharmaceutical trials that include a placebo arm:scientific justification; clinical and ethical justification; provision of informed consent; recruitment ofpatients hospitalized voluntarily; prevention of harm; administration of additional potential therapeuticinterventions; benefit to patients participating in the study; control and follow-up procedures for the studyas determined by the local Helsinki Committee; appointment of a supervisory mechanism by theadministration of the medical institution where the study is being performed.

412140.3. Integrating Values in Risk Analysis of Biomedical Research Part 1Duff R.Waring, York University (dwaring@yorku.ca)This paper will be presented in two parts by Drs. Duff Waring and Trudo Lemmens. The first presentationby Dr. Duff Waring will focus on a philosophical discussion of the role of values in framing risk analysesand the relevance of a risk cautious perspective in research ethics board deliberations. This presentationoffers a critical appraisal of risk assessments of new biomedical technologies with a particular emphasis ongene transfer and stem cell research. While the therapeutic and commercial potential of this research is wellpublicized, the normative and methodological problems pertaining to the assessment of its potential risks toresearch participants have received less attention. These problems are relevant to governmental agenciesand regulators and to Canadian Research Ethics Boards which have a mandate to ensure that risk toparticipants in biomedical research is minimized and proportionate to potential benefit. Dr. Waring buildson previous analyses of risk assessment as a value-laden, political exercise in regulatory science. He notesthat the parties to a risk debate can bring different value-frameworks to the process of biomedical researchreview and sees the potential for a conflict of interest if risk assessments are formulated exclusively by theparties who propose the research. They may be more prone to taking risks for the sake of possible benefits.In short, they might be much less risk cautious than some of the research participants who would assumethe risks. Dr. Waring argues for a review process that aims to balance the interests of those proposing riskwith the risk cautious interests of those who might assume it.140.4. Biomedical Research in the 3 rd World: Ethical Perspectives from 3 rd World PeopleDanielle Laudy, University of Montreal (d.laudy@umontreal.ca)Marius Kedote, University of MontrealBiomedical research subjects human beings to health hazards for the sake of the public good. This moralquandary has to be resolved. Many 1 st World countries (US, Canada, France, GB, Australia) have adoptedregulations and/or laws based on three principles: autonomy; beneficience, including non maleficience;justice in terms of free and informed consent from the research subject, proportionate risks and benefits,equitable distribution of both burdens and benefits of research. Now, the Third World countries arebecoming more and more concerned with biomedical research. In 2000, 27% of all drug applicationssubmitted by pharmaceutical companies to the FDA relied upon at least one foreign clinical trial. Thisnumber could be significantly higher today because of substantial savings in cost and time. The CIOMS isworking very hard to apply the ethical standards in local circumstances. Unfortunately, many difficultiesappear.The initial ethical review is fulfilled in the 1 st World, according to cultural traditions from the 1 st World.This sociocultural applicability cannot be appropriately adapted to fit the 3 rd World, because: anindividual’s free and informed consent has no meaning in a society where one’s role relies on the ties whichbind him to the group, in a community whose chiefs and elders are responsible for the personal well-beingof every member; proportionate risks and benefits are defined according to wealthy industrialized countries.Therefore, risks are under evaluated in the 3 rd World where human beings are still living in unhygienicconditions and dying of starvation under totally different circumstances than in developed countries. Inaddition, few if any research ethics committees exist in those countries. Such committees are usuallylimited to one person, for example a physician or the Dean of a faculty of medicine. These committeesdrastically lack scientific expertise and have a shortage of human and financial resources. It seems verydoubtful that they could identify Serious Adverse Events (SAE) or risks and, even less, find a remedy for

413them. From a utilitarian perspective, biomedical research would not be a top priority of the leaders of suchcountries. The presentation will include an explanation from the Deans of the Faculties of Medicine fromBlack Africa relating to their judgment about the state of biomedical research in their country, and theirsuggestions regarding health improvements for their people. This information was compiled throughinterviews and questionnaires collected in Black Africa by an African research assistant.140.5. Integrating Values in Risk Analysis of Biomedical Research Part 2Trudo Lemmens, University of Toronto (Trudo.lemmens@utoronto.ca)Following Duff Waring’s analysis of the role of values in framing risk analyses and the relevance of a riskcautious perspective in research ethics board deliberations, Trudo Lemmens will discuss three types of risksthat warrant a more stringent regulatory approach to medical research. These are risks of physical orpsychological harm to participants, risk to the objectivity and scientific integrity of research and risks tosocial values. The presentation will focus in particular on how conflicts of interests impact on scientificintegrity and may undermine important social values. The argument will be made that a new regulatory orlegislative model is required to deal with these risks. Our analysis will lead to the conclusion that a newregulatory model is crucial to restore the integrity of medical research and to rebuild public trust.140.6. Gender, Health and Research: Mapping the Regulatory IssuesBelinda Bennett, University of Sydney (belindab@law.usyd.edu.au)In the period since World War II there has been an increasing focus on ensuring that individuals whoparticipate in medical research are protected from harm. Concerns about informed consent, voluntaryparticipation in research and protection from unnecessary risks have all been key features of thedeclarations and guidelines that have been developed around the world. In recent years there has beengrowing literature on the need to specifically address issues of gender in medical research. There areconcerns that the under-representation of women in medical research may ultimately have adverse impactson women as there may be insufficient information about the implications of new treatments for women.One of the reasons why women have tended to be underrepresented in medical research is due to concernsover the potential impact of experimental treatment on a fetus if a woman is pregnant or becomes pregnantin the course of the project. This paper will consider the arguments around inclusion of women in clinicalresearch and will explore the regulatory challenges that arise in this area.

414141. Research Ethics II: Research Ethics and Clinical Practice141.1. A more critical eye: Using history to look at experimentation ethics betterGary S. Belkin, Bellevue Hospital Center, New York (Gary.belkin@med.nyu.edu)The contemporary discourse around experimentation ethics tends to emphasize certain themes, and tends tohighlight certain controversies. What gets attention, what gets framed as an “ethical issue,” reflects cultureand history? Core principles and concerns that animate debates in experimentation ethics either implicitlyor explicitly tend to rely on certain historical understandings of the unique value and contribution of amedical ethics movement starting in the roughly late 1960's, and how research practices, or abuses,evolved. Those assumptions about historical context crucially shape ethical commitments yet havegenerally been unsophisticated and superficial. I will argue that such prevailing understandings requiresignificant revisions. A more careful use of history instead offers more nuanced pictures as to how ethicalissues around research get raised, become important, and are understood, and thus allows a more criticaleye to the priorities and framework of contemporary conventional wisdom in this important area.141.2. Bayesian Methods applied to Ethically Optimizing Clinical Trials in MentalHealth ResearchGuillermo Diaz Pintos, University of Castilla-La Mancha, Spain (guillermo.diaz@uclm.es)Clinical trials begin from the general dilemma of the dual role of healer and scientist when conducting aclinical investigation. As healer, the physician is bound by various professional codes to act in the patient’sbest interest. As scientist, the physician’s main concern is to respect the scientific canons of validexperimental design, which may require that the physician sacrifice the goal of individualized besttreatment for statistical efficiency. The moral view of the doctor-patient relationship construed as anindividual rights-based ethical relationship is sharply distinguished from an “efficiency” or “utilitarian”approach. While the latter could justify an individual’s sacrifice for the greater social good, the rights-basedapproach is strongly “deontological”. There is a consensus among bioethicists that a set of ethical principlescan be drawn on to ethically assess new proposals for modified clinical trials. Bayesian probabilisticmethods applied to clinical trials in mental health research area may produce improved health outcomes forpatients while obtaining sound scientific data and accommodate both ethical and scientific imperatives.141.3. La Protection des Majeurs Inaptes au Niveau de la Recherche: Comment Définirles Frontières entre Bienfaisance et Injustice?Danielle Laudy, University of Montreal (d.laudy@umontreal.ca)Ethics in research pay special attention to vulnerable populations by setting up stronger protection againstpotential abuses. Quebec society has opted to inscribe this ethic concern in legislation. Article 21 of the

415Quebec Civil Code (1994) states precisely, in the case of a disabled person, consent related to research hasto be given by the tutor or trustee. A very clear distinction is thus established between consent for care by aspouse, next of kin or someone who shows a particular interest for the adult can give consent for thatresearch (art.15 Quebec Civil Code). A less strict amendment introduced in 1998 provides an exception inthe case of unexpected disabilities. The legislator chooses not to go further. The aim of this presentation isto establish the following basic principles:In real life, article 21 deprives a number of categories of patients from participating in research projectswhich may well benefit them. «Over-protection» translates as «injustice».It is important to rethink the parameters of «protection» aimed at the disabled from the following themes:definition of the risk level to which each research project subjects the disabled; proportionality betweenrisks and benefits for the individual and the group; importance of protecting and promoting the littleautonomy this person can still enjoy.Several alternatives will be submitted and discussed.141.4. Can Research Ethics Committees Approve Unlawful and Disapprove LawfulResearchPierre Mallia, University of Malta (pmallia@synapse.net.mt)This presentation is the result of a keynote talk presented in Privireal, an EU FP5 project, which had as itssubject data protection of genetic material.Research ethics committees were established in the post-war period to protect patient rights. As suchtherefore they are an international requirement, which over-rides any rules, which a country can impose.Although many countries are uniform in there legislation with respect to patient rights, this phenomenonmust not be overlooked or forgotten. It is argued therefore that notwithstanding our position being one oflegal positivism or realism, the same law in must protect a research ethics committee. RECs see thatresearch respects the normative values of society. There may be legislation that is unethical or evenimmoral to some, and other legislation that prohibits research that the committee feels is quite ethical. It isthen up to the researcher to take the necessary risks. RECs are not legal bodies in themselves and cannotgive legal advice. Neither are all the members legally qualified. Indeed one cannot use the fact of RECapproval to legalize his or her research. The function of the REC is prescriptive and not legislative.

416142. Risk Assessment I: Psychometric Developments in ForensicPsychiatry142.1. Violence risk Assessment as Pragmatic Science: The case for ContextualConsideration”Michael R. Davis, Monash University(Michael.Davis@med.monash.edu.au)James R. P. Ogloff, Monash UniversityOver the past three decades violence risk assessment has gone from being perceived as a futile endeavor toa viable practice with considerable predictive accuracy. This shift is due to substantial research activity andthe development of formal risk assessment schemes. These tools reflect a nomothetic level of analysis,identifying risk factors that reliably predict violence across cohorts of released individuals. These factorsare usually coded retrospectively from file information and thus focus on historical, dispositional, andclinical aspects of the individual. Therefore, the role of contextual factors in violence has been largelyneglected. Indeed, contemporary risk assessment tools are accurate in spite of the effects of context. It canthus be hypothesised that if contextual information is considered, particular historical or clinical risk factorsmay be more accurate in particular situations and less applicable in others. This paper views riskassessment as a pragmatic science, one driven by the need to understand and solve particular problems incontext. This is distinguished from the positivist search for universal laws. It is argued that the importanceof contextual factors must be acknowledged, particularly as predictive power in the contemporary literatureis reaching a plateau, with many risk assessment tools featuring similar predictors and comparable accuracyrates. The literature regarding contextual influences is reviewed and an empirical survey of clinicians’opinions regarding contextual variables is described. Both of these suggest similar risk factors and indicatethat practicing clinicians do consider contextual information important. Accordingly, strategies forconducting contextual violence risk assessment research are proposed, in order to provide an empiricalfoundation for future contextual consideration. It is argued that such research will need to consider theinteractive nature of previously identified contextual factors, as well as determine new risk factors thatremain hidden in large-scale nomothetic studies. The likely benefits of this focus for both clinical practiceand theory development are outlined. It is concluded that a pragmatic, idiographic approach to riskassessment can complement existing nomothetic knowledge and aid clinicians in developing thoroughformulations of violence applicable to the individual case.142.2. Factor Analysis of the Bumby Molesting Scale (1996)Véronique Muschang, University of Montreal (vero_muschang@yahoo.com)The relevancy of cognitive variables in the etiology and the maintenance of sexual aggression have beensought upon for some time by numerous researchers (Abel, Becker & Cunningham-Rathner, 1984;McGrath, Hoke & Vojtisek, 1998; Ward, Hudson, Johnston & Marshall, 1997). Even though researchers inthe sexual aggression domain have concentrated their efforts in the development of psychometric measuresof cognitive distortions (Abel & al., 1984 ; Abel, Gore, Holland, Camp, Becker & Rathner, 1989; Bumby,1996; Hanson, Gizzarelli & Scott, 1994), consulted literature (Abel & al., 1989; Arkowitz & Vess, 2003;

417Bumby, 1996; Burt, 1984; Cortoni, Gordon, Malcom & Ellerby, 1991; Finklehor, 1984; Hanson, Gizzarelli& Scott, 1994; Malamuth, 1984; Marolla & Scully, 1986; McGrath, Cann & Konopasky, 1998; Murphy,1990; Pollack & Hashmall, 1991; Stermac & Segal, 1989; Stermac, Segal & Gillis, 1990), reveals that fewempirical studies concentrate on this topic, the majority of published research concerns descriptive, clinicaland anecdotal reports. Bumby (1996) clarifies that the greatest difficulty lies in the psychometric deficiencyof the evaluation techniques. However, the Bumby (1996) cognitive inventory has excellent psychometricqualities. In fact, the internal consistency is excellent and the Alpha coefficient is .97. The test-retestreliability during a two-week period is of .84, which indicates an acceptable temporal stability. However,two bodies of research (Arkowitz & Vess, 2003; Rouleau, Barsetti, Lavallée & Tétrault, 2003) allow us toquestion the discrimination presented in the Bumby (1996) cognitive inventory of child abusers betweenthe child abusers and the control group when used in a clinical context. Moreover, the Bumby (1996)inventory is one-dimensional and does not possess a threshold that would permit the determination of thepresence or absence of cognitive distortions. These last questions were not approached by the author of theinventory. In this presentation, an exploratory factorial analysis of 200 child abusers having answered thisquestionnaire during the pre-treatment evaluation, will allow us to reveal the different factors measured bythe inventory.142.3. Risk Assessment among Belgian Forensic PatientsThierry H. Pham, University of Mons-Hainaut (thierry.pham@crds.be)This paper addresses the classical dimensional evaluation of three violent behavior prediction instrumentsin Belgium: The Hare Psychopathy Checklist (1991), the Violence Risk appraisal Guide (Webster et al.,1994) and the Historical-Clinical-Risk-20 items (HCR-20, Webster et al. 1997). We evaluated male adultoffenders and their respective clinical and institutional files. The population came from either (a) a highsecurity prison or a (b) forensic hospital.In the first part of the paper, we assessed the correlations between the type of offences and the differentscores of the three instruments. The population was composed of 80 offenders. The three instrumentscorrelated significantly to the violent offences like robbery, but not to murder or sex offences. It issuggested that these instruments are more related to instrumental than to reactive violence offences.In the second part of the paper, we assessed the predictive validity of each instrument for both general andviolent recidivism. We divided the population of 60 offenders in two parts by using the split median score.For each instrument, we compared the high score group vs. the low score group in term of predictivevalidity. Statistical analyses consisted in survival curves (log rank coefficient) and Receiver OperatingCharacteristics (area under the curve). The PCL-R, the VRAG, and the HCR-20 presented significant logrank coefficients for both and general and violent recidivism. The same instruments presented also amoderately large area under the curve (> to .70) for both general and violent recidivism.Finally, we assessed the correlations between the three instruments. This last result suggested that thePCL-R the VRAG and the HCR-20 presented a large common variance. It was particularly true betweenthe PCL-R and the HCR-20 total scores.The overall results rather encourage the use of these instruments in Belgian clinical settings. However, wecautioned that other epistemological exploitations of these instruments might be of interest. Moreover, toour knowledge the VRAG and the HCR-20 have not been submitted to a categorical approach. Such anapproach may clarify the complex relationship between risk assessment and mental disorders.

418142.4. Toward a Taxonomic Approach to the HCR-20Gilles Côté, Institut Philippe Pinel de Montréal (gilles_cote@uqtr.uquebec.ca)Sheilagh Hodgins, Institut Philippe Pinel de MontréalMarc Daigle, University of Québec at Trois-RivièresWidely used in the field of clinical forensic psychology, the HCR-20 Violence Risk Assessment Scheme isgenerally presented as a continuous/dimensional measure in scientific literature. The use of this instrumentin a dimensional/actuarial mode (addition of item scores) has traditionally been recommended for researchbut not for clinical practice. However, the guidelines for establishing a clinical judgment remain more orless defined. In practice, many clinicians resort to the total scores on the H, C, and R scales of theinstrument. Nevertheless, it is legitimate to question whether the dimensional approach is the mostappropriate for research purposes. Between June 1998 and March 2003, 178 individuals with a severemental illness (schizophrenia spectrum disorder, bipolar disorder, or major depression) were assessed usingthe Structured Clinical Interview (SCID-IV) and the HCR-20. Most were re-assessed at a two-year followup.Correspondence and cluster analyses revealed a typological approach to be better adapted than thedimensional approach in predicting violent behaviour considering the heterogeneity of the SMI population.These results open up new venues for analyses as well as for the conceptualisation of violence riskprediction in both research and practice.142.5. Trans-cultural Variations of the Structural Model of the Psychopathy Checklist inFrench-Speaking PopulationsFanny Malingrey, Institut Philippe Pinel de MontréalGilles Côté, Institut Philippe Pinel de Montréal (gilles_cote@uqtr.uquebec.ca)The structural model of the Psychopathy Checklist-Revised (PCL-R; Hare, 1991) continues to be a matterof contention among researchers in the field of forensic psychology. After a decade of reign by the twofactormodel developed by Hakstian, Harpur, and Hare (1988), Cooke and Michie (2001) disputed theoptimal number of factors in the PCL-R on the strength of more sophisticated statistical analyses. Theysuggested that a three-factor hierarchical model better accounted for psychopathy. Recently, Hareproposed a new model for the structure of PCL-R, in which the two initial factors were subdivided in twosub-factors (Hare, 2003). The purpose of this presentation is to clarify the structural model of the PCL-Rusing two French-speaking samples. Two types of statistical analyses (PCA) revealed that a three-factormodel rendered a better account of the structure of the samples. Second, cluster analyses were run on eachsample to establish a typology of the individuals assessed with the PCL-R. The results of these categoricalanalyses, which served to discern the discriminating characteristics of the psychopaths, challenge the use ofa cut-off score with the instrument. This trans-cultural study will contribute to enhance the validity of thestructural model of the PCL-R.

419142.6. Short term Predictive Power of SAVRY Violence risk Assessment in FinnishAdolescent Forensic PatientsMonica Gammelgard, Tampere School of Public Health, University of Tampere, Finland(monica.gammelgard@vvs.fi)Violence risk assessment is an important aspect for treatment planning and rehabilitation for youth withaggression and impulse control problems. The Psychiatric Treatment and Research Unit for AdolescentIntensive Care (EVA) admits youth with forensic background and/or violent and non-compliant behaviour.As a first unit in Finland, the EVA has adopted routine structured violence risk assessment using theSAVRY instrument. The SAVRY was translated to Finnish by the last author and pilot tested in the EVAunit. During the first 1.5 years of the unit’s being open, 24 adolescents aged 11-17 have been assessed withSAVRY. The SAVRY assessment takes places during the initial 2 months assessment period which aims atcreating an appropriate treatment plan with specific sensitivity to aggression management issues andincreasing self-control. All the adolescents assessed have displayed moderate to high overall risk, with anumber of items in high risk level, as is expectable given the nature of the unit. Associations betweenSAVRY risk estimate and violent behaviour during inpatient care are presented. Specific emphasis is givenfor the particularly difficult-to-manage aggressive behaviour displayed by young girls.142.7. Convergent Validity of Psychopathy in Belgian Antisocial Populations: Cognitiveand Emotional CorrelatesThierry H. Pham, University of Mons-Hainaut (thierry.pham@crds.be)Recently, Cooke and Michie (2001) developed a 3-factor hierarchical model in which a coherent superordinatefactor, psychopathy, is underpinned by three factors: Arrogant and Deceitful Interpersonal Style,Deficient Affective Experience, and Impulsive and Irresponsible Behavioural Style. The paper providesdata collected on male adult offenders coming from either a Belgian forensic hospital or a Belgian highsecurity prison.In this paper, we will first present the cognitive and emotional correlates between the 3-factor model andthe following cognitive and emotional self-report domains:• aggression (N=180) (the 4 factors of the aggression questionnaire of Buss and Perry, 1992:physical aggression, verbal aggression, anger, and hostility),• impulsivity (N=100) (the 3 factors of the BIS 11, cognitive impulsivity, motor impulsivity andnon-planning, Patton, Stanford & Barratt, 1994), and• alexithymia (N=100) (the 5 factors of alexithymia questionnaire of Bermond-Vorst, operativethinking, emotionality, definition of affect, and imagery, 1994) (N=90).• traumatic stress (N=100) as measured by the self-report measure of acute stress (StanfordAcute Stress Questionnaire, Gardena, 1995).Psychopaths have also been described as deficient in the selective attention and executive domain(Lapierre, Braun & Hodgins, 1995; Roussy & Toupin, 2000; Pham et al., 2003). However, no data havebeen provided yet on the cognitive domain of vigilance and sustained attention. We also present data onthe relations between the 3-factor model and the domain of attention as measured by the ContinuousPerformance Test-II (Conners, 2000). In this study, 60 male adult forensic patients were investigated. Theresults contradicted the global hypothesis of an attention deficit in psychopathy. This disorder is morerelated to selective attention and executive function deficit but not to vigilance and sustained attention.

420Finally, we discuss the potential heterogeneity tapped by the total psychopathy score of the PCL-R.Indeed, both the self-reports and experimental measures encouraged the conceptualization of separatefactors of psychopathy (interpersonal, emotional and impulsive and irresponsible behavioural style) incognition and emotional domains.143. Risk Assessment II: ‘Violence Profiling in ForensicPsychiatric Patients’143.1. Community Risks in Psychosis-Prevalence, Predictors and ManagementElizabeth Walsh, Institute of Psychiatry, London, England (sppmemw@iop.kcl.ac.uk)Deinstitutionalisation has resulted in multiple challenges for people with psychosis living in thecommunity. This includes the increased risk of committing violent acts and being the victim of such actscompared to others members of the population. Identifying interventions to reduce these risks require study.Aims: (1) To establish the prevalence of and risk factors for violent assault and violent victimization among708 urban dwelling people with psychosis; (2) To examine whether increasing the intensity of communitycare influences the prevalence of violence and violent victimization compared to standard community care.708 patients with psychosis were recruited and interviewed using a battery of research instruments.Patients were randomized to receive either intensive community care (ICM) or standard care (SCM) andfollowed for 2 years. The prevalence of violence and violent victimization were estimated and comparedbetween groups and baseline factors examined as possible risk factors for these outcomes.Twenty two percent of patients assaulted another person and 20% were the victims of assault over the twoyearperiod. Eighty patients (23%) in the ICM group committed assault compared to 78 (22%) in the SCMgroup (p=0.86, OR 1.08; 95% CI 0.78-1.44) whereas 54 (20%) in the ICM group and 67 (27%) in the SCMgroup were the victims of assault (p=0.04, OR=1.48; 95%CI, 1.02-2.22). Risk factors for assault includedillegal drug use, personality disorder, younger age, previous history of assault and violent convictions,being a victim of violence, and receipt of special education. Risk factors for violent victimization includedillegal drug use, less family contact, personality disorder, history of violent convictions and early age atonset of illness.Violence and violent victimization are prevalent in those with psychosis in cities. Increasing the intensity ofcommunity care reduced the prevalence of violence but not violent victimization. The implications of thesefindings will be discussed.

421143.2. Violence amongst Women with PsychosisKimberlie Dean, Institute of Psychiatry, London, England (k.dean@iop.kcl.ac.uk)Whilst men commit the majority of violence in society, the gender gap has been shown to be narrowedamongst those with mental illness. The presence of psychosis is known to increase risk of violence andsuch violence has been found to be associated with substance misuse, non-compliance with treatment,disorders of personality and the presence of specific psychotic symptoms. Little is understood, however,about the determinants of violence for women with psychosis. We thus set out to prospectively examineclinical and demographic predictors of violent outcomes over two years of follow-up in a communitysample of women with psychosis. Three hundred and four women with psychosis were recruited and theirprevalence of violent assault estimated using multiple data sources over two years. A comparison was madebetween those who were violent and those who were not, on multiple baseline socio-demographic andclinical factors to identify risk factors for violence. Overall, seventeen percent of the sample of womenphysically assaulted another person over the two years. A previous history of assault, previous non-violentconvictions, African-Caribbean ethnicity, a history of victimisation, high levels of unmet need and thepresence of Cluster B personality disorder were independently associated with assault. A positiveinteraction was found between African-Caribbean ethnicity and the presence of Cluster B personalitydisorder in terms of the impact on risk of violence. Violent women were also found to be more costly toservices than those who did not commit assault. In conclusion, we found that nearly one fifth of a sampleof community dwelling women with psychosis assaulted another person over the two years of observation.Established risk factors for violence such as a prior history of violence and co-morbid personality disorderwere found. In addition, factors such as violent victimisation, non-violent conviction and unmet needs forcare were found to be important. These may reflect sources of risk, specific for women and clearly requirefurther investigation. Substance misuse did not predict assault in the sample. The implications of thesefindings in terms of biological, psychological and social management will be discussed.143.3. Profiling Chronically Aggressive Behavior in State Hospital PatientsCameron Quanbeck, University of California at Davis (Cameron.Quanbeck@ucdmc.ucdavis.edu)Previous research on institutional aggression has viewed these patients to be a homogeneous group and hasstudied aggressive acts as unitary, e.g., one act of violence is equivalent to another. Because recent studieshave shown that patients commit aggressive acts for varied reasons, inpatient aggression appears to be amore complex phenomenon. Research has suggested that an aggressive act can be categorized by factorsmotivating the assault: (1) Impulsive, an assault committed in response to an immediate provocation andassociated with loss of emotional control; (2) Organized, a controlled, planned assault committed for aspecific purpose or goal; and, (3) Psychotic, assaults committed by an individual acting under the influenceof delusions, hallucinations, and/or disordered thinking. Our research has suggested that in addition tothese classifications, frequency of assaults may be an added category. Certain patients assault morefrequently than others and may exhibit different types of assaultive behavior. We will discuss: (1) theimpulsive precipitants, organized motives, and psychotic symptoms driving these different forms ofaggression; (2) if one motivating factor is predominant in causing the assaultive behavior of a patient overan extended period of time; and, (3) how subtypes of chronically aggressive patients differ in terms ofdemographic, clinical, and developmental correlates. How findings from this study have implications formanaging and treating chronically aggressive psychiatric inpatients will be discussed.

422143.4. Factors Associated with Types of Institutional Aggression: Is Gender an Issue?Barbara McDermott, University of California at Davis (bemcdermott@ucdavis.edu)One of the primary prediction issues in forensic psychiatry is determining if and when an individual will beviolent. This prediction generally involves determining the potential for future violence once the individualis released into the community. However, recently, actuarial instruments designed to aid in theseestimations of violence risk also have been used to identify patients more likely to exhibit aggressivebehavior while in the hospital or incarcerated. Recent studies indicate that the Hare Psychopathy Checklist– Revised (PCL-R) is one factor associated with higher levels of aggression both in the community and ininstitutions. For example, in the MacArthur study of violence risk, the PCL-R was the most importantfactor in distinguishing between low and high risk (of violence). Additionally, both anger and impulsivitywere associated with increased likelihood of violence. We prospectively evaluated 75 patients at NapaState Hospital committed as either NGRI or MDO using violence risk instruments, symptom ratings and theNovaco Anger Scale. Our preliminary findings indicate that aggression in the hospital is driven bydifferent factors, dependent on the gender and legal class of the perpetrator and status (staff versus patient)of the victim. Although there were no differences between either gender or legal class on the measures ofaggression and seclusion and restraint, variables that were associated with these measures differed by bothcharacteristics. For women, more characterologic problems were associated with aggression and thisaggression was directed primarily at staff, while for men, hostility was associated with aggression towardspeers and clinical issues were more predictive of aggression towards staff. Results will be discussedregarding implications for assessment and management.143.5. The Prediction of Community Outcomes of Forensic PatientsAdam Deacon, Forensicare, Brunswick, Australia (Adam.Deacon@Forensicare.vic.gov.au)Forensic Patients are patients who have been found not guilty of a serious crime (often homicide) on thebasis of mental impairment (formerly known as insanity), or have been deemed unfit to stand trial due tosevere mental illness. This study examines the risk factors for reoffending and rehospitalisation afterdischarge from secure hospital care for Forensic Patients detained under the Crimes (Mental Impairmentand Unfitness to be Tried) Act 1997 and its forerunner legislation. Subjects comprise all patients releasedfrom secure care at Forensciare inpatient services since the opening of forensic rehabilitation services inJanuary 1991, up until April 2002.Using only information known at discharge, patients are rated from case notes on clinical and psychosocialvariables, and scored on five rating scales, with supposed utility in predicting future violence. These ‘riskassessment instruments’ purport to offer significant advantages over unstructured clinical judgement aloneand may be used to judge appropriate timing of release from hospital, and for suggesting which factorsneed to be most carefully targeted in rehabilitation programs. The main outcome measures, obtained fromcase notes, are: time for reoffence; time for rehospitalisation; whether hospitalised or reoffence occudrredwithin 1, 2 or 3 years of discharge.Preliminary data will be presented.

144. Risk Assessment III: Risk Assessment in Forensic Practice423144.1. Predictive Validity of the German PCL-SVEmilie Bruß, Clinic for Psychiatry and Psychotherapy, Kiel, Germany (ebruß@zip-kiel.de)Christian Huchzermeier, Clinic for Psychiatry and Psychotherapy, Kiel, Germany,(huchzermeier@psychiatry.uni-kiel.de)In the last years, risk assessments have developed to a structured procedure by using validated instruments.In Germany, validation studies for instruments like the HCR-20 and the PCL are still in progress.In this prospective study, the predictive validity of the PCL-SV, German version, for intramural incidentswas examined: Prisoners of a German jail and patients of a special security forensic hospital were assessedwith the structured risk assessment instrument PCL-SV at the beginning of their incarceration. In the nextstep, two subgroups were formed—one representing the high-scorer (psychopaths), the other the low scorergroup (non-psychopaths). Both groups were studied in the sense of an extreme-group-comparison inrelation to the incidents in terms of sub cultural behaviour, physical violence, and other incidents duringtheir incarceration /hospitalisation.The first preliminary data of this study, including a follow up period of about 12 month, will be presented.So far we examined about 40 violent offenders who were inmates of a jail and a special security hospitalfor mentally disturbed offenders. Based on preliminary result, that offenders with a high score(psychopaths) showed significantly higher rates of intramural incidents. including violence behavior andsub cultural activities than non-psychopaths: thereby indicating that the predictive validity of the PCL-SVscores was found to be good.The main aim of this ongoing study is to make a contribution for establishing the predictive validity of theGerman version of the PCL-SV. These results will be discussed with regard to results of current Germanvalidation studies of other work groups (i.e. Stadtland, Nedopil, 2004), and with regard to studies that havebeen done before in North America.144.2. Structured Violence Risk Assessment with the HCR-20 in Forensic ClinicalPracticeVivienne de Vogel, Dr. Henri van der Hoeven Clinic, Utrecht, The Netherlands(vdevogel@hoevenstichting.nl)In this prospective study, the Dutch version of the HCR-20 (Webster, Douglas, Eaves, & Hart, 1997), aviolence risk assessment instrument, was coded independently by three rater groups—researchers–,treatment supervisors, and group leaders—for 127 male patients admitted to a Dutch forensic psychiatrichospital. During case conferences, the three independent raters discussed and agreed upon consensus scoresand the final violence risk judgment. HCR-20 codings were studied in relation to incidents of physicalviolence during treatment. The mean follow up period was 21.5 months.The aim of the study was twofold: (1) to establish the predictive validity of the Dutch HCR-20; (2) to gaininsight into differences between researchers and clinicians in the accuracy of their risk assessments with theHCR-20. The predictive validity of the HCR-20 consensus scores was found to be good to excellent. AUC

424values and Pearson correlations were highly significant for all subscales, the total score, and the final riskjudgments. We found no differences between researchers and treatment supervisors in predictive accuracy.Group leaders compared with the two other rater groups performed worse. The Clinical and Riskmanagement subscale scores and final risk judgment as rated by the group leaders were not significant inpredicting violence. Interestingly, the consensus between the threerater groups was most predictive.Implications and recommendations for structured violence risk assessment in clinical practice arediscussed.144.3. Putting Risk into a Clinical Context: A Formulation-based Model for Assessingand Managing Problem BehaviorsAndrew Carroll, Victorian Institute of Forensic Mental Health, Melbourne, Australia(Andrew.Carroll@forensicare.vic.gov.au)Christopher Drake, Victorian Institute of Forensic Mental Health, Melbourne, AustraliaThe past decade has seen an explosion of interest in the field of ‘risk assessment’ in mental health. Severalwell-validated, structured tools have been developed to assist in the assessment of risk, particularly in theareas of violence and sexual offending. Some include ‘dynamic’ variables, and so assist with management,as well as assessment of risk. Used on their own however, they lack the idiographic focus necessary toconstruct optimal assessments, and management plans.We intend to present a formulation-based “Problem Behaviour Model” which has been developed in the‘Problem Behaviour Clinic’ of the Victorian Institute of Forensic Mental Health in Melbourne, Australia.The model has been designed as a relatively simple heuristic framework to assist in making sense ofproblematic behaviours, such as interpersonal violence, stalking, sexual offending, fire-setting, and utteringthreats. It draws on various sources, including social learning theory, neurobiology, and cognitivebehaviouralmodels. It has been developed by psychiatrists and psychologists, and attempts to synthesiseideas from both disciplines. It includes both assessment and management stages, and is designed tocomplement, rather than compete with, more structured models based on nomothetic approaches. Themodel will be presented, utilising a typical ‘Problem Behaviour Clinic’ case history as an example.144.4. Prognostic Decisions in German Hospital Treatment OrdersLutz Gretenkord, Clinic for Forensic Psychiatry, Haina, Germany (Lutz.Gretenkord@psych-haina.de)In this paper the relevance of empirically based prognostic evaluations in German hospital order treatmentis pointed out. The paper has three parts:(1) Description of the legal background of German hospital order treatment and the Haina ForensicHospital. Prognostic evaluations are of utmost importance, because decisions on levels of security, leave,and release depend on them. Some decisions (for example level of security) are met by hospital staff, others(for example release) are met by court.(2) Decision processes regarding prognosis in the Haina Forensic Psychiatric Hospital. They include someredundancies for safety reasons; involved are the medical director, consulting psychiatrist, therapist, andnursing staff.

425(3) Empirical data. In the Haina Forensic Psychiatric Hospital structured risk assessment instruments (PCL,HCR-20) are applied. Subjects are 220 mentally disordered offenders treated during a 12 months period.Levels of security are related to the clinical and risk items (CR-10) of the HCR-20. There are robustcorrelations between CR-10 items and levels of security. The CR-10 seems to be a good indicator oftreatment progress. The use of the CR-10 has made clinical language more precise and treatment morestructured.The more refined decision processes regarding prognostic evaluations have had beneficial effects, forinstance in the last years the number of escapes has become much smaller.It is suggested, prognostic decisions must be optimized by applying well defined structured decisionmaking processes and using results of empirical research to prevent, as much as possible, incidents duringhospital order treatment and reoffending after discharge.144.5. Dynamic and Static Predictors of Risk in Dutch Forensic PsychiatryM.W.G. Philipse, Pompe Mental Hospital, Nijmegen, The Netherlands (m.philipse@pompestichting.nl)This paper discusses a study conducted in the Netherlands during the years 1996 through 2004, in anattempt to find dynamic predictors of reoffending risk in forensic psychiatric patients. The project was thefirst of its kind, in The Netherlands, to address the risk assessment theme extensively, the first to test theaccuracy of clinical risk assessments within the forensic system, and the first to do so in a multi-centreproject.A 47-item checklist of hypothesised dynamic risk indicators was constructed, on the basis of clinical input.Clinicians were also asked for a direct rating of perceived risk. Additionally, a second checklist was used torecord historical (static) data.The study was conducted prospectively in 7 forensic hospitals. Checklists were rated by the responsiblehead clinician for every patient discharged into the community in the years 1996 through 1998 (n=151).Final follow-up data on criminal recidivism were obtained June 2004. Additionally, inter-rater reliabilityand test-retest reliability studies were conducted.Checklists were factor analysed to determine if an underlying conceptual framework was present.Reliability was evaluated through intraclass correlation coefficients. Predictive validity was assessedthrough logistic regression and ROC-analysis.A six-factor structure was established for the dynamic checklist. Reliability findings were found to bevariable, though generally acceptable. Follow-up results showed that 19% of patients had been convictedfor a new violent or sex offence during an average follow-up of over 6 years. The final prediction modelcomprised four static and no dynamic predictors, and had good predictive validity. Direct clinicalassessments of risk were unrelated to outcome.Implications of findings and their relevance to clinical practice are discussed. It is also argued, the findingsmore realistically reflect the performance of a practically feasible, structured risk assessment procedure inactual clinical practice than those in many other studies. Some advantages and drawbacks of prospectivestudy designs are highlighted.

426145. Schizophrenia in Forensic PopulationsThis session explores the issues of schizophrenia, violence, substance abuse, psychopathy and riskassessment with data from a longitudinal study of patients with schizophrenia drawn from a high securitypsychiatric hospital in Scotland. It includes international comparisons of its findings and examines in detaila similar cohort from Australia.145.1. Identification and Outcome of Patients with Schizophrenia in a ForensicPopulationJonathan Steele, University of EdinburghLindsay D.G. Thomson, University of Edinburgh (L.D.G.Thomson@ed.ac.uk)Rajan Darjee, University of EdinburghJohn Crichton, Royal Edinburgh Hospital, Edinburgh, ScotlandTo date outcome studies in schizophrenia have concentrated on patients in the adult general psychiatricpopulation. This study considers those patients with schizophrenia drawn from a high security psychiatrichospital. It describes the treatment pathway and outcome of a cohort of patients with schizophrenia fromScotland and Northern Ireland detained in conditions of special security in 1992-1993.The progress of these patients over the subsequent years has been chartered by means of casenote review,patient interview, key worker interview and analysis of pharmacological, incident and Scottish CriminalRecords Office (SCRO) data. Results will be presented on the patients’ progress in terms of their socialfunctioning, location and recidivism. The nature and context of further violence in these patients will bedescribed. Ten years after the initial study 75% of patients continue to require hospital care, contrary to thetherapeutic optimism expressed initially.145.2. Risk Assessment in Patients with Schizophrenia in a Forensic Psychiatry Setting:The Predictive Validity of the VRAG, H-Scale (of HCR-20) and PCLRLindsay D.G. Thomson, University of Edinburgh (L.D.G.Thomson@ed.ac.uk)Michelle Davidson, University of EdinburghRajan Darjee, University of EdinburghThe assessment of risk of harm to others is an essential component of work in forensic mental health. Anumber of risk assessment tools have been developed in North America but require evaluation in aEuropean context. This study tests the predictive validity of the VRAG, the historical scale of the HCR-20and the psychopathy checklist in the prediction of further violence in patients with schizophrenia drawnfrom a high security psychiatric setting.A retrospective analysis of the case notes for 169 patients with a diagnosis of schizophrenia identified inthe State Hospital Survey was carried out and ratings made using these risk assessment measures. Data on

427outcomes in terms of recidivism (Scottish Criminal Records Office) and violent incidents were collectedfrom patients, carers, case notes and computerised incident recording systems.Seventy-eight percent of subjects were involved in some form of violent incident (defined as any actinvolving physical contact with another person, any sexual incident and any physical aggression toproperty) over the 10 years of the follow up period. These instruments failed to predict any violent incidentor serious incident (defined as physical violence resulting in injury, any sexual contact incident and any firesetting). They could not predict future violence in patients with frequently occurring incidents but there wassome predictive effect for frequently occurring serious incidents (AUC values: HCR-20 0.624; VRAG0.660; PCL-R 0.641). All three measures achieved moderate accuracy in predicting any recidivism (AUCvalues: HCR-20 0.714; VRAG 0.725; PCL-R 0.715) or violent recidivism (AUC values: HCR-20 0.755;VRAG 0.754; PCL-R 0.830).These instruments are of use in predicting long term risk of recidivism and violent recidivism. Moreresearch is required on the prediction of incidents of violence within an institutional setting.145.3. Schizophrenia and Substance Misuse in Forensic Psychiatric SettingsRajan Darjee, University of EdinburghJonathan Steele, University of EdinburghLindsay D.G. Thomson, University of Edinburgh (L.D.G.Thomson@ed.ac.uk)Over the last decade there has been increasing recognition of the importance of alcohol and drug misuse inpatients with schizophrenia, and in particular many studies have shown a significant relationship betweenschizophrenia, substance misuse and violence. However there have been very few studies of thisassociation in patients in high security psychiatric settings. This study compares patients withschizophrenia, drawn from a forensic population, with and without a history of substance dependence.Diagnoses of alcohol or drug dependence were made on the original cohort of 169 patients withschizophrenia drawn from high security psychiatric care using the St Louis Criteria (Feighner et al, 1972).A comparison was made of patients with and without a history of substance dependence and logisticregression used to determine those factors of greatest significance.Patients had high rates of substance dependence. Comorbid patients were more likely to be from the Westof Scotland, to have forensic histories, to suffer from affective symptoms and to have antisocial personalitydisorder. They were less likely to have negative symptoms, formal thought disorder, suffer from learningdisability and be civilly detained. Comorbidity was more common in patients who had been admittedrecently. In terms of outcome, comorbid patients were more likely to improve symptomatically and to bedischarged than were their non-comorbid peers. A similar proportion of each group was involved in violentincidents, but comorbid patients were responsible for fewer incidents. Comorbid patients were, however,more likely to be reconvicted.Substance misuse is increasing amongst high security patients with schizophrenia. However the resultspresented here indicate that the outcomes of comorbid patients are no worse, and are perhaps better, thantheir non-comorbid peers.

428145.4. Schizophrenia and Comorbid Antisocial Personality Disorder and/or Psychopathy:The Effect on OutcomeJohn Crichton, Royal Edinburgh Hospital, Edinburgh, ScotlandLindsay D.G. Thomson, University of Edinburgh (L.D.G.Thomson@ed.ac.uk)Rajan Darjee, University of EdinburghJonathan Steele, University of EdinburghThere is a clear body of evidence that personality disorder increases the likelihood of violence in patientswith schizophrenia. Little consideration has been given however, to factors other than violence, which areindicative of a patient’s outcome. This study examines the effect of the diagnosis of comorbid antisocialpersonality disorder (ASPD) and/or psychopathy on the outcome of forensic patients with schizophrenia.The St. Louis criteria (Feighner et al. 1972) and the Psychopathy Checklist - Revised were applied to allpatients in the cohort.Fifty six of the 169 patients with a diagnosis of schizophrenia had a comorbid diagnosis of ASPD. Thispresentation compares the outcome of patients with schizophrenia alone with patients with comorbidschizophrenia and ASPD, and patients with comorbid schizophrenia and psychopathy in terms of theircurrent placement, functioning and aggression.146. Screening and Diagnostic Assessments of Young Offenders146.1. Findings from a European Survey of Justice, Health, Education and Social Careand Legislative Responses to the Needs of Young Offenders with Mental HealthProblemsSusan Bailey, University of Central Lancashire (ntattersall@bstmht.nhs.uk)The challenge of early identification, assessment, treatment and ongoing needs for risk managed servicedelivery for juveniles in contact with the law and who have complex mental health needs, has long beenrecognised (Bailey & Dolan, 2004). It has been played out as it is in the punishment versus welfare debatethat has existed over the last 250 years. Within different legislative, policy and service delivery inindividual countries it is important to be able to compare core similarities and differences in the way wework with young people who offend, have mental health problems and who are all too often alienated fromand by our societies. Following on from our earlier study of adult mentally disordered offenders acrossEurope, the current study has collected data on the response to juvenile mentally disordered offendersacross Europe. The study was carried out by postal survey, followed up where necessary by further writtenand telephone questions, with key organisations and individuals across Europe. Fundamental differences inage of criminal responsibility, juvenile justice legislation and service consultation, stage of development ofmultidisciplinary child, and adolescent mental health services exist and there is an urgent need to bring

429together core underlying principles to ethical policy and equitable services, especially for diverse groupingsof ethnic minorities in each country.146.2. Measuring Quality of Diagnostic Assessment for Juvenile CourtNils Duits, Ministry of Justice, Amsterdam, The Netherlands (N.Duits@fpd.dji.minjus.nl)Juvenile forensic diagnostic assessment and advices for juvenile court as a basis for decisions can have farreaching consequences for juvenile delinquents and society. Improvement of quality and guidelines aretherefore needed. One can examine quality of the diagnostic assessment for juvenile court from theperspective of utility; users must define what they expect from quality. With a clear concept of quality andan organizational grip on the framework of the juvenile forensic system one can clarify quality and enablequality management.A double concept mapping consensus method has been used to clarify quality of juvenile forensicdiagnostic assessment for juvenile court. This has been done among (1) groups of ‘users’ (n = 57) and (2) agroup of ‘makers’ (n = 25) of these diagnostic assessments.This has enabled the development of a quality instrument for quality evaluation. This is needed forindividual means and supervision and for quality evaluation of diagnostic files. Problems and possibilitiesof the development and methodology of this instrument will be discussed. Preliminary results of researchwill be presented.146.3. The BARO.ch Screening for Adolescents with Anti-social Behaviour: A TwoyearFollow-upDaniel Gutschner, Institute for Forensic Child and Youth Psychology and Psychiatry,Bern, Switzerland(daniel.gutschner@ifkjb.ch)Klaus SchmeckTheo Doreleijers, Free University of AmsterdamThe BARO.ch is a semi-structured interview for detecting psychiatric pathology of juvenile offenders in thefirst contact with authorities. Furthermore, the BARO.ch gives indications for further penal and othersanctions.The aim of the first study was to examine the psychometric properties and the feasibility of the semistructuredscreening instrument BARO.ch. For this research the results of 125 delinquent juveniles wereused. Two years after the first assessment, the juvenile court gave information about the recidivism.The reliability and the interater reliability ranged from good to very good (α = .80 and r= .84) and thecorrelation between the psychopathology according to BARO.ch and the diagnoses according to the ICD 10turned out to be significant (r = .79; p < 0.001). In 15 % of the juveniles, the juvenile court took on nofurther legal measures and 60% were treated with psychotherapy. The recidivism rate was 67 % for thejuveniles, for which the BARO.ch suggested a psychopathology, and 71 % for juveniles with a psychiatricdisorder (n = 85).

430This study has shown that the BARO.ch has good psychometric properties. We also see that there areassociations between the psychiatric disorders and recidivism and between the BARO.ch analysis and typeof offences.146.4. Ascribing Criminal Responsibility to Young Offenders – Strengthening theMarriage Between Law and Developmental PsychologyMark Tyszkiewicz, Queensland University of Technology (tyszkiewicz@staff.bgs.qld.edu.au)In responding to juvenile offenders, it is highly desirable for a criminal justice system to meet, and balance,the needs of the victim, community, and offender. One important consideration for achieving this result, isthe process by which criminal responsibility is ascribed to young offenders.Whilst many jurisdictions world-wide rely on the attainment of a prescribed chronological age as the basisfor presuming that an individual has achieved sufficient cognitive and/or psychosocial competence to beheld responsible for his or her actions, there are wide fluctuations between jurisdictions as to which age ismost appropriate. Furthermore, within jurisdictions, the bases for prescribing particular ages are often notfounded on research data. One reason for this is that the disciplines of law and developmental psychologyhave traditionally not enjoyed a close relationship.This paper outlines a model which could be used by a jurisdiction in developing its criminal law responseto young offenders. By integrating developmental psychology and juvenile justice findings, the modelattempts to address the three hierarchical difficulties which often beset the ascription of criminalresponsibility to juveniles. The first of these difficulties is conceptual - in a given jurisdiction, does thereremain a need to afford special protection to juvenile offenders? The second difficulty is ascriptive -should there remain a need, and on what basis should the protection be afforded? The third difficultyrelates to application – if protection is prescribed by way of the consideration of an individual’sidiosyncratic developmental competencies, how can evidentiary fairness be maintained?The juvenile justice system in Queensland, Australia, will be used to illustrate the difficulties encounteredin ascribing criminal responsibility to young offenders and how the model may be applied.146.5. Falling Through the Cracks: The Care and Protection of Young People at RiskNeisha Shepherd, Children and Young Persons Legal Services, Newcastle, Australia(neishashepherd@bigpond.com)Increasingly, young people appear before the Children’s Criminal Court with significant personal problems,including complex mental health issues, substance use and past experiences of abuse and neglect. Theseyoung people between the ages of 10-16 years are particularly vulnerable and in need of highly specialisedcare placements. Whilst young people are afforded special protection in accordance with State Law and theUnited Nations Convention on the Rights of the Child, issues can arise concerning who is prepared to takelegal responsibility over these young people. Through case studies, this presentation will discuss theinterface between law, mental health, juvenile crime and child protection, as they relate to these youngpeople. In these circumstances, issues of legal responsibility may be challenged as arguments are madeabout the inability to provide alternate placements given the young persons behaviour and/or mental healthand attitudes. As a result, young people who face the criminal jurisdiction may find themselves remandedin custody, or if released on bail, homeless as they are unable to return to their families and cannot legally

431consent to an alternate care placement. It is these young people that may find themselves enmeshed in alegal battle as they seek the State’s intervention to assist them, because their safety cannot be otherwiseassured. To leave a young person at risk without protection from the State is to ignore the intention ofParliament in Australia, the proper interpretation of the law being the paramount interests of the youngperson, and the United Nations Convention on the Rights of the Child.147. Seclusion in The Netherlands147.1. The Process of Implementation of “The Quality Criteria in Using Constraint” in12 Dutch Psychiatric HospitalsTineke Abma, University of Maastricht (T.Abma@zw.unimaas.nl)In a former project eight criteria for good care concerning constraint were developed in collaboration withstakeholders in the field. The quality criteria are grounded in principles from the ethics of care –responsibility, respect, openness and dialogue (Berghmans, et. al., 2001). In a two year project, effortswere made to implement these criteria in twelve different institutions in The Netherlands. The selectedinstitutions vary in size, location, patient population and staff. The implementation of the quality criteriaimplies a cultural change in the hospitals, because constraint is a structural part of the daily practice. Achange in attitude of professional health care workers and relationships between professionals and clients isneeded.An evaluation study was completed to monitor and facilitate the process of implementation in theparticipating hospitals. Research activities included: (a) interviews with participants in the hospitals(project leaders, managers, nurses, clients), (b) four meetings with project leaders in which managerialissues were discussed, and (c) three meetings with clients from the participating hospitals to talk aboutclient-participation in the projects. The evaluation study demonstrated that the following factors contributedto the success or failure of the projects: (1) a sense of urgency, the persuasion among stakeholders that thepractice should and could be improved; (2) a coalition that took leadership in the process; (3) creativityamong practitioners; (4) support of the management in hospitals. Other relevant factors includecommunication and the visibility of small, but undisputed successes.147.2. The Use of Seclusion in Psychiatric Hospitals in The Netherlands: The influenceof Staffing LevelsWim A. Janssen, Kenniscentrum GGNet, Warnsveld, The Netherlands (Wim.janssen@ggnet.nl)Patients are still placed in seclusion rooms in Dutch psychiatric hospitals. Seclusion is a very invasiveapproach, which restricts patient's freedom. It is a method used only in extreme situations to controldangerous or violent behavior. Patients are then locked up in a specially designed seclusion room. Dutchnurses play an important role in the decision making process. The influence of nurses in the team (specificcharacteristics: staff complements; the number of nurses in the team; staff composition in regard to the

432number of males or females in the team, education level and experience,) on the use of seclusion is studiedby way of retrospective correlational research in four psychiatric hospitals in the Netherlands. It can beconcluded from this research that staffing factors, such as staff complement and staff composition, have alimited influence on the application of seclusion. The influence of the variables ‘staff complement’ and‘staff composition’ was very small on the admission wards. In long-stay wards, some influence could beidentified. This study describes the influence of variables such as ‘bed occupancy/staff ratio’, male/femaleratio’, ‘mean work experience’ and ‘spread in years of work experience’ in order to contribute to a betterunderstanding of staff complement and composition on the use of the seclusion.147.3. The Use of Seclusion and Restraint in The NetherlandsBert Lendemeijer, University of Maastricht (B.Lendemeijer@ggnet.nl)Giel Hutschemaekers, De Gelderse Roos, Wolfheze, The NetherlandsThe use of seclusion & restraint in the Netherlands is part of ongoing (international) discussion and debate.The use of seclusion is of particular focus of discussion. From an international perspective, the use ofseclusion in the Netherlands is a frequently used intervention and applied for longer periods of time. One ofthe results of the national discussion and debate is the need for changes and reform to hospital admissionpolicies. The studies described are primarily focussed on quantitative exploration of use of seclusion andrestraint during the years 1996 - 2003 and possible changes as results of the attempts to change practice.Research questions:What is the incidence of the registered use of seclusion and restraint in Dutch psychiatric hospitals duringthe years 1996 – 2003?What are the characteristics of the registered use regarding duration, frequency and content of theseinterventions?What are the demographic characteristics of patients involved?Which trends in time can be identified?A descriptive design was used in order to explore the registered use of seclusion & restraint in theNetherlands during the years 1996 – 2002 in twelve hospitals, and an attempt was made to describe changesin usage during 2002- 2003. Data was collected from the national database on the use of seclusion andrestraint; alternate data was used based on information from the individual databases of twelve psychiatrichospitals, involved in the Dutch project on coercion and compulsion. Descriptive analyses were carried outin order to explore the data and describe trends and changes during 1996 - 2003.More then 40 000 registered incidents of seclusion or other forms of restraint are described and analysedover the years 1996 – 2002, and more then 4000 incidents were analysed in the study regarding the use ofseclusion and restraint in twelve hospitals in 2002 and 2003. The results describe the use of seclusion andrestraint in the Netherlands, and some trends and changes can be identified. Characteristics of thisregistered use and the involved patients are described.Trends on the actual use of seclusion and restraint can be identified. Characteristics of the incidents and ofthe involved patients are identified. Conclusions on changes formulated as results of activities not reflectsubstantial data. One of the reasons for this is due to the validity of the collected data; registered data arenot always a reflection of daily practice. In order to understand identified trends and changes, moreinformation about daily practice needs to be collected. In order to make an adequate interpretation of thisquantitative study, we need to understand the relationship between the actual use of seclusion and restraintin daily practice as compared to the registration of use, as found in the databases. More efforts should bemade regarding this topic. In cases where the registered data was compared with information on dailypractice, a better understanding of practice and changes made can be observed. These studies show that it is

433possible to better collect data and draw more substantial conclusions on the seclusion practices on the levelof the individual hospital or unit and proves to be more difficult and thus more poorly obtained on anational scale.147.4. Explorative Qualitative Monitoring and Evaluation of Seclusion by Patients,Nurses and Psychiatrists: Keeping up the Critical DialogueBert Molewijk, University of Maastricht (B.Molewijk@zw.unimaas.nl)Ron Berghmans, University of MaastrichtGuy Widdershoven, University of MaastrichtThe nursing team of a closed ward with intensive treatment facilities executed a qualitative and explorativestudy on the actual quality of seclusion. The study was aimed at the monitoring and evaluation of seclusionincidents by patients and caregivers. Moreover, the study functioned as a means to continue the process of acritical dialogue on the quality of seclusion.Research questionsHow do patients, nurses and psychiatrists (or psychiatrists in training) evaluate the same seclusionincidents?With regard to the quality of seclusion, which topics need further elaboration in future structuralquestionnaires, staff-meetings and the actual seclusion policy?Which positive and negative process results are observed?A special research team on seclusion developed a semi-structured questionnaire with approximately 30items. After the ending of a seclusion incident, involved nurses and psychiatrists filled in the questionnaire.Patients filled in the questionnaire during an interview with the involved nurse. An independent universityresearcher analysed the collected questionnaires by means of an explorative descriptive analysis. Theanalysis was presented to the research team and the nursing staff as validity check. Afterwards, thequestionnaire was improved (shortened and focused).Ten seclusion incidents were evaluated by nurses, psychiatrist and patients during a period ofapproximately 4 months.The results for each research question will be discussed in detail. In general, questionnaires resulted in aremarkable insight in to the practice and policy of seclusion for the specific ward. Patients and caregiversdisagreed about the justification and quality of the seclusion. Surprisingly, most caregivers were satisfiedwith the seclusion procedures. Most criteria for seclusion were not described in detail, both for patients andcaregivers. The study revealed new possibilities to improve the practice and policy of seclusion.Even this small amount of seclusion incidents already caused a rich explorative qualitative analysis, whichgenerated important topics for further elaboration and discussion (such as: the need for more attention forprevention, creative alternatives, communication on concrete seclusion criteria, and effectiveness ofseclusions).Several results will be open for the discussion (such as: the pro’s and con’s of subjective or rigid guidelinesfor seclusion; indirect results & goals of the study; the degree to which caregivers’ subjective fears arejustified).

434147.5. The Nurse Consult, a Programme to Coach Staff Confronted with TraumaticAggression-on-duty, a Project on a Forensic Psychiatric Setting in AltrechtMargret Overdijk, Forensic Psychiatric Hospital Roosenburg, Altrecht, the Netherlands(m.overdijk@altrecht.nl)The project called “Aggression Coach” was started in November 2002 at the forensic psychiatric hospitalRoosenburg, as a result of many aggression incidents that took place at the hospital. A large number ofnurses were traumatised and injured because of these incidents. Because of the aggression and the violence,many patients were secluded for a long period; increasing seclusion and restraint were the only solutionswe had for the increasing number of violent incidents. But because many of the nurses were injured andstaff morale was decreasing, it was difficult to give all the patients the attention they needed, and there wasa big problem balancing security needs with treatment needs.The project started after we read the article “Reducing staff injuries and violence in a forensic psychiatricsetting” by E. Morrison. A nurse consultant (Aggression Coach) started by asking all the nurses to fill in aspecial report after an aggression incident; as a result of these reports, the Aggression Coach spoke with thenurses about these traumatic experiences. The goal was to decrease the fear of the nurses during their work.They would be able to take care of early physical interventions, thus preventing a physical attack. Theaggression management plans (signal plans) were made up for all the patients and they made it possible forthe multidisciplinary team to take the same early interventions. In these plans the patient is given choices,and less restrictive alternatives are tried before the use of seclusion and restraint. Also, the hospital starteddocumentating/measuring of all the aggressive and violent incidents of 6 patients, during one year. Becauseof all these interventions the number of aggressive incidents decreased by 30% after the one year period.The total number of days that patients were secluded for also decreased, by 30%. More significantly,perhaps was that the nurses feel much safer and more capable of finding the right mix of security withclinical treatment.148. Self-Destructive Behaviours in Prison I148.1. The Role of Impulsivity in Impulsive Aggression: A Prototype of Impulse ControlDisordersErnest S. Barratt, University of Texas (ebarratt@utmb.edu)Self-destructive behaviours in prisons are in general related to a spectrum of impulse control disorders. Thisspectrum of disorders includes, for example, anti-social personality disorder, borderline personalitydisorder, substance abuse, IED-M, and suicide. It is generally agreed based on research to date thatimpulsivity is common to all of these disorders and is one of the primary reasons that there is often a highco-morbidity among them. Impulsivity involves neural circuits related to self-control and behaviouralinhibition. The “impulses” or activating neural systems vary among the disorders. For example, impulsiveaggression is characterized by anger, hostility, and irritability as activators and involves the amygdala andselected neurotransmitters. The impulsive control system involves, in contrast, frontal inhibitory circuits

435and serotonin. These activation/inhibition systems can be out of balance in either and or both directions.This paper will discuss the multi-dimensional nature of impulsivity, the interaction of impulsivity withbehavioural activation mechanisms, and techniques for measuring both types of constructs. Recent researchinvolving the anterior cingulated cortex in monitoring decision-making and choice behaviours related toimpulse control behaviours will also be discussed.148.2. Identifying Suicide Risk in Penal InstitutionsEric Blaauw, Erasmus University (ericblaauw@hotmail.com)Taking up almost half of all deaths in penal institutions, suicide is the main cause of death among prisoners.It is not easy to distinguish suicidal inmates from non-suicidal inmates; many inmates are characterised byaspects that, in a normal population, would be indicative of an increased suicide risk (such as addiction,psychiatric history and past broken relationships). Therefore, it was necessary to examine thecharacteristics that distinguish inmates with a high suicide risk from 'normal' inmates. This was donethrough a research project consisting of a record’s study; the study focussed on the characteristics,conditions of death, and possibly identifiable signs of inmates, prior to the 95 suicides that had beencommitted in detention centres, prisons and special treatment (TBS) institutions in the period 1987-1997.The research project also consisted of interviews with 221 randomly selected non-suicidal inmates from theregular population of inmates in all Dutch penal institutions. Comparison of the characteristics of these twogroups showed that it was possible to construct a good screening device for suicide risk (consisting of eightquestions). abased on a rating scale with a demarcation value of 24 points, around 18% of all inmates, andup to 95% of the suicide victims were placed in the high-risk of suicide group. The presentation addressesthe method of the study, risk factors for suicide and the constructed screening instrument.148.3. Suicidal Behaviours and Severe Mental Disorders in Canadian DelinquentPopulationsMarc Daigle, University of Québec at Trois-Rivières (marc_daigle@uqtr.ca)Gilles Côté, Institut Philippe Pinel de MontréalSheilagh Hodgins, Institut Philippe Pinel de MontréalBelkasem Abdous, Institut Philippe Pinel de MontréalGeneral mental health condition of inmates and of their suicidal behaviour was investigated in a Canadiansample. We also looked at a specific sample of those having severe conditions who were liberated fromincarceration or involuntary placement in hospitals. Subjects were evaluated with a battery of tests andquestionnaires at time of incarceration, at time of liberation and two years later. On the whole, 520 subjectswere investigated at least once and 114 were re-interviewed at follow-up time. Results show the extent ofthe problems at the three times of observation. In addition, research showed that although these subjectswere incarcerated, hospitalized, and/or treated mainly because they had violent tendencies towards others,they also displayed violence against themselves. As for the 114 files that were re-opened for follow-up, 9subjects had died, and the majority of those deaths were of violent causes. This study concludes that it iscrucial to investigate all aspects of violence with this clientele, and not only the violence bringing them tocourts.

436148.4. Experiences with the Routine Administration of the Viennese Instrument forSuicidality in Correctional Institutions (VISCI)Parick Frottier, JA Mittersteig, Vienna, Austria (Patrick.Frottier@justiz.gv.at)Teresa MatschnigFranz KönigStefan Frühwald, Community Mental Health Services, St. Poelten, Austria(psd.fruehwald@stpoelten.caritas.at)The assessment and estimation of suicidal risk constitute a serious and difficult task for any mental healthprofessional. If we add to this, the challenges that may be presented by a specific population at higher risk,the task appears even more complicated.Since the beginning of the nineties, a research group investigated the phenomenon of prison and jail suicidein Austria. In a case control study all suicides in all Austrian jails and prisons between 1975 and 1999 wereinvestigated; all records of all suicides (n=220) were evaluated, plus records of the controls (n=440).The Viennese Instrument for Suicidality in Correctional Institutions presented here is based on the resultsof this case-control study and on research on literature examining suicide prevention in general, and withinthe prison population in particular. With suicide rates in custody being higher than in the generalpopulation, and given evidence that these rates have been increasing over the last 20 years, the screening ofpropensity to suicide for newly admitted offenders is necessary. Screening will assist in a betterunderstanding of this phenomenon, and will provide a valid estimation of the suicide risk in order tohopefully to stop further increase of suicide rates in jails and prisons. Screenings will be implemented asroutine assessment for every prisoner in all Austrian prisons, beginning in autumn 2005.We will present the first results of the pilot project: the routine administration of VISCI in a high securityinstitution for mentally disturbed prisoners in Austria.148.5. Results of a Case-Control Study of Jail and Prison SuicidesStefan Frühwald, Community Mental Health Services, St. Poelten, Austria(psd.fruehwald@stpoelten.caritas.at)Suicide rates in custody have been increasing during the last decades. Suicide prevention in correctionalinstitutions is difficult, because few risk factors and indicators of vulnerability are presently known. A casecontrol-studywas conducted to investigate the relevance of criminal history, psychiatric morbidity andsocial integration for suicides in prison. For every suicide that occurred in Austrian correctional institutionsbetween 1975 and 1999 whose personal record was available, two controls were selected to matchcorrectional institution, sex, nationality, age, custodial status, and time of admission. Several parameters ofthe subjects including psychiatric characteristics, previous suicidal behavior, criminal history, andindicators of social integration, were compared. Of 250 recorded suicides, 220 personal files were availableand matched to 440 controls. The most important predictors for suicide in custody were a history ofsuicidality (status post attempted suicide and suicide threat), psychiatric diagnosis, psychotropicmedication, a high violent index offence and single cell accommodation. Several more criminological,psychiatric and social parameters were unequally distributed between cases and controls, indicatingrelevance for suicide prevention in this high-risk setting. A significant finding is the importance of suicidalbehaviour for suicides in correctional institutions, which had been contradictorily discussed thus far. This

437case control study demonstrates the necessity for mental health professionals to take suicidal behaviour asseriously in custodial settings as in any other circumstances.148.6. A Comprehensive Approach to Inmate Suicide PreventionJane Laishes, Correctional Services of Canada, Ottawa, Canada(laishesjp@csc-scc.gc.ca)This presentation will address the Correctional Service of Canada's (CSC's) comprehensive multidimensionalapproach to addressing inmate suicide prevention. The suicide rate in Canadian federalprisons is 3.7 times higher than the rate within the general public. In CSC institutions, suicide is the secondleading cause of death after natural causes. CSC’s research has shown that inmates who attempted suicidedisplayed more severe maladjustment problems, had dysfunctional families, extensive psychiatric histories,extensive criminal histories, and discipline problems as compared to other inmates. They were also foundto have more problems adjusting within the institution. These findings suggest that inmates who attemptsuicide have a wide range of interpersonal difficulties and few coping skills. Further, most of the inmateshad expressed some type of suicidal ideation in the past, had made previous attempts, and had self-injured.The majority of inmates who commit suicide appear to have had psychiatric diagnoses or symptoms. Manyhad been recently transferred.CSC conducts a comprehensive investigation into the events surrounding all suicides. A psychologistparticipates in the investigation specifically to conduct a psychological review of the inmate. Within thecontext of the data collected from these investigations and CSC’s research findings, the presentation willhighlight what is being done to translate knowledge gained into improved prevention and interventionactivities in order to reduce the number of suicides. Specifically, four areas will be highlighted: policiestargeting detection, intervention and staff training; improved risk identification; health promotion activitiesincluding the Inmate Suicide Awareness and Prevention program; and improved investigation procedures.149. Self-Destructive Behaviours in Prison II149.1. Self-Mutilation and Suicide Attempt: Distinguishing Features in Male CustodialInmatesJohannes Lohner, Practicing Psychologist, Berlin, Germany (ou810@compuserve.de)Self-injurious behavior involving self-mutilation and suicide attempts by inmates while under custodialauthority is a major problem for prisons and jails (prevalence, legal obligation for suicide prevention, stressfor officers). The distinction of “serious” vs. “non-serious” and often manipulative suicide attempts asdistinct phenomena, each with its own clinical features is controversially discussed in current literature. Ifdistinct clinical presentations and histories can be observed, then an estimation of the seriousness of eachsuicide attempt can be simplified, and appropriate treatment of the individual case becomes possible.

438This study has 2 main goals: On one hand, self destructive individuals are compared to a matched controlgroup containing individuals showing no tendencies towards self-harm in order to find characteristics thatpredict future self-injurious behavior. On the other hand, inmates showing self-injurious behavior aredivided into subgroups of self-mutilators and suicide attempters (and mixed motive/ambivalent attempts)on the basis of intent. Afterwards, the clinical presentations of the individual inmates constituting thesubgroups are compared.100 inmates showing self-injurious behavior and a matched control group of 50 inmates are interviewedand tested with a variety of psychological tests (SCID, PCL-R, BDI, BHS, BSI, SIS, etc.) and their prisonand health files are examined. The groups are matched in terms of age and custodial characteristics.The study will be finished shortly before the IALMH-congress and first results will be presented in thesession.149.2. Bullying among prisoners: Understanding victim responsesJane L. Ireland, University of Central Lancashire (JLIreland1@uclan.ac.uk)Prison bullying research remains in its infancy when compared to the more established fields of school andworkplace bullying, with the first study into prison bullying published in 1996. Prison research although inits infancy is evolving, particularly with regards to the focus of studies. In recent years there has been amove away from merely describing the nature and extent of bullying towards a more detailedunderstanding of the intrinsic characteristics and behaviours demonstrated by those involved. This paperwill explore in particular, two victim groups relevant to prison bullying research, namely pure victims(those solely reporting being victimised) and bully/victims (those reporting victimisation and perpetration).A review of the literature will be presented that includes details of recent studies where the characteristics,both behavioural and intrinsic, of these groups have been explored. The paper will conclude by outliningtwo models that may prove of value in understanding victim responses in prisons, specifically the role offear and the application of social information processing. It will be argued that victims demonstrate a rangeof behaviours, including self-injurious behaviour and aggression and that these are motivated by fearresponses and represent an adaptive approach to social problem solving in a hostile environment. Thepaper will conclude with some directions for future research.149.3. Risk Factors Associated with Self-harming Behavior in Settings ofIncarceration __ Problems of Definition and PredictionNorbert Konrad, The Charite, Berlin, Germany (norbert.konrad@charite.de)Johannes Lohner, Practicing Psychologist, Berlin, Germany (ou810@compuserve.de)This presentation will review international literature on self-injurious behavior in prisons and jails over thelast two decades. These studies from a variety of countries investigated different samples (jails or prisons;female or male inmates). We only chose those studies, which used a comparison sample of non selfharminginmates. The results concerning potential risk factors for deliberate self-harm are contradictory toa large extent, because of the differences concerning selection of sample and dependent variables (selfharmwithout suicidal intent versus suicide attempt). Moreover, some methodological problems ofpredicting deliberate self-harm are discussed. This review is part of a larger project, which will be

439presented later on, at the congress (Self-Mutilation and Suicide Attempt: Distinguishing Features in MaleCustodial Inmates).149.4. Self-Harm in Prison: Prevention and Intervention Strategies – A Review of theCurrent LiteraturePeter Camilleri, Australian Catholic University (P.Camilleri@signadou.acu.edu.au)Morag McArthur, Australian Catholic UniversityThis project commenced as part of the Australian Capital Territory’s (ACT) Government preparation forthe establishment of a prison. The ACT is a geographically small jurisdiction that encompasses the NationalCapital of Australia (Canberra) with a population of just over 330,000. It does not have a prison as yet, andpeople sentenced to custodial terms are currently housed in a separate state of Australia. In developing aprison, the ACT Government wanted to learn from the experiences of other jurisdictions.A key issue for the management of prisons is the self-destructive behaviour of inmates. Inmates have amuch higher rate of both suicide and self-harming behaviour than the general population. Since the 1990s,the Royal Commission into Aboriginal Deaths in Custody has dominated the Australian prison systemagenda, making more than 330 recommendations. In Australia over the last decade, the prison populationhas doubled, the number of inmates with drug and alcohol addiction increased, there has been an increasein mental illness of inmates, lengthy sentences (‘truth in sentencing’ laws), privatisation of prisons and anincrease in suicidal behaviour as well as suicides.This paper explores what progress researchers and policy makers have made towards understanding andresponding to the problems of suicide and self harm in custody over the last 15 years. It also examinescurrent program initiatives and strategies for minimising self-harm. The common elements of successfulprograms are: comprehensive strategy for prevention, family support and visits, support form otherprisoners, support from prison officers; support from prison visitors, and an active and focusedrehabilitation program.149.5. Suicide Amongst Patients Admitted to a Medium Secure UnitStephen Barlow, St Nicholas’ Hospital, Newcastle-upon-Tyne, UK (Stephen.Barlow@nmht.nhs.uk)The risk factors of suicide in the general population have been well documented within the literature. Thedifficulty for professionals working in secure settings however, is that patients often manifest many of themore general risk factors associated with suicide. The challenge therefore is to identify the individuals atmost risk of suicide in this already high-risk sample. The present study utilised a control groupmethodology to examine the characteristics associated with suicide in a high-risk population. The details ofall patients admitted to a medium secure forensic psychiatric unit between 1976 and April 1995 wereexamined. Death certificates were obtained on those patients who had died prior to October 1997. Thosepatients who received a Coroner’s verdict of suicide or an open verdict were included in the study group.Controls were drawn from the remaining patient population, matched according to time of admission to theunit. Significant group differences emerged on demographic and personality characteristics. Theimplications of these finds are discussed in regards to risk assessment and intervention.

440150. Semiotics and Social Significance of Violence150.1. Media Images, Signs, and the 'Hyper-reality' of the Predatory PsychopathicOffender: The Case of Aileen WuornosBruce Arrigo, University of North Carolina at Charlotte (barrigo@email.uncc.edu)Media manufactured images abound. As semiotic theory reminds us, these representations are signs:floating and evolving meanings exchanged in a digitized, technologically expansive, and mass mediatedinformation culture identified as the “ultramodern.” Conceptually speaking, the insights of Jean Baudrillardhave been most influential in drawing society’s attention to this phenomenon. Other French social theoristswho have contributed to this semiotic enterprise include Lyotard, Lacan, Foucault, Derrida, Deleuze, andGuattari. Collectively, they remind us that the postmodern condition of our time necessitates new forms oflogic, reasoning, and knowing. These alternative vocabularies of sense-making are critical if we are tocomprehend the operation of the political economy, and its marginalizing effects, in the hyper-real andvirtual information age.One example of this phenomenon relevant to law and psychology is sexual offending and serial killing. Inthe context of Aileen Wuornos, the recently executed predatory serial murderess, a plethora of sign imageshave been (and continue to be) conspicuously consumed by the public. The most conspicuous sources forthese sign images or simulacra come from such media outlets as Cable TV, the Hollywood film industry,radio broadcasts, newspapers, and the Internet. Interestingly, though, the consumption of these images assimulations, begs several questions about the appearance-reality dichotomy, especially given ultramodernsociety. For example, the meaning of the psychopathic sexual offender, especially for the public, is reducedto stylized, hyper-real visualizations; counterfeit re-presentations of the factual or authentic. This thesis, inrelation psychology, law, public policy, and their nexus, has tremendous implications for the psychopathicoffender, as well as other so-called ‘criminals’ (e.g., sexual offenders). In short, reality implodes, meaningis vanquished, and knowledge is territorialized. What is ‘consumed’ in a technologically sophisticatedinformation culture are the sign images for the predatory serial murder. These imitations are reified, indeedlegitimized, through psychology’s efforts to establish the science of offender profiling and the law’s effortsto legislate human behavior (SVP statutes).150.2. Discursive Struggles over Meanings after the Aotearoa Domestic Violence Act(1995)Mandy Morgan, Massey University (c.a.morgan@massey.ac.nz)This paper provides a brief introduction to a programme of psychosocial research focused on how serviceproviders in Aotearoa/New Zealand understand violence against women in the home subsequent to theintroduction of Domestic Violence Act (1995). The programme includes analyses of interviews withwomen and men who have made use of interventions for stopping violence and as well as informationcollected from doctors, police officers, and lawyers. In each study, the focus has been on identifying howthose involved in interventions into domestic violence are also involved in struggles over the meanings ofthe phenomenon, and how these struggles affect intervention. The theoretical and methodologicalframework that informs the research strategies of the programme is described briefly. A summary of eachstudy is presented and the implications of the findings for discursive struggles within the fields of

441intervention and service provision are discussed. The paper concludes with a discussion of threeproblematics that emerge from understandings common to all studies in the programme.150.3. Psychoanalytic-discursive Construction of Subjectivities in Te Rito (2002),Aotearoa/New Zealand Government Policy for Domestic Violence PerpetratorInterventionPeter Branney, University of Leeds (p.e.branney@leeds.ac.uk)Changing the Subject (Henriques, Hollway, Urwin, Venn, & Walkerdine, 1984) offered two main turningpoints relevant for this paper. The first was a critique of the assumptions in psychology around theunderstanding of what it is to be a person—that is, subjectivity. In particular, they looked at what thisassumed subjectivity implied, for example, combating racism. The second presented a critically reworkedpsychoanalytic approach for theorising an alternative subject. I will argue that we need to continue to askhow subjectivity is reconstructed, especially in institutions that govern responses to men’s violence. Asone way of doing this, I shall outline a critical psychoanalytic discursive approach to reading theconstruction of subjectivities (Parker, 1997). The focus will be on a recent Aotearoa/New Zealand policyfor domestically violent men (Te Rito; 2002), while considering some implications of the subjectivitiesconstructed within.150.4. Narrative Form and the Morality of Psychology’s Gendering StoriesLeigh Coombes, Massey University (l.coombes@massey.ac.nz)This paper reads particular fragments of poststructuralist theory to constitute a narrative epistemologicalposition that enables questions of the morality of psychology’s narratives of gendered subjectivities.Drawing on the work of Lyotard (1984) and White (1987), I theorise narrative form as complicit with moralorder and the morality of subject positioning. I then question the positioning of a particular woman througha narrative telling of her psychology. The specific narrative is the judge’s summation in a murder trialwhere the case is defended through a plea of insanity. The accused woman’s psychology is told throughreference to trial evidence: the expert testimony of psychologists and psychiatrists. Fragments from thejudge’s summation and from expert testimony are read to exemplify the moral order of the positioning theyenable and constrain. The implications of this reading for interventions in terms of the social powerrelations of legitimate psychological knowledge are discussed.150.5. Powers, Pain, and the Injustices of RapeNicola Gavey, University of Auckland (n.gavey@auckland.ac.nz)Historically, the psychological impact of rape on women has been of little interest to the law or widersociety. Since the 1970s, however, the psy-disciplines and the women’s movement have converged todocument the traumatizing potential of rape. “Rape trauma syndrome” was documented by Burgess and

442Holmstrom in 1974, and more recently the broader notion of ‘posttraumatic stress disorder’ (PTSD) hasbeen employed to describe the impact of rape for some women. While this has clearly been important forthe recognition of women’s pain and harm through the injustice of rape, here I draw on Foucauldian ideasof discourse, power, and governmentality to argue that this relatively new recognition has potentiallydouble-edged effects. For instance, when it is required by authorities to be documented before statecompensation or civil remedies can be awarded; or, even more perniciously, when it is required by courtsas evidence that a crime of rape has occurred (see Des Rosiers, Feldthusen & Hankivsky, 1998). Currentpractices such as these deploy recognition of the trauma of rape in ways that contribute to itsdepoliticization and, arguably, to shoring up the very binarized notions of gender that support rape and itsinjustices in the first place.151. Sentencing of Juveniles Who Commit Serious Offences151.1. Young Criminals in Prison: Actual Dutch Policy and PracticeFrans Douw, Forensic Observation and Treatment Department of the Dutch Prison System, The Hague,The Netherlands, (fdouw@multiweb.nl)Giancarlo Fornaro, Policy Department of Youth Facilities, The Hague, the Netherlands(G.Fornaro@dji.minjus.nl)In Holland we are now facing one of the largest transformations of our juridical system in twenty-fiveyears. Our prisons and youth facilities are too expensive and, at the same time, need to be more effective.Why is our youth criminality increasing? We do not really know. We see children with low IQs becomingschool dropouts. Parents often are not capable of keeping their authority over them, but we also seecriminality committed by children of very strict and severe parents. We notice an increase of diagnosedPDD-NOS amongst children who are admitted to the youth care.In Holland, we hardly know anything about the effectiveness of all the (very expensive) different measureswe take to attack youth criminality. A few years ago we identified a group of young adults (18 till 23 yearsold) and put them in separate, so-called ‘JOVO – departments’ in our adult prison system. Currently, anevaluation of this approach is being carried out, and the expected outcome is fairly predicted. Within thisgroup we see individuals with a very long history of police contacts, alternative sanctions and sentences.They have to be approached in a very strict way to keep order in the prison, and it is not advisable tonegotiate about house rules. At the same time, individual support and training sometimes can be successful.The biggest problem, inside the prison and on the streets, is the role of group behaviour on the actions ofthe individual, which demands a violent reaction for every insult or act of ‘disrespect’ and a tough attitudetowards authorities.This paper will review the status of Dutch policy and practice concerning young incarcerated people.

443151.2. Holding Youths Responsible: What Neuroscience and Psychology Tell Us aboutAdolescents’ CulpabilityThomas Grisso, University of Massachusetts (Thomas.Grisso@umassmed.edu)In the U.S.A., significant legal reforms in the 1990s have greatly increased the sentences and other negativeconsequences for youths found guilty of delinquencies in juvenile court. In addition, changes in laws inmany states made it easier to try youths as adults in adult criminal courts, lowering the age for ‘transfer’ tocriminal court (often to 12 or 13) and increasing the range of offences for which this may be done, so thatyoung offenders receive adult sentences if found guilty in adult criminal courts. This has become the focusof intense national debate in the U.S.A. In 2004, the U.S. Supreme Court decided whether individualstried in criminal court for offences while they were adolescents could be given the death sentence. [Thecase was not decided at the time of this abstract, but will be reported at the conference.] Recent findingsthat approximately two-thirds of youths charged with offences have serious mental disorders has increasedthe debate concerning whether the legal reforms of the 1990s went too far.To inform this debate, many developmental researchers in the U.S.A. have summarized recent evidencethat adolescents typically do not have the capacities of adults to make decisions that take into consideration(in an adult-like way) the consequences of their behavior. This presentation will review the evidenceassociated with these summaries. It will focus on recent research based on magnetic resonance imagingconcerning neural development of the prefrontal lobe and executive functions, as well as evidenceregarding cognitive development, emotional development related to impulse control, and psychosocialdevelopment.The sum of these results suggests that adolescents (at least until 15 or 16 years of age, on average) areimmature in their decisional capacities compared to adults (on average). The implications of these resultswill be discussed, especially their use in theories of youths’ culpability. On the one hand, are those whouse the data formulating the argument that youths should be held “less culpable” for their offences becauseof their relative immaturity. On the other hand are those who argue that youths’ lesser maturity, when theyhave committed very serious crimes, only portend greater dangerousness when they have matured andtherefore warrant full adult sentences, so that youths who “do adult offenses” should pay “adult penalties”for the sake of public safety.151.3. Mental Disorders among Juvenile OffendersEileen Ryan, University of Virginia (er3h@virginia.edu)Juvenile offenders have a significantly higher rate of mental illness than adolescents in the generalpopulation. Research findings indicate that at least 60 percent of incarcerated youth have a major mentaldisorder (not including conduct disorder). Several studies indicate that the prevalence of mental disorderamong female offenders is even higher than in male juvenile offenders. Untreated psychiatric disordersmay contribute to, or exacerbate criminal behaviour in both youth and adults, by a variety of pathways.Developmental immaturity, especially in the areas of judgment and decision making are crucial areas forforensic evaluation and research. However, there has been little scientific inquiry into the influence ofmajor mental illness (especially affective and anxiety disorders) on the decision-making processes ofadolescents who engage in criminal behaviour, as well as the potential additive effects of mental illness anddevelopmental immaturity on other issues of crucial legal importance, such as competence to stand trial andculpability. The wave of legislation in the United States aimed at facilitating the transfer of youth fromjuvenile to adult court has advanced far more rapidly than the research into vulnerabilities of such youth.

444Despite considerable advances in our understanding of psychopathology among adolescents, mentaldisorders remain under diagnosed and untreated, particularly in the offender population. Despiteempirically validated treatments for both mental illness and conduct disorder, the goal of rehabilitation hasincreasingly given way to punishment without appropriate treatment. The state of the field with respect theprevalence of mental illness among adolescent offenders and treatment will be presented. This presentationfocuses on the implications of trying youth with mental disorders as adults, as well as the importance ofthorough psychiatric evaluation with a developmental perspective of transferred youth.151.4. Issues in Transfer from Juvenile to Adult Criminal Court in the United StatesChristopher R. Thomas, University of Texas (crthomas@utmb.edu)Beginning in the 1980’s, forty of the United States changed procedures to facilitate the transfer of casesfrom juvenile to criminal courts in response to rising youth violence and crime. Transfers that werepreviously decided by judicial review are now required by statute or sought at the discretion of theprosecutor. This presentation describes the legislative and judicial development of procedures for transferto adult criminal court and reviews several studies investigating the impact of the various changes.Research reports indicate that the changes in transfer did not always fulfill their intended goals and oftencreated unintended consequences, such as a disproportionate impact on minorities. The implications ofthese findings are discussed.151.5. The Israeli Legal Approach Towards Sentencing of mentally disordered juvenilesAssaf Toib, University of Virginia (atoib@mscc.huji.ac.il)The presentation will introduce the approach of Israeli law to the treatment and sentencing of juveniles whocommit offences. The first part of the presentation will focus on the Israeli therapeutic approach concerningtreatment of juveniles. In this part, the key term minor in need will be explained and its application tojuveniles who suffer from mental disorders will be discussed. The second part of the presentation will focuson how this therapeutic approach affects the sentencing of both juveniles in general and juveniles whosuffer specifically from mental disorders. In the last part of the presentation, a comparison between theIsraeli and the American legislation concerning sentencing juvenile offenders will be offered.151.6. ‘Manifest Madness’: Change and Continuity in the Insanity DefenceArlie Loughnan, London School of Economics (a.e.loughnan@lse.ac.uk)This paper examines the development, construction and operation of the insanity defence in England andWales. The paper focuses on the history of the insanity defence in attempting to understand the role of thecontemporary insanity defence in the criminal law on a more general basis. The insanity defence is usuallyunderstood 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

445through 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’ ratherthan ‘medicalised’. I argue that the key to understanding the development of the insanity defence lies not intheoretical binaries but in lay understandings of mental illness. This often neglected aspect of the insanitydefence goes some way toward explaining change and continuity in this area of the law.152. Sex Offenders I: Key IssuesThe management and treatment of sex offenders has been evolving over the past thirty years. It has becomea specialty in not just the mental health field but in criminal justice and corrections as well. The mostcurrent approach to sex offender management and treatment calls for all fields to bring their knowledge andarea of responsibility together in a team approach to management and treatment sex offenders. This sessionis comprised of 5 experts in their area of sex offender management and treatment with a 30-yearperspective. We will be discussing some of the key elements of sex offender management and treatment.152.1. Sex Offender Risk Factors and the Underlying Character PathologyBarry Anechiarico, The Counseling and Psychotherapy Center, Needham, USA (Barryatcpc@aol.com)This panel presentation will discuss the risk factors most correlated with sex offender recidivism andexamine the character pathology underlying sexually exploitative behaviour. Static and dynamic riskfactors in sex offenders has been researched extensively in the past several years and has identified a clusterof factors in sex offenders that indicate intimacy deficits and difficulty regulating strong negative emotionalstates. The study of self-esteem development and trauma recovery provide useful theory to betterunderstand the underlying character disorder in sex offenders. Addressing the character risk factors in sexoffenders—intimacy deficits, self-esteem deficits, behavioural and emotional dysregulation has been anongoing challenge in the field. By understanding the character pathology of sex offenders as stemmingfrom a fundamental attachment disorder and ensuing narcissism, we can draw on cognitive behaviouraltreatment interventions aimed at the issue of pathological narcissism. Narcissism is a character trait thatcuts across several diagnostic categories. By definition narcissism is the lack of empathy for the experienceof others and using others as a means to one’s own ends. Sexual exploitation is a narcissistic act. The workof both cognitive-behaviourists and object-relation-theorists are useful in developing therapeuticinterventions to address the narcissism in sex offenders. The research and theory underpinning thisperspective will be discussed in this presentation.

446152.2. Enhanced Relapse Prevention and the Role of Deviant Arousal Reduction in theManagement and Treatment of Sex Offenders in the CommunityTim Sinn, Massachusetts Treatment Center for Sex Offenders, Needham, USA (Sinnapse@Msn.com)This panel discussion will describe an enhanced relapse prevention model of treatment, R.U.L.E.(Responsible, Understanding, Learning, Experience). This model addresses both the behaviour disorderand the character disorder in sex offenders. The four RULE model components are basic principles ofchange. There are several important risk factors that are addressed in this model. While an offender’s denialof his offending behaviour (Responsibility) is an obstacle to an offender’s full recovery, denial has recentlybeen found not to be a significant recidivism risk factor for offenders who are in treatment. There are manyother more significant risk factors that reduce risk if addressed in treatment even while an offender is indenial. These factors are included in this treatment model and are considered part of the relapse preventionplan. This model also includes a treatment progress tracking system that provides treatment progressinformation to the offender and the community containment team.In this presentation the role of deviant arousal reduction and medication interventions will also be discussedas key factors in sex offender management. This prevention model combines not only core risk factors butborrows clinical perspectives for the fields of violence prevention, addictions treatment, and the treatmentof abuse and trauma.152.3. Specialized Sex Offender Parole and ProbationRichard Gaskell, The Counseling and Psychotherapy Center, Needham, USA (GaskellHallman@aol.com)In this panel presentation the role of the specialized sex offender probation and parole unit in themanagement and treatment of sex offenders will be discussed. The containment model of the managementand treatment of sex offenders in the community has become the state of the art of sex offender treatment inthe community. Issues to be covered include: special conditions for sex offenders; information therapistsand probation and parole need to share; what acute dynamic risk factors are relevant for communitysupervision; what is the containment approach; what is the role of polygraphy in the supervision andtreatment of sex offenders. Probation and parole need to be especially cognisant of the acute dynamic riskfactors in sex offenders.Acute risk factors constitute the daily and weekly changes in the sex offender’s internal and externalenvironment that increases their risk to re-offend. These risk factors include the following: Emotional RiskFactors (feeling alone, constant worrying, feeling entitled, feeling depressed, emotionally repressed);Cognitive Risk Factors (deviant fantasies, homicidal or suicidal thoughts, thoughts of using drugs/alcohol,thoughts of using pornography); Interpersonal Risk Factors (exaggerating stories, taking a victim stance,showing off/bragging, snap judgments about others, having to win/be on top); Physical Risk Factors(personal hygiene, not sleeping/sleeping too much, upset stomach, nervousness, fidgety/biting fingers, selfharm); Self-statement Risk Factors (“It’s no use”, “I will never…”, “Nothing is going right”, “If Ionly…”). The use of these factors and other risk factors applied to community sex offender supervision willbe discussed in this presentation.

447152.4. Decision Making for Sex Offender Community AccessDennis McNamara, The Counseling and Psychotherapy Center, Needham, USA (DENNISatCPC@aol.com)In this panel presentation, the role of the specialized sex offender probation and parole unit in themanagement and treatment of sex offenders will be discussed. The containment model of the managementand treatment of sex offenders in the community has become the state of the art of sex offender treatment inthe community. Issues to be covered include: special conditions for sex offenders; information therapistsand probation and parole need to share; what acute dynamic risk factors are relevant for communitysupervision; what is the containment approach; what is the role of polygraphy in the supervision andtreatment of sex offenders. Probation and parole need to be especially cognisant of the acute dynamic riskfactors in sex offenders.Acute risk factors constitute the daily and weekly changes in the sex offender’s internal and externalenvironment that increases their risk to re-offend. These risk factors include the following: Emotional RiskFactors (Feeling alone, Constant worrying, Feeling entitled, Feeling depressed, Emotionally repressed);Cognitive Risk Factors (Deviant fantasies, Homicidal or suicidal thoughts, Thoughts of usingdrugs/alcohol, Thoughts of using pornography); Interpersonal Risk Factors (Exaggerating stories, Taking avictim stance, Showing off/bragging, Snap judgments about others, Having to win/be on top); PhysicalRisk Factors (Personal hygiene, Not sleeping/sleeping too much, Upset stomach, nervousness,Fidgety/biting fingers, Self harm); Self-statement Risk Factors (“It’s no use” , “I will never…”, “Nothingis going right”, “If I only…”). The use of these factors and other risk factors applied to community sexoffender supervision will be discussed in this presentation.152.5. Community Corrections: The Successes and Failures in Developing a Continuumof Care for Sex Offenders from a Secure Setting to the CommunityTim App, Northeastern University (t.app@neu.edu)This panel presentation begins with the premise that sex offenders are sentenced to prison, parole, andprobation as punishment not for punishment. This is the guiding principle of respectful sex offendermanagement. This presentation will look at the Massachusetts Community Correctional program andreview the requirements that were set for sex offenders before they could access community correctionsand what their requirements were once they were in the community. Institutional sex offender treatment isthe beginning of comprehensive sex offender management and treatment. Risk reduction cannot beeffectively measured until the inmate starts to work his relapse prevention program in the community. Thisapproach to sex offender community treatment and management is designed to provide containment of sexoffenders who are in the community. Effective treatment and management of sex offenders in thecommunity requires a team of stake-holders. This team includes treatment providers, probation and paroleofficers, and victim advocates. In addition, sex offender management in the community needs to useinterventions such as the polygraph, phallometric assessments, Abel screen, home monitoring, and otherarousal reduction behavioural and chemical interventions. This presentation will review Massachusetts’start and stop with such a program and look ahead to Maine’s new initiative to create such a program.

448152.6. Constructing an Explanatory Model of Child Sexual AbuseLouanne Lawson, University of Arkansas (lawsonlouanne@uams.edu)There is considerable information on child sexual abusers’ cognitive distortions (Marshall, Hamilton, &Fernandez, 2001), social skills deficits (Valliant, Gauthier, Pottier, & Kosmyna, 2000) and patterns ofoffending behavior (Hudson, Ward, & McCormack, 1999). However, while we know something about howoffenders isolate themselves and their victims, gratify their sexual appetites, and justify their actions(Lawson, 2003), we have limited understanding of why they do so. Offenders’ deficits have been carefullystudied but their strengths are not as well understood. Understanding offenders’ strengths is important notonly because such understanding builds a foundation for victim and offender treatment, it also helps societyprotect vulnerable children from offenders who use their strengths to continue to engage children sexuallyand to hide their actions.As child sexual abuse prevention and identification efforts shift toward sex offender registration, riskassessment and community notification, an explanatory model (Kleinman 1980) of child sexual abuse fromthe offender’s perspective, including what causes it, why it starts when it does, how long it lasts, what itdoes to the offender, what offenders fear, and what it would take for the offender to stop, would contributesubstantially to efforts to develop a coordinated system for preventing, predicting, and remediating theeffects of child sexual abuse. Therefore, this study is designed to:• Describe the offenders’ perspectives on aetiology, timing, effect, severity, duration, fears,problems, and interventions related to child sexual abuse (Kleinman, 1980).• Identify the linkages among the offenders’ strengths and deficits, in relation to their sexuallyabusive behaviour.It is part of an ongoing program of research examining the relationship between offenders’ and therapists’explanatory models of child sexual abuse with the goal of further developing sex offender treatmentmodels. The study is in progress.153. Sex Offenders II: Law, Justice and Therapy153.1. Regulation of Sex Offenders after Prison On the Cheap – The Texas ApproachMichael J. Churgin, University of Texas (mchurgin@mail.law.utexas.edu)Texas has embarked on a scheme to treat convicted sex offenders following the end of their prisonsentences different from that employed by other states. When legislators first proposed to create a civilcommitment scheme for in-patient services for sex offenders following their sentences, the fiscal noteaccompanying the bill indicated the cost would be prohibitive. The Texas Department of Mental Healthand Mental Retardation indicated it would need a new facility with staff to administer such a program.Therefore, the proposal died, and a program of close monitoring on parole along with registration of sexoffenders was implemented.

449Subsequently, the legislature enacted a law that provides for civil commitment – outpatient commitment forthis population. To be eligible, you had to have been convicted of two prior felonies. Once placed onoutpatient commitment, if you violate one of the treatment plan’s conditions, you will face a newly createdfelony. Since Texas has a habitual offender scheme, if you are convicted of violating the condition of thetreatment plan, you face incarceration for from 25-99 years.The statute has been in force for a few years, and there have been several court decisions by intermediateappellate courts of the state. One has found the statute unconstitutional, while others have upheld it. Thispaper will examine the operation of the scheme and explore the legal issues.153.2. Loathing the Sinner, Medicalizing the Sin: Why Sexually Violent PredatorStatutes are UnjustJohn Douard, Rutgers University (douard@rci.rutgers.edu)In fifteen states, persons convicted of one or more sexually violent offenses may be involuntarily civillycommitted at the end of their criminal terms if they suffer from a mental disorder that renders them likely tore-offend sexually. Facially, these statutes place the burden on the state to show that the sex offender meetsthe Constitutional standard of dangerousness. The key to proving dangerousness is the proof of a mentaldisorder. However, the United States Supreme Court (Kansas v. Hendricks, 521 U.S. 346 (1997); Kansasv. Crane, 534 U.S. 407 (2002)) recently found that the sort of mental disorder that must be proven need notbe the sort of mental illness required for involuntary civil commitment in the states that have promulgatedsexually violent predator laws. All that must be shown is that the sex offender has a “mental abnormality”or “personality disorder” that affects his cognitive, emotional or volitional capacities such that he is highlylikely to sexually recidivate.As anyone who has worked with these statutes knows, the vague notions of “mental abnormality” or“personality disorder” used to justify involuntary civil commitment are nothing more than pretextsdesigned to ensure that convicted sex offenders are incarcerated as long as possible, in the most shamingconditions possible. Later in the paper, I will describe those conditions in some detail. First, however, Iwish to characterize what I regard as the real function of sexually violent predator statutes, and why Iconsider that function as tending inexorably to produce unjust outcomes in a democratic political culture.My thesis states that statutes purporting to civilly commit sex offenders on the ground that they suffer frommental disorders that render them at high risk to reoffend are expressions of fear, hatred and disgust: fearand loathing. Disgust is a fear of contamination, and in this context, it is a fear of contamination by personswho engage in sexual conduct that forces us to confront our animal natures. We don’t merely hate the sin;we hate the sinner, and we want the sinner to be removed from our presence. However, disgust is notsupportable by public reasons, and laws that express disgust are likely to result in the unjust treatment ofsex offenders as incapable of acting as free and responsible agents.

450153.3. The Importance of Personality and Sexual Vicitmization in Forensic Inpatientswith a Sexual OffenceManuela Dudeck, Ernst-Moritz-Arndt-University (manuela.dudeck@uni-greifswald.de)Sven Barnow, Ernst-Moritz-Arndt-UniversityCarsten Spitzer, Ernst-Moritz-Arndt-UniversityMalte Stopsack, Ernst-Moritz-Arndt-UniversityMichael Gillner, Ernst-Moritz-Arndt-UniversityHarald J. Freyberger, Ernst-Moritz-Arndt-UniversityStudies in the forensic psychiatric context indicate that persons in prison and psychologically disturbedsexual offenders have a high degree of traumatic experiences. Their socialisation and, above all, their ownacceptance of risk during sexual attacks play a decisive part. In addition, the diagnosis of a personalitydisorder, particularly in Cluster B according to DSM-IV, has been discussed in recent publications aspredicting sexual offences. The aim of this study was to investigate the extent to which the diagnoses andtraumata of sexual offenders differ from those of non-sexual offenders.Against this background, 51 male, forensic psychiatric patients at two forensic clinics in Mecklenburg/WestPomerania, Germany, were examined. Various self-evaluation questionnaires served to ascertaindissociative and general psychopathology and interpersonal problems and to specify their temperament.These data enabled us to compare the variables recorded for sexual and non-sexual offenders.No links were found between sexual offences and forensic or socio-demographic variables. Nor was itpossible to identify any differences in dissociative and psychopathological factors between sexual offendersand non-sexual offenders. However, the comparison between these groups showed that the former morefrequently reported sexual abuse in their biographies and the diagnosis more frequently indicated anarcissistic personality disorder. But the logistic regression analysis coupled with age pointed to only onesexual abuse in childhood as a significant factor.To summarise, our data show that sexual abuse in a person’s own earlier history was the only pointer tocommitting a sexual offence. This supports the idea that one’s own traumatic experiences are reproducedlater and indicates the significance of dealing with traumatic experiences in childhood for this group ofoffenders.153.4. The Evaluation, Treatment, and Legal Disposition of Sexually Violent Predatorsin the United States: A Current OverviewDaniel P. Greenfield, Seton Hall University (dpgfldmd@msn.com)Richard I Friedman, Office of the Public Defender, Newark, New JerseyJohn Douard, Rutgers UniversityIn the United States, since the landmark legal decision of Kansas v Hendricks in 1997, a great deal ofclinical, legal, and law enforcement time, interest, and effort have been devoted to paraphilics adjudicatedand institutionalized (via civil commitment) as ‘Sexually Violent Predators’.

451This interdisciplinary panel will present a current overview of the clinical evaluation, classifications, andtreatment of sexually violent predators, and of the (quasi-criminal) disposition of such individuals in theUnited States. The interactions of clinical and legal issues with these individuals often present ethical anddiagnostic dilemmas: Those issues will also be addressed by this panel.First, definitions and subtypes of ‘Paraphilias’, ‘Sex Offenders’, and ‘Sexually Violent Predators’ (‘SVPs’),and variants of those conditions are presented and discussed. Next, diagnostic assessment of individualswith those conditions, including current approaches to testing and clinical evaluation, will be reviewed.Third, the two broad treatment approaches to the paraphilias—therapeutic/behavioural andpharmacotherapeutic—are reviewed, the former emphasizing behavioural interventions, and the latterdiscussing selective serotonin reuptake inhibitors (‘SSRIs’), androgenic hormonal, and anti-epileptic drug(‘AED’) approaches. This clinically-focused part of the presentation will be a predominantly didacticformat, using visual aides and a lecture presentation format.The second part of this presentation emphasizes legal and ethical issues in working with paraphilics, sexoffenders, and SVPs, from a practical perspective. This part of the presentation departs from the didacticformat, and consists of a panel discussion among Dr. Douard (an attorney and academic philosopher), Mr.Friedman (an attorney also trained in social work), and Dr. Greenfield (a physician/psychiatrist).153.5. Telling Her Story: Assisting the Accusing Witness in Sexual Assault TrialsEilis S Magner, University of New England (emagner@metz.une.edu.au)The accusing witness in criminal trials for sexual assault often finds the process of testifying a horrendousordeal. Where the witness is exposed to cross-examination by the accused in person or where the witness isrequired to testify at a second trial, the horror may become overwhelming. In the context of the Skaf case inNSW, the accusing witness has been faced with both prospects at different times. In 2003 the NSWlegislature enacted the Crimes (Sexual Offence Evidence) Act to protect accusing witnesses from crossexaminationby the accused himself. It has been held that the procedure did not cause a miscarriage ofjustice. In 2005 the same legislature is considering a proposal to allow video tape from a first trial to beused in a retrial. While these proposals clearly serve the therapeutic interests of the accusing witness, thequestion is posed whether they serve the interests of justice. The author advocates giving the accusingwitness some control over whether she will testify in person but queries whether the use of videotape willbe effective.

452154. Sex Offenders III: Law, Justice and Therapy II154.1. Sex Predator Laws and the Preventive StateEric S. Janus, William Mitchell College of Law (ejanus@wmitchell.edu)Prof. Carol Steiker warns that the United States is verging toward a “preventive state” in which the stateattempts to “identify and neutralize dangerous individuals before they commit crimes by restricting theirliberty in a variety of ways”. Sex predator laws are a key example. Enacted in 16 states, and underconsideration in two more, these laws are among the most aggressive challenges to the balance betweenliberty and security in liberal democracies. This paper will explore the limits of the preventive state and theimplications of the sex predator laws. This paper will argue that the civil rights revolution of the past fiftyyears has cabined the preventive state in significant ways. But the war on terrorism following the 9/11attacks has produced new pressures to strengthen prevention. The sex predator laws provide a model forexpanding the preventive agenda. This paper will argue that the predator laws are dangerous because theyundercut the key ways in which liberal societies have sought to curtail the most virulent and dangerousforms of preventive laws.154.2. From Fantasy to Criminal Act: The Role of Fantasized Gratification in SexualCrimesRoberta Monico, University of PaviaCristiano Barbieri, University of PaviaAlessandra Luzzago, University of Pavia (aluzzago@unipv.it)Sexual violence is a debated theme, although never really exhausted, since it involves the participation ofmany components: biological, psychological and sociological. Some restricted or obvious interpretationscan’t get to the root of the problem, as they stop to the events, but they do not go beyond them, trying tobreak through what comes before and after the facts.Yet, the so called sexual crimes, are sometimes only seemingly “sexual”, because sexuality is only thetarget to which aggressiveness is addressed against a person, of which it is not recognized nor the human orthe ontological constitution. In other words, it isn’t recognized any right of sexual freedom as a further partof personal freedom to the victim, that is not conceived as a subject, carrier of desires, needs and, most ofall, “humanity”.In this case the crime, either if contained in the limits of a rape, or if degenerated in a homicide, always hasunderlying perverse fantasies: sadist, narcissistic, megalomaniac, cannibalistic, necrophilic, etc. Thus,these fantasies might surface many years before the crime is committed; this doesn’t mean they are lessdangerous when translated in a criminal project first, and in a criminal behavior second.According to a “tassonomic” approach on the basis of the type of fantasy, classifications of the so called“sex offenders” have been created, although the same sexual crime may be committed by different types ofcriminals. Therefore, it is necessary to always remember that these categories are theoric models, that canactually be present in the same individual; thus it is often risky to confuse theoretical classifications (that

453tend to unify behaviors on the basis of settled parameters) with the subjects carrying out these behaviorsbecause these subjects, on a personal level, always remain unique and unrepeatable.On the other hand, in a “relational” approach the attention is focused on the psychological pathway beyondthe crime, and on intra-psychic functioning of the so called “sex aggressor”. Furthermore, at least fourdifferent dynamics have been identified at the origin of sexual crimes: predatory, compensatory, sadist andenclosed anger. Within these dynamics, search of personal satisfaction is not likely correlated to the sexualact, but to the suffering of the victim or to the sense of omnipotence produced by his or her suppression.In the attempt to focus the attention on the dynamic beyond the sexual crime, it is important both to graspits fantasy origin and to evaluate the transition from desire to concrete criminal act. This is of fundamentalimportance, either to better study this phenomenon and eventually investigate prevention strategies on thevictim, or to evaluate the responsibility of the criminal and probability of recidivism.154.3. Aggression Among men with Intellectual Disability who Offend SexuallyVivienne Riches, The University of Sydney (vriches@med.usyd.edu.au)Angry and aggressive behaviour is a significant issue affecting men with intellectual disability who offend.A high incidence of disruptive, antisocial behaviour and overall emotional/behavioural problems and/orpsychopathology was also found to exist in a study of men at significant risk of re-entering the NSWCriminal Justice system related to sex offending behaviour. This is not surprising since typically they camefrom lower socio economic backgrounds, were unemployed, and had histories of disconnected familynetworks, institutional care, poor education and poor social skills as well as personal histories ofvictimisation that made them vulnerable to abuse. A two year evaluation of a specialist community basedresidential unit found that clinical intervention in the form of cognitive behaviour therapy had limitedeffects, with some improvements noted in social interaction skills and interpersonal tolerance. However,substantial drops in disruptive antisocial behaviour, as measured by the Developmental Behaviour Checklist(Einfeld & Tonge, 1994, 2000) occurred for some men who were in the unit as well as men who wereliving alone with 24 hour supervision. The more stable, predictable living environments and lifestylesituations, regardless of residential model, appeared to be a critical factor in reducing disruptive andaggressive behaviour among this population. Consequently, while therapeutic intervention is important, thecritical impact of the environment cannot be ignored and has significant policy implications.154.4. Personality Disorders in Rapists and Murders of a Maximum Security Prison inBrazilS.P. Rigonatti, University of Sao Paulo School of Medicine, Brazil (ect@hcnet.usp.br)A.H.G. Vieira Filho, University of Sao Paulo School of Medicine, BrazilM.A.F. Caires, University of Sao Paulo School of Medicine, BrazilJ. Arboleda-Florez, University of Sao Paulo School of Medicine, BrazilA.P. Serafim, University of Sao Paulo School of Medicine, BrazilThis study presented original data on psychological and psychiatric features of a Brazilian prisonerspopulation. International literature on Forensic Psychiatry and Forensic Psychology has revealed high rates

454of psychopathic traits or immature personalities in prisoners from maximum security prisons. Individualswith personality disorders [IPD] tend to display criminal behavior more frequently than do controls.Compared to other criminals, IPDs start their “crime careers” much earlier, commit more crimes, and havea broader range of criminal activities. Re-imprisonment rates in IPDs are higher than the other criminals.According to data from the United Nations [UN], Brazil ranks third in terms of prison overpopulation. Evenin developed states such as São Paulo, the rate of criminal reincidence stands at 45%. The possibleimplication of personality disorders and crime requires broader and more in depth studies in order to berelevant. This study was drawn for the research of a sample of 100 prisoners convicted of rape andhomicide, in a maximum-security prison in Brazil. A questionnaire was distributed, which analyzedvariables including: age, race, marital status, level of education, number of children, history of psychiatrictreatment, history of drug use and nationality. Other data collected was directed towards physical healthcomplaints, characteristics of the victim [gender and the type relation with the criminal], the term ofconviction, and the time of reclusion. The semi-structured interview processes used to collect data included:SCAN [Schedules for Clinical Assessment in Neuropsychiatry], SIDP-R [Structured Interview forPersonality Disorders by DSM-III R], MMSE [Mini Mental Status Examination], and NVI [Non-VerbalIntelligent Test].The statistical analyses used the following tools: the Student’s t-test, the chi-square test and/or theFischer’s exact-test. The significance level of 0.005 [p≤0.005] was adopted for all tests. The results showedno significance differences between rapists and murderers based on variables of age, race, mental status,level of formal education or number of children.Interesting findings and their consequent implications will be discussed. Reference will be made to theprototype subject in both groups, being a white man, in his thirties, with loving relationships other thanmarriage, with a elementary level of formal education and a mean of two children. As well, both groupshad average penalties longer than 30 years and most of the studied subjects had served just a third of theirpenalties at the time of the interview. Previous psychiatric treatments were found at relativity lowfrequency in both groups. Other interesting results include a relationship between cocaine use and rapists.The presentation will also highlight the high number of antisocial and sadistic personalities in both groups.155. Sex Offenders IV: Law, Justice and Therapy III155.1. Narratives of Danger and Redemption: Community and State Responses to SexOffendersMichael Petrunik, University of Ottawa (lavon@magma.ca)In the United States and Canada, and more recently the United Kingdom, a body of sweeping communityprotection legislation has developed since the late 1980’s to deal with public fears with regard to thesupposed grave menace posed by predatory sex offenders, particularly against children. The measures ofsurveillance and incapacitation provided by such legislation include provisions for the registration of sexoffenders, community notification, post-sentence civil commitment or intensive community supervision,peace bonds (restrictions on freedom of movement in the community), chemical castration, and enhancedpolice data bases. These developments have been propelled by narratives of dangerousness, tales of thetragic consequences of the State’s past failure to deal with monstrous individuals and expressions of fearfor the future and political damage if action is not swiftly taken. More recently, contrasting narratives ofpotential redemption for individuals designated as high-risk offenders have emerged, the most striking

455example of which is associated with the Canadian community justice initiative known as Circles of Supportand Accountability (COSA) for High-Risk Sex Offenders.On the basis of my 30 years of study of international developments in dangerous offender legislation andrelated risk management strategies (along with my experiences as a volunteer working with “high-risk sexoffenders), I examine the salience and impact of different approaches to dangerousness and social controlnotably, forensic clinical, just desserts, community protection and restorative justice approaches. Each ofthese approaches has its own narrative of danger with different voices prominent or absent in accounts ofhow they should work or actually do work. In looking at Circles of Support and Accountability, I willshow how this initiative, with its twin slogans of “no more victims” and “no one is disposable” tries tomaintain a delicate balance between the concerns of community protection and restorative justice, betweenrisk management and community reintegration.155.2. Reflecting On 17 Years of Successful Sex Offender TreatmentLea Studer, University of Alberta (lea.studer@amhb.ab.ca)The Phoenix Program at Alberta Hospital Edmonton is showing consistent long-term treatment effects forsexual offenders when compared to many other treatment programs. Over more than 17 years, there hasbeen a significant decrease in sexual recidivism when comparing completers of our program with noncompleters.This significant result is found both when using cumulative data over time as well as usingcohort data across time. For example, in the first five year cohort group, sexual offense recidivism was 8%for completers compared with 24% for non-completers after a mean follow up time of 13.1 years postdischarge. Program evaluation has also shown that several robust predictors of sexual recidivism used inmost actuarial risk assessment tools are no longer predictive of sexual recidivism after treatment in ourprogram. These include: number of prior sexual offenses, serum testosterone levels, having exclusivelymale victims, and the offender's own severity of sexual abuse history. Two important conclusions becomeevident. Firstly, this treatment program is effective and these effects are maintained over time. Secondly,treatment completion of certain programs needs to be accorded due significance in risk predictionalgorithms. Possible reasons as to why this program is showing consistent efficacy as compared to sometreatment programs will be highlighted and discussed.155.3. Sexual Violent Predator Evaluations/Trials as Ex-Officio Oath ProceedingsGerard Werckle, California Department of Corrections, USA (gjwerckle@aol.com)Compelled testimony by the defendant in SVP civil commitment trials has survived Fifth Amendmentchallenge because of the non-criminal nature of the process. A point not raised in the legal arguments,however, is that a modern form of ex-officio oath procedure pervades the common law jury trial. Thus:• the citation is not based upon a new charge but, on the "notoriety" attached to conviction ofsexual offenses that have been legally declared to be "infamous;"• the defendant is required to respond to questions during the forensic mental health interviewwithout knowing the line of inquiry;• for all practical purposes, this interview takes place under oath because the defendant can becompelled to testify at trial about his or her responses.

456The ex-officio oath, deriving from the Canon Law of the Roman Church, continued in use in Englishecclesiastical courts after the Reformation, most controversially, in the prerogative court of HighCommission. The oath was apparently utilized in Colonial Virginia prior to the abolition of the HighCommission in 1641 and, the adoption of the Common Law in that Colony, twenty years later. NeitherCrown nor Parliament, however, ever asserted the ecclesiastical jurisdiction of the Church of England inAmerica, the principal jurisdiction in which the ex-officio oath had been administered. This was ajurisdiction that, since the time of the High Commission, had been closely linked to the royal prerogativewhich was abolished by the American Revolution. Admiralty jurisdiction was the only other major non-Common Law jurisdiction in the Colonies and its expansion to enforce the Stamp Act was a factor in theRevolution.155.4. The Moral Pathology of Forensic Psychiatry—Not Otherwise SpecifiedJohn Douard, Rutgers University (douard@rci.rutgers.edu)Timothy P. Foley, Practicing Psychologist, Ardmore, USA (tp.foley@verizon.net)The categorical approach to diagnoses of mental disorders exemplified by the DSM-IV, seems to havesome plausibility when it is used to diagnose mental disorders that have become historically entrenched,such as schizophrenia or paranoia. However, recent categories that are not entrenched rely on discretionaryclinical judgment to such a great extent that they result in an unacceptable number of false positives.The diagnoses that are most susceptible to the false positive problem are such diagnoses as Paraphilia NotOtherwise Specified and Personality Disorder Not Otherwise Specified. These are extremely importantdiagnoses, because they are the most common categories used in forensic psychiatric assessments of sexoffenders for the purpose of civilly committing them after they have served their criminal sentences.Further, personality disorder NOS may well be used in the future to civilly commit violent criminals whoare completing their criminal terms, even though they have not committed sex offences. Thus, thesecategories should be carefully scrutinized.This paper will argue that NOS categories reveal the weakness of the categorical approach to diagnoses ofmental disorders. They exemplify the problem of false positives. Recent work on cognitive science andthe law by Stephen Winter and Anthony Amsterdam suggests that legally significant categories cannot bedefined by necessary and sufficient conditions for inclusion, but rather, that they are specified byprototypes.When we apply prototype theory to reasoning about mental disorders, we discover that NOS categories areempirically empty. When legal reasoning about the propriety of civilly committing sex offenders is basedon such empty DSM categories, the result is profoundly unjust. Prototype theory is not only good science,but morally imperative.

457156. Sex Offenders V: New Approaches156.1. A Monster for Our TimesJerome G. Miller, National Center on Institutions & Alternatives, Augustus Institute, Basye, USA(jeromem@shentel.net)After describing the cannibals, ghouls, goblins, vampires, and “child guzzlers” that have terrifiedcivilizations from their beginnings, the British social historian Marina Warner ended in placing thepedophile atop her pantheon of monsters. “Paedophiles,” she wrote, have become “our late millennialogres” – bringing the bogeyman “very much closer to home than aliens or medieval devils.” I intend tobriefly outline the social contexts within which monsters of the past have emerged and analyze the modernmechanics of limning the pedophile qua monster. The bulk of my paper will concern itself with exploringthe specific ways in which selected legal, professional, economic, and political interests converge to castthe pedophile in quasi-mythological terms – as a unique entity so threatening that “normal” measures ofanalysis no longer apply.I will explore the effects of an increasingly powerful, highly politicized criminal justice system in theUnited States upon academic and professional research, theory, and practice relative to the sexualparaphilias in general, and pedophilia in particular – e.g. influencing the questions posed, distorting results,and bestowing credibility upon an entrepreneurially-driven labeling and treatment industry steeped inquasi-prosecutorial-medical folklore.156.2. On the Construction of Sexual CrimesNils Christie, University of Oslo (Nils.Christie@jus.uio.no)Acts are not, they become; their meanings are created as they occur. The meaning of crime is thus a productof cultural, social and mental processes. So is also the case with various types of acts seen as sexual crimes.I will exemplify with two types of acts, paedophilia and being the customers of prostitutes. This paper willoutline factors leading to the present deep disgust directed against those committing acts of paedophilia,this in contrast to the strong resistance against giving customers of prostitutes the status of being criminals.156.3. Good Practice and Dilemmas in the Community Management of a High Risk SexOffenderJackie Craissati, Oxleas NHS Trust, Kent, England (Jackie.craissati@oxleas.nhs.uk)Managing high risk sex offenders in the community poses many challenges in the current climate of publicprotection and media interest. There is relatively new legislation which requires the registration of sexoffenders – sometimes for life – and statutory duties for probation and police services to monitor high risk

458sex offenders. Currently mental health services have a duty to co-operate with these Multi-agency PublicProtection Arrangements (MAPPA) although the nature of this ‘co-operation’ has not been fully defined.The Challenge Project is a well-established community assessment and treatment project, which nowtargets personality disordered sex offenders. There is an evidence base which suggests that the treatmentmodel – embedded within a psychologically informed management system – may be reducing recidivismand failure in the target group.There are dilemmas inherent in a multi-agency approach where public protection is the dominant theme,and thus may stifle attempts to address psychological need in this client group. This is particularly salientwith high risk personality disordered sex offenders, when paradoxically, risk may be raised rather thanlowered by stringent restrictive management approaches. This presentation will outline the principles ofthe programme, and illustrate the associated management dilemmas for the staff and agencies involved, bymeans of a detailed case study. Martin is a child molester with a history of contact sexual offences againstboys and repeated failure in the community; he has a diagnosis of borderline and antisocial personalitydisorder, and a sadistic element to his sexual fantasies. The strategy for his community managementincluded individual and group treatment, medication, residence in a hostel, and couple work (with his newpartner). Difficulties arose in disentangling the interplay between his unusually disclosing presentation toprofessionals, increased alcohol consumption in the face of stress, and inter-agency conflict regarding theshort and long-term imposition of restrictions on him.156.4. Working Beneath the Radar: Opportunities for Practice to lead Policy?Andrew Rutherford, University of Southampton (a.f.rutherford@soton.ac.uk)The existing high levels of political and media interest regarding sexual offending are not usuallyconducive to sound practice developments, especially where these are community-based.Tough policy initiatives regarding sexual offenders, often of an excluding nature, are increasingly seen asthe starting point of official strategies. In this sense the sexual offender is a demonic symbol within broaderstatements, often themselves largely symbolic about crime.This paper explores aspects of this contemporary challenging context and asks how might rational practicedevelopments better inform the policy-making process. Lessons are drawn from other areas of activity withregards to the shaping of criminal policy. Particular attention is given to the Lucy Faithful Foundationwhich was established some years ago in England as a centre for research and practice regarding sexualoffending. The ups and downs of this Foundation with its community-based centre provide a useful casestudy for consideration of how modest progress might be achieved.Given the high volatility of this topic in the political and public imagination, rational and sustained effortsmay often have to proceed 'beneath the radar'. How this progress in this direction might be achieved willform the central sections of this paper. It is suggested that these issues are especially problematic wherepublic policy-making is in the hands of 'progressive' politicians who regard themselves as being 'left ofcentre'.

459156.5. Considerations in the Reunification of Incest Offenders and Their Families: ARelapse Prevention ApproachSandy Jung, Forensic Assessment & Community Services, Edmonton, CanadaCurtis Woods, University of Alberta (sandyjung@cha.ab.ca)Reunification is a gradual and well-supervised procedure in which a sex offender is allowed to re-integrateback into his familial network where the victim is present. Ideally, this takes place after both the offenderand victim have adequately demonstrated progress in their respective therapy programs and following theoffender’s verbal written acceptance of full responsibility for his sexual deviancy and for making the victimendure the abuse. Key to this process is that the offender makes no request for forgiveness and asks noquestions of the victim. If renewed contact between the offender and his familial network is agreed uponwithout hesitation by both parties and ramifications of such a decision is clarified, reunification isconsidered. Several areas of concern should be noted. These include, but are not limited to, the fact thatoffenders continue to pose some level of risk for re-offending even after completing treatment ofsupervision, that the main priority in considering this reunification process is the emotional and physicalsafety of potential victims, and that supervisory agents should be capable of and willing to removeoffenders from residences with victims rather than remove the victim. With these concerns in mind, it isproposed that a relapse prevention model could be utilized. A comprehensive family relapse preventionplan could be incorporated to address identifiable risk factors, to expand on resources and strategies, and toclarify serious consequences to the offender. This presentation offers a discussion of concerns and risksinvolved in reunification, prerequisite stages to reunification, and practical approaches to implementingfamily reunification.157. Sex Offenders VI157.1. Recidivism in a Group of Sexual Delinquents in the NetherlandsAnnelies Daalder, Ministry of Justice, The Netherlands (a.daalder@minjus.nl)It has been proven that sexual delinquents know a recidivism rate of 90%. It’s a very important politicalissue whether these offenders should return to society (at least not without a severe control of theirbehavior). Specific recidivism of sexual offenders is a very current issue in the Netherlands. TheRecidivism Monitor demonstrate that sexual delinquents were significantly more likely to sexually reoffendin a 5-year period after their release from a correctional facility than were a group of other non–sexoffending delinquents. The high frequency of recidivism with convicted sexual perverts is mainly due tothe compulsive character of perversion. Essentially, it has become evident that imprisonment does notwork! A multidisciplinary treatment is needed, using a combination of social guidance, after-care and aform of GPS.

460157.2. Recalled Parental Bonding, Adult Attachment Style, and Personality Disorders inChild MolestersStefan Bogaerts, University of Tilburg, The Netherlands (s.bogaerts@minjus.nl)This lecture presents recalled parental bonding, adult attachment style, and personality disorders in childmolesters and reports on the findings of two separate studies. A first study examines differences between agroup of 84 child molesters and 80 matched normal control subjects. This study found that the antisocialand the schizoid personality disorders especially are typical for the molester group; at an interpersonal levelthis group can be typified by recollections of an uncaring father and mother, recollections of an elevatedlevel of autonomy emanating from the father, and insecure current attachment patterns. A second studycompares a subgroup of personality-disordered child molesters to a subgroup without personality disorders.This study revealed that recollections of the role of the father in parenting are decisive. The personalitydisorderedgroup reports that the father was both more uncaring and granted more autonomy. Concerningthe current adult attachment style, an avoidant and anxious-ambivalent attachment style characterised thedisordered subgroup. We argue that the results are important for treatment. Since recalled parentalexperiences play a role in the development of personality disorders and child molestation, psychotherapistsshould integrate interpersonal tools in treatment, especially in the therapeutic work with child molesterswho received less parental sensitivity and suffer from personality disorders.157.3. Sexual Offending and PsychopathyFrédéric Declercq, University of Ghent, Belgium (frederic.declercq@Ugent.be)A large body of empirical research and clinical findings have shown that psychopathy— as conceptualisedby Hare—is a risk factor for violence in general, and for sexually violent behaviour in particular.Polymorphic anti-social behaviour being one of the features that characterises this syndrome, psychopathscan be found amongst child-molesters (intra-familial as well as extra-familial), rapists, exhibitionists,sexual murderers and serial sexual killers. However, the sexual offences of psychopaths appear to bemotivated by other factors compared to non-psychopaths. Summarizing, we may say that their offences arethe logical offspring of their distinctive personality. Their typical way of interpersonal and affectivefunctioning can be described as follows: grandiose; callous; dominant; manipulative; lacking guilt, fear andanxiety, and being incapable to establish intimate bonds with others. If their sexual offences are a result oftheir personality, their victimology will evidently bear its stamp. Factors that discriminate betweenpsychopaths and other sexual offenders that will be discussed in this paper are: cold bloodedness instead ofintense emotional arousal; consciousness and deliberateness instead of compulsiveness; absence of fear,anxiety and guilt; unknown instead of known victims. Last but not least, the sexual offences ofpsychopathic offenders are likely to be more violent, for example, more sadistic, than are those of otheroffenders.

461157.4. The Treatment of Sex Offenders in a Dutch PrisonAndré Rijk, PI Breda, The Netherlands (a.rijk@breda.dji.minjus.nl)PI Breda, located in the south of Holland, is a remand centre for charged but not yet convicted inmates.This is the sole prison institution of its kind in Holland, with a special ward for sex offenders. Presently inHolland, most of the convicted offenders receive treatment aimed at relapse prevention, on a voluntary ornonvoluntary basis. However, currently there is a lack of treatment capacity, as a result of which manyinmates who have to undergo treatment must wait in our remand centre. Partly on the request of inmates, atreatment program was initiated in this remand centre in 1999. This treatment program is a co productionof PI Breda and Forensic Clinic “De Grote Beek” Eindhoven. The treatment method was based on state ofthe art methods of treatment programs used in the Dutch clinics and outpatient programs for sex offenders,adapted to the prison situation. The Dutch authorities were initially very reluctant and critical about thisinitiative, since treatment is not a goal of the Dutch prison system and the system therefore does not need tobe equip for such treatments. The program however, is a success, according to inmates, therapists andclinic personnel. Partly as a result of this success, the Dutch policy in relation to treatment in prison hasbeen changed for 3 years. Treatment directed at relapse prevention should be part of the Dutch prisonprogram. At the same time, these requested initiatives still must meet certain requirements in order to beaccepted and financially supported. The way in which this is to be arranged is currently subject todiscussion, as a consequence of economic recession and changes in political climate. Despite this period ofuncertainty, we have made effort to meet these requirements while simultaneously continuing to developthe program in order to offer the inmates a more extensive opportunity for aid while institutionalized.157.5. Mental Illness and Sexual Offending: Review of LiteratureJochem Willemsen, University of Ghent, Belgium (Jochem.Willemsen@Ugent.be)In the past decade, attention has grown for sexual offending in the mentally ill. We present the results froma review on this topic, using Web of Science, Medline and PsychArticles. In the literature, three sorts ofmotives for offending in mentally ill are distinguished: 1) psychotic symptoms, 2) symptom distress and 3)deviant fantasies. Research has shown that the first motive has a limited impact: psychotic sex offenders arerarely directly motivated by symptoms as delusions and hallucinations. Nevertheless, most of the mental illoffenders are psychotic at the time of their offence. Therefore, it seems more plausible that psychotics aremotivated by the distress caused by their symptoms (e.g. anger, arousal, low self-esteem) than by thecontent of their symptoms. The mental ill offenders themselves report more often motives of ‘revenge’,sexual frustration, anger and arousal. Unfortunately, this motive of distress in the mentally ill remainslargely unexplored in the literature. A third motive are deviant fantasies. There is evidence that deviantfantasies play an important role in a considerable subgroup— though not all—of the general sexualoffenders. We found studies that confirm the presence of deviant fantasies and sexual obsession in aconsiderable part of the mentally ill sex offenders. We will discuss the role of these deviant fantasies inmentally ill sex offenders.

462158. Social Exclusion, Mental Health and Criminal Law158.1. Gambling as State Sponsored PsychopathologyManya Scheftsik, Practicing Psychologist, North Queensland, Australia (m.phouston@optusnet.com.au)The only undisputed, necessary and sufficient condition that causes 312.31 Pathological Gambling (DSM-IV), is gambling behaviour itself. In NSW, the opportunity to engage in gambling behaviour has beenpromoted by the state government through its proliferation of gambling venues and opportunities in thelater half of the 1990s. It can be argued that this constitutes one of the greatest social experiments of alltimes as NSW now has the greatest number of electronic gaming machines per capita in the world.Prior to the passing of legislation allowing the establishment of a casino in Sydney and the licensing ofpublic houses as gaming venues, there was the policy of harm minimisation in recognition of the potentialfor an increase in the number of cases of pathological gambling. Pathological gambling was to beaddressed in a manner similar to drug and alcohol abuse despite the fact that this disorder is not a type ofaddiction. Unlike alcohol or tobacco, gambling is strongly revenue positive, so that the government ofNSW has to balance its fiscal needs against the potential for the creation of a major mental health problemin this state. This paper addresses these conflicting issues from both a psychological and a treatmentperspective.158.2. Homeless People with Serious Mental Illness and the Community Mental HealthCare Project in Australia: ‘Anxiety’, ‘Harm’ and ‘Control’ in ContextLynda Crowley-Cyr, James Cook University (lynda.smith@jcu.edu.au)The following two papers are part of a project that offers two complementary examinations of official andpopular discourses. These discourses construct homeless serious mentally ill people as deviant or dangerous‘others’ and deny their citizenship and state-sanctioned placelessness in Australia’s urban centres. They dothis under the rubrics of social protection, care and control. The project involves unpacking a variety ofcomplex discourses constructing official and popular definitions of home/lessness, place/lessness and socialexclusion. Homelessness is a convenient euphemism that protects the empowered from confronting themagnitude and complexity of the impacts of the 'othering' and excluding processes that are synonymouswith homelessness. One cluster of discourses involves labeling the placeless as ‘homeless’, ‘itinerants’,‘hobos’, ‘bums’ or ‘bludgers’ ‘sponging’ off the system permitting popular and official victim blaming,stigmatisation and the self blaming internalisation of such labels. Legal discourses legitimise the processesof denial, demonization and ‘othering’ while valorising institutionalisation, social exclusion and retribution.Solving the apparently intractable problem of homelessness and placelessness requires radical re-definition.The practices of restoration, participation and reconciliation for social exclusion require new discourses ofplace and space.This paper focuses on the homeless who are disabled with serious mental illness living in the communitysince the development of the community mental health care project in most Western market orientedsocieties.

463It proceeds from the idea that for everyone, the community mental health care project is a progressivereform enterprise that seems fantasy-like. Community mental health is an imaginary zone through whichprotection, care, identity, belonging and control are mediated.I explore the consequences of imagining the community mental health care project in this way bydiscussing the situation for some homeless people with serious mental illness living in the community inAustralia.158.3. Social Exclusion, Denial and Social Pathology: Ethnocide and Law in NorthQueenslandPaul Havemann, James Cook University (paul.havemann@jcu.edu.au)This paper links together a variety of complex interlocking themes namely:• the legal, political and economic aspects of social exclusion;• the construction of interdictory space to sequester class from class and race from race inghettos of mind and place;• the phenomenon of the denial of the harm of ethnocide in official discourse and practice;• the practice of victim blaming: labeling of homeless Indigenous People in North Queensland'surban centres and ideas for reconciliation and peace building as dimensions of a sociallyreflexive practice of governance.The thesis advanced is that the explanatory paradigms which explain the social and health predicament ofhomeless Indigenous People both condition, and are conditioned by the legal responses of state and citygovernments. Laws react by legitimating social exclusion through ‘move on’ powers to deter vagrancywhile social and medical responses are ahistorical , ethnocentric , reactive, atomising and pathologising.Legal and medical reactions are frequently mutually reinforcing and self-justificatory. This process mirrorsthe state of official denial of genocide and ethnocide that has constructed Indigenous homelessness andassociated pathology. Both Indigenous Peoples, the dominant community and the ‘medical-legal-healthcomplex’ of control and problem definition need to narrate a radically new and shared understanding of thepast in order, reflexively, to build a new order for a just future and healthy co-existence.158.4. The Construction of Social Exclusion Through Mental Health and Criminal lawJoe Morrissey, James Cook University (joe.Morrissey@jcu.edu.au)In Western society an individual’s freedom is one of the most important human rights. The circumstancesin which the state or its agents may deprive the citizen of liberty are limited and clearly circumscribed bylaw, usually the criminal law.Depending on jurisdiction, psychiatrists and other mental health professionals can deprive a citizen ofliberty. This paper will outline the compulsory detention provisions of mental health legislation inAustralia. It will then contrast the provisions for review of or appeal against compulsory detention with therequirements when a citizen is detained by police officers after an alleged offence. The topic will beexplored in terms of the parens patriae and coercive functions of the state. Reference will also be made toappropriate human rights principles as incorporated in Australian practice.

464The comparisons will then be used to identify principles which should apply to circumstances in which amental health professional deprives the citizen of liberty. Reference will also be made to the author’sresearch which provides a diagrammatic representation of the balance between security of the population asa whole and the least restrictive environment for treatment. The role of mental health workers as part of thecoercive function of the state will also be explored.158.5. A Dickensian world in 2004: The Role and Need for Advocacy, in Addition to theLaw, in the Support and Well-Being of Mentally ill Residents in CommunalAccommodationPaul Houston, James Cook University (m.phouston@optusnet.com.au)This presentation will address the main issues surrounding the intervention and form of advocacy requiredfor the protection of the most vulnerable members of society. These are mentally and intellectually disabledpeople, especially those who are aged and residing in private hostels and boarding houses. The focus of thepresentation will be on the current state of affairs in North Queensland.The vulnerability of these citizens has been clearly identified by the Queensland Government in newlegislative amendments to the Residential Services (Accommodation) Act 2002. However, law reform isnot in itself ever sufficient. In practice it is clear that without the scrutiny of an inspectorate or support of anindependent advocate, deplorable financial exploitation and the abuse of such patients will continueunabated.Numerous concerns primarily relating to the abuse, both physical and mental of the residents living inhostels and boarding houses have been raised by family, friends, carers and support workers. As a reactionthe Queensland Government has funded the Advocacy Service to give a voice to the vulnerable. This paperevaluates the scope and limits of the Advocacy Service to promote the rights and dignity of these citizensand to invoke the responsibilities of state and other agencies for their well-being.159. SSRIs and Collisions Between Medical, Legal andRegulatory Worlds159.1. Magic Bullet – Mistaking Medicine for MagicTania Evers, Barrister and Solicitor, Sydney, Australia (tania.evers@fjc.net.au)“Formerly, when religion was strong and science weak, men mistook magic for medicine: now, whenscience is strong and medicine weak, men mistake medicine for magic.” Thomas Szasz – Sydney, 2000.I took a 50mg tablet of Zoloft in the night when I awoke depressed – I thought it would work like a magicbullet, it didn’t. I felt worse. I took four more tablets. I was feeling worse and worse. My wife got up tomake me a cup of tea and to light a fire. I thought this was man’s work and got up to help her. As she

465passed me, I felt I was mad, my head was blowing up, expanding. I saw my own face – red and bloatedwith my hair standing on end…and then I realised I had killed my wife.” The words of David Hawkins,aged 74, charged with murdering his wife of almost 50 years. Never a history of any violence, the ultimategentleman. A loving, caring father and husband. This was the view held of him by family, friends andformer work colleagues.My brief was to appear for Hawkins. I was intrigued by the discrepancy between these accounts and thediagnoses of the two psychiatrists involved, one of whom gave the defence of insanity on the basis ofdepressive psychosis, the other the defence of manslaughter on the basis of abnormality of mind due to adepressive condition.A colleague and I set out to find more about Zoloft in view of what seemed to me inexplicable behaviour,given the absence of any significant psychiatric history, and the temporal connection between the injestionof Zoloft and the killing. On the basis of research we found, linking SSRIs to suicide and violence, allthe lawyers involved in the case, including the Crown Prosecutor and the Judge, were firmly of the viewthat without the Zoloft, Hawkins would not have killed his wife. The lawyers thought this obvious. Mostpsychiatrists do not.The case received extensive publicity in 2001 and the Australian regulatory body, The Therapeutic GoodsAdministration, contacted me wanting our research materials so it could conduct an evaluation of theassociation, if any, between sertraline treatment and homicidality. In its report it concluded, “In the case ofHawkins, there is a possible causal role for Sertraline based on emergence of acute serotonintoxicity/serotonin syndrome….”159.2. Federal Pre-emption – How the U.S. Food and Drug Administration has Becomean Advocate for the Drug Industry Against the Consumers it Has a Duty toProtectKaren Barth Menzies, Attorney-at-law, Los Angeles, USA (KBMenzies@BaumHedlundLaw.com)Baum Hedlund, Attorney-at-law, Los Angeles, USAAn alarming new trend has begun in pharmaceutical litigation. Governmental regulators are interveninginto private lawsuits to support the drug companies and fight against the consumers. FDA is arguing thatapproval of a drug precludes all lawsuits against the drug companies for any risks caused by their drugs,even when the drug company knew about the risks, but did not warn, and even hid the risks from doctorsand the public.In 2002, the FDA intervened in two SSRI cases, arguing for GSK and Pfizer, and against the privateconsumer. In the first case, FDA argued that GSK should be able to advertise Paxil as “non-habitforming.” Since then, and even before, regulators in numerous countries, including the U.S., have requiredGSK to warn that Paxil causes withdrawal/dependence/discontinuation. In the second case, FDA arguedthat it would not permit Pfizer to warn about Zoloft-induced suicide. Since then, regulators in numerouscountries, including the U.S., are requiring/requesting suicide warnings for SSRIs, including Zoloft.These particular interventions were orchestrated by one of the drug industry’s darlings, Daniel Troy, who,just over a year before being appointed Chief Counsel for FDA, served as a Pfizer attorney in legal combatagainst FDA.These governmental interventions illustrate how, as one commentator put it, “a White House can use itsadministrative and legal powers to change the regulatory terrain without taking the often arduous course ofasking Congress to change the law”. Another commentator said the FDA’s intervention into privatelitigation “certainly does raise the question of the fox in charge of the chicken coop”.

466Congressional investigators recently learned that Pfizer paid Daniel Troy $358,000 in 2001 prior to histaking office as FDA Chief Counsel in August of that same year.In fighting for compensation and drug safety, the consumers now must take on not only multi-billion dollarcorporations, but also the FDA.159.3. Epistemic Capture and the Medical Construction of Mood Disorders – The Caseof SSRIsJohn Merson, University of New South Wales (j.merson@unsw.edu.au)This paper will examine the funding of biomedical research by the pharmaceutical industry and especiallythe management of clinical trail data that is published in leading peer reviewed journals. These journals areseen as epistemic gate keepers in legitimising diagnosis and in establishing the therapeutic benefits ordisadvantages of new branded drug treatments compared to that of older generic products. It will furtherexamine the role of journal literature in the establishment of ‘evidence based’ medical guidelines. Thisestablishment of ‘best practise’ in diagnosis and prescription, also forms the basis for medical insurancecoverage in many countries, and the parameters of professional discretion in terms of diagnosis andtreatment. This in turn underpins professional indemnity insurance for medical practitioners, and thegrounds for litigation in the case of malpractice. The question raised in examining this model ofinstitutional stakeholders in relation to SSRIs is whether commercial interests are overriding scientificevidence in controlling the knowledge base that informs diagnosis and drug prescription. This is a criticalissue in the light of the controversy now surrounding SSRI drugs, their over-prescription, and their possiblelinks to increased rates of suicide amongst young people.159.4. Regulatory Capture in an Era of Global Pharmaceutical Markets: The Role ofRegulators as Members of an Emerging Transnational Capitalist ClassTim Reed, University of Sussex (T.Reed@sussex.ac.uk)In advanced capitalist economies, the state is charged with regulating the quality, safety and efficacy ofpharmaceuticals in the ‘public interest’. This is undertaken in an attempt to protect the public from theconsequences of an unfettered free market in drugs which has, from time to time, put public health injeopardy. This paper argues that when the pharmaceutical market is restrained, opposing interests with astake in the outcomes of regulatory decision making emerge, which attempt to divert the regulatory processin their favour. One approach to understanding how interests might be operationalised to distract theinterests of the State is ‘capture theory’ (Bernstein 1955). Capture theory suggests that over time theinterests of the regulator and regulated converge and a regulatory agency comes to represent the interests ofthe regulated industry over and above any other interest with which the agency may have been charged.Capture theory, however, is not without its limitations, mainly because it applied specifically to NorthAmerican state regulation, and we now live in era of a globalised pharmaceutical market, and apharmaceutical industry which seeks regulation in an increasingly regional and transnational arena. Bydrawing on the work of Sklair (2001) and analysis of original documentary and interview data, this papersuggests that capture theory might equally be applied to the actors and agencies operating in thetransnational arena of pharmaceutical regulation. Thus, regulators engaged in the regionalisation ofsupranational regulation in the European Union and the transnationalisation of regulation through the The

467International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticalsfor Human Use (ICH) can be characterised as members of a Transnational Capitalist Class whose interestsare squarely affiliated to those of capital over and above those of public health.159.5. The Effects of Side Effects of SSRIs and Atypicals on Mental Health ServicesYolanda Lucire, University of New South Wales (lucire@ozemail.com.au)SSRIs and Atypicals have side effects, the most undeniably measurable of which are suicides and suicidalacts. These appeared in clinical trials at the FDA as analysed by David Healy and Arif Khan.Suicide is the tip of an iceberg of problems: agitation, akathisia presenting as suicidal, homicidal andviolent ideation or mimicking or complicating psychosis. Together with mania, manic switch, voicehallucinations and psychosis, phenomena which have been independently described as side effects of SSRIsand atypicals, side effects of treatments now seem to make up one third of admissions to a rural psychiatricward.This suggests that the 100% increase in mental health presentations since 1992, the 300% increase inseparations for suicide attempts, and the 300% increase in suicides of persons under mental health careruns parallel to the increased prescribing of these medicines and to a naive tendency to use atypicals tocounter the side effects of SSRIs, particularly voice hallucinations.There has also been an enormous increase in homicides where mental health issues are cited from 6 to 36 ina given year and in homicides by patients under mental health care in NSW.160. Stalking Current Clinical Challenges and InternationalPerspectives I160.1. The Stalking of Mental Health Professionals by Their ClientsRosemary Purcell, Deakin University (rosiep@deakin.edu.au)Martine Powell, Deakin UniversityThere is emerging recognition that mental health professionals are susceptible to various forms ofintrusiveness by clients, stalking among them. However information regarding the contexts in which suchstalking emerges and the behaviors to which clinicians are subjected is limited. This presentation willexamine the results of an empirical study investigating the nature, extent and occupational impacts ofstalking behaviours by clients.An anonymous postal survey was distributed to 1750 psychologists whose names were randomly selectedfrom the Psychologist’s Registration Board in Victoria, Australia.

468Of the 830 respondents, 13% reported a protracted episode of stalking by a client, involving multipleintrusions (eg. at least 10) which persisted for one month or more. Some 5.5% of psychologists weresubjected to this level of stalking in the year prior to the study. Resentment (44%) and infatuation (17%)were the most commonly perceived motivations for the intrusions. The mean duration of stalking was 4.2months, and the behaviours typically involved repeated, intrusive telephone calls (65%), unwantedapproaches (59%), loitering (42%) and vexatious complaints or the spreading of malicious gossip againstthe psychologist (29%). The majority of practitioners altered their professional practice as a consequence ofthe harassment (70%) and a quarter considered leaving the profession.The results of this research indicate that stalking by clients is a salient professional issue that requiresgreater attention to better manage conduct that is potentially damaging both to practitioners and clients.This presentation will explore the implications of these results and explore strategies for minimizing therisks of stalking by clients, or effectively managing such episodes if they occur.160.2. Violence in StalkingDavid James, North London Forensic Service, Enfield, England (david.james5@ntlworld.com)The fear of coming to harm is central to the phenomenon of stalking, both in terms of research definitionsand in terms of the framing of anti-harassment legislation in most of the jurisdictions where this exists.However, whereas stalkers may elicit fear of violence in the victim, and some may directly threatenviolence, only a minority go on to commit violent acts. This presentation will examine what is known aboutthe characteristics of those stalkers who commit acts of violence compared with those that do not. It willconsider our own research findings that different degrees of violence have different associations and willexamine the role of threat.160.3. Evaluation of Stalking Cases by Police: A European Multi-centre StudyGian Maria Galeazzi, Community Mental Health Service of Sassuolo, Azienda USL di Modena, Italy(galeazzi@unimo.it)Laura De Fazio, University of Modena and Reggio EmiliaAnne Groenen, Catholic University of LeuvenModena Group on Stalking, University of Modena and Reggio EmiliaLittle research data are available regarding perception and attitudinal factors affecting recognition ofstalking cases, appropriateness of interventions and/or referrals and risk assessments in stalking cases bypolice.This presentation reports findings of a multi-centre European study, funded by the European Commission’sDaphne Program to prevent and combat violence against children, young people and women.Sociodemographic, cultural and attitudinal factors (emerging from attitudinal questions regarding courtshipbehaviours and stalking as a phenomenon) that could influence the evaluation of stalking cases wereexplored in police officers using a survey presenting 16 case vignettes. There were 12 typical a prioriderivedstalking scenarios depicting varying degrees of severity of harassing behaviours having strangers,acquaintances and ex-partners as perpetrators and 4 controls vignettes, considered not to be stalking casesby the researchers. For each vignette, Likert type and multiple-choice questions explored perceptions andevaluation of risk of complicating violence, abnormality and illegality of the behaviours, intervention

469options and support- and treatment- needs for both victim and stalker. 328 front-desk policemen fromBelgium, Italy, the Netherlands and United Kingdom responded. Results showed that, in general, policeofficers were able to discriminate stalking from non-stalking vignettes. Italian police officers rated stalkingvignettes as depicting more normal situations than Dutch and English colleagues, and less illegal than allother countries’ colleagues, reflecting differences in national availability of specific laws prosecuting thiscrime. The severity of the stalking behaviours depicted in the vignettes did influence police officers’recognition of the behaviour as stalking and also their ratings on the risk of physical violence. Italian policeofficers rated risk higher when stalkers stalked strangers instead of an ex-partner or an acquaintance, whenresearch shows that this is not the case. The findings point at clear information and training needs on thetopic of stalking in the population explored.160.4. Assessing and Managing Stalkers: Findings from a Specialist Stalker’s ClinicRachel McKenzie, Monash University(Rachel.Mackenzie@med.monash.edu.au)Stalking is a generic term that encompasses a wide variety of behaviours, relationships and motives. As aresult of the growing acknowledgment of the complexities involved in stalking, there has been an increasein the number of stalkers referred to forensic specialists for diagnostic evaluation and treatment. Fewstudies however have investigated whether specific psychological characteristics are associated withparticular subtypes of stalkers. Given that the psychological influences underlying stalking behaviour arelikely to be fundamental to the efficacy of management strategies, the systematic assessment of varioustypes of stalker becomes an essential step in the development of appropriate interventions. Thispresentation will examine the findings of a large empirical study investigating various aspects ofpsychological functioning (e.g., psychopathology, intelligence, anger and attachment) among stalkersreferred to a specialist clinic over a two year period. Employing the multi-axial typology developed byMullen et al. (1999), comparisons between the subtypes of stalkers on instruments such as the WASI,STAXI-2, and MMPI-2 are presented. Also presented are data related to the efficacy of InterventionOrders, and the prevalence of threatening and physically violent behaviour. The implications of thesefindings in the management of stalkers by clinicians, law enforcement, and the judiciary are discussed.160.5. The Relationship Between Features of Stalking and Psychopathology of VictimsEric Blaauw, Erasmus University (ericblaauw@hotmail.com)Information on the psychological consequences of stalking on victims is scarce. Research has hardlyreported about standardised measures of psychopathology or the impact of specific stalking features onvictims’ psychopathology. The presentation addresses a study that aimed to investigate whether stalkingvictims have a heightened prevalence of psychopathology, and the extent to which symptom levels areassociated with stalking features. Stalking victims (N=241) completed the General Health Questionnaireand provided information on specific features of their stalking experiences. High levels of psychopathologywere found among stalking victims. Symptom levels were comparable to those of psychiatric outpatients.Seventy eight percent had a symptom level indicating a diagnosable psychiatric disorder. The frequency,pervasiveness, duration and cessation of stalking were associated with symptom levels, but explained only9 percent of the variance of the level of distress. It is concluded that stalking victims generally have manysymptoms of psychopathology. The symptoms are largely independent of features of their stalkingexperience. These findings indicate that better therapy outcomes can be expected from therapies focusingon boosting general coping skills and on decreasing general vulnerability than from therapies focusing on

470specifically dealing with the stalking situation. Practical implications of these findings are also discussed inthe presentation.160.6. Unwanted Attention and Stalking: a Comparison of Experiences from the CanaryIslands and the United Kingdom.Karl A Roberts, University of Leeds (k_roberts@tasc.ac.uk)Lourdes García Averasturi, University of LeedsA study is reported that examined the experience of ‘unwanted attention’ (unwanted communication,contact, approaches from another person) and ‘stalking’ (repetitive unwanted attention from anotherindividual that instils fear in the victim) of two nationalities of participants. All participants were universitystudents, 102 from the United Kingdom (86 females, 16 males) and 105 from Gran Canaria (56 females, 49males). Participants completed a questionnaire about their experiences of, and how they coped with,unwanted attention from another person. On the basis of their responses participants were classified intothose who had experienced stalking and those who had not. The majority of participants (74%) indicatedthat they had experienced unwanted attention. The United Kingdom sample was more likely to reportexperiencing unwanted attention, although similar prevalence rates for stalking were found for the twogroups (22% UK sample; 23% Gran Canaria sample). For both nationalities a pattern of results consistentwith previous research was found: males were more likely to be the perpetrator and females the victim ofunwanted attention and stalking; perpetrators and victims were more likely to know each other prior to theonset of unwanted attention or stalking; there were no age related demographic differences betweenparticipants who experienced stalking; those who did not and between perpetrators of stalking andperpetrators of unwanted attention. Different experiences of unwanted attention were found for the twogroups, the UK sample was more likely to experience violent conduct (physical assaults, verbal abuse). Thetwo samples used different methods of coping with unwanted attention, the Gran Canarian sample wasmore likely to use ‘social contact’ coping methods e.g. discussion with friends, discussion with theperpetrator, whereas the UK sample was more likely to seek legal sanctions and use threats to deter theperpetrator. The findings will be considered in the light of previous research and their impact as regardscross cultural analyses of stalking will be considered.161. Stalking Current Clinical Challenges and InternationalPerspectives II161.1. Stalking: A Treatment Approach for OffendersWerner Tschan, Private Practice, Basel, Switzerland (tschankast@bluewin.ch)It is estimated, that between 10 and 15% of the entire population experience stalking in their life. After therecent implementation of legal approaches to prevent stalking and the increasing understanding of the

471psychological reasons leading to stalking behavior, there is a need to establish specific treatmentapproaches for stalkers. Traditionally, stalking was considered as part of a psychiatric disorder. By focusingon the stalking behavior a new conceptual understanding can be gained. Based on unsecure attachmentbehavior and impaired executive functions due to reduced impulse control the presenter discussespreliminary treatment experiences with stalkers.As stalkers usually are not motivated to change their offensive behavior, a treatment concept must be basedon legal obligations, which helps to provide effective interventions. By establishing common goals, thestalker’s motivation increases gradually during the treatment process. In most cases the treatment goals aredirectly derived from the aim of the stalking behavior: e.g. wish for an intimate relationship, need for anemployment, etc. The treatment helps the stalker to achieve his goals in an socially acceptable way. Inaddition to the cognitive behavioral intervention technique a variety of other approaches such as social skilltraining, assertiveness training, etc., are part of the approach.161.2. Psychiatric Evaluation in StalkingCristiano Barbieri, University of PaviaMaria Critsina Fidone, University of PaviaAlessandra Luzzago, University of Pavia (aluzzago@unipv.it)Psychiatric expertise on the author and victim of stalking imposes the evaluation of the relationshipbetween the supposed victim and the hypothetical persecutor, because stalking has an essentially relationaldimension.Clinical psychiatry has described the psychopathologic conditions concerning the amorous area (from theso called “Phantom lover Syndrome”, to the so called “Othello’s Syndrome”; from the love delirium to theerotomaniac delirium of Clèrambault); criminological research has shown the existence of personalitydisturbance and of substance abuse in the so-called stalkers. However stalking is placed in either acommunicative or meta-communicative context, considering the psychopathological background of thesubject and the interaction between the two different personality structures.This fact is crucial in a psychiatric evaluation, which for the criminal concerns essentially responsibilityand/or probability of recidivism, whereas for the supposed victim concerns suitability to testify.About responsibility, a “stalking” behaviour might configure as an infirmity only if it can be reasonablylinked to an identified psychopathological setting, in other words only “if” the action gains the significanceof disease. From this point of view, the presence of a delirious disturbance may become primary torecognizing a legally relevant mental disease.On the other hand, if in the so called stalker emerges “only” an abnormal personality structure (borderline,narcissistic, paranoid, sadist or a set up of pathologies), it becomes much more difficult to recognize thevalue of disease to the action; it is better not to develop any evaluative “automatism” on this matter, statedthat between basic personality and delirious disturbances there are some evolutional paths that appear asalmost privileged “courses”.On the contrary, in order to asses the suitability to testify of the hypothetic victim, ruled out a deliriousdisorder, which might deprive the subject of the needed requirements, the evaluation of the personalitybackground remains primary. Yet there could be doubt on the capacity of subjects with serious personalitydisturbances (e.g. borderline, histrionic, narcissistic, paranoid, etc.) to represent situations of supposedpersecution in a sufficiently true way.Thus, the study of the “relationship” between victim and persecutor may gain great interest, because apartfrom the documented actions, what matters is how the subject relates to another; actually this relation is

472modulated on a number of dynamics in which love and hate, jealousy and tenderness, revenge andforgiveness, aggressiveness and self-control appear to be intricate.In this regard, the analysis of the affective relationships permits location of those “paths of desire” that mayhide a pathologic behavior if altered or distorted or in any case deprived of the recognition of another. It isthis intrinsic human deficit that might gain forensic relevance.161.3. Lifetime Prevalence and Impact of Stalking in a German PopulationH. Dressing, Central Institute of Mental Health, Mannheim , Germany (dressing@as200.zi-mannheim.de)C. Kühner, Central Institute of Mental Health, Mannheim , GermanyP.Gass, Central Institute of Mental Health, Mannheim , GermanyThere is a lack of community-based studies on prevalence rates of stalking and the impact of stalking onvictims in European countries. Data of the first community-based study on stalking in Germany arepresented. A postal survey was sent to a stratified random sample of 1000 women and 1000 men ofMannheim, a middle-sized German city. The survey included questions on demographic variables and a 51-item self-report stalking questionnaire on the experience of harassing intrusions. Almost 12% of therespondents (women 17.3%, Men 3.7%) reported having been stalked. A multiple regression analysisrevealed a significant effect of victimization on psychological well-being. Physical assaults were reportedby 30.8% of the victims. The study confirms findings from the few existing larger epidemiological studiesfrom other countries, indicating a substantial impact of stalking in the community. Consequences withregard to reforms of penal law and future community mental health research are discussed.161.4. Findings from www.stalkingsurvey.comLorraine Sheridan, School of Psychology, University of Leicester (Lorraine.Sheridan@le.ac.uk)A detailed questionnaire was placed on the internet (www.stalkingsurvey.com) in October 2004. This verylong and detailed survey had been completed by more than 600 victims of stalking by mid-December 2004.The majority of victims were British, and all provided a wealth of information about their experiences.Respondents were asked questions that had not been covered by previous works that have focussed uponthis victim group. For instance, detailed questions were asked concerning financial and social losses, andrespondents were asked exactly how many individuals had been affected by each case of stalking.Questions were asked that sought to identify indications of escalation and predictors of sexual and physicalviolence. The responses of more than 20 official bodies, as well as the reactions of family and friends, andthe satisfaction of victims with these, were examined. Respondents were also asked to give their views onhow they personally responded to the stalker and specifically how stalking should be handled by theauthorities. This presentation will provide an overview of the findings that relate to these and otherquestions. Early analyses suggest that a significant proportion of respondents were suffering fromdelusions, and an overview of the most dominant forms of delusion will be provided. At the time of writingthis abstract, the stalking survey is being launched in other European countries, enabling part of thepresentation to be devoted to international comparisons.

473161.5. Assessing and Managing the Risks in the Stalking SituationRachel MacKenzie Monash University(Rachel.Mackenzie@med.monash.edu.au)Michele Pathé, Victorian Institute of Forensic Mental Health & Monash University, Victoria, AustraliaRosemary Purcell, Deakin UniversityJames R P OgloffTroy McEwanStalking is a common social problem which produces psychological and social damage in its victims and isoften driven by psychiatric disorder in its perpetrators. Assessing and managing the risks in the stalkingsituation is a task which not infrequently falls to the mental health professional. The domains of risks in thestalking situation are not confined to violence, but include psychosocial damage to the victim, chronicity orrecurrence of the stalking, and for the stalker arrest and incarceration. This presentation will outline aStalking Risk Profile designed to structure and guide assessment and management. This involves divisionsbased on duration and typology for stalker and victim. Specific profiles for stalker and victim can then bederived before incorporating all this information into a systematic evaluation of each domain of risk. Theassessment is closely linked to management strategies to counter specific ascertained risks and futurehazards. These strategies will be limited, or facilitated, according to the current legal and mental healthcontexts which impact critically on the stalking situation.161.6. The Association Between Stalking Victimisation and Psychiatric Morbidity in aRandom Community SampleRosemary Purcell, Deakin University (rosiep@deakin.edu.au)Michele Pathé, Victorian Institute of Forensic Mental Health & Monash University, Victoria, AustraliaA number of studies have assessed psychopathology among victims of stalking presenting to specialistservices for assistance, however the mental health needs of victims in the community is unknown. Thispresentation will explore the results of the first known empirical study to examine the association betweenstalking victimisation and psychiatric morbidity in a representative community sample.A random community sample of adults completed surveys examining the experience of stalking intrusionsand current mental health. The General Health Questionnaire [GHQ-28] and the Impact of Event Scale[IES] were used to assess symptomatology in subjects reporting brief harassing intrusions (n=196) orprotracted stalking (n=236) and a matched control group reporting no such harassment (n=432). The resultsindicated that rates of caseness on the GHQ-28 were significantly higher among stalking victims (36.4%)than both controls (19.3%) and victims of brief harassment (21.9%). Psychiatric morbidity did not differaccording to the immediacy of victimisation, with 34.1% of victims meeting caseness criteria on the GHQ-28 one year after the stalking had ended.This study demonstrates that stalking is a damaging form of victimisation which, in a significant minorityof victims, is associated with psychiatric morbidity that may persist long after the behaviour itself hasceased. Recognition by mental health practitioners of the immediate and long term impacts of stalking isnecessary in order to assist victims and help alleviate distress and long term disability.

474162. Stigma I162.1. Stigmatization and Access to Mental Health Treatment in Latin America: Threatsand PerspectivesMaría Cecilia Acuña, Pan American Health Organization/World Health Organization, Washington, USA(acunamar@paho.org)Mónica Bolis, Pan American Health Organization/World Health Organization, Washington, USA(bolismon@paho.org)When associated with access to mental health care, stigmatization creates a series of adverse conditionsleading to exclusion in care. In some cases, exclusion is self-inflicted due to the detrimental social andeconomic consequences of stigma (stereotyping, discrimination at the workplace, mistrust, and fear).People under such conditions are reluctant to seek health care with the consequent negative impact overtheir own health and well being, and the repercussions on the system as a whole, including direct costs ofhealth care provisions; increased costs resulting from inefficient use of health care facilities; and indirectcosts produced by preventable disability and lost productivity among this population group.Aside from the above mentioned, stigmatization is aggravated by systemic determinants of exclusion suchas poverty, gender and ethnicity, and by a model of care that does not consider mental health as a priority.Mechanisms have been created to address these risks at different levels of the normative spectrum. Newforms of participation that strengthen spaces where concerns may be raised by civil society at the policyformulation level, complement these mechanisms.The objective of this paper is to analyze stigma in access to mental health care in some Latin Americancountries and review current experiences to address the threats of associated exclusions in healthassociated.162.2. Stigma of Mental Illness: The Forensic ComponentJulio Arboleda-Flórez, Queen’s University (arboledaj@pccchealth.org)Stigmatization is a stereotyped and negative attitude held against somebody or a group based on somecharacteristic the person or the group possess. Unfortunately, held negative attitudes do not just remainwithin the stigmatizing person, but often they lead and are extended to discriminatory practices that havemajor deleterious impacts on the well being of the individual being stigmatized or of the group.Discrimination impacts on the enjoyment of lawful entitlements or denial or lawful prerogatives. Onoccasions, discriminatory practices underlie the reason for forensic psychiatric evaluations. Thispresentation will discuss issues of stigmatization and discrimination within the context of forensicevaluation and independent medical examinations.

475162.3. Violence and the Stigma of Mental Illness: The Role of Forensic CareBeate Schulze, Psychiatric University Hospital, Zurich, Switzerland (beate.schulze@bli.unizh.ch)Despite increased efforts to reduce the stigma related to mental illness, public attitudes are still dominatedby the perception that mentally ill people are generally violent and dangerous. Studies investigating theassociation between mental disorder and violence, on the other hand, show that this belief is not groundedin empirical findings—especially when one considers attributable risk.This discrepancy is likely fuelled by media reporting on criminal offences—often suggesting mental illnessas the cause of seemingly unmotivated, particularly horrific crimes. Reporting patterns in different types ofmedia will be presented.At the same time, the heightened public discussion on the role of mental illness in criminal behaviour hasbeen accompanied by an increase in the number of criminal offenders who have been admitted forpsychiatric treatment. In addition to the legal system, psychiatry appears increasingly considered as anadequate institution for dealing with criminal offenders.This involves both chances and risks: on the one hand, mentally ill offenders increasingly have access toappropriate treatment rather than mere incarceration—with potentially more positive outcomes and betterpublic security. At the same time, mental health care and its clients may be growingly associated withviolence, if forensic units are based at general psychiatric hospitals—establishing a visible link.Measures to reduce mental health-related stigma and improve the conditions for effective forensic care willbe proposed: including (1) placing forensic care visibly within the legal rather than medical system, (2)continuing public relation efforts, especially facilitating contact with people who have a mental illness todispel stereotypes of violence, and (3) basing forensic care on specific forensic treatment models, coupledwith a general orientation on clients’ personal resources and recovery—which is also likely to reduce theprominence of violence among provider attitudes in general psychiatric care.162.4. The Stigma ExperienceHeather Stuart, Queen’s University (hh11@post.queensu.ca)The stigma of a mental illness can be worse than the illness itself. International organizations, such as theWorld Psychiatric Association and the World Health Organization, have identified stigma as the majorchallenge facing mental health systems and have developed anti-stigma programs designed to fight stigmaand discrimination because of mental illness. Despite these efforts, little is known about the direct stigmaexperiences of people with mental illness and their family members. Consequently, it is difficult to targetanti-stigma programs to areas that are most problematic, or evaluate their effects in terms of changesexperienced by those who encounter stigma. This presentation will describe the results of an initiative todevelop measures of the stigma experienced by consumers. Items were selected from theory and fromqualitative studies describing experiences of consumers. The initiative included 82 participants, all ofwhom had a serious mental illness and were living in the community. To ensure a wide range of stigmaexperiences, subjects were recruited from hospital-based outpatient programs, community clinics, andconsumer-focused advocacy groups. Two scales demonstrated high internal consistency: one measuringthe breadth of stigma experienced and the other measuring the severity of impact of stigma on aspects ofdaily lives. Results supporting these analyses will be highlighted and sub-group differences in stigmaexperiences reviewed. Results will be placed in the broader context of measurement issues.

476162.5. Human Rights and a Good Life For Those With a Mental Illness: Where Will theStigma Pendulum Stop?Angus H. Thompson, University of Alberta (gus.thompson@ualberta.ca)Recognition of the stigma that may be associated with a particular condition, such as mental illness, oftenbrings with it the assumption that it (stigma) must be eradicated, that those that hold stigmatizing views areignorant (if not evil), and that new anti-discrimination laws and/or a massive campaign to increase publicawareness represent the proper steps to take. This presentation will make the case that this model may notalways lead to an improvement in the lives of persons who have a mental illness. Furthermore, that it mightbe better for all concerned if we were to recognize that some "stigmatizing" statements are accurate, thatthe tendency to group ideas and form stereotypes needs to be understood as a generally useful attribute, thatwe need to consider "human rights" as a means to an end, not as an end in itself, and that identifyingstigmatizing behaviour can often be stigmatizing in its own right.It is suggested that the focus should be on solving the actual problems faced by those with a mental illness,such as housing, employment/recreation, and unrewarding relationships. From the point of view of thepublic, attention might be best focussed on dangerousness, specifically, rather than on the global notionsand unclear solutions that are engendered by the term “stigma”.163. Stigma II: Experiences of Mental Disorder163.1. Youth Experiencing First Episode Psychosis: Identity IssuesKatherine Boydell, University of Toronto (katherine.boydell@sickkids.ca)It has been documented that up to 2 percent of adolescents suffer from psychosis. The emergence of apsychotic illness generates acute distress and confusion in young people, their family, and friends, as wellas in mental health workers, such as school counsellors and general practitioners.There is often an extended period of delay (2-3 years on average) when problems intensify, as does anassociated frequent failure to access appropriate help. In addition, help may be sought in inappropriatesettings. These delays may be damaging to a young person, often in the critical period of adolescence.Maturation is sometimes put on hold, social and family relationships are strained or severed, and vocationalprospects are derailed. Social networks are often lost and many youth fail to build a positive identity.Secondary problems such as substance abuse, unemployment, and behavioural problems may develop orintensify and the illness itself may become more deeply ingrained.This presentation is based on a series of qualitative interviews with young people who have experiencedpsychosis. It will focus on youth narratives of identity, both before, during, and following their experienceof a first episode of psychosis.

477163.2. Stigma and ShameLars Dahlgren, Umeå University (Lars.Dahlgren@soc.umu.se)Stigmatization implies a process in which people, and especially their behaviour, are, for some reasons,labelled as negative: it is a negative process. Following lines from Erving Goffman, the concept of stigmais associated with analysis of deviant identities and behaviour. Narratives of stigma and stigmatization aremost often about unlucky fates of different types, all of which are characterized by humiliation and feelingsof shame.The reasons for stigmatization vary with time and space, and can be regarded a social construction,meaning that knowledge and social action goes hand in hand and that a given stigma has a historical andcultural specificity. There are at least three conditions that generate shame and similar emotions inprocesses of stigmatizations: triggers (something starts the process), vulnerability (among specific groupsof people), and social context (surrounding the process). These three conditions are all present in the groupof people I will focus on in my presentation, namely; members of the family of origin to violent offenderswith schizophrenia, preferably the mothers. They are deeply involved in acts of violence, sometimes selfdirected. They belong to a group of people whose abilities to cope with the problem have diminished duringthe long sickness story of the violent offender (most often sons). They experience very limited access tosupport from people in the neighbourhood as well as from the society.The presentation will focus encounters between the family of origin and different actors relevant for theirstigmatized situation. Theoretically, the focus will be guided by the sociology of emotions, represented bysociologists like Thomas Scheff and Randall Collins.163.3. On Stigma and Discrimination of the Mentally Ill in Europe – Report from aWHO Task ForceLars Jacobsson, University Hospital, Umeå, Sweden (Lars.jacobsson@psychiat.umu.se)Gross physical and behavioural deviances evoke negative feelings, albeit for different reasons. This createsstigma and results in discrimination. Mental disorders belong to the most stigmatizing conditions in mostsocieties worldwide. WHO/Euro has appointed a task force to study the situation regarding stigma anddiscrimination of mentally ill in Europe, and to propose actions. The task force has looked into legislation,resources allocated to psychiatric services, experiences of stigma and discrimination by families. Personswith mental illness are discriminated against in legislation, the resources allocated to services to childrenand adolescents with mental disorders, and also to the elderly. Given that attitudes towards mentally ill arenegative and prejudiced, legislation and resource allocation are not congruent with needs.. It is, however,also apparent that there are a lot of activities trying to combat stigma and discrimination in most Europeancountries: user groups, family associations, as well as professional groups are running anti-stigmacampaigns; while legislation is revised according to human right aspects and changes in the traditionalcustodial psychiatric care system are being implemented. The paper will give a panoramic view of thesituation regarding stigma and discrimination in Europe, and also present out-lines of an action plan forcombating stigma of the mentally ill in Europe.

478163.4. Schizophrenia and Violence: Experiences of ParentsAnnika Nordström, Umeå University (annika.nordstrom@psychiat.umu.se)In a qualitative study, parents of eleven adult sons diagnosed with schizophrenia, who had committed aviolent crime, were interviewed. The Grounded Theory method was used for analysing the material. Fourstatus passages were identified: the onset of mental disorder, the diagnosis of schizophrenia, the violentbehaviour, and the recent referral to forensic psychiatric treatment.Guilt and worry, in connection to the onset and the diagnosis, did not affect the emotional closenessbetween the parent and their child as much as the violent behaviour did. Fear and uncertainty, about whatthe son was capable of doing, distanced the parents from their son. Unawareness of any details of the recentcriminality and diagnosis, had a negative impact on the contact both between parents and son, as well asbetween the parents and psychiatric professionals. Great disappointment was expressed concerning earliershort-term psychiatric treatment. However, the referral to forensic psychiatric treatment was a statuspassage that gave hope for a positive development.The importance to view parents as a resource is stressed. The study underlines that psychiatric serviceinitiatives must support and educate parents.163.5. Psychological Factors Related to Associated Stigma in Relatives of Persons withMental IllnessMargareta Östman, Malmö University (Margareta.ostman@hs.mah.se)Stigma affects not only people with mental illnesses, but their families as well. Understanding how stigmaaffects family members, both in connection with psychological feelings towards the ill person and inconnection with psychiatric services, can increase knowledge of the situations of these families.Relatives of both voluntarily and compulsorily admitted patients to acute psychiatric wards wereinterviewed concerning psychological factors related to associative stigma in a multicentre study. In anaddition, underage children in families where a parent was severely mentally ill were also interviewed.Relative experience psychological factors related to stigma occurring in thoughts about life and deathtowards the patient and themselves, were considered. Among relatives experiencing the patient’s mentalillness, 40% of the total group had developed mental health problems of their own. The childrenexperience their family as stigmatized by others and lack support in communication with other adults.Interventions are needed to reduce the costs of psychological factors related to stigma in relatives ofpersons with mental illness.

479163.6. Reaching Out: Evaluation of A School-based Anti-stigma ProgramHeather Stuart, Queen’s University (hh11@post.queensu.ca)The Reaching Out program was developed by the Schizophrenia Society of Canada (through a programinitially developed by the British Columbia Chapter) to raise awareness and understanding aboutschizophrenia among high-school youth. The program guides teachers through this sensitive topic:providing a resource kit, including a 20-minute videotape of insights offered from individuals living withschizophrenia; a dramatization of a young person exhibiting the early warning signs of the illness; lessonplans to steer student discussions about the content of the video; instructions for role-playing exercises; andfactual information about schizophrenia and its treatment. This presentation will review the findings of theprogram evaluation conducted in eight high schools across Canada. Student performance on knowledgeand attitude questions were assessed prior to initiating the program, at baseline, then again followingcompletion of the program (571 surveys in total). There was a large improvement in students’ knowledgeabout schizophrenia following the Reaching Out program and a much smaller, but still statisticallysignificant improvement in their behavioural intentions towards people with schizophrenia. Thisevaluation demonstrated that mental health content can be included successfully in school-based curriculaby providing teachers with video and lesson plan resources. The evaluation results also indicated that agreater emphasis would need to be placed on targeting programs based on age, gender, and geographicregion.164. Substance Abuse and Jazz164.1. Jazz and Substance Abuse: How Bill Evans Became a Master Pianist and JazzInnovator in a Heroin-Addicted StateD. Philip Brown, Southern Illinois University (phibrown@siu.edu)Pianist Bill Evans was one of the few white jazz musicians accepted by black bop artists. His rhythmic andmelodic sophistication helped transform the sound of jazz. His classical music background led him toexplore modal harmony, which opened new vistas in jazz improvisation. In spite of his creativity, Evanswas still subject to many negative forces in his life. He wrestled with a heroin addiction throughout muchof his career. Despite his addiction and the resultant physically and mentally debilitating effects, hemaintained extremely high levels of performance and creativity.The debilitating effects of his addiction took their toll physically and emotionally and, no doubt, impactedthe rise and fall of his career resulting in an early death at the age of 51. How Evans remained creative inspite of substance addiction is significant to understanding his contribution to the artistic and culturalhistory of American jazz.This presenter will address the positive and negative impact of drug addiction on Evans' ability to functionas a creative artist. The question of concern will be how an addictive state of mind impacted the artist'screative output. In addition, the panel will address the significance of mental and physical health relative to

480the creative process, and how artistic inspiration is influenced by mental and physical problems caused byaddictions.164.2. Jazz and Substance Abuse: Charlie Parker—The Paranoia of a Creative, butDrug-Addicted GeniusDavid C. Clark, Bellarmine University (bluesax7@yahoo.com)Charlie Parker has long been recognized as one of the most creative jazz musicians in the history of themusic. He, along with Dizzy Gillespie, is recognized as one of the originators of the bebop style of jazzplaying. The sophisticated level of harmonic, rhythmic, and melodic understanding required to play thismusic has been the basis of much research and study. As one of the most creative jazz legends of his time,Parker was still subject to many negative forces in his life. He wrestled with addictions to drugs and/oralcohol throughout his career. Despite his addictions and the resultant physical and psychological effectsthat ultimately became debilitating, he maintained extremely high levels of performance and creativity. Infact, some reviewers suggest that his most creative work was done during and after a stay at a mentalinstitution in Camarillo, CA.While he remained focused and fastidious on stage, the paranoia that developed from addictive behaviorinfluenced his interactions with other musicians and those in his personal and social circles. Thedebilitating effects of his addiction took their toll physically, resulting in his early death at the age of 35.Yet, he maintained a creative edge that established his work as seminal in the development of jazz style.Indeed, his musical influence became so pervasive that musicians who aspired to his level of artistryfollowed his destructive path to drugs and alcohol. How Parker and other jazz artists during this timeperiod remained creative, in spite of substance addiction, is significant to understanding their contributionto the artistic and cultural history of America.This presentation will address the positive and negative impact of the addictive substances on their abilityto function as creative artists. A question of concern will be whether the creative output of these artistswould have been enhanced without their substance addiction, or whether the addictive state of mind couldhave provided a heightened level of creativity. In addition, the panel will address the significance ofmental and physical health relative to the creative process, and how artistic inspiration is influenced bymental and physical problems caused by addictions. Implications for today's creative artists will beexamined.164.3. Jazz and Substance Abuse: The Psychological Impact of Addiction on the Abilityof Performing Artists to Create and PerformMichael Cuyjet, University of Louisville (mjcuyj01@louisville.edu)The power and mystique of jazz and its creators has been an ongoing challenge for historians andresearchers. The development and demonstration of creative genius, as it relates to the jazz musician, hasbeen one of the most elusive elements of this American-bred music. For many jazz musicians, substanceabuse has been an inescapable thread that permeates their careers. Indeed, many careers and lives of jazzartists have been short circuited due the impact and influence of addiction.The psychological impact of drug addiction has been well documented. No doubt, the long-termperformance ability of these artists was negatively impacted by their addictions. Nevertheless, many of

481these artists not only continued to perform, but maintained high levels of artistic productivity at varioussignificant points in their careers. While there is a long-term negative effect due to substance abuse, someresearchers indicate that there is a possibility of enhanced creativity among some jazz artists. The questionfor this panellist is whether the influence and impact of drugs on the performer's psyche, and their ability tocreate, is positive or negative.During the 1940s and 1950s, a prolific period of jazz creativity, some of the most creative jazz legendswrestled with addictions to drugs and/or alcohol. Performing in environments that were conducive todeveloping addictions, coping with the psychological pressure of maintaining a high level of performancein a competitive atmosphere, and dealing with negative societal and psychological factors contributed to afragile psyche that provided the impetus for addiction.This fragile psyche resulted in both psychological and social challenges for such artists. How countlessjazz artists during this time period remained creative, in spite of substance addictions, is significant tounderstanding their contribution to the artistic and cultural history of America. Drawing on his backgroundin psychology, this panellist, along with the other panellists, will consider the following questions:Was the work of these jazz artists truly inspired?What was the impact of the addictive substances on their ability to function as creative artists?Would their creative output have been enhanced had they not been addicted to substances?How did the challenge of overcoming both psychological and physical problems created by addictionimpact their levels of creativity?Was the sacrifice of psychological and physical health significant to the creative process?Is there evidence to refute the impact of controlled substances as a positive influence on creativity in a jazzsetting?164.4. Jazz and Substance Abuse: Jimmy Raney - Master Guitarist, Impulsive AlcoholicJefferson Sherman, Bellarmine University (gensherman@prodigy.net)Jimmy Raney, a stellar but troubled guitarist of the era, represented the antithesis of the hard-edged,aggressive sound of bebop with his laid back cool style. His early 1950s recordings, with tenor saxophonistStan Getz, exemplify what came to be known as the West Coast sound. The ever-present harmonic andmelodic sophistication of jazz was enhanced by a more intense polyphonic rhythmic interplay. In spite ofhis creativity, Raney was still subject to many negative forces in his life. He wrestled with an impulsiveaddiction to alcohol throughout his career. Despite his addiction and the resultant physically and mentallydebilitating effects, he maintained extremely high levels of performance and creativity. With medication tocontrol his compulsion, Raney was able to play and record for an extensive period of time. However, heencountered many periods of limited productivity due to his addiction.The debilitating effects of his addiction took their toll physically and emotionally and, no doubt, impactedthe rise and fall of his career. How Raney remained creative, in spite of substance addiction, is significantto understanding his contribution to the artistic and cultural history of America.Based on personal interviews and interaction with the artist, this panellist will address the positive andnegative impact of alcohol addiction on Raney's ability to function as a creative artist. The question ofconcern will be how an addictive state of mind impacted the artist's creative output. In addition, the panelwill address the significance of mental and physical health, relative to the creative process, and how artisticinspiration is influenced by mental and physical problems caused by addictions.

482164.5. Jazz and Substance Abuse: Road to Creative Genius or Pathway to PrematureDeathGerald H. Tolson, University of Louisville (jerry.tolson@louisville.edu)The power and mystique of jazz and its creators has consistently challenged jazz historians and researchers.The development and demonstration of creative genius as it relates to the jazz musician has been one of themost elusive elements of this American-bred music. Jazz performers exploit environmental, social,experiential, psychological, and emotional factors as they simultaneously combine the elements oflistening, composing, and performing to construct a musical portrait on an ever-changing sound palette.Indeed, the artist's response to, and manipulation of, these influences holds answers to the success of manygreat legends of jazz.During the 1940s and 1950s, some of the most creative jazz legends wrestled with addictions to drugsand/or alcohol resulting in careers that were sidetracked or prematurely ended. Performing in environmentsthat were conducive to developing addictions, coping with the psychological pressure of maintaining a highlevel of performance in a competitive atmosphere, and dealing with negative societal and psychologicalfactors contributed to a fragile psyche that provided the impetus for addiction. Despite much psychologicaland physical pain, these artists excelled in their artistic endeavor. How these jazz artists remained creative,in spite of substance addictions, is significant to understanding their contribution to the artistic and culturalhistory of America. The panel will explore the impact that drugs and alcohol had on the creative genius ofselected jazz musicians during this prolific period of jazz creativity.Recent research by among others, Dr. Frederick Spencer, and continued research by panel members hasprovided new information regarding this challenging topic. The panel will examine the impact ofcontrolled substances on creative activity, from both a psychological and physical perspective. Indeed, thepanel will consider whether substance abuse was a positive or negative factor in the success of these jazzmusicians. Implications for today's creative artists will be considered.165. Substance Abuse in Sweden165.1. Psychiatric Comorbidity, Psychological Characteristics and Outcome in Groups ofCompulsorily Committed Alcoholics in the South of Sweden Between 1990 and2000Björn Sallmén, Karlsvik Rehabilitation Center, Höör, Sweden (bjorn.sallmen@project-maps.com)Four hundred and six substance abusers (197 coerced and 146 voluntarily admitted men; 41 coerced and 22voluntarily admitted women) were participating in a clinical study at Karlsvik Rehabilitation Center,between August 1990 and May 2000. In 1990-1993, the primary target group was socially maladjustedsubstance abusers from the metropolitan area of Malmoe. From 1994 and onwards, a more heterogeneousand generally more socially adjusted group of clients from all parts of Sweden were admitted.

483Experiences of negatively perceived coercion were assessed in the beginning of treatment and at dischargeafter 3-6 months. Psychiatric comorbidity was assessed according to SCID for DSM-III-R/DSM-IV.Prevalence of psychiatric comorbidity (axes I + II) was high (72%). Eighty-two percent of the compulsorilycommitted and 59% of the voluntarily admitted subjects reported violations of integrity related tocircumstances of treatment. No differences between women and men, or between the two sub-samples,were recorded. At the discharge interview, 83% of the compulsorily treated subjects and 52% of thevoluntarily treated subjects still perceived the coercive actions as wrong or violating to personal integrity.Although coercive experiences were reported with similar frequency during the years of the study, thenature of coercive reports changed, starting with admittance of the new target group in 1994.The less socially adjusted sub-sample of 1990-1993 reported more coercive experiences related totreatment at the institution, than did clients admitted after 1994 (e.g. coercive implementation fait accompli,persuasion and threat). After 1994, reports focused more on societal interventions prior to admission (e.g.misinformation, police transportation, threats of coercion at declination of voluntary treatment, andpowerlessness in the overall process). Reports of violations of integrity prior to admission were mostfrequent among socially stable subjects, admitted for the first time, while these reports were rare amongsocially more maladjusted subjects.It is concluded, that negatively perceived coercion are frequent among substance abusers in public Swedishinstitutional care, regardless of psychiatric comorbidity or socio-demographic background. Among sociallywell-adjusted abusers and for abusers with no earlier experiences of institutional care, increased sensitivityand attention to the processes leading to institutional care is recommended.165.2. The Moral Question and the Existential Suffering - How an Alcohol AbuserExperiences Compulsory Treatment and Reacts to ItJan Arlebrink, Malmö University (jan.arlebrink@teol.lu.se)The aim of this study was to investigate how compulsory treatment of alcohol abuse is experienced bypersons forced to submit to it, the majority of whom are negative in their attitude toward treatment of thissort. The importance of considering the results obtained not in isolation but within a larger context isemphasized. Among the elements of this context examined is alcohol abuse generally, why those involveddrink excessively, and how they experience their situation.Interpreting the experience these persons have of their situation, involves taking account the ethical andexistential world in which they live and their philosophy of life. The legal statutes that apply and theimplications these can have are discussed. Important concepts considered are those of autonomy andintegrity.The results of the investigation indicate that a person forced to submit to compulsory treatment for hisalcohol abuse, often ends up in a traumatic crisis with little chance of working through it satisfactorily. Avariety of reasons for this are pointed out: one is the person's failing to understand why he has been forcedto receive treatment; another is the person's lacking an adequate language to deal with the existentialquestions his situation gives rise to; having lived as an alcohol abuser for many years also results in theperson's sense of self-respect being very low; in addition, the institution providing treatment generally hasno adequate possibility of helping the person to work through his crisis.As a conclusion, one can ask on the background of the empirical, legal, psychological, existential, andethical aspects whether it is morally right to force someone to a treatment that person himself does notwant.

484165.3. A Randomized Controlled Trial of Aftercare Treatment Following InvoluntaryCare for People with Substance AbuseMarianne Larsson-Kronberg, Lund University (marianne.kronberg@alk.mas.lu.se)In Sweden, a person with severe substance abuse can be ordered by the court to six months of involuntarycare at specialized institutions. According to the legislation, it is obligatory for social services to provide anaftercare plan in cooperation with the patient. In a previous study, we concluded that very few aftercareplans were actually made and even fewer were influenced by the patient’s opinions on what should beincluded in such a plan. Less than 25% of the aftercare plans were carried out.In September 2003, we started a randomised, controlled study comparing intensive case management inaftercare to aftercare, as usually provided by social services in the municipality. Eleven municipalities andthree involuntary institutions have accepted participation. The project will recruit 240 participants duringthree year. The case management intervention lasts for six months, and will include relapse intervention aswell as linkage to services.A manual has been developed for each intervention, with the caseworker’s introduction of the project to thepatient at the involuntary care institution as the first contact. An extensive aftercare plan for ten life-areaswill be performed a few weeks before release from the institution in accordance with the social worker, thestaff at the institution, and the patient. The plan includes interventions in the fields of physical health,mental health, finances, work/studies, addiction treatment, family network, friends, housing, skills, andcriminality. The plan will have goals set for the whole six month period, then on a monthly and a weeklybasis. The aftercare managers file a weekly report on actions taken, and will get intervention feedbackbased on the manual.An extensive interview battery will be used at intake at the institution, at the end of the aftercareintervention, and six months after last contact. Social worker in charge of the case and familymember/friend will also be interviewed at the same time period as the patients.165.4. Stages of Change as Outcome Measure from Compulsory TreatmentDavid Öberg, Project-MAPS Foundation, Maastricht, The Netherlands (david@project-maps.com)In Sweden, few follow-up studies exist to evaluate treatment outcome. One reason is methods of evaluatingoutcome have generally not been optimal.The present study concerns Karlsvik, a Swedish rehabilitation centre participating in the internationalIPTRP/Biomed2-project. 38 voluntarily participating clients were eligible for follow-up. The subjectsconsisted of 22 compulsorily committed and 14 voluntarily admitted men, and 2 compulsorily committedwomen, admitted between January 1997 and September 1998, with a mean age of 36 years. Twenty-one ofthe subjects had alcohol as the principal drug of choice, 8 Amphetamines, 6 Benzodiazepines, and 3opiates. Psychiatric comorbidity, assessed by the Structural Clinical Interview, DSM-IV, was present in73% of the subjects. Initial data collection also included the Addiction Severity Index and the MonitoringArea and Phase System, (including stages of change measurement CHANGE). As discharge CHANGE wasused and again at follow-up. In addition to the ASI, MAPS-up was distributed to participating clients in ansix month personal follow-up and at three years post-discharge.The areas of alcohol, drugs, and psychological health were analysed at follow-up, where a progression orthe consolidation of earlier progressions in stage of change was defined as a positive outcome. At the sixmonth personal follow-up, three of the subjects were dead. Among the remaining subjects, 8 were, for

485different reasons, unavailable. Of the remaining 27 subjects, improvement was present in 66% concerningalcohol use, 61% concerning drug use, and 62% concerning psychological health, measured by stage ofchange at follow-up. All subjects participating at the six month follow-up, remained at the three yearfollow-up. Sixty-three percent of the subjects had successful outcome at the three year follow-upconcerning alcohol, 73% concerning drug use, and 80% concerning psychological health.A major problem within the addiction research field is the manner in which methods outcome aremeasured. Consumption days, relapses etc. does not alone explain changes of problem behaviours. Methodsof assessing “stage of change” provide a new and promising angle in which treatment outcome can beevaluated.165.5. Compulsory Treatment of Alcohol and Drug Abusers in SwedenVera Segraeus, Stockholm University (vera.segraeus@stat-inst.se)The National Board of Institutional Care in Sweden is, since 1993, responsible for compulsory treatment ofalcohol and drug abusers. Sweden is rather unique, having a special law of compulsory treatment within thesocial welfare system; but, during the last ten years, the number of beds have has fallen from 1000 to 340.There is an ongoing discussion about compulsory treatment in Sweden. Some consider it a patriarchal relic,and other consider it a humanitarian duty to care for the outcasts. The researchers want to have some proofof the value of compulsory treatment.A Research and Development unit has been working since start. The main aim is to promote research andmethod-development in institutional compulsory treatment. The presentation will sum up the moreinteresting findings of the research, and present the ongoing development-work. The main research areasare: 1) evaluation, follow–up; 2) the change process, client perspective, staff attitude, and ethical questions;3) organisation and cooperation between different care organisations; 4) law and practice. What lies ahead?What conclusions can be drawn from the research, and what areas will be of interest within the comingyears?

486166. Substance Abuse I: Amphetamines, Mental Health and Law166.1. Clinical and Sub-Clinical Symptoms of Psychosis in a Sample of Young,Injecting Amphetamine UsersSharon Dawe, Griffith University (S.Dawe@griffith.edu.au)David Kavanagh, University of QueenslandRoss Young, Queensland University of TechnologyJohn Saunders, University of QueenslandAmphetamine use has emerged as a major drug problem in Australia and especially in SE Qld where its usefar exceeds that of heroin. Among amphetamine users there appears to be a substantial but poorly describedexperience of mental disorders that range from frank psychoses to subclinical symptoms that includeabusive and aggressive behaviors, suspiciousness and impulsivity.In order to define the extent and nature of mental health problems and to gauge what treatment responsesare appropriate for the health care system, we conducted a systematic examination of these symptoms in acohort study of 232 amphetamine users presenting at a Needle Syringe Exchange Program. Measuresincluded 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 was20.8 (+6.2) years and 21% scored > 3 on the PS. The relationship between positive symptoms and recentamphetamine use was investigated using hierarchical multiple regression. After controlling for previoushospital admissions for psychosis, and other drug use (cannabis and alcohol), recent amphetamine use wassignificantly predictive of current positive symptoms.These data raise important clinical questions on how best to approach the treatment of amphetamine bothpharmacologically and psychologically, given the high rate of comorbid psychotic illness.

487166.2. Dynamic Pupillometry and its Use in the Prognosis of Relapse in AlcoholDependent PatientsAlexander Dvorak, Medical University Vienna (alexander.dvorak@meduniwien.ac.at)I. Hertling, Medical University ViennaK. Ramskogler, Medical University ViennaG. Böck, Medical University ViennaL. Linzmayer, Medical University ViennaJ. Grünberger, Medical University ViennaH. Walter, Medical University ViennaO.M. Lesch, Anton Proksch Institute, Vienna, AustriaThe chronic intake of alcohol in harmful amounts leads to a shift in the balance of all neurotransmissionsystems in the central nerve system. For instance, an overexprimation of acetylcholinesterasis sensitivemuscarinergic receptors leads to an increase of apoptosis in the cholinergic basal frontal lobe. After theingestion of psychotropic substances, cholinergic receptors induce a miosis of the pupil, whereas sympathicreceptors lead to a dilatation (mydriasis) of the pupil.The Receptortest, used in pupillometry, is a non-invasive method to evaluate an occurring deficit ofacetylcholinesterasis and the resulting cognitive impairment of the patient assessed.During this examination, drops of tropicamide (a potent anticholinergic and mydriatic substance) areapplied 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 firstresult, and the difference stands in direct correlation to any decrease in cholinergic receptors, whereas adeviation of over 20% can be seen as pathologic.Earlier studies showed, that alcohol-dependent patients usually show a greater dilatation compared tobaseline as found in control-groups. These aberrations are never as high as seen in patients suffering fromAlzheimer’s disease.In our trial, we performed the receptor-test on 52 alcohol dependent patients, between the 2nd and 4th dayof 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 tosuffer a relapse, this examination method can be used to better assess the probability of an upcomingrelapse 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 alcoholrelapses in forensic alcohol dependent patients.

488166.3. The Course of Psychotic Symptoms in Young Amphetamine Users Admitted withEarly PsychosisLeanne Geppert, Griffith University (leanne.geppert@griffith.edu.au)Sharon Dawe, Griffith UniversityWilliam Kingswell, The Park Centre for Mental Health, Queensland, AustraliaThe symptom profile of amphetamine induced psychosis is usually considered to mimic that seen in othernon-drug induced psychoses, especially paranoid psychosis. However, few systematic investigations havebeen conducted and none that control for stage of illness (early stage vs. chronic) and assess substance usein detail. In this study young people with early psychosis (less than 3 previous episodes) underwent detailedassessment of historical factors implicated in the development of psychosis, recent substance use andcurrent 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 PsychiatricRating 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 justunder half of the sample smoking cannabis (30% smoked > 20 days) in the last month. Amphetamine usewas reported by 40% of the sample with 15% using > 20 days in the last month. Preliminary analyses havebeen conducted to determine the relationship between amphetamine use and symptoms at admission. Thereis a significant r between manic excitement and amphetamine use, and a significant negative correlationbetween 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 thosewithout had some similarities; e.g., positive symptoms. However, days of amphetamine use was related tothe severity of symptoms rated as manic excitement (hostility, grandiosity, distractibility, excitement,elevated mood and motor hyperactivity). Further, there are fewer negative symptoms in those subjects withgreater number of days of amphetamine use.166.4. Amphetamines, Psychosis, and the Insanity DefenceWilliam John Kingswell, The Park Centre for Mental Health, Queensland, Australia(Bill_Kingswell@health.qld.gov.au)Amphetamine use is a significant public health problem in Australia generally and in Queenslandparticularly. Amphetamine is the second most popular illicit drug (after cannabis) and the most commonlyinjected drug in Australia. Markedly abnormal mental states occur following the use of amphetamines andamphetamines can induce an acute or chronic psychotic state. These mental states often result in hospitaladmission and place a significant burden on health services. One large metropolitan hospital in Brisbanehas reported 2.5 admissions per day to the mental health unit for the management of amphetamine relatedpsychiatric disorder. The distinction between “intoxication”, transient or chronic “psychotic states” and thelegal definition of “mental disease” causes some confusion for psychiatrists and lawyers. Amphetaminerelated 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 currentpatterns of amphetamine usage in Australia and within Queensland,

4892. 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 numberof cases decided in that division of Queensland’s Supreme Court.And finally suggests some guidelines for practitioners involved in assisting courts determine insanityprovisions when amphetamine abuse is a complicating issue.166.5. Epidemiology of Drug AbuseWilson Compton, National Institute on Drug Abuse,Bethesda USA (wcompton@nida.nih.gov)The past 30 years of research in the United States on the epidemiology of drug use, drug use disorders andrelated health conditions such as HIV, has provided major insight into these conditions. Drug use peakedin the late 1970’s, decreased across the 1980’s, increased again in the 1990’s and has remained generallystable during the past few years. Within this broad pattern, specific epidemics of crack cocaine,amphetamines, club drugs (such as 3,4-methylenedioxymethamphetamine), heroin and prescription opioidsas well as associated epidemics of HIV and other infectious diseases have been identified and tracked. Inaddition to major accomplishments in surveillance, drug abuse epidemiology has traditionally focused onidentifying 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 includeboth careful cross-sectional and longitudinal observational studies as well as clinical epidemiologyexperiments in which prevention interventions serve as tests of specific etiological theories. Now, the fieldneeds to focus on linking basic science with epidemiology in order to make progress in understanding thesecomplex health conditions.166.6. Addiction and Developmental Disability: Research and TreatmentMorwenna Nieuwold, Hoeve Boschoord, Boschoord, The Netherlands(M.nieuwold@hoeveboschoord.dji.minjus.nl)Maria Trentelman, Hoeve Boschoord, Boschoord, The Netherlands(M.Trentelman@hoeveboschoord.dji.minjus.nl)Hoeve Boschoord is an institute in the North of Holland where people with developmental disabilities andproblem behaviour are treated. Although the majority of those instituionalized, have been sent by the court,some people 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 researchdepartment of Hoeve Boschoord, an examination of the literature on this specific combination has beenconducted and results are shown. Furthermore, implications of these findings for treatment are discussed.

490Treatment in Hoeve Boschoord is based on a behavioural approach. The development of a treatmentprogramme aimed at substance use disorder and developmental disability will be presented. A picture of thecurrent state of affairs is painted on the basis of real-life cases, and practical experience of patients and fieldworkers. Difficulties in the treatment of this population are discussed, such as required treatment and theimplications of cognitive deficits.167. Substance Abuse II: Forensic Aspects in DifferentContexts167.1. Shaping Behavior Among Drug-Involved Parolees: The Step’n Out: Study of CJ-DATSPeter Friedmann, Brown Medical School (pfriedmann@lifespan.org)In the United States, the community correctional and outpatient addiction treatment systems have limitedcollaboration and communication, which may lead to a multitude of behavioral expectations with variablereinforcement. Research supports that behavioral outcomes are optimized when behavioral expectationsare few in number, clear, and consistently reinforced. This presentation will describe the development andearly implementation of the Step’n Out Study, a 4-state randomized trial that is part of the NIDA CriminalJustice Drug Abuse Studies (CJ-DATS) collaborative. The Step’n Out Study examines whethercollaboration between the parole and outpatient addiction treatment systems can improve treatmentadherence, drug use, and public safety outcomes among drug-involved parolees. The specific aims ofStep’n Out are:• To systematize collaborative assessment, treatment orientation, planning, and monitoringbetween supervision officers, treatment counselors and clients; and• To encourage therapeutic relationships and lasting behavioral change through a coordinated,supportive approach to supervision that emphasizes the client’s pro-social goals and positiveresponses to their attainment.167.2. Drug Abuse and Crime: The Intersection of Public Health and Public SafetyJack Inciardi, National Institute on Drug Abuse, Bethesda, USA (james.inciardi@mvs.udel.edu)Over 50 percent of adults incarcerated in U.S state and federal prisons acknowledge using alcohol or drugsat the time of their offense. It is estimated that 70 to 85 percent of the 6.9 million adults incarcerated or onparole have substance abuse problems, but only 13 percent receive treatment under correctionalsupervision. Without treatment, offenders with substance abuse problems often relapse to drug use andcriminal behavior. Research has demonstrated that providing treatment services to offenders withsubstance abuse problems, is an effective strategy for reducing crime and substance abuse. Critical

491questions remain as to what types of substance abuse treatment programs and services work best withoffenders, and how to integrate them into criminal justice settings. This presentation will provide anoverview of the connection between drug use and crime, examine key principles of effective drug treatmentwith offender populations, and highlight research efforts underway to integrate substance abuse treatmentand services within criminal justice settings.167.3. Substance Abuse and HIV Infection: Progression and ResistanceDavid Vlahov, New York Academy of Medicine (dvlahov@nyam.org)The role of illicit drugs on the rate of HIV progression has been suggested by in vitro studies, which havestimulated investigation in observational cohort studies. Internationally, clinical epidemiolgists haveconducted multiple analyses to examine the effect of injection and non-injection drug use on HIVprogression. Analyses have been directed at the following outcome measures: CD4 cell decline, T-cellhomeostasis, serum immune activation markers, HIV viral load, and progression to AIDS includingestimation of the incubation period of AIDS and neurologic manifestations during asymptomatic HIVinfection. Before the introduction of highly active antiretroviral therapy (HAART), epidemiologicalevidence suggested a modest role of injection drug use on immunological progression of HIV infection;however the evidence is mixed since the introduction of HAART. While injection drug use has beenassociated with reduced access to antiretroviral therapy, therefore comparisons between drug users andother risk groups showed less effect overall. More recent studies with addressing access have shown highlyactive antiretroviral therapy to be associated with dramatically improved survival in this population.However considerable challenges remain for adherence, resistance and relapse to high risk behaviorsassociated with initiation of potent antiretroviral therapy.167.4. Doping and International Sport: A Question of Mental Health, Law or Ethics?Zhu Li Jing, University Hospital, Vienna, Austria (zhulijingq@gmx.net)Doping is frequently seen as a problem in its origin and causes limited to the field of ethics and the law.However, strategies of doping prevention would be seriously flawed, if factors outside of the field of lawand ethics were not considered as contributing to the acceptance of doping by athletes. Still, personalfactors and the possible role of other issues are frequently neglected in the present discussion of doping inathletes.In a qualitative study with athletes from different cultures, factors contributing to the acceptance of dopingwere explored in a multiethnic sample of athletes. Defining doping acceptance as a category in thequalitative interview, factors directly dependent on mental health problems in international diagnosticsystems could be identified, underlining the importance of sport psychology and clinical psychology in thedevelopment of prevention programmes against doping in professional sport. It does not appear justified tolimit understanding and prevention of doping to legal strategies, such as urinary tests and confirmation ofgeneral ethics.

492167.5. Forensic Value of CDT in Patients With Liver DiseaseKathrin Ramskogler, University of Vienna (drozdek@worldonline.nl)Carbohydrate deficient transferrin (CDT), a biochemical marker of chronic alcohol consumption, is used byresearchers and clinicians alike in a variety of populations. Levels of CDT may be affected by certain typesof medical illnesses and conditions. Thus, the interpretation of CDT results may need to be carefullyexamined in these populations. Because CDT is synthesized, glycosylated, and secreted by the liver, the useof CDT values in patients with liver disease has been an area of focused interest.Recent results suggest, an elevated CDT value may not accurately represent alcohol consumption inpatients with liver disease. CDT values should be viewed with caution in any patient with liver cirrhosis.Determination of parameters reflecting liver impairment (such as PT) could help interpreting the reliabilityof CDT. Still, in conditions such as severe liver disease higher than normal levels of CDT are produced,thereby reducing the specificity of this marker for detecting abusive alcohol consumption.167.6. Criminal developmental trajectories in childhood and its impact on mental health,substance abuse and abusive intimate relationships in Portuguese young adultsCarla Alexandra Paiva, University of Minho (cpaiva@iep.uminho.pt)Bárbara Figueiredo, University of MinhoIntroduction: Negative developmental histories during childhood could have repercussions on behaviourand mental health in adulthood. In particular, violent socialization and victimization experiences have amajor role on the onset of the criminal behaviours that are most of the times maintained in adulthood, anddetermining mental health status.Aims: To determine the association between criminal developmental trajectories, mental health status,substance abuse, and violence in close relationships in young adults.Methods: Sample: 500 Portuguese university students, 64.6% females, mean age 23 years old, 84.8% in adating relationship, 61.5% for a period time longer than 1 month. Instruments: Personal and RelationshipsProfile (Straus et al., 1999; Paiva & Figueiredo, 2001). Brief Symptom Inventory (Derogatis, 1993,Canavarro, 1999). Revised Conflict Tactics Scales (Straus, Hamby, Boney-McCoy, & Sugarman, 1996,Paiva & Figueiredo, 2001), Statistics: descriptive and inferential, independent samples t test, discriminantfunction analysis (stepwise)Results: Twenty five percent of the sample fit in the clinical index of psychopathology (BSI); 25% reportedimpairment associated with substance abuse (19% alcohol, 21.6% drugs, 16% substances); and 46.3%perpetrated or received some kind of abuse during the last year against/by the partner.In terms of criminal history during childhood, the variables analysed were: violent socialization (observed,experienced, inside and outside family), crime - type (property, violent), age of onset (early versus later); itsassociation with BSI total index, (clinical or not) was determined. Violent socialization experiences wereassociated with higher psychopathology (M=15.5 + 4.17 versus M=13.8 + 2.97, t (343)=-3.953, p=.000),but not criminal history total (M=10.6+ 2.78 vs M=10.28+2.64, t(332)=-.880, n.s). To have been a victimof violence during childhood was the best discriminant between clinical and normal psychopathologygroups (Wilks Lambda=.937, F(1,323)=21.816, p=.000). However, for substance abuse it was criminalhistory (Wilks Lambda=.777, F(1. 220)=63.166, p=.000). The perpetration of abuse in close relationships is

493predicted, both violent socialization and criminal history with later onset (Wilks Lambda=.942,F(2,413)=12.611, p=.000).Conclusion: Psychopathology in adulthood is related to negative developmental trajectories. Earlyexperiences of violent socialization and victimization have a determinant role in the maintenance of otherdeviant behaviours in adulthood, like substance abuse and violence with a partner. Deviance trajectories arealso considered a risk factor for mental health in adulthood. Micro and macro level interventions are neededas early as possible in the development. Similarly, an integrated action plan considering psychosocial andlegal dimensions designed for risk individuals as a way to prevent mental illness and deviant behaviours isalso essential.168. Suicide168.1. Issues in the Control and Regulation of Suicide Promotion and Assistance Overthe InternetBrian L. Mishara, University of Quebec at Montreal (mishara.brian@uqam.ca)David N. Weisstub, University of MontrealThe promotion and description of suicide methods on the internet have led to widespread concern that legalcontrol is mandated. Apart from value concerns pertaining to attitudes about suicide, the guarantee offreedom of expression presents a serious challenge to the introduction of restrictive laws. Recentdevelopments in Australia and Europe are presented, noting jurisdictional complexity as an obstacle toeffective application. Finally, scientific data of an epidemiological nature are revealed to be insufficient towarrant making causal assertions about the internet and its relation to suicidal acts, including those ofvulnerable populations. Recommendations are made with respect to public education and suicideprevention.168.2. The Biology of Impulsivity: Relevance to Suicidal BehaviorLaurence R. Tancredi, New York University (lrtancredi@yahoo.com)The bio-assay and imaging studies of impulsivity will be reviewed, with the objective of speculating onwhat is happening in the brains of afflicted individuals. Impulsivity is associated with a wide range ofbehavioural abnormalities, from conduct disorders, to violent offences against oneself and others. Thispresentation will focus predominantly on the biology of impulsivity as it applies to suicidal behaviour.Several questions will be addressed. Among the most important: Can the potential for impulsivity beidentified early? What can be done to alter the outcome, to preclude the manifestation of impulsivity? Inwhat ways is the impulsivity of suicidal behaviour similar to and different from that associated with harmto third parties? What mechanisms, if any, exist in the brain to control or alter the outcome of impulsivity?The legal and ethical implications of impulsivity for suicide will also be addressed.

494168.3. The Epidemiology and Etiology of Suicidal BehaviourAndrew Slaby, New York University (AESlaby@aol.com)Approximately 1% of individuals are known to die by their own hands. While the majority of suicides areby individuals with psychiatric illness, the presence of a psychiatric disorder alone does not explain suicide.The majority of those who die by suicide are depressed. Hopelessness, however, more than depressionpredicts who dies by suicide. Even more than hopelessness, however, it appears impulsivity can, in theabsence of depression, determine who dies by suicide. The speaker will discuss the evolution of thinkingby suicidologists regarding self-inflicted deaths with particular emphasis on recent findings in biogeneticresearch.168.4. Whose Life is it Anyway? – Ethical Issues in SuicideJohn Cutcliffe, University of Northern British Columbia (cutclifj@unbc.ca,There can be few ethical issues that prompt more passionate and polarised debate than those matterspertaining to end of life decisions. While on initial consideration, the subject of suicide may appear to bespared the vagaries of such interrogation; however, on closer inspection we see that the subject is repletewith hitherto unresolved ethical dilemmas.Accordingly, this presentation summarises and offers up for discussion a number of principal questionswhich should inform the subsequent ethical discourse around the matter of suicide. These key questionsare:Whose life is it anyway?Is suicide ever the right thing to do?Is there such a phenomenon as a rational or appropriate suicide?What role, if any, should healthcare practitioners play in assisted suicide?Clearly, such ethical issues are important topics for consideration for those directly or indirectly involved inthe care of the suicidal person, and I will not belabour the obvious connection between the individualpractitioner’s own ethical and philosophical stance on suicide and the resultant ‘care’ the suicidal personreceives. Case law and existing examples from practice will be drawn upon in order to better inform thediscussion, in the hope that this can contribute to more fully informed ethical standpoints and give rise tomore fully informed practice.168.5. Suicide in Mexico TodayGuido Belsasso, American British Cowdray Medical Center, Mexico City, Mexico(belsasso@infosel.net.mx)Mexico has one of the lowest suicide rates in the world: 3.4 per 100,000 inhabitants. Roughly 9 to 10Mexicans kill themselves daily. With the population of 110 million, there are 4 million depressed patients,

495roughly 1 million manic-depressives and 15% of these commit suicide. Suicide is the 18th cause of deathin the general population.Suicide was recognized by the Indian cultures well before the discovery of America in 1492. In the currentpresentation, we explore the epidemiological data with emphasis on age, sex, religion, occupation, time ofthe year, marital status, method used, and the comparison of the different geographical zones in the country.We also compared Mexico to the rest of the world, according to World Health Organization data. Wecompare and report various studies on suicide from 1974 to date in psychiatric, general hospitals, and thesocial community. A reference is made to current public health studies of the Mexican states with thehighest incidence of suicides, and the new programs that are being designed and implemented to preventthe problem.We also studied suicide among the peasants, rural inhabitants, and the native Indians like the Taraumaras.We compare the suicide rates to drug abuse and alcohol problems, and establish the difference betweenthose who have intended to commit suicide.We explore the attitudes of the Mexican people to suicide and death from the sociological to the historicalviewpoints. We report the legal aspects of suicide, both in the Penal Code and the guidelines to theinsurance companies. A comment is made on the influence of the catholic religion on suicide in Mexico.168.6. Cognitive Function in Persons with Depression and Relationship to SuicideWilfred G. van Gorp, Columbia University College of Physicians & Surgeons(vangorp@pi.cpmc.columbia.edu)Cognitive impairments have been described in many cognitive domains in persons with affective disorders,especially those with major depression or bipolar disorder. Cognitive impairment can either occur in thestate of acute illness (“state related”) or in the non-depressed or manic state, presumably as a result ofmultiple episodes of depression or mania over the person’s life (“trait related”). We will review theliterature, which shows that the presence and intensity of cognitive impairment is significantly related toboth number and duration of episodes of affective illnesses over the person’s life. This presentation willfocus on the literature reviewing the neuropsychological impairment of those in the euthymic state (traitrelated).The questions of which cognitive domains are affected as a consequence of affective disorder will then beexplored. Research indicates, that memory and executive functions are differentially affected in personswith affective illness, and these implicate effects on temporal/hippocampal and frontal lobe structures.Evidence for these findings will be reviewed.Finally, that frontal lobe or executive functions are differentially affected in persons with affectivedisorders bears directly on the issue of suicidality in these individuals. As the frontal lobes relate toplanning, anticipation of consequences, deliberation before acting, and the ability to inhibit impulsiveactions, it can be seen that impairment in this domain can produce impulsive, poorly thought out actions.Implications for suicide risk assessment and management will be discussed, as it bears on forensic issues.

496169. Survivors of Persecution and Torture I169.1. The Use of the UN Convention against Torture and Other Cruel, Inhuman andDegrading Treatment or PunishmentBent Sørensen, International Rehabilitation Council for Torture victims (IRCT), Copenhagen, Denmark(BS@IRCT.org)The Convention Against Torture was adopted in consensus by the UN General Assembly on 10 December1984 and went into force on 26 June 1987. By June 2004, the Convention has been ratified by 136 states,out of 194 possible. The Convention is always in force, in peacetime as well as wartime. There is nopossibility for derogation, and the prohibition against torture is absolute. The Convention gives a veryuseful and easily operational definition of torture. All ratifying states have the duty to punish torturers(regardless of their nationality and regardless of the nationality of the victims – impunity may never betolerated); to vindicate the victims; to educate relevant personnel (including medical) about the prohibitionof torture; and to review interrogation methods and inspect places of detention. On several occasionsduring the last years, there have been discussions about the Geneva Conventions. Are the Conventions atall in force during special circumstances (The war in Afghanistan for example), or not? Is there at all astate of war (the precondition for the Geneva-Conventions to be in force)? Instead of referring to theGeneva Convention, it can be advocated to States to use the Convention Against Torture as the legalbackground for examination of cases, and bring the alleged perpetrators before court and for vindication ofthe victims of torture.169.2. The Burden of ProofHelen Jaffe, Association for the Victims of Repression in Exile, Nanterre, France (contact@avre.org)The French Ministry of Health required Avre, a medical non-profit organization, to conceive and write ahand book for general practitioners confronted with a victim of torture, under the control of a panel ofexperts in the country.In France, a considerable number of persons have been subject to torture. Their physical and psychologicalcomplaints may be linked to their past sufferings. A leading question may be how to gain a patient’s trust,so that the subject of past torture may be discussed.More than 20 years of experience treating victims of torture in countries where torture is used on a largescale have helped to develop some principles and strategies. These are provided to our GP colleagues, tohelp patients feel complete understanding and support. A goal is to prevent certain patient situations: “wehave not been heard and sometimes not even listened to” as reported by Dr Yaël Danieli, a U.S. psychiatristwho interviewed survivors from the Nazi camps, when talking about their experience of the Holocaust totheir practitioners.

497169.3. The Gomez Paquiyauri vs. Peru Case Before the Inter-American Court on HumanRights: Making States Accountable for Torture and Extrajudicial Execution ofChildren in the Context of Internal Armed ConflictsMonica Feria, London School of Economics (monicaferiatinta@hotmail.com)In 1991, Emilio and Rafael Gómez Paquiyauri, two Peruvian children aged 14 and 17, were arrested in thestreet outside their home, tortured and extra-judicially executed by the Peruvian Police.The police stated that the minors had been killed in an “armed confrontation” and that they were“terrorists”. However, TV cameras had been present when the children were detained, and showed thepolice suddenly stopping the children whilst out walking, pulling their hair, blindfolding them, beatingthem, and forcing them into the trunk of a police car. An hour after their arrest, the children were left deadin a morgue with labels on their bodies stating they were unidentified. They had been taken to a desolatelocation, Pampa de los Perros (Dogs’ Land), tortured and killed. Their hands had been shot whilst theywere alive and their faces had been destroyed by bullets. The mouths of the boys were full of earth, theirtrousers full of holes as if beaten with an iron stick, and the police had urinated on them.The father of another victim tortured and killed in similar circumstances the same day, denounced thecrimes on national television. The scandal forced the State organs to ‘investigate’ the events. However,only the lower ranking non-commissioned police were found criminally responsible for the killings andwere released after serving just a short time of their sentence. Nobody was investigated or charged forhaving tortured the children and impunity prevailed. Instead of securing justice, the judicial systemensured that those who ordered, planned and carried out a policy of terror against the civilian population (inthe context of the internal armed conflict that Peru lived through during those years), could go unpunished.After 13 years of seeking justice, the Gomez Paquiyauri family had their case heard by the Inter-AmericanCourt of Human Rights (the regional counterpart to the European Court of Human Rights in Europe). Thehearing took place in Costa Rica in May this year and a final judgment on the case is to follow shortly.169.4. The Gomez Paquiyauri v Peru Case Before the Inter-American Court on HumanRights: Making States Accountable for Torture and Extrajudicial Execution ofChildren in the Context of Internal Armed conflicts – Part II: General AspectsInge Genefke, International Rehabilitation Council for Torture Victims (IRCT), Copenhagen, Denmark(Inge.Genefke@irct.org)This presentation takes up the paper by Feria reporting as a lawyer on the case of Emilio and Rafael GómezPaquiyauri, two Peruvian children who survived torture. The case is taken up by the author (Inge Genefke),who served as an expert in the court case, to analyse the general and medical aspects of the case. Torturehas been denied by the State of Peru in the present case and is an issue that the Court will judge.The Gomez Paquiyauri case will be the first international case concerning the protection of children in thecontext of armed conflict to be adjudicated by a court and as such, will represent a landmark decision. TheAmerican Convention on Human Rights contains a specific provision for the protection of children andtherefore the Inter-American Court of Human Rights has the jurisdiction to pronounce on individual rightsof children under complaint procedures in a way no other international judicial body can. Due to theirvulnerability, children are overrepresented in civilian populations enduring torture and unlawful killings in

498the context of armed conflicts. As a result, this case will set a precedent worldwide on the duties that Stateshave – even in times of war – towards children.169.5. Review of Torture Assessment Methods in Sri LankaU.C.P. Perera, Ruhuna Faculty of Medicine, Sri Lanka (cliffordperera@yahoo.com)Torture is endemic in modern Sri Lanka and measures taken to reduce it are at crossroads. The incidence ofcivil war related torture in the north and east of the country has been reduced during last few years, whilethe civilian torture cases mostly committed by the police in the rest of the country are on continuousincrease. Despite having an effective legal framework to counter torturous practices locally, the extent towhich that mechanism was used by the authorities is arguable. The torture victims are referred for medicolegalexamination by medical officers at various levels and these reports are mostly inconclusive withregard to evidence of torture. The lack of a well scrutinized system for psychological assessment of torturevictims has been noted by many experts for years, and this has led to a grave misrepresentation of evidenceof torture in the court cases. All these deficiencies have direct impact on rehabilitation initiatives designedfor the torture survivors. Therefore, what is currently essential is the need for an evaluation of the physicaland psychological examination systems pertaining to torture victims in Sri Lanka, with a view ofimplementing better rehabilitation modules while utilizing the legal mechanisms available to the fullestcapacity.169.6. Shubhodaya Center for Rehabilitation of Victims of Torture and ViolencePradeep Agrawal, Shubhodaya Center for Rehabilitation of Victims of Torture and Violence, India,(p_agrawal@bol.net.in)The Shubhodaya Center in India was established in Delhi in 2000, to provide comprehensive rehabilitationto the victims of torture among Indian and refugee populations. It was initiated with the support fromIRCT. The refugees in India primarily belonged to Mayanmar, Afghanistan, Srilanka, Iran, and Tibet. Ateam of social workers, physicians, psychologists and psychiatrists, and physiotherapists provide care to thetorture victims. The Shubhodaya center has conducted several scientific studies in these communities tostudy various psychological and physical consequences of torture on the victims. The victims in the studywere randomly picked up from areas where torture cases were reported. A detailed socio-demographicPerforma was prepared to record the necessary details. Specific scales were used to study the torture casesand their consequences; several significant findings were revealed. Survey findings will be presentedduring the congress. Certain surveys of refugee populations revealed that stigmatized groups were hesitantto contribute to data collection. Certain refugees are granted refugee status by UNHCR, but some have notbeen granted this status, and they suffer; a large number of these refugees have settled in New Delhi (thecapital of India). These people have formed their own small closely linked communities. They face a greatdeal of strife in India, though not necessarily through physical alientation (their skin colour etc. allows themto blend in), rather through cultural, linguistic and financial circumstances. Refugees suffer in their nativecountries, and continue to suffer in India; they are isolated through dialect and some because of psychiatricproblems, manifested in part due to circumstance. Torture and its consequences are not a priority area forthe Government in India, and it is relatively a new subject for public exposure. It was not until recently thatpeople began to admit torture occurred in India, let alone discuss the issue publicly. With the openness in

499the government, and establishment of National Human Rights Commission, people feel free to talk abouttorture. These issues and their effects will be discussed in detail during the presentation.169.7. Constituting the “Insane” in Supermax ConfinementLorna A. Rhodes, University of Washington (lrhodes@u.washington.edu)In the United States, supermax confinement is increasingly used as a routine management tool; while prisongrowth has slowed slightly, new supermax facilities continue to be built. Much of the debate about theseprisons centers is about 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 illprisoners remain in supermax facilities; even when transferred out, they may be held under similarconditions. Drawing on research from Washington State, I will describe the supermax population as awhole and will then present an ethnographic case study of a “borderline” prisoner held alternatively underboth supermax and psychiatric forms of “lockdown” and restraint. This case raises questions about therelationship 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 ambiguouscategory within the prison and how the diagnostic system and managerial decisions combine to producethis result. Second, what are the consequences of this ambiguity for prisoners? I will show how they occurwithin the terms of an institutional environment in which psychiatric treatment itself resembles theconditions of supermax. Finally, I will consider the situation of those not recognized as mentally ill andraise concerns about how supermax confinement can be approached in terms of its general, as well asspecific, harm to prisoners and about how this harm might be framed in public discourse.170. Survivors of Persecution and Torture II170.1. The Gomez Paquiyauri v Peru Case Before the Inter-American Court on HumanRights: Making States Accountable for Torture and Extrajudicial Execution ofChildren in the Context of Internal Armed conflicts – Part III: Medical IssuesHans Petter Hougen, University of Copenhagen (Hans.Petter.Hougen@forensic.ku.dk)In 1991, Emilio and Rafael Gomez Paquiyauri, two Peruvian boys aged 14 and 17, were arrested in thestreet outside their home, tortured and extrajudicially executed by the Peruvian police.Both deceased were autopsied at the Institute of Forensic Medicine, Ministerio Publico, Callao, Peru. Theprotocols from the two autopsies did not meet the usual forensic pathology standards. It was evident fromthe autopsy reports that the two victims had died of gunshot wounds, though description of the wounds andthe wound paths were missing. The autopsy reports consisted mainly of statements and not of descriptionsupon which impartial conclusions could be made. Autopsy photos, which are crucial in homicide cases,were not taken, and no further forensic investigations like toxicology screening, microscopy, or relevantDNA- typing were performed. Photos taken by the family after the autopsy, showing the dressed bodies in

500the coffins, and revealed several lesions due to blunt force entry, which were not described in the autopsyreports. The photos also revealed that one of the victims, Rafael Gomez Paquiyauri, had been shot in thehands at a short distance prior to death.The autopsy findings and the insufficiency of the autopsy reports will be discussed.170.2. Aspects of the Past in the Presence of the HolocaustVera Passweg, University Hospital, Vienna, AustriaMajor violence in the dimensions of the holocaust before and during the Second World War against theJewish population of Europe has been shown to lead to severe long-term consequences on many levels.The example of Vienna, once a capital strongly influenced by Jewish culture, and now home of only asmall community is taken to demonstrate the presence of such acts as a continued psychological factormore than fifty years after the war. Recompensation is an ambivalent concept in the face of such complexdevelopments over time, reflecting multi-layered processes that are discussed in the presentation.170.3. "I cannot know you…” Approaches to Culture-sensitive Systemic Psychotherapywith RefugeesIngrid Egger, Zebra Association, Graz, Austria (Ingrid.egger@zebra..or.at)In this presentation I want to describe some topics about the possibilities and risks of culture-sensitivityfound in psychotherapeutic work with refugees. I want to locate these activities in a socio-political systemto stress the basis of our journey into foreign cultures and environments. Based on practical and exemplarywork with the association ZEBRA; I want to demonstrate which "equipment" and which “travelcompanions” are indispensable for this task.170.4. The Burden of ProofSibel Agrali, Primo Levi Center, Paris, France (primolevi@wanadoo.fr, primolevi@primolevi.asso.fr)A serious dilemma surrounds the subject of delivering medical reports to support asylum claims of patientshaving undergone torture. On the one hand, patients, led to believe that such a report is essential inenhancing their chances of obtaining refugee status by “proving” that they have indeed been tortured,obstinately seek the much-coveted document. On the other hand, we are placed in a pervert situation wherewe desperately search for traces - objective, indisputable traces – of past torture. We, as healthprofessionals working in the field for so long, know better than any one else that torture isn’t intended, isn’tdesigned to leave traces, or rather, that months or years after, sequellae of torture is mostly psychosomaticand/or psychological and mostly non-specific. Which cause are we really serving as health professionalswhen we play the role of expert in the context of increasingly restrictive asylum laws and procedures? TheIstanbul Protocol (a comprehensive manual for the efficient documentation of torture) was ultimately

501intended for investigators wishing to denounce the use of torture, pursue torturers and torturing states, andassist victims seeking reparation.Instead of following the dangerous drift that the restrictive application of the 1951 Geneva Convention hastaken in most European countries, we should put more effort into informing and lobbying about the truenature of torture and its effects while more efficiently helping our patients in the elaboration of detailednarratives for their asylum claims.171. Survivors of Persecution and Torture III171.1. Day hospital: A New Approach for the Treatment of Traumatized Refugees inGermanyNora Balke, Centre for the Treatment of Torture Victims, Berlin, Germany (n.balke@bzfo.de)The day clinic at the Center for the Treatment of Torture Victims in Berlin (BZFO) is the first of its kind inGermany. Its participants include traumatized torture victims and survivors of civil war from regions of theformer Yugoslavia, Turkey, Lebanon, Iran, and other countries.Patients participating in this unique program are offered a structured program with specific attention givento the therapeutic process. The various therapeutic approaches offered by licensed therapists include art,garden, physiotherapy, individual, group, and gender-specific therapy. In matters concerning their asylumprocess or problems regarding their residential status, patients are counseled and officially supported by anexperienced team of social workers.Among the goals of the day clinic are to occupy the patients with practical and meaningful activities thatwill serve them not only in their struggle to improve their mental health, but also offer practical guidancefor integration in the society of the foreign land in which they now find themselves. On a small scale, thisintegration is practised through communal activities such as cooking, playing team sports, and workingtogether on a garden project; all activities which promote participation and mutual cooperation. On a largerscale, patients benefit from a variety of activities aimed at their personal integration into German society.This is achieved in part by weekly field trips to museums and other places of interest in Berlin, and on amore practical level with a German language course and training in the use of public transport - inparticular with anxiety control in the underground metro.The paper will begin with a brief overview of the project’s development thus far, and go into further detailin regards to the specific therapy offers mentioned above, their treatment goals, and some of the problemswe experience in the initial phase. Our experiences will be demonstrated with a case study of one of ourpatients, showing the efficiency of treatment as well as the negative and positive experiences we haveencountered so far.

502171.2. Care for CaregiversLilla Hárdi, Cordelia Foundation for the Rehabilitation of Torture Victims, Budapest, Hungary(lilhardi@axelero.hu)In the process of rehabilitating survivors of torture, a new aspect is becoming more and more important:care for the caregivers. Every professional in connection with human beings is threatened by the danger ofvicarious traumatization and burning out. The author demonstrates ways of caring (with psychologicalprocesses) for medical staff, social workers of refugee camps, interpreters, and the eligibility officers of theImmigration Office in charge of refugees being survivors of torture. For a duration of 4 years, thepsychiatrist and the non-verbal therapist have met the caregivers for supervision sessions monthly. Eachsession has a verbal and a non-verbal part in order to elaborate the psychological processes in both ways.Negative as well as positive transferences appear in the psychotherapeutic work with the team. Theirproper interpretation is the focus of the verbal part of the session. Special situations appear in case analysesof torture victims and other seriously traumatized clients. The interview in the legal process with theeligibility officers might remind the client of interrogation in prison, where the legal persons and theinterpreter are identified with the torturers. This, as well as feeling of shame and guilt, results in the clientbeing unable to speak about his/her experiences in the torture chamber and thus eligibility officers refuserefugee status. Denial of the legal person might result in the client being declared a “liar”. The role andtraumatization of the interpreters are also important topics. The latter can be prevented by regulardebriefing at the end of the working day. These sessions also contain psycho-educative elements toincrease the psychological mindedness of the caregivers. The non-verbal part contains relaxation andcontact exercises. Sometimes individual support is needed besides the group process as a concurrentpsychotherapeutic help to the group member. Supervision and support is needed as a preventive aspect andas an important tool in the process of teambuilding and case handling.171.3. Models of Training in Forensic Evaluation of Human Rights AbusesMonika Krautgartner, University Hospital, Vienna, AustriaForensic evaluation of sequel to war, torture, and human rights abuses has become a major issue in manysettings including prevention, legislation, and asylum law. Standardisation and training is a key issue in thequality of findings and the prevention of secondary sequels. The Istanbul Protocol (IP) on thedocumentation of sequels to torture, developed by an international expert group, has been accepted as astandard by international key organisations including the IRCT and the UN. The Istanbul Protocol containsa major Psychiatric part that requires special training. The training programme used by the WPAconcerning the IP and the general training programme presented cover a large range of aspects of thissubject.

503171.4. Implementing the Istanbul Protocol: The Uganda ExperienceSeggane Musisi, Makerere University, (segannemusisi@yahoo.ca)Introduction: The Istanbul Protocol (IP) is a set of international guidelines providing for the investigation,assessment, documentation, rehabilitation and redress of alleged victims of institutionalized torture.Endorsed by the UN General Assembly in 2001, the World Medical Association (WMA) and theInternational Rehabilitation Council for Torture Victims (IRCT) embarked on a project for its worldwideimplementation, beginning with 5 test-countries of Uganda, Morocco, Mexico, Sri Lanka and Georgia.Objective: The objective of this paper is to describe Uganda’s experience as the first country in the worldto implement the IP and to discuss the lessons learned in this exercise.Method: A combined WMA and IRCT team visited Uganda to prepare for pilot implementation of the IPwith funding from the European Union (EU). Three identified local consultants, (co-coordinator, medicaland legal), worked with the Uganda Medical Association and the Uganda Law Society to recruit 45doctors, 25 lawyers and 5 NGO specialists to attend a one-week training workshop on the investigation,assessment, documentation, rehabilitation and redress of torture victims in Uganda as provided for in the IPguidelines. Twelve international and local doctors and lawyers facilitated the workshop in the form ofmedical and legal lectures followed by group discussions and then presentations in joint plenary sessions.The workshop was launched by the Prime Minister, the EU and Dutch ambassadors.Results: Forty-five doctors, 25 lawyers and 5 NGO personnel were trained. These became the trainerswho went out in their respective districts to train others in the implementation of the IP through a nationalNGO which was launched with regional networks. The doctors and lawyers felt that they had learnt a lotfrom each other, including how they could work together to combat the problem of torture in Uganda.Conclusion: A number of lessons were drawn from this exercise: The political profiling of the workshopgave it recognition and committed government to accept instituting torture eradication measures in thecountry. For the first time, lawyers and doctors trained and worked together on the common problem oftorture eradication. It was felt that joint lecture sessions followed by parallel discussion groups and thenjoint plenary sessions gave the best results for the training. A national NGO with regional networks was feltthe best way forward for nationwide implementation. Uganda’s experience clearly demonstrated that theworldwide implementation of the Protocol was possible, the only limitation being funding.171.5. The massacre of Nanking: A testing stone for the transcultural understanding ofwar crimesThomas Wenzel, University Hospital, Vienna, Austria (drthomaswenzel@web.de)The massacre in the Chinese city of Nanking ( 南 京 大 屠 殺 ) in 1937 by Japanese troops can be seen as oneof the most atrocious massacres in human history. Careful present day scientific analyses of witness reportsand data demonstrate that an assumed more than 300,000 people, mostly civilians, were killed, and anadditional high number of civilians were raped, tortured, lost their property or were persecuted in otherways. The history of not solving the legal, financial, medical and psychological problems created lasts up tothe present day and leads not only to suffering for the survivors and their families, but also to increasingtensions between both countries, reflecting the effects of a policy different in many respects from thatfollowed in other countries and in the international legal community. The presentation analyses thepolitical, legal and psychological developments and implications of this crucial event in Asian history,compared with the experience of impunity and persecution of perpetrators and the impact on survivors and

504families in European countries that are characterized by different cultural and historical backgrounds butshare the concept of international standards with regard to war crimes.171.6. A Silent Legacy: Understanding My Grandmother’s Refusal to Testify beforeHUAC in 1955Susanna Rasmussen, Madison, Wisconsin, (serasmussen@uwalumni.com)My paper is a personal exploration of the reasons my paternal grandmother Darina Rasmussen invoked herFifth Amendment privilege, and refused to testify before the House Un-American Activities Committee(HUAC) when she was subpoenaed in 1955. At the time my grandmother had been employed for 4 yearsby the United Electricians, Radio, and Machine Workers of America in Milwaukee, WI, the union wasinfamous for the high Communist infiltration within its membership. My piece explores the historicalcontext: what brought my grandmother to the UE and what brought HUAC’s attention to my grandmother,and the questions that arose as a result of her refusal to testify. For example: was she a Communist orsimply putting herself at risk to protect others she knew were involved with the Communist party? Howdid her experience going to Washington to testify affect my family and what legacy does it leave behind forme today –especially post 9/11 when American’s civil liberties are sacrificed in the name of security. Sincemy grandmother passed away in the winter of 1997 when I was still a teenager, I have never had theopportunity to ask her face to face. All I have are family stories, a few of her articles and a copy of thetranscript of my grandmother’s testimony before HUAC in 1955.172. Survivors of Persecution and Trafficking: A Review ofCurrent Issues172.1. Psychology, Torture and Human RightsSolvig Ekblad, Karolinska Institute, Stockholm, Sweden (Solvig.Ekblad@ipm.ki.s)Torture, in our modern context, is used as part of a covert terrorizing process of state-sponsored humanrightsviolence against minority religious, ethnic, or other communities. Even though it is difficult toinvestigate torture, we know from asylum seekers and refugees the physiological, psychological, and socialimpacts. The second author has reviewed the literature regarding emotional reactions to torture andorganized state violence (Turner, 2004). In reviewing the Amnesty International book on combatingtorture, Silove (2004) consider that the challenges in fighting torture from September 11 to Abu Ghraib liesin ignoring international forums. Not only medical doctors but also psychologists can figure out thephysical and mental costs of torture and other harsh treatment. In the literature it is mentioned that militaryuse psychology knowledge, such as The Arab mind (Patai, 1973) a study of Arab culture and psychology.Referring to Silove (2004) “A far more sophisticated, multisectoral exhange is needed to allow members ofsociety to understand the perils they faced by sacrificing human rights, risking a return to a dark ages inwhich brute force reigned. Collectively, the medical professional has a legitimate role in that debate” (p.

5051916.). This presentation will give examples how psychological knowledge in similar way as medicine hasbeen and are used as a tool for torture. International arena must be more transparent for such knowledge inorder to pay serious attention to prevention.172.2. Provision of Support Services for Trafficking VictimsAileen Kennedy, University of New England, Australia (akenned5@une.edu.au)It is estimated that seven hundred thousand to two million women and children are trafficked across bordersevery year, with about three hundred thousand trafficked in South East Asia. A small but significantpercentage of women working in the Australian sex industry have been illegally trafficked to Australia.Underreporting and non-prosecution of offences is a complex and difficult matter which, it is argued, hasbeen inadequately addressed at both a legislative and administrative level. The Australian governmentrecently announced a $20 million package to combat trafficking in persons, including ‘a comprehensivevictim support package’. This paper will explore the current scheme of provision of post-traffickingsupport for victims in Australia whereby the provision of such support is contingent on the victim’sparticipation in prosecutions. As noted by a prominent advocate in the area, ‘this approach stands in starkcontrast to support services for other victims of violence, particularly for Australian survivors of sexualassault and domestic violence.’ In Italy support services and protection visas are available even in theabsence of participation in prosecution, and this appears to have assisted in bringing successfulprosecutions. This paper will thus adopt a comparative analysis of the efficacy and adequacy ofrehabilitation and support in Australia for victims of trafficking and examine the links between provision ofsupport and the effective combating of trafficking in Australia. The efficacy of such support will bemeasured in part by reference to increased reporting and prosecution of offences.172.3. The Palestinian Prisoners, From Torture in Prisons to Traumatic Reality Treatingthe HeroesR. Zaqoud, Gaza Community Mental Health Programme, Gaza Palestine (iyadgc@gcmhp.net)The Palestinian experience in treating torture survivors after years of imprisonment in the Israeli Detentioncenters and prisons is very peculiar. Palestinian prisoners are subject to continuous and organized violencefrom the date of arrest to the time of release. Various forms of torture are documented and the prisoners areleft suffering for a long time from the inevitable consequences of humiliation. Upon release they areconfronted with the more traumatizing reality, many of them feel that their struggle against the occupationproved worthless, creating an overwhelming feeling of frustration and anger. While the society treats themas HEROES, they are victims nevertheless. The process of victimization is suppressed to keep the image ofthe veteran. They identify with the new position and stay suffering wordlessly, leading to sweepingsymptoms and grievance. When help is offered, the heightened stigma hinders them from the therapy. Inmy paper, I will tackle this phenomenon and describe some research and clinical work that helped me inassisting these extraordinary victims.

506172.4. Ethics and Human Rights: Lessons from the War against TerrorismJames Welsh, Medical Program AI, London, England (jwelsh@amnesty.org)Violent acts commonly described as acts of terrorism have happened for centuries. Forceful reactions bygovernments to colonial struggles and internal conflicts also have a long history. However, the "waragainst terrorism (or terror)" as currently understood can be dated to 11 September 2001 -- the day of acoordinated attack on New York and Washington DC using hijacked passenger planes as weapons. On 13September 2001, US President Bush said, "Now that war has been declared on us, we will lead the world tovictory"; other governments promptly joined the "war against terror". The following month, AmnestyInternational expressed its concerns about the introduction in many parts of the world of legislative,procedural, and other initiatives that restricted individuals' rights and that were justified as part of the fightagainst "international terrorism". Other human rights groups expressed similar concerns. The bombing ofAfghanistan and Iraq and the taking of thousands of prisoners for interrogation led to accusations of the useof torture by US and allied forces. Health personnel working in US military prisons were criticised in 2004for tolerating, condoning, or event participating in, cruel or degrading treatment. Meanwhile,indiscriminate acts of violence by small, armed groups continue and individuals continue to be stripped oftheir rights if they are identified as targets of the war on terrorism. This paper discusses the impact of"terrorism" on human rights and examines ethical and human rights aspects of the "war against terrorism"with particular reference to the implications for the health professions.172.5. The Istanbul Protocol: Indications for Asylum CasesMonika Freidl, University Hospital (Monika.freidl@meduni.wien.ac.at)Monika Krautgartner, University HospitalWolfgang Prause, University HospitalThomas Wenzel, University HospitalThe Istanbul Protocol has been accepted internationally as a standard for the documentation of torturesequels. The exact description of necessary procedures underlines the need of its application in all relevantsituations.Asylum cases frequently rest on the ability to prove torture as an indicator of “justified fear of persecution”,though torture is also relevant in asylum practice in other questions, such as defining “traumatization”, orunderstanding observed impairment in procedures.This presentation uses case examples from asylum cases to discuss the possibilities of using the IP as aforensic mental health tool in this context. The Istanbul protocol contains parts that are also important inthe understanding of the interaction between interviewer and refugee and are frequently neglected ormisunderstood in asylum procedures, including a wide range of aspects such as transference, brain trauma,or disorientation during torture or after the interview. Applying standards and standardized trainingsystems can become a protection for survivors of torture in exile.

507173. Terminal Illnesses, Euthanasia and Assisted Suicide I173.1. The Dutch Euthanasia Law: Legal, Medical and Social Developments in the Areaof Voluntary Active Euthanasia and Other End-of-life DecisionsGerrit K.Kimsma, Free University of Amsterdam (gk.kimsma@vumc.nl)After 25 years of building up acceptance of voluntary active euthanasia, a ‘euthanasia law’ became activein the Netherlands in April 2002. This paper will focus on the structure of the jurisprudence, thedevelopments in medical professional ideas/practices and present problematic issues, needing furthermanagement and choices. The ‘bottle necks’ that are experienced by the medical profession, as outlined inJune 2004 shall be compared with the positions of the Dutch Government as outlined in a letter to theParliament of July 2004. I shall finish my presentation with a description of developments in the area ofend-of-life interventions with Alzheimers patients.173.2. The Practices and Laws on Euthanasia and/or Physician-assisted Suicide: AComparison of Oregon (USA), The Netherlands and BelgiumLuc Deliens, Free University of Brussels (luc.deliens@vub.ac.be)Els De Keyser, Free University of BrusselsLinda Ganzini, Oregon Health and Science UniversityGerrit van der Wal, Free University of AmsterdamIn the Netherlands (2002), Belgium (2002) and Oregon (1994) euthanasia and/or physician–assisted suicidehas been legalised under strict due care criteria and after confirmation with a notification procedure. In theNetherlands both medical acts, namely euthanasia and physician–assisted suicide, have been legalised. InBelgium and Oregon (USA) only, respectively, euthanasia and physician–assisted suicide have beenlegalised.Because in the Dutch society the norm setting on euthanasia and physician-assisted suicide has been widelydeveloped through jurisprudence, the law is less extensive on the due care criteria than in Oregon andBelgium. Furthermore, the medical associations and medical guidelines support the Dutch law, and anetwork of support and consultation physicians has been implemented. Because in Belgium, jurisprudenceand professional guidelines are lacking, the euthanasia law is less supported by professional caregivers thanit is in The Netherlands. In the USA, the Oregon Death with dignity Act, the first law ever to regulatephysician-assisted suicide, remains highly controversial.All three countries are decriminalising euthanasia and/or physician assisted suicide only when the attendingphysician has respected the due care criteria. Some of these are similar, for example the patient must bewell informed about the diagnosis and prognosis; the opinion of the consulting physician must be taken inconsideration, etc. while others clearly differ.The euthanasia and the physician assisted suicide practices and the due care criteria for these practices, asdescribed in the laws, will be discussed and compared across countries in this paper.

508173.3. Hard Cases for the Belgian Euthanasia LawFreddy Mortier, Ghent University (Freddy.Mortier@UGent.be)The Belgian euthanasia law is in force since September 2002. It allows euthanasia, under specificconditions, in patients suffering hopelessly and unbearably, either terminal on non-terminal. I would like tofocus on the case of a request for euthanasia recently brought before an ethics committee in a hospital. Thecase concerns a 34 year old woman with a psychiatric history of severe depression and borderlinepersonality syndrome, also suffering from perhaps minor but persistent physical discomforts. The patientwas examined by a psychiatrist independent from the physician to whom the euthanasia request wasaddressed. I will analyse the (extensive) expert report submitted by the psychiatrist and highlight theintricate problems it raises in assessing the patient’s competency, in determining the very hopelessness ofthe patient’s condition, as well as in guaranteeing the general carefulness of the consultation by thephysician of colleagues. I will draw on comparable cases of requests for euthanasia or physician-assistedsuicide by psychiatric patients in the Netherlands (that sometimes have been brought before the courts) andtry to answer two sets of questions: (1) what standards for good medical practice, if any, are suggested bythe cases at hand; (2) whether and how effective legal control by the federal evaluation commission ofproblematic cases might be achieved, so that psychiatric patients may be sufficiently protected.173.4. Who Should Determine Capacity When a Patient Who Cannot Speak Requeststhat Life-sustaining Treatment Be Withheld? A Case StudyColleen Cartwright, Southern Cross University (ccartwri@scu.edu.au)Under both common law and statute law in Queensland and other states/territories of Australia, and indeedin 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 forcompetent adults to make their wishes known for health care they would, or would not, want if at somefuture time they lost the capacity to communicate. In most cases the legislation provides for completion ofa written document of their wishes (in most cases called an Advance Health Directive) and/or theappointment 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 ispresumed to be competent unless they are proven to be otherwise, and the onus of such proof rests withthose who claim that the patient is not competent. However, in some cases determining a patient’scompetence may be difficult, e.g. when a patient is unable to communicate verbally and/or when it issuspected that the patient’s current life-threatening 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 wasquadriplegic, using only head movements to respond to questions and there was disagreement betweenconsultant psychiatrists and the treating intensive care and spinal unit specialists, as well as betweenmembers of the patient’s immediate family, in relation to the patient’s capacity. The case was sent to theGuardianship and Administration Tribunal for a determination. The Tribunal’s finding and the outcome ofthis case will be discussed.

509174. Terminal Illnesses, Euthanasia and Assisted Suicide II174.1. Withdrawing and Withholding Treatment for Terminally Ill Infants when ParentsInsist that Treatment Must Be Continued: The Role of the CourtsLoane Skene, University of Melbourne (l.skene@unimelb.edu.au)Sometimes parents demand that full active treatment must be given to their terminally ill child, but doctorsand nurses, backed by the hospital’s clinical ethics committee, believe that such measures may not be in thechild’s best interests, and that the child should be offered only palliative care.Medical staff commonly believe that they should be the ones to determine the appropriate treatment. If theyfeel compelled by the family to continue life-sustaining measures that they do not consider to be in thechild’s best interest, it becomes 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 bemissed by health professionals. They say that the determination of what is in the child’s best interest cannotbe determined objectively from the doctor’s viewpoint. A life that is ‘not worth living’ may be different fora 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 thetreatment 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 healthprofessionals to act contrary to their clinical judgment?The author reviews recent case law in the UK, Australia and New Zealand and concludes that it isextremely unlikely that a court would direct medical staff to provide treatment they do not think isclinically in a patient’s best interests.174.2. Truth-telling in Terminal Cases: Right, Duty, or Proscription?David Novak, University of Toronto (david.novak@utoronto.ca)One of the perennial questions asked in the course of medical practice is whether a patient determined to beterminally ill should be told of the physician’s judgment of the probability of his or her imminent death. Iswhat has been called the issue of “truth-telling” a right, a duty, or a proscription? Does a patient have aright to know of his or her terminal condition? If so, what is the source of this right? Why is its exercisejustified? Does a physician have a duty to tell a patient of his or her terminal condition? Would there besuch a duty if the patient did not request to be told the truth about his or her chances for survival? Is there aproscription of such truth-telling? Could such truth-telling, in effect, be a death sentence, indicating to thepatient 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 abdicationof his or her responsibility to the patient, however remote the chances of recovery or however unpredictablethe time of death probably is?This paper will argue that the “right to be told” can be most cogently exercised by religious patients, whocan be defined as those (Jews, Christians, or Muslims) who believe that they will be judged by God at thetime of death to be worthy or unworthy of an unending world where death has finally been transcended.

510Such patients would surely want to assert the right to be told of their condition so as to better resolvelingering moral and spiritual conflicts in their life while there is still time to do so. This would better enablereligious patients to prepare for the end and depart this world in peace with God and fellow humans, thushaving reason to believe themselves worthy of that transcendent future. Many religious traditions wouldcall this summation of one’s life “atonement” or “ultimate reconciliation.” But religious patients mustexplicitly assert this right to know their true condition to their physician in order for there be a correlativeduty on the part of the physician to tell the fatal truth to them. Without such explicit assertion in the form ofa request — “please Doctor, am I going to die soon?” — there is good reason for patient to suspect that thephysician, who tells them of the imminence of their death, is engaged in premature self-exoneration fromthe 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 medicalconditions, it is reasonable for religious patients to seek out — other professional abilities being equal — areligious physician who would better understand their right to be told the truth, and the physician’s duty totell it to them, and to care for them unconditionally. Such truth-telling should only be proscribed if it mightlead the patient to despair of further life in this world (however brief), which could even lead to what mightbe termed “pre-emptive suicide,” or if it might lead the patient to despair of ever being worthy of the life ofthe world-to-come.174.3. Confusion between Euthanasia and other End of Life Options: Implications forPublic Policy and Practice.Isabelle Marcoux, University of Quebec at Montreal (marcoux.isabelle@uqam.ca)This paper discusses the public’s understanding of euthanasia and the implications of their conceptions ofeuthanasia for public policy and decision making. The right to decide the “how” and “when” of death isbecoming one of the major ethical challenges in most industrialized countries. Public debate has beenfuelled by increased media coverage of specific cases (e.g. Diane Pretty in the UK, Vincent Humbert inFrance), 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 majority in favour ofeuthanasia is often cited as a justification for legalizing these practices. However, public opinion pollresults concerning euthanasia may be misleading. Our study, conducted in Quebec, revealed that people areconfused about what constitutes euthanasia and that people often confuse euthanasia with other end of lifepractices, 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 foundthat people who thought that withholding and withdrawing treatment equated to euthanasia were morefavourable of these practices. Widespread confusion about the nature of euthanasia limits the validity ofpoll results and can influence people’s support for public policies, as well as their decision-makingconcerning end of life practices.174.4. Psychiatry’s Normalizing Gaze at the End of LifeMalcolm Parker, University of Queensland (m.parker@uq.edu.au)Psychiatry is extending its sphere of influence in numerous fields, one of which is end-of-life decisionmaking.The assessment of patients’ decision-making capacity by a psychiatrist, in terminal illness

511situations, 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 theirdecision-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 andmeaning, 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 withterminal illnesses, and the desire to die, which motivates requests for assistance. The link is consideredstrong enough to define requests to die as always pathological.The principle of mandatory psychiatric assessment/review of requests for assistance to die, and theacceptance of Demoralisation Syndrome as a psychiatric category, both raise important questionsconcerning the medicalisation of existential cognitions at the end of life. In this paper I explore a numberof links between psychiatry, medicine, science and ethics, to support the claim that these recentdevelopments in psychiatric theory and practice work to illegitimately normalise and entrench thetraditional medical opposition to active assistance in dying.174.5. Mental Health Community Intervention Stops Suicide Tendency in Tabasco:Preliminary ResultsJaime Mier Y Teran Suarez, Health Secretariat, Tabasco, Mexico (jmier@saludtab.gob.mx)In Mexico, the annual suicide rate rose 3.34% between 1995 and 2002. In Tabasco death by suicide is the12 th cause of death, with rate of 10.6%, a threefold of the national level with an increasing tendency until2002. An open transversal prospective study was conducted in order to find the effectiveness of proceduresincluding: screening by qualified personnel in primary health care, epidemiological mental health brigadesand 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. Onlyone patient in the control group commited suicide. The increasing suicide tendency was contained. Theresults of this investigation suggest that suicide risk detection by qualified health personnel and proper careis efficient in preventing suicide.

512175. Terrorism and the Unknown Enemy175.1. Culture of Martyrdom: Psychology of the “Jihadist” PersonalityImat Amidjaya, H. Douglas Singer Mental Health and Developmental Disabilities Center; Rockford, USA(amidjaya@aol.com)In Paris, I plan to give an integrated discussion on current data and theories regarding the conflict betweenreligious militant fundamentalism and modernity; the psychological aspects of religious militant fanaticism;the origin and underlying motivations of suicide missions; the making of a martyr; and other aspects of thepsychology of terror. Politics, culture, economics, and business are intricately involved in the phenomenacalled terrorism. To understand terrorism, it is necessary to understand the conflicting political ideologiesand the history of regional conflicts, such as the Israeli-Palestinian conflict. I am, however, a clinicalpsychologist, not a political scientist. My presentation focuses on personalities, motives, and otherunderlying psycho-dynamics.I believe that the conflict of today, which continues to produce terror and death, is the conflict betweenmodernity vs. militant religious fundamentalism. Modernity stands for tolerance for diversity, globalthinking, and the acceptance of the inescapable reality of conflicting and opposing ideologies, politics, andreligions. Modernity also stands for human rights and the acceptance of the inter-dependency of nationsand societies.Nothing is more important in understanding the world of Islam today, the world of religions in general, andthe phenomena of terror other than the pervasive differences between moderate and fundamentalist Islam.Moderate Islam, found in Indonesia, urban Malaysia, modern Pakistan, and urban centers in some of theMiddle Eastern countries, is characterized by modernity. Fundamentalist Islam and other fundamentalistreligiosity are characterized by pervasive self-righteous contempt for all other religions and all societiesthat do not embrace one’s religion. Psychologically, a Christian’s contempt for Muslims is identical with aMuslim’s contempt for Christians, identical with an atheist’s contempt for believers, and identical with aRepublican’s contempt for a Democrat, or an Apple computer user’s contempt for all Microsoft-systembased computer users. They are all fundamentalist, potentially deadly at worst, and divisive at best. In thefinal analysis, modern liberal education and economic growth can be expected to produce the gradualdisappearance of fanaticisms and fundamentalisms, and the development of modernity.175.2. Terrorism, Trauma and Disaster ResponseKenneth Busch, Illinois Psychiatric Society (kbusch@metlife.com)The catastrophic destruction of the World Trade Center and the Pentagon on September 11, 2001 was alarge scale terrorist strike, which caused mass casualties and severe disruption to America. In the aftermathof 9/11, terrorists remain intent on attacking the United States, which poses an enormous threat tohomeland security.Terrorist actions can elicit strong responses to extraordinary events. The scope of the trauma can be severeand consist of: sudden awareness of body and life threat, exposure to the dead, contact with the mutilatedand grotesque, physical harm or injury, loss of significant others, loss of property and information stress.Terrorism and mass disasters precipitate a broad spectrum of emotions to these sudden, unexpected, and

513violent events, which can include: immense stress, intense fear, anger, anxiety, depression, panic,bereavement, and loss, and longer term consequences such as post traumatic stress disorder (PTSD).The ongoing terrorist threats present complex challenges which cross all jurisdictions such as: lawenforcement agencies, fire departments, emergency medical services, hospitals, clinics, American RedCross, mental health associations, and the media. This presentation will focus on preparedness andreadiness for the event of a potential terrorist attack, establishing relationships and partnerships with keyplayers, providing information on the psychological consequences of terrorism, and on mental healthassessments and interventions for trauma victims such as providing basic needs, psychological first aid,triage, CPR, identification of altered mental status and etiology, and referrals to specific hospitals and otherphysicians.175.3. Enemy Images, Archetypes, and Propaganda PotentialsSandra B. McPherson, The Fielding Graduate Institute, Santa Barbara, USA (smcpher1@earthlink.net)Jeffrey Donnelley, Allen Hancock College (jdonnelly@hancockcollege.edu)Theoretical and applied observations of development suggest a biologically and psychologicallydetermined human potential for dichotomous thinking and defenses of splitting and projection. Suchcognitive schemas provide a readiness to respond to war propaganda where messages of hate and ‘us versusthem’ motifs are created to enhance the ability to do battle. In 1989-90, adults and adolescents from avariety of contexts were asked to produce drawings illustrating their concept of an enemy; a second set ofdrawings was obtained in 2004 from an area importantly dependent on the U.S. military establishment.Initial analysis of the first set of drawings indicated strong predominance of male over female gender, theclear presence of dichotomous thinking, and the presence of standard enemy image artistic devices (typicalof propaganda art throughout western history). Results also showed that pictures illustrating the projectednature of the enemy image were a rare occurrence, including those from persons who identified with peaceand justice work. In the current project, a more refined system for categorizing image characteristics wasdeveloped and reliability established. Re-scoring of the original sample and data from the second groupallowed comparisons over time. Results lent support for the theory that underlying, often unconsciousmechanisms serve well the purposes of war makers.175.4. Consequences of World Wars, PTSD and the Law: Is law and Psychiatry at aDiscourse?Yega Muthu, University of Technology Sydney (muthu@law.uts.edu.au)The purpose of this paper is to critically describe the way in which the courts have analyzed claims forposttraumatic stress disorder (PTSD) pursuant to the Diagnostic Statistical Manual for Mental Disorders(DSM-IV-TR) and the International Classification of Diseases (ICD-10). Previous studies have identifiedtraumatic exposure and PTSD as predictors of physical health complaints without considering therelationship between exposure and PTSD. The study, which is the subject of this paper, examines theunique associations of war-zone exposure and PTSD with perceived physical health outcomes in world warveterans who responded to a series of psychological, exposure, and health questionnaires. Results suggestthat the effects of traumatic exposure on perceived health are partially mediated by increases in PTSD afterexposure, supporting studies on the effects of stress on health.

514In this paper, I will draw attention to the problems that exist in determining the causation of psychiatricdisorders for the purpose of deciding issues of compensation. What is at issue is the different standards ofcausation that operate in law and psychiatry. With the increase in terrorism in some parts of the world,more individuals are exposed to traumatic events that may cause posttraumatic symptoms either to them,friends or members of their family. In the absence of an actual physical lesion, the courts have becomeskeptical and wary of extending the defendant’s liability to cover alleged damage, such as PTSD. Theinherent fears are that evidence can be confabulated. Hence, the courts make a linguistic interpretation inview of the struggle between the law and PTSDAlthough terrorists attacks and other catastrophes are not uncommon, however, the case law pertaining topsychiatric injury is on the rise. The interplay, however, between law and psychiatry is declining. It isunfortunate that the law lags behind psychiatric evidence and in part this may seem unfair.175.5. International Crimes & PTSD: Avenues for CompensationStathis Palassis, University of Technology Sydney (stathis@law.uts.edu.au)In this paper I will be examining select international crimes and identifying how the international legalsystem addresses criminal and civil liability issues surrounding the commission of these atrocities, inparticular avenues available for compensation. The purpose of the paper is to critically evaluate both directand indirect compensation avenues available for victims of post traumatic stress disorder (PTSD) arisingfrom the commission of international crimes. International crimes are generally accepted as including: warcrimes, genocide, crimes against humanity, aggression, torture, and terrorism. International Criminal Law(ICL) examines the response of national and international courts to serious violations of internationalhuman rights or international humanitarian law that reach the legal threshold of international crimes. One ofthe major shortcomings of ICL is the failure of international law to prevent or punish serious human rightsand humanitarian violations amounting to international crimes: we continue to pursue short-term nationalinterests rather than the attainment of global human values. Nonetheless, the international community hasso far created a variety of international courts and criminal tribunals to try natural persons allegedlyresponsible for committing serious atrocities and other international crimes. Generally, the internationalcriminal tribunals do not provide for formal victims compensation regimes. Of particular interest, however,is the International Criminal Court (ICC) which is currently establishing a victims compensation regime.This paper will commence by outlining what crimes are considered to be international crimes. Based onthat classification, I will then outline appropriate courts and tribunals that have jurisdiction to hear thesematters regarding both criminal and civil liability questions. I will then use that framework to discuss whatavenues, if any, victims of international crimes have for compensation for PTSD in the various courts andtribunals, concentrating in particular on the ICC.175.6. Metaphors, Narrative and Elaboration of Traumatic EventsMartien Brands, University of Liverpool (brands@liv.ac.uk)IntroductionFrom linguistic analysis is it clear that metaphors are important vehicles of expressions of our experience.Especially when listening to persons who tell traumatic events to professionals it is crucial to remain ‘close’with the narrator. This closeness can be achieved by tuning in to the semantic network of the person.

515Metaphors can serve as guidelines in this process. Understanding their form and what they represent canfacilitate the account and eventual elaboration of traumatic events.Research on metaphorsMetaphors exist in many different forms: spatial, ontological or personalized, and structural or abstract.Within these broad categories, special types refer to e.g. travel schemas, (‘I could not go further’, ‘I feltblocked’) or spatial constructions (‘I felt no more solid ground’ etc). By responding with words andmetaphoric expressions who belong to the same schema or ‘network’, the professional as listener can,together with the narrator, more easily explore those meanings which are key to understand what has reallyhappened and what the impact is on that traumatized person.PresentationIn the presentation examples of case studies from medical practice are discussed which clearly show theenrichment of the original story by addition of the correct metaphors. Moreover, a cognitive model ispresented which assists in documenting graphically the enrichment and subsequent transformation ofnarratives which have been approached metaphorically. The application will also be shown in a currentprogramme with homeopathic medicine in Bosnia where metaphorically coloured narratives are used forthe diagnosis and treatment of Post Traumatic Stress Disorder.ApplicationsBoth in medical as in juridical contexts after war situations, the conscious perception of metaphoriclanguage may assist in ameliorating communication between professionals and those who suffered fromtrauma in these events. This can be part of training programmes both for relief workers and lawyers as wellas for mediators in preventative activities.176. Therapeutic Jurisprudence I: Problem Solving Courts176.1. Taking a Therapeutic Approach into Canadian Courtrooms and Some ProblemSolving Court Processes in CanadaPaul Bentley, Ontario Court of Justice (Paul.Bentley@jus.gov.on.ca)The notion that judges should apply a problem-solving approach to the matters that come before them is notnew. Mental health practitioners, for example, have long contended that mental illness is a health issuerather than a criminal law matter, and that the criminal justice system is ill equipped to deal with mentallyill people. In the 1980’s, it was the turn of the addiction community to argue that incarceration alone didlittle to break the cycle of drug use and crime for substance-addicted offenders. More recently, agenciesand practitioners who confront the daily realities of domestic violence have made the case that focusingonly on guilt or innocence does little to stop the cycle of abuse or protect survivors of violence from furtherassault.Over the past several years, a number of specialized (problem-solving) courts have developed in Canada inan attempt to address these concerns. Such courts are based upon the principles of TherapeuticJurisprudence, which regards the law (including its procedures and rules) itself as a social force that oftenproduces both therapeutic and anti-therapeutic consequences to the participants, legal proceedings, andsociety at large.

516My presentation will deal with the general application of the therapeutic approach to Canadian courtroomsand the concept of judges as change agents in generalist court settings. During the years I have presided inproblem-solving courts, I have become increasingly aware that the approach employed there could beadapted to other courtroom situations. While criminal court matters quickly came to mind, I believe thatthe problem-solving approach has application in broader contexts: for example, to the trial judge presidingover a docket of civil and /or family matters. How could she apply the skills of problem solving andtherapeutic jurisprudence to her daily experience in the courtroom? How could a judge apply these skills inan appellate court or at a pre-trial hearing?Though critics of problem-solving courts have cautioned against the newly intrusive role of judges and itsimpact on the independence of the judiciary, the problem-solving model has shown signs of being avaluable agent of change.It may be too early to tell how successful the application of Therapeutic Jurisprudence and problem solvingskills have been in transforming the way we think about courts and the results we expect them to achieve.However, there is little doubt that they offer an opportunity to end “revolving door justice”, where the samedefendants are recycled through the court system repeatedly.176.2. Therapeutic Jurisprudence and Some Problem Solving Court Processes in CanadaSharon L. Van de Veen, Provincial Court of Alberta (s.vandeveen@just.gov.ab.ca)Over the past several years, a series of specialized (problem-solving) courts or court processes haveevolved within the criminal justice system in Canada. These courts are based upon the principles ofTherapeutic Jurisprudence that regards the law (including its procedures and rules) itself as a social force,which often produces both therapeutic and anti-therapeutic consequences to the participants, to the legalproceedings, and to society at large.Problem solving courts have arisen in criminal court cases involving drug offences, Domestic Violence,mental health related offences, and Aboriginal justice. This presentation will describe several problemsolvingcourts and court processes in Canada along with their various characteristics. The objective ofthese courts is to reduce recidivism by dealing with the underlying issues that cause criminal behaviour,thereby assisting both offenders and victims alike. Frequently, underlying issues include mental healthissues such as drug/alcohol addiction or psychological issues, which manifest themselves in criminalbehavior.Therapeutic Jurisprudence and problem solving courts have been embraced as a matter of policy by theUnited States Conference of Chief Justices and the United States Conference of State Court Administratorsin August 2000. In addition, the United States Trial Court Performance Standards of 1997 direct trialcourts in the United States to be concerned with the social outcome of court cases and with whether thesocial problems are truly addressed by the outcome of judicial proceedings.In Canada, the 1996 sentencing provisions added to the Criminal Code of Canada, along with subsequentinterpretations of that legislation by the Supreme Court of Canada, have added significant emphasis torestorative justice objectives in sentencing, and thus community-based dispositions. This fundamental shiftin emphasis within the criminal justice system has led to the evolution of problem-solving courts.More specifically, two prominent features of the 1996 Sentencing Amendments to the Criminal Code willbe discussed. The first of these is the creation of the conditional sentence order, which allows offenders toserve their gaol sentence in the community under the supervision of the authorities, and in accordance withcourt-mandated conditions. The legislation prescribes certain preconditions for such community-basedgaol sentencing and these will be discussed. With respect to the order itself, there are both statutoryconditions, which the offender must comply with, as well as optional conditions imposed by the judge

517taking into account individual needs and circumstances. Optional conditions frequently involve counselingand/or treatment for various health and mental health issues.The second major addition to the 1996 Criminal Code of Canada sentencing provisions, which will bediscussed, involves the principles of sentencing that judges must consider in their determination of theappropriate sentence. In addition to the traditional sentencing objectives such as denunciation, deterrence,and rehabilitation, the new provisions also direct judges to use all available sanctions other thanimprisonment that are reasonable in the circumstances for all offenders, with particular attention to thecircumstances of aboriginal offenders. The Supreme Court of Canada has interpreted these provisions tomean that the Parliament of Canada has directed the courts to reduce the number of offenders sentenced toincarceration.Due to the shift toward community-based sentencing in Canada, the use of Therapeutic Jurisprudence ineveryday trial processes and in appellate courts is evolving and deserves further study and attention.Though critics of problem solving courts have cautioned against the newly intrusive role of judges and itsimpact on the independence of the judiciary, the problem-solving model has shown signs of being avaluable addition to the existing criminal justice system in Canada, specifically designed to reducerecidivism by addressing the underlying issues causing criminal behavior to occur. It may be too early totell how successful problem solving courts have been in transforming the way we think about courts andthe results we expect them to achieve, but there is little doubt that they offer a ray of hope to end “revolvingdoor justice” where the same defendants are recycled through the court system repeatedly.176.3. Collaborative, Problem-solving CourtsPeggy Fulton Hora, Superior Court, California, USA (phora@alameda.courts.ca.gov)Deborah Chase, Administrative Office of the Courts, California, USACollaborative, problem-solving courts have exploded in the United States. From the first drug treatmentcourt in 1989 to over 1,100 by the end of 2003, this model has expanded to include mental health courts,community courts, teen courts, unified family courts, domestic violence courts, and others. As of Dec.2003, almost 1,700 collaborative courts are fully operational in the United States. This session will reviewthe types of courts operating on a national level and more closely examine various state's (California hasthe largest number of collaborative courts) efforts to expand and institutionalize the drug treatment courtmodel. Judge Peggy Hora has written and spoken extensively both nationally and internationally on themodel and teaches a course on Co-Occurring Mental Health Disorders for the National Judicial College.Dr. Deborah Chase is an attorney/psychologist with California's Administrative Office of the Courts who isan expert in domestic violence and unified family courts. Both speakers have worked collaboratively withmental health professionals in implementing these model programs.176.4. Mental Health Courts – The Effectiveness of Restoring Order in the Law and LifeScott S. Anders, Washington District Court, USA (scott.anders@clark.wa.us)Peggy Fulton Hora, Superior Court, California, USA (phora@alameda.courts.ca.gov)Collaborative, problem-solving courts have exploded in the United States. From the first drug treatmentcourt in 1989 to over 1,100 by the end of 2003, this model has expanded to include mental health courts,

518community courts, teen courts, unified family courts, domestic violence courts and others. As of Dec.2003, almost 1,700 collaborative courts are fully operational in the United States.Mental Health Courts are one type of problem-solving court that employs “therapeutic jurisprudence (TJ)”.Winick & Wexler, the “fathers of TJ”, say TJ proposes the exploration of ways in which, consistent withprinciples of justice, the knowledge, theories, and insights of mental health and related disciplines, can helpshape the law. Problem-solving courts exemplify this model.This session will review the types of courts operating on a national level and more closely examine variousstate's (California has the largest number of collaborative courts) efforts to expand and institutionalize thedrug treatment court model. Judge Peggy Hora has written and spoken extensively both nationally andinternationally on the model and teaches a course on Co-Occurring Mental Health Disorders for theNational Judicial College.176.5. Avoiding Anarchy and Providing Due Process through a Model Mental HealthCourtRandal B. Fritzler, Innovative Legal Solutions, Vancouver, USA (fritzler@pacifier.com)The nation’s jails have become de facto, the mental health institutions of this decade. In order to addressthe needs of seriously mentally ill individuals in the legal system, a rapidly increasing number ofjurisdictions have begun to develop mental health courts. These courts are designed to divert the mentallyill from jails and prisons into community-based programs that provide a range of services, which mayinclude housing, substance abuse treatment, traditional medical services, and psychological counseling.Although these courts are well intentioned, they lack uniform principles, standardized procedures, and basicdue process protections for the specialized court’s clients. Particularly in jurisdictions where coordinationbetween courts and mental health providers is poor, many mentally ill inmates may be done a disservice.The author argues that there is a critical need for a nationally disseminated model for mental health courts.The author describes a model mental health court based on the principles of therapeutic jurisprudence thatavoids due process pitfalls. The key components of such a court are identified and uniform principles,standards, and procedures for mental health court operations are proposed.177. Therapeutic Jurisprudence II: Problem Solving Courts II177.1. A Framework for Understanding the Psychological and Cultural Assumptions inProcedures for Solving ProblemsThomas D. Barton, California Western School of Law (t barton@cwsl.edu)The simple yet powerful thesis of the Therapeutic Jurisprudence movement is that legal rules andprocedures can be designed and used in ways that promote mental wellbeing. Therefore, they should be sodesigned (balanced of course by the need for legal institutions to remain effective and efficient).

519My paper addresses procedures rather than substantive rules or reforms. Much can be revealed about thebasic values of a group and the expected impacts of its activities, through examining the procedures bywhich the group solves problems. My paper will suggest a framework for examining the psychological andcultural messages that are necessarily embedded in any group procedure for problem solving. Providingsuch a framework offers a vocabulary to help assess the therapeutic or anti-therapeutic qualities of anyactual or proposed legal procedure.Inherent to any procedure for solving problems are answers to the following questions: 1. Who may speak?2. Who can speak? 3. What counts as a legitimate argument in this procedure? 4. What counts as successand what as failure, in the methods and resolutions of this procedure? 5. Of what are those using thisprocedure most afraid?Important moral and psychological lessons emerge from the varying answers that would be given if thesequestions were asked of existing legal procedures. In proposing reforms or entirely new procedures,lawyers and others should ask the questions and reflect on the answers obtained. Doing so will increaseappreciation for the potential personal and community impacts of the proposals. That, in turn, may promptrefinement of the proposals, or provide arguments that could speed their implementation.177.2. Therapeutic Jurisprudence – a Transportable Process from Special Courts toGeneral CourtsJohn Walker, District Court of New Zealand (walkerj@courts.govt.nz)A legitimate purpose of sentencing for offences is the protection of the public, and dealing with theunderlying cause(s) of repeat offending helps to serve this purpose. When opportunities arise for a court touse its authority and processes to marshal resources to determine the underlying cause of offending, thelong-term interests of a community can be advanced. This is one of the underlying rationales for DrugCourts and other problem-solving courts.Not every community, however, can sustain a separate specialist court. Such courts are generally to befound in areas of high population density. In New Zealand, the population of 4 million is widely spread,thus only a few centres could justify the resources necessary for a stand-alone court. Ways have to befound to transport the key underlying features of a problem-solving court to the everyday work of a Judgein general court.The pilot Youth Drug Court in Christchurch, New Zealand, has introduced New Zealand judges to theconcept of Therapeutic Jurisprudence. It is a pre-sentence model using existing legislation and involvingthe Family Group Conferencing, which is integral to the Youth Justice system in New Zealand. It uses thekey features of consistency of judge, interdisciplinary team involvement, regular in- court monitoring, andimmediacy of entry into treatment.177.3. Therapeutic Jurisprudence and Sex offenders: A Psycho-Legal Approach in Courtand CorrectionsAstrid Birgden, Department of Justice, Victoria, Australia (Astrid.Birgden@justice.vic.gov.au)Both law and psychology are concerned with sex offenders changing their behaviour. In order to changebehaviour effectively, it will be argued that legal and psychological responses should be coordinated,

520address both individual offender and community needs. At present, the criminal justice system placesgreater weight on community protection than offender protection, and sex offenders have somehow beentreated differently from other types of offenders. Therapeutic jurisprudence provides a framework tocombine legal and psychological processes to balance offender and community protection. Legal andcorrectional practitioners can work together to encourage offenders to change, and so reduce the likelihoodof re-offending. In court, sex offenders can be encouraged by legal actors to engage in therapeuticallyoriented pleas, engage in cognitive restructuring around the offence, and devise rehabilitation plansresponsive to risk and need. In corrections, sex offenders can be engaged by clinicians and correctionalofficers through individualised and ethical interventions, resulting in rehabilitation plans that provide for anew personal identity (i.e., not only the prevention of relapse). Upon release, higher risk sex offendersrequire community support rather than stigmatisation. Therapeutic jurisprudence, with its emphasis onincreasing therapeutic effects and decreasing anti-therapeutic consequences of the law, provides thenecessary guidance for legal and correctional practitioners.177.4. Introduction to the Containment Approach for Managing Sex OffendersKim English, Colorado Division of Criminal Justice, Denver, USA (Kim.English@cdps.state.co.us)Colorado Division of Criminal Justice has completed two national telephone surveys of probation andparole supervisors in the United States who work with sex offenders. These studies also included in-depthfield research in 13 U.S. states and 27 jurisdictions, resulting in a description of a "Containment Approach"to managing sexual offenders. The Containment Approach has five components that will be outlined in thispresentation.A growing number of practitioners in the U.S. are utilizing the Containment Approach, a comprehensive setof policies and practices pertaining to the monitoring, supervision, and treatment of sex offenders thatallows many, but not all, sex offenders to more safely spend portions of their sentences in the community.Key containment team members include the probation/parole officer, the sex offense-specific treatmentprovider, and the post-conviction polygraph examiner. New models based on therapeutic jurisprudenceinclude the court as a key player, providing the advantage of offenders seeking out and engaging in sexoffender-specific treatment.In this presentation, empirical evidence will be presented regarding the value of using the containmentapproach for risk management and treatment of sex offenders. These research findings and the implicationsfor treatment, supervision, and public policy will be presented in the larger context of the containmentapproach.177.5. Incorporating Feminist Theory and Insights Into a Restorative Justice Response toSex OffensesC. Quince Hopkins, Washington and Lee University (hopkinsq@wlu.edu)Mary P. Koss, University of ArizonaSex offenses, particularly non-penetration sex offenses and acquaintance sexual assault, are all toocommon, particularly in the United States. Because these crimes reinforce women’s fear of crime, andrestrict spatial and social freedom, it is paramount for criminal justice systems to act affirmatively in

521responding to them. Unfortunately, in the U.S. it does not. First, the criminal justice response typicallyfails to recognize that these types of sex offenses are often markers of a future sex-offending career --particularly if the offender does not receive appropriate therapeutic intervention. Second, the criminaljustice response typically fails to provide victims a meaningful voice or control over the process or sanctionimposed. Thus, when sanctions imposed emphasize incarceration or a fine, not only do these outcomes notredound to the victim’s benefit, empirical studies demonstrate that they are out of sync with what victimsassert they want from the offender – namely, an apology, acceptance of responsibility, and some form oftreatment focused on helping the offender not re-offend against another person. In addition, studiesdemonstrate that victims of date/acquaintance rape end up more traumatized by the criminal justice processitself, during which their own integrity often ends up on trial. Restorative justice processes emphasize thatcrime harms relationships, that crime response is the victim’s duty, and finally, that reintegration of theoffender into the community may be critical to prevention of re-offending. Restorative justice processesthus offer a meaningful and more appropriate approach to responding to date/acquaintance rape and nonpenetrationsex offenses. Such an approach has been implemented by the authors in a researchdemonstration project, entitled RESTORE, which is operating in Pima County, Arizona. This project hasdrawn upon feminist insights in development, with a program designed to respond to some concernsexpressed by feminist criminologists about the application of restorative justice to gendered violence. Atthe same time, RESTORE emphasizes sex offender treatment as an important component. Preliminary datafrom the pilot research program demonstrates the solidity of the theory that under-girded the design of theprogram.178. Therapeutic Jurisprudence III: Problem Solving Courts III178.1. Sex Offender Re-entry Courts: A Proposal for Managing the Risk of ReturningSex Offenders to the CommunityJohn Q. La Fond, University of Missouri-Kansas (lafondj@umkc.edu)Bruce J. Winick, University of MiamiLegal strategies recently enacted in the USA to protect society from dangerous sex offenders generally usetwo very different approaches: long-term incapacitation or outright release. The first strategy relies onharsh criminal sentences or indeterminate sexual predator commitment laws. The second relies primarilyon registration and notification laws. Both strategies rely on prediction models of dangerousness.Authorities determine at a single moment the likelihood that offenders will sexually recidivate and thenchoose the appropriate type of control for an extended period. This paper reviews the problems ofpredicting sexual recidivism in the context of both strategies. It then proposes special sex-offender re-entrycourts to manage the risk that sexual offenders will re-offend. Risk management allows decision-makers toadjust calculations of individual risk on an on-going basis in light of new information and to adjust the levelof control. Drawing on Therapeutic Jurisprudence —a belief that legal rules, procedures and legal roles canhave positive or negative psychological impact on participants in the legal system—these courts canimpose, and then adjust control over sex offenders in the community. In a sex-offender re-entry court, thejudge is a member of an interdisciplinary team that uses a community containment approach; the offender,as a condition for release, enters into a behavioral contract to engage in treatment and submit to periodicpolygraph testing. This TJ approach creates incentives for offenders to change their behavior and attitudes,

522thereby reducing their recidivism risk and earning more freedom. It can also monitor compliance andmanage risk more effectively.178.2. Antipodean Therapeutic Jurisprudence in Action: The Contemporary Role ofAustralia Mental Health Review Tribunals in Mandating Community TreatmentDuncan Chappell, New South Wales Mental Health Review Tribunal, Boronia Park, Australia(duncanchappell@doh.health.nsw.gov.au)In the international mental health arena, the involuntary treatment of persons suffering from a mental illnesswhile still residing in the community remains a matter of significant controversy. In contrast, incontemporary Australia, compulsory community care for the mentally ill is now a widely accepted practice,and recognised by mental health legislation in all state and territorial jurisdictions. Controversy remainshowever, regarding both the effectiveness of this treatment and the safeguards put in place to protect thecivil liberties of those affected by mandatory treatment orders.In this paper, an appraisal is made of the contemporary role of Australian mental health review tribunals inbalancing the interests of mentally ill persons and the public, in decision-making about communitytreatment. This appraisal draws in particular upon the experience of the New South Wales (NSW) MentalHealth Review Tribunal, the largest quasi-judicial body of its type in the country, which currently makesmore than 4,000 community based treatment and counselling orders annually. The paper points to thedearth of empirical data available at present about most aspects of mandated community treatment – adeficiency that could soon be ended by a large multi-jurisdictional research project, about to commence,designed to examine from a consumer perspective the operations of mental health review tribunals in NSW,Victoria, and the Australian Capital Territory.178.3. Drug Courts: Using Treatment and Accountability to Stop the Revolving Door inJusticeKaren Freeman-Wilson, National Association of Drug Court Professionals, USADrug courts are special court dockets that treat non-violent drug offenders through the use of acomprehensive approach directed at changing offenders’ lifestyles. A dedicated team of judges,prosecutors, defense counsel, treatment professionals, therapists, social service professionals, lawenforcement personnel and others work together to monitor participants on a consistent basis. Participantsare required to participate in treatment and other mental health counseling, undergo urine tests, performcommunity service, pay program fees, obtain employment or further their education and engage inactivities that lead to sustain recovery. The first drug treatment court was established in Miami, Florida in1989. Today there are 1600 in existence and approximately 400 in the planning phase. There are also over20 drug courts outside of the United States in Canada, Jamaica, Bermuda, Scotland, Ireland, and othercountries. Evaluations of existing courts have resulted in a reduction in recidivism, reduction in drug use,cost savings, and immeasurable social benefits.

523178.4. The Health Impact Assessment of Crime PreventionAlex Hirschfield, University of Huddersfield, Great Britain (a.hirschfield@hud.ac.uk)Although there is growing literature on the health impacts of being an offender or crime victim (e.g. stress,psychological trauma, loss of confidence, mental health problems), less is known about the health impactsof crime prevention. The latter potentially influence a number of key health determinants through projectsthat modify the physical environment (e.g. environmental improvements, enhanced home security), reducefear of crime (e.g. greater surveillance, presence of street wardens) and empower communities (e.g.neighbourhood watch schemes). Health Impact Assessment (HIA) can be used to identify the healthimpacts of ‘doing something about crime’ both positive (e.g. crime reduction) and negative ( e.g. turninghomes into fortresses, crime displacement). It is usually applied prospectively so that the negative healthimpacts of policy can be mitigated and any positive impacts maximised. The process involves closescrutiny of policy proposals to identify how they are likely to affect key health determinants and the extentto which they are likely to widen or narrow health inequalities. The approach adopts a socio-environmentalmodel of health, is primarily qualitative and involves canvassing the views of key informants (e.g. expertsin public health) and stakeholders (policy practitioners, local residents) about likely impacts of policyinterventions. This presentation examines the application of HIA to crime prevention policies payingparticular attention to a study funded by the UK Department of Health on the health impacts of theGovernment's Reducing Burglary Initiative. It concludes with a discussion of how HIA relates to theconcept and application of Territorial Jurisprudence.179. Therapeutic Jurisprudence IV: Expanding Problem-SolvingCourts to the Family Court179.1. An International Perspective on Therapeutic Jurisprudence: The Russian ContextVeronika Artemyeva, Saint Petersburg State University of Architecture & Civil Engineering(nicsan@mail.wplus.net)Thomas Franklin Waters, Northern Arizona University-Yuma (Tom.Waters@nau.edu)The concept of law as a positive intervention, as compared to a punitive social response, has experiencedconsiderable success in United States in the form of various specialized courts. These courts, designed tosolve specific social problems such as drug abuse, alcohol abuse, domestic violence, family dependency,juvenile delinquency, and community justice, have demonstrated both therapeutic and cost effectiveness.As a country in transformation, the Russian Federation faces many similar societal problems. In seekingalternatives to traditional judicial responses, therapeutic jurisprudence is being explored as one possibility.Topics covered in this presentation will include an environmental overview; challenges to socialtechnology transfer; Russian perception of justice, Russian perception of treatment; and what the futureholds.

524179.2. Bringing Therapeutic Jurisprudence into the Family Courts: Assessing thePrevalence of Personality Disorders in High Conflict Family Court Cases andCreating a Protocol for Attorneys and MediatorsEllen Waldman, Thomas Jefferson School of Law (Ellenw@tjsl.edu)Although widespread use of mediation in the United States pre-dates the birth of therapeutic jurisprudence(TJ) by at least a decade, it would make more sense if the emergence of these movements were exactly thereverse. After all, mediation seemingly responds to the central critiques and challenges presented by TJ totraditional lawyering approaches. TJ’s exhortation that lawyers consider the mental health implications oftheir interventions nicely jibes with mediation’s rejection of the brutality of the adversarial stance, andembrace of a kinder, gentler form of disputing. Renouncing the traditional lawyer’s assumption that adispute resolution process is successful if it correctly applies abstract legal norms to the facts at hand,mediation practitioners and scholars look instead to disputant satisfaction and the degree to whichempowerment and recognition have been achieved as the primary measure of success. Even the names ofvarious regnant mediation models are redolent of a mental health focus: transformative mediation,cognitive–systems mediation, facilitative mediation.What if, despite this therapeutic focus, the mediation community has failed to identify a huge mental healthissue in its midst- one that would require a re-assessment of some of the field’s standard assumptions and are-tooling of some of the most commonly deployed mediation techniques? In this paper, we argue thatmany frequent users of the family court system in the United States suffer from personality disorders thatgo undiagnosed by their lawyers, and, perhaps more devastatingly, their mediators. We argue that familylawyers and mediators are woefully uneducated regarding the prevalence and characteristics of thesedisorders, and that this ignorance frequently results in poor handling of their disputes. In this paper, wepresent quantitative data, drawn from surveys of family attorneys in Southern California, suggesting thedepth of the problem, provide tools for practicing attorneys and mediators to help cope with thesedisputants, and suggest modifications of current mediation theory and practice to better accommodate thesymptoms and behaviors of personality-disordered clients who find themselves enmeshed in the FamilyCourt system.179.3. Difficult Divorces and Therapeutic StrategiesZulema Wilde, Cámara Nacional de Apelaciones en lo Civil de Capital Federal, Buenos Aires, Argentina(wildehon@fibertel.com.ar)The purpose of this workshop is to present the work performed by both a judge-appointed interdisciplinaryteam hearing cases concerning family law matters, and a group of psychoanalysts hearing divorces that takeexcessively long periods of time. These psychoanalysts have a very high belligerence level in order tohandle the legal difficulty of the conflicts at stake.Even though we do not have significant statistical data in view of the limited number of cases underanalysis, the conclusions are qualitative and of an exploratory nature, based on the deep analysis made ofeach such case.The conclusion reached up to this point is that a work as the one described, i.e. negotiation techniques withCourt hearings and family psycho-diagnosis, allows the decrease of belligerence between the parties, andsuch fact shows (in the studied cases) a remarkable trend towards reaching total or partial agreements.

525179.4. Waitakere, New Zealand – Family Violence Court: A Model Based on Logic,Common Sense and Fairness but One not Speedily Adopted or Followed by OtherCourts. Why?Philip James Recordon, District Court Judge, Auckland, New Zealand (Judge.Recordon@justice.govt.nz)As in most parts of the world, domestic violence is an ongoing, repetitive problem. It is linked frequentlywith anger, alcohol, and drugs. This paper will discuss a pilot program now being implemented in a familycourt in New Zealand to provide long-term solutions to this pervasive problem.Prior to the commencement of this pilot scheme, as many as 80% of our reported cases were falling overbefore reaching defended hearings. The reasons for this are similar to those experienced throughout theworld- the victim's injuries heal and their need for the perpetrator, financial and otherwise, increases. Toassist these families in the longer term and to help ensure police involvement, judges, as quickly aspossible, ask the perpetrator to accept responsibility for the offending on the understanding that, if there arecertain issues present (such as anger), (s)he will address them over a period of time with recognizedcommunity agencies. Incentives, such as a community-based sentence or a discharge with no convictionare often provided. The goal is to have the same judge and prosecutor involved throughout the case frombail to completion and to have progress and compliance monitored periodically.The court has a protocol designed to address difficulties that can arise with visiting judges who use thetraditional method of judging. Despite initial success, difficulties remain in gaining acceptance for thisapproach at higher levels of government. Challenges include lack of funding for evaluation, inadequateencouragement and support, and a sense that our approach is out of the mainstream. Our primary objectiveis to focus on all those affected by the violence - to look to the present and the future – and to strengthenand stabilize families while reducing the risk of violence.179.5. Using Collaborative Family Law Techniques in Civil Action Domestic ViolenceCasesCindy Lenoff Zatzman, Practical Ethics Inc., Miami, USA (clzatzman@aol.com)Within the collaborative family law movement, some legal practitioners encourage the use of aninterdisciplinary team to assist couples in the divorce process. Specifically, mental health practitioners(among other specialized “experts,” such as financial analysts, etc.) are employed in the dissolution ofmarriage process to assist with isolating and addressing individual issues within the process. This paperdraws upon the value of using mental health practitioners in the dissolution process. When such amultidisciplinary team is used, the parties will often achieve a resolution more quickly and at a lower costthan if the matter had been litigated.In collaborative settings, where both parties have resolved to achieve peaceful, healing resolution of theirfamilial dissolution, mental health practitioners may assist most commonly in serving as communicationscoaches for parties having difficulties with open, respectful, and candid communications or, perhaps, asparenting coaches when parenting issues are difficult to resolve. When domestic violence is a factor indissolution, mental health practitioners become an even more important part of a team effort at resolution.In fact, it is not necessary that the civil/family court matter (injunctive relief, dissolution of marriage,paternity) be resolved entirely through collaborative family law process or techniques. The value of aninterdisciplinary team, however, becomes increasingly more significant and can have more profound resultsin resolution, even when the matter is otherwise litigated.

526Domestic violence victims typically have much emotional/psychological work to do in transforming intosurvivors. This transformative process can have a significant impact on the progress, or lack thereof, in thecivil resolution of family matters. This paper will present case study analysis in order to demonstrate theeffectiveness of using a mental health/legal counseling team effect to move a domestic violence victimthrough the legal process.180. Therapeutic Jurisprudence V: The Role of the Lawyer180.1. Therapeutic Jurisprudence and the Evolving Rehabilitative Role of the CriminalDefense LawyerDavid B. Wexler, University of Arizona at Tucson (davidBwexler@yahoo.com)Therapeutic jurisprudence (TJ), which began in the academy, has begun to enter the world of law practice.The first inroads were probably in the area of legal counseling and office practice. In the criminal law area,TJ reached the world of practice principally through the judiciary and, especially, in the form of problemsolvingcourts, such as drug treatment court, domestic violence court, and mental health court. Now thatcourts have begun to create a legal culture receptive to TJ, practicing criminal lawyers are following suitand are using TJ in their practices. This presentation will discuss this emerging expanded role of thecriminal defense lawyer, detailing how greater attention is now being paid to issues of diversion, deferredsentence, post-offense rehabilitation, plea negotiation, sentencing, and non-incarcerative alternatives suchas probation. In each of these issues, TJ principles and methods are used to trigger client motivation toparticipate in rehabilitation, to encourage offenders to understand high-risk situations and propose ways toavoid them, to enhance offender compliance with release conditions, and to reinforce offender desistancefrom crime. The presentation will also focus on the new challenges to legal education posed by theexpanded rehabilitative role of the criminal defense attorney.180.2. Repression and Denial in Criminal LawyeringSusan Bandes, DePaul University College of Law (sbandes@depaul.edu)The question of how lawyers defend clients accused of terrible crimes has been thoroughly examined froma moral/ethical standpoint. Whereas there is a well-established mainstream discourse about these ethicalquestions, the emotional aspects of lawyering, and indeed, of legal reasoning itself, are treated as bothisolated from the ethical/moral issues and as marginal or off limits. Yet it is increasingly clear thatquestions about legal decision-making cannot be neatly divided into intellectual and emotional spheres, orinto doctrinal, strategic, ethical, and emotional quadrants.Therefore, this paper explores how, in an emotional sense, one defends people accused of terrible crimes,and what toll such defense takes, both professionally and personally. The focus of the presentation isthreefold: 1) It explores the emotional strategies employed by criminal defense lawyers, how this mayaffect their ability to represent their clients, and how work is integrated into their lives. In particular, it

527focuses on the defense mechanisms by which certain parts of the job are made abstract and kept at adistance, while others are made immediate and concrete. 2) It suggests that similar mechanisms andstrategies are used outside the context of criminal defense law. 3) It argues that legal discourse needs toovercome its current aversion to discussing the emotional aspects of lawyering, and that we ignore theemotional realm at great detriment to the well-being of both lawyers and their clients.The presentation draws from an article that is part of my long-term project of exploring the relevance ofemotion theory to the legal realm. See, for example, Susan Bandes, Empathy, Narrative, and VictimImpact Statements, 63 U. Chi. L. Rev. 361 (1996) and Susan Bandes, The Passions of Law (N.Y.U. Press2000).180.3. Applying Therapeutic Jurisprudence to Child Welfare Reform: Examining theRelationship between Kinship Care Policy and Kinship Caregiver Mental HealthSacha Coupet, Loyola University Chicago School of Law (scoupet@luc.edu)This paper is based on a group study of African-American kinship caregivers in urban communities(Detroit, Michigan; Philadelphia, Pennsylvania; Chicago, Illinois). The focus of the study was anexamination of the role of cognitive appraisals and family dynamics as predictors of psychologicaladjustment and well-being. Kinship caregivers were defined as those relatives raising related children inthe absence of a biological parent. Both informal kinship care providers (those arrangements establishedoutside of the formal child welfare system) and formal kinship care providers (those arrangementsestablished because of legal intervention in the child welfare system) participated in the study.In an era of dwindling fiscal resources and an increasing child welfare population, legislators,administrators, and child welfare advocates have directed their focus on reforming programs that alreadyexist within and outside the current system. In addition to public-private partnerships, kinship foster carehas been among the most vigorously pursued reform measures. The 2000 US census revealed that6,042,435 children under that age of 18 years, or 1 in 12, live in a household that is headed by the child’srelative. For approximately 2.3 million of these children, their biological parents do not live in the home.Kinship caregivers continue to both stem the flow of children entering foster care and relieve anoverwhelmed child welfare system that lacks adequate placement for all of the children in their custody.However, kinship caregivers meet this pressing child welfare need at their own peril. Studies illustrate thatkinship caregivers differ from non-kin caregivers in several meaningful ways that leave them morevulnerable to poor long-term mental health and well-being outcomes. These differences include, amongothers, marital status, family income, age, and education.Anti-therapeutic outcomes are almost foreordained when legislation and child welfare policies, such as theyexist today, continue to deny the financial assistance, social support, and legal status necessary for optimalcaregiver mental health and well-being. The study upon which this paper is based found that both cognitiveappraisals and family dynamics were significantly related to kinship caregiver mental health. Examiningkinship care through a therapeutic jurisprudence lens, this paper uses the stress and coping findings toexplore how certain kinship policies (including subsidized guardianships and Title IV-E funding) and lawsregulating and defining families can better yield desired mental health and well-being outcomes.

528180.4. What Law Schools Can Do to Ensure Career Satisfaction Among GraduatesLinda H. Morton, California Western School of Law (lm@cwsl.edu)My presentation will focus on the potential role of legal education in helping to ensure law schoolgraduates have satisfying careers upon graduation. Over the past year, I have been studying thecomponents to career satisfaction in lawyers, and participated in the collection of empirical data fromCalifornia Western on this subject. Much of lawyers’ career satisfaction depends upon the nurturing of lawstudents’ mental health. My presentation will explain what “career satisfaction” is; how it is fostered; andthe role of law schools in developing and encouraging this satisfaction. I will specifically describe theinvolvement of my own law school, California Western, in promoting it. An outline of my proposedpresentation follows below.I.Career Satisfaction DefinedA. by the American Bar AssociationB. by the literature on the subjectC. by empirical study conducted at California Western this past yearII. Components and Sources of Career Satisfaction, as described by A., B., and C., above (having controlover one’s work, having one’s expectations met, etc.)III.The Potential Role of Law Schools in Nurturing Career Satisfaction, and Consequences if they do notA. What Law Schools are doing nowB. Law Schools’ obligation to nurture career satisfactionC. Consequences of failing to nurture career satisfactionIV. How Law Schools Can Nurture Career SatisfactionA. As described by sources in I. A., B. and C., aboveB. What California Western is doingC. Further suggestions from the author180.5. Therapeutic Jurisprudence as a Tool for Lawyers Counseling Sexual MinoritiesAmy D. Ronner, St. Thomas University School of Law (aronner@stu.edu)Gay, lesbian, bisexual, and transgender clients can present some unique challenges for lawyers. This is notto suggest that such individuals are so different from the rest of the human race or to equate their sexualorientation or gender identity with a disability. Rather, what makes their issues distinctive is that theybelong to a group that bias and exclusion has historically disadvantaged.Lawyers counseling sexual minorities can borrow from a relatively new movement in the law called“therapeutic jurisprudence”, which is the “study of the role of the law as a therapeutic agent”. Therapeuticjurisprudence, with its focus on mental health and law as a social force, can provide a unique and pragmaticperspective: it can help lawyers identify emotionally charged areas that need to be considered in alleviatingstress for clients. In counseling clients, especially those societally bashed, it is important to be alert toextant wounds and try to select legal remedies that do not reactivate them or rub the psyche raw. In this

529presentation, the speaker will suggest ways that a therapeutic jurisprudence lawyer can effectively counseland select strategies for gay, lesbian, bisexual, and transgender clients that help empower and heal.181. Trauma and Torture: The Psychosocial Dimensions181.1. The Sense of Justice, Impunity and the Relief of Traumatic StressYaya de Andrade, Psychosocial Trauma Institute, Vancouver, Canada (ydeandrade@shaw.ca)The author will discuss that in this short Century many people continue to seek relief and suffer fromtraumatic stress. New organizations and projects emerge side by side with traditional resources, and theirgoal is to promote a better understanding of the impact of traumatic events on children, adults, families, andcommunities.Psychologists provide a variety of services related to those suffering from such experiences. Clinicallyspeaking, the relief of traumatic stress is based on interplay of bio-psycho-social features of individuals andcultural mechanisms, among other factors, but it has become evident that although all factors are relevant,none are sufficient to achieve integration of traumatic experiences and to restore sense of justice.Those working with traumatized individuals know that their clients are vindicated as their assailants and/orabusers are charged, and publicly denounced. The legal process may at times be difficult, as people have tostand and describe, again and again, the brutality of their traumatic experiences. Nevertheless it is a modelin which there is an attempt to clarify who is victim and who is perpetrator, who is responsible for personalor environmental damage, and who is taking proactive roles. Hopefully, such process distinguishesbetween impunity, injustice and restitution, restoration.The effects of major traumatic life events add up to acute and/or chronic bio-psycho and socialdysfunctions of people of all ages and cultural background. Nevertheless, the effects of traumatic eventsare mediated by daily hassles, and moderated by perceptions of justice, personal coping, and socialadjustment. Therefore, in order to have a favorable balance of resources (losses and gains); we must placeeffort not only on individuals and their wellbeing but also in their surroundings (family and community)and certainly on policies, and the justice system.181.2. The Work of the Centre International de Ressources Juridiques (CIRJ)Catherine Duhamel, Centre International de Ressources Juridiques, Montreal, Canada(catherine.duhamel@cirj.org)On October 23, 2000, Canada committed itself to prosecute those who have committed crimes againsthumanity, war crimes, or genocide with the passing of Crimes Against Humanity And War Crimes Act,(S.C.) 2000, Chapter 24 (C-24) into the law. To encourage the application of this new law, theInternational Crimes Legal Information Bureau was set up in 2001.

530Canada's new law is an important legal tool that will enable Canada to prosecute alleged perpetrators ofcrimes against humanity, war crimes, and genocide. The Act effectively modifies Canada’s legislation toimplement the 1998 Rome Statute of the International Criminal Court. 20 years after the 1985 Commissionof inquiry into the presence of World War II criminals in Canada, how can alleged perpetrators of suchcrimes be brought to justice in Canada? What assistance can a victim get through the International CrimesLegal Information Bureau in Canada?181.3. Creating a Bystander Syndrome for Torture – The U.S. CaseGerald Gray, The Center for Survivors of Torture, San Jose, USA (geraldgraycal@sbcglobal.net)For such human rights violations as torture to be used openly by a democratic government, a significantnumber of citizens must be unresisting passive bystanders. The example commonly pointed to is Germanyduring the rise of the Nazis, but before they had complete control and the citizenry had a choice aboutintervening.Can a bystander syndrome be consciously created by a democratic government? Is that being attempted inthe U.S. now? What might be the role of government psychologists? Despite U.S. public revulsion totorture at Abu Ghraib Prison in Iraq, there has been no sustained or strong opposition to official torture, yeta number of acts by the government stand as examples of psychological manipulation to immobilize publicopinion. In conclusion, some examples are:An attempt to redefine "torture" to exclude psychological torture, thus excluding the acts at Abu Ghraib andelsewhere as torture. This also denies knowledge of the last 20 years of torture treatment, which shows theworst and longest lasting effects of torture are often psychological.Calling the acts at Abu Ghraib "abuse, which is technically different from torture" (Secretary Rumsfeld),while not revealing to the public that both in legislation and in political asylum appeals in U.S. courts, theacts at Abu Ghraib are described and accepted as torture by the same government.Exposing the U.S. public to acts of torture which it does not understand as torture, both from lack ofexperience and lack of knowledge of clinical and legal standards (for instance, "disappearing" people)Using understanding of "situationist" psychology to create circumstances in which torture will occur bytroops who are never given a direct order to torture, thus providing the government with deniability.181.4. Impact of Impunity on Survivors of TortureEzat Mossallanejad, Canadian Centre for Victims of Torture, Toronto, Canada (ezat@ccvt.org)At the Canadian Centre for Victims of Torture (CCVT), we have been involved in ongoing treatment andrehabilitation of survivors of war and torture on an ongoing basis. We have found impunity a majorobstacle towards of efforts. There is a regrettable tendency in human history to leave perpetrators ofmassive horrible crimes unpunished. We have documented the cases of clients who have gone through theunfortunate process of retraumatization by finding their victimizers unpunished.Widespread human experiences during transitional periods have shown that it is hardly possible for victimsto forget the horrible past and build a humane society while agents of tyranny and darkness – torturers,rapists, perpetrators of genocide and war crimes – walk freely along with no compunction. In 1996, Itraveled to Rwanda, visited seven cities, and heard from cross-sections of people about requirements of

531building a post-genocide peaceful society. I found a common belief of the need for reconciliation as aprerequisite for reconstruction. Nevertheless, reconciliation was considered impossible without introducinga kind of justice for victims of 1994 genocide.I have documented the cased of CCVT clients who have arrived in my office, terrified and distraughtbecause of seeing someone resembling their torturers. The fear, the pain, and the memories are too much tobear. Physically overcome, clients as such have to bear tremendous psychological pain. The triggeringeffect of what they see has sometimes been so powerful that it required hospitalization. Experiences suchas these have impressed upon the Canadian Centre for Victims of Torture the long term and profoundlydestructive consequences of impunity for survivors of torture and war.It is important to understand the complexity of the issue and the long road that is ahead. There is a need torestore the human and civil dignity of victims and provide them with reparation. Truth, reconciliation(amnesty), reparation, and rehabilitation must come together. Victims should be compensated financiallyas well. There is also a need for physical & psychological rehabilitation of survivors through counselling,trauma intervention, and other means. The process of justice and accountability should be comfortable andsafe in the eyes of survivors. Impunity will never be effectively addressed without the full and meaningfulparticipation of survivors. They should be allowed to raise their voices and rewrite the history of theirnations.181.5. Aftermath: Justice and Impunity in Transition SocietiesJoan Simalchik, University of Toronto (joan.simalchik@utoronto.ca)Many countries in Asia, Africa, Europe, and the Americas have been engaged in democratic transition afterperiods of dictatorship and war. Frequently, these transition governments have been the result of pactedagreements between divided constituencies in newly emergent, but yet unreconciled civil societies.Prolonged exposure to war, repression, and organized violence produced cultures of fear and psychosocialobstacles to the establishment of good governance and a human rights culture (Juan Corradi, Elizabeth Lira,Manuel Antonio Garreton). In many of these cases, the price paid for an end to human rights atrocities wasimpunity for the perpetrators.Fragile transition societies have been impacted by psychosocial trauma/destruction composed of threeconstituent elements: organized state violence, social polarization, and institutional lies (Ignacio MartinBaro). All three elements and their legacies continue to influence social and political development duringthe (re)construction of democracy. This process is exacerbated by the ongoing effects of impunity – or lackof justice and recognition – by victims of the previous regime. Without a process for justice, institutionallies continue; society remains divided between victims, perpetrators and bystanders; and the effects of stateviolence remains unmitigated.This paper analyzes these psychosocial dilemmas and discusses the impact of impunity and its subsequentconsequences for individuals, families and the wider community. Efforts to facilitate psychosocial renewalas an antidote to traumatic impact of war and dictatorship are presented along with mechanisms to promotereconciliation and a sustainable democratic culture. Truth commissions, human rights tribunals, criminalprosecutions, and commemorative practices are examined.

532182. Treatment of Serious and Violent Juvenile Delinquents182.1. Clinical and Demographic Characteristics of Young Adults Mandated to CourtOrdered Outpatient Psychiatric Treatment in an Inner City SettingEraka Bath, New York University (bathe01@med.nyu.edu)Objective: The clinical and demographic characteristics of the young adult population (age 18-24) in courtmandated outpatient psychiatric treatment has not been greatly studied. Our goal is to evaluate this cohortin the AOT (Assisted Outpatient Treatment) Program of New York County. There are very few studies onyoung adults who are court mandated to psychiatric treatment. As the juvenile justice system expands as alocus of primary psychiatric care for adolescents with emotional and behavioral disturbance, the interfacewith the judicial system becomes more pronounced and intractable with these individuals. It is important togather knowledge about this group who are likely to have long term and frequent utilization of mentalhealth and criminal services.Data Sources: MEDLINE search conducted in August 2004, review of references within the retrievedarticles, and utilizing a chart review of all AOT patients age 18- 24. We will examine medical recordsprovided for the AOT referral process as well as the evaluations conducted by the forensic psychiatristsinvolved in the commitment process. There have been approximately 150 AOT participants between theages of 18-24 through the Bellevue Hospital AOT program, out of 1000 total AOT clients in the history ofthe Manhattan program.Method: This will be a descriptive study using the methodology of a retrospective chart review of files onall patients aged 18- 24, who have had at least one AOT order since the inception of the program. TheManhattan-based AOT Program was founded in 2000. Charts will be screened for a variety ofdemographic data including (but not limited to) the type of psychopathology, presence or absence ofsubstance abuse, history of child abuse, family history, educational attainment, types of medication ordered,number of orders issued, history of violence, arrest, and incarceration.Hypothesis/Conclusion: We hypothesize that this subset of AOT will display increased violent behavior(towards self and others), a higher rate of co-morbid substance abuse, and are more likely to be male and ofa racial minority than the general AOT population.182.2. Adolescent Sex Offender Treatment Programs from 1985-1999: An Examinationof Psychopathy, Risk and Criminal OutcomesHeather Gretton, Youth Forensic Psychiatric Services, Burnaby, Canada(Heather.Gretton@gems7.gov.bc.ca)Adolescent sexual violence poses a serious problem for society. Adolescents exhibiting many psychopathictraits are at greater risk for ongoing non-violent and violent offending into early adulthood. Very littleinvestigation has been conducted on the role of psychopathic traits in adolescent sex offenders. Studies todate indicate that adolescent sex offenders with many psychopathic traits make up a unique subgroup ofadolescent sex offenders with a propensity to generalized offending and violence, rather than sex offendingper se. The present study uses a combined retrospective-prospective follow-up, designed to examine thecriminal outcomes of approximately 380 youths referred to a sex offender treatment program (SOTP) in

533Burnaby, British Columbia from 1985-1999. The program is community-based, providing treatment andsupport to adolescent sex offenders and their families. The treatment model is primarily cognitivebehavioraland relapse prevention model, with group and individual components. Youths who attend theprogram undergo a clinical and psychometric assessment of their psychological functioning and areasrelated to their offending behavior. The Psychopathy Checklist: Youth Version (PCL:YV) and otherbackground data was coded from file information. Criminal record information, including charges andconvictions, will be collected to a follow-up date of 2005. Sex offending youths who completed thetreatment program will be compared with sex offending youths who either dropped out or did not receivetreatment during the same time period. Treatment outcomes and implications for adolescents with manypsychopathic traits will be discussed.182.3. Organisation of Psychiatric Assessment and Treatment of Serious JuvenileDelinquents in The NetherlandsCoby Vreugdenhil, Juvenile Justice Institution Rentray, Lelystad, The Netherlands(postbus@vreugd.demon.nl)In The Netherlands, seriously delinquent adolescent boys can be convicted to either plain detention or todetention with treatment options. Recently, it was found that ninety percent of a large representativesample (N=204) of seriously delinquent incarcerated boys between 12 and 18 years of age had at least onepsychiatric disorder. After controlling for sociodemographic and crime-related characteristics and formertreatment parameters, the presence of a psychiatric disorder was not associated with allocation to detentionwith treatment.Indication criteria for psychiatric assessment are still quite arbitrary and the assessments themselves arelargely unstandardised. It should be examined whether standardised indication and assessment can improvethe efficiency of allocation to detention programs with and without treatment options. In addition, toprovide effective psychiatric treatment, the juvenile justice system should become part of a communitywidesystem of care. The integration of treatment services within youth detention centres, combined witheffective follow-up and case management services upon release, may be the most clinical and cost-effectivemeans of preventing serious criminal recidivism.The current practice of psychiatric assessment and treatment of seriously delinquent adolescents in TheNetherlands will be discussed and suggestions for improvement will be given.182.4. Treatment Process and Outcomes of the Mendota ModelMichael F. Caldwell, Mendota Mental Health Institute, Madison, USA (caldwmf@dhfs.state.wi.us)This paper will present data on the change process and ultimate outcomes of the Mendota JuvenileTreatment Center, a specialized program for treating highly aggressive incarcerated delinquent boys inMadison, Wisconsin. The Mendota Juvenile Treatment Center (MJTC) is a 29-bed clinical/correctionalhybrid facility that is operated by a state psychiatric hospital but administered under the Administrativecode of the State of Wisconsin Department of Corrections (Caldwell & Van Rybroek, 2005). The programhas operated since 1995 treating an average of 65 youth per year.For this paper, 101 youth who were treated in the MJTC program were matched with 101 youth who wereassessed but not treated in MJTC using a propensity score analysis matching procedure (Rosenbaum &

534Rubin, 1983; Rubin, 1997). This procedure attempts to reduce the potential for group assignment bias inobservational studies. The two groups did not differ significantly on a wide range of variables that predictpersistent offending in juvenile delinquents. Re-arrest data was collected on the participants for 4 yearsafter release from custody. After controlling for group assignment bias with propensity scores and time atrisk, the treatment group had re-arrest rates for serious and violent offenses that were half that of thecomparison group.An analysis of the cost to State taxpayers was done by extrapolating figures on criminal offense costsgenerated by Cohen (1998) to current costs and local prison costs. This showed that although the MJTCprogram daily bed cost was twice that of the usual treatment services, the MJTC program had a long-rangecost-effectiveness ratio of 5 to 1 when compared to treatment in the usual secured juvenile correctionsfacility. This translates into a return on the marginal cost of MJTC treatment of over 500% over the fouryearfollow-up.Additional preliminary data on the change process drawn from repeated measures during treatment will bepresented. This data indicates that changes in behavioral control and cognitive distortions may play a rolein the effectiveness of the MJTC program.182.5. Lessons Learned from the Mendota Juvenile Treatment CenterGregory J. Van Rybroek, Mendota Mental Health Institute, Madison, USA (vanrygj@dhfs.state.wi.us)The Mendota Juvenile Treatment Center (MJTC) is a unique treatment center for the most unmanageableand aggressive juvenile delinquent boys in the State of Wisconsin. Established in 1995, the program is ajoint project between the Department of Corrections and a state mental health institute. The programoperates under the administrative rules of the Department of Corrections as a maximum-securitycorrections facility, but is housed, staffed, and operated by the mental health institute. Several studies havedemonstrated that the program reduces violent offending by about half, even for juveniles with high levelsof psychopathic traits.This paper will discuss the organizational and programmatic structure of MJTC, including political issuesthat have arisen in this unusual joint project. The paper will also discuss the staffing and structure of theprogram, philosophical orientation, and techniques used to treat highly aggressive and “psychopathic”youth. Included in the presentation will be discussion of the features believed necessary to open andsustain a program geared toward the assessment and treatment of violent juvenile youth while alsoattending to necessary security considerations. The significance of understanding dynamics of staff-youthinteractions, coupled with treatment approaches, will be described within a model of treatment developed atthe facility. The program will discuss the critical leadership and administrative factors that come to bear inthe development of a clinical-correctional program. Finally, the most violent of youth become successfulinside a secure facility, and the conditions needed for successful re-entry into the community are provided.Based on valuable “lessons learned” in the creation of this hybrid program, a model for operation of futuresecure juvenile corrections will be proposed.

535183. University and Research in the Netherlands183.1. Impulsive Affective Aggressive and Violent BehaviorRob Brouwers, Tilburg University (R.Brouwers@ggzgroningen.nl)M. Appelo, Tilburg UniversityKarel Oei, Tilburg University, (t.i.oei@uvt.nl)We all use, if necessary, a kind of force in achieving a goal, but know to stop. For instance, we pushheavily on the door that stuck. Every day, you can read in the newspaper, someone is overreactingviolently, just on a small provocation.There are some questions, firstly, why the reaction has been so extremely aggressive and violent? Thebehaviour in particular, does not correspond to the level of provocation. Secondly, does impulsiveaggression have a pathologic colour like psychopathy? Thirdly, what factors do have discriminative valuein the occurrence of impulsive aggressive behaviour?This study goes about neurobiological, cognitive and social factors in relation to impulsive aggression. Forthe first question a possible jump in arousal provides new information in rapid-response impulsivity.Someone makes an impulsive decision to behave aggressively, but aggressive violent behaviour occurs,while depending on other factors. Biologic factors may give an indication in the case of impulsiveaggressive behaviour as a pathologic phenomenon, for instance, through a malfunctioning of the amygdala.Current literature is lacking a factor that discriminates when someone, on an impulse, is behavingaggressively. We will present factors that are associated with the subject. We formulate a furtherdescription of the subject and the title, and put forward definitions for a new type of impulsive aggression.We will present the first results, developed with our new instrument to find people at risk. Furthercomments of the audience on this subject will be welcome.183.2. The Dutch Version of the J-SOAPRuud Bullens, Free University of Amsterdam (R.Bullens@compaqnet.nl)This presentation will show the results of our research concerning the Dutch version of the J-SOAP(Juvenile Sex Offender Assessment Protocol II; Prentky & Righthand, 1994; Prentky, Harris, Frizzell &Righthand, 2000). The J-SOAP is a risk-assessment instrument for juvenile sex offenders. It consists offour scales in total; two scales are more static in nature:• sexual urge/preoccupation• impulsive/antisocial behaviorTwo scales are more dynamic in nature:• intervention• Stability of home/community

536Research has been done on data of 111 Dutch juvenile sex offenders: 37 from in-patient facilities, and 64from outpatient treatment programs. The J-SOAP seems to be a promising tool for assessing the risk ofrecidivism a juvenile sex offender represents.183.3. Psychotherapy and Detention Politics: Results from a Model for the Assessmentof the Psycho-Social Health of Inmates and the Indication for Their TreatmentKarel Oei, Tilburg University, (t.i.oei@uvt.nl)There is a relationship between a person’s mental state and his/her social environment. The authors presenta model that defines psychosocial health in terms of the interaction of the individual with their socialsurroundings. The model is built upon four key-concepts that describe one’s social communication andinteraction with environment: a) social openness, b) adaptability, c) ability to exercise influence, and d)self-detachment. The authors consider the concepts skills that people need to survive and interact withintheir social environments. Essential for the concept of psychosocial health is that a person is not fully at themercy of his/ her environment, but that (s)he is able to react appropriately to it. A person should be able toopen up (able to accept the influence of the environment), to adapt to it (able to comply with demands ofthe environment), exercise influence over it (able to make some changes), and close oneself off (detachingoneself from the environment).The model presented may function as a tool of indication for psychotherapy in detention and may serve as acommon language for the professionals who treat inmates with psychological and psychiatric problems. Ofcourse, the proof of the pudding – empirical research - cannot be served yet, but in day-to-day practice, themodel seems to be helpful in resolving the choice of treatment for inmates.183.4. Treatment for Incest Offenders on Probation: Experimental ResultsVictor Kouratovsky, Practicing Psychologist, Rotterdam, The Netherlands (Kouratovsky@planet.nl)J. Frenken, Leiden UniversityKarel Oei, Tilburg University, (t.i.oei@uvt.nl)Between 1989 and 1991, an experimental form of treatment for incest offenders was carried out inRotterdam, the Netherlands. Criminally persecuted suspects found guilty of violating the Dutch penal lawsconsidering sex with a minor in a familial setting, having met certain conditions, were given the choicebetween going to prison or entering a treatment program. The court followed the progress of the treatment.Over two years, there were 68 suspects and possible candidates, 37 of whom entered the treatmentprogram. The treatment program was combined with a research program to evaluate the results. A widerange of information was collected, including specifics about the victims (number involved, age, sex, andduration of sexual abuse); nature and frequency of criminal sexual activities; societal background andfunctioning; criminal records; psychiatric and psycho-diagnostic assessments; as well as detailedassessments of treatment goals, homework, and progress. A two-part follow up consisted of:• assessment of treatment goals, psychosocial functioning and (mental) health, 18 months aftercompleting the program• analysis of recidivism rates, 14 years after the index case (N = 68), comparing the conditionsof treatment (n = 30), drop out (n = 7), and no treatment (n = 31)

537The results for the treatment condition (n = 30), 18 months after treatment completion proved positive forapproximately one third and questionable, not traceable, or negative for the respective last thirds. After 14years, there is no indication of positive change in general recidivism rate for the treatment condition. Thegroup as a whole, despite their age at follow up (mid-fifties), shows a consistent involvement with the penalsystem. In the course of the treatment program, certain difficulties in the treatment arose. Thesedifficulties are consistent with the type of structural psychopathology that became apparent. It cantherefore be hypothesized that the group as a whole is chronically vulnerable to outside disturbances insocial and societal functioning and that this should be a long-term focus for treatment programs in thefuture.183.5. Youth Crime and Social Factors in the NetherlandsKarel Oei, Tilburg University (t.i.oei@uvt.nl)In this study, we formulated the following question, “Is this the case? And if not, what is going on in youthcrime?”Is there a disconcerting increase in youth crime, particularly in the Netherlands? What connection is therewith upbringing, related problems, and possible shifts in this area? Research (Loeber & Farrington, 1997,Loeber & Slot, 2002) has shown that members of the ‘hard core’ of youth crime were causing problemsbeginning at very young ages. Prevention is therefore aimed at early support in upbringing. Problems inupbringing and the family situation, however, only partly explain the development of youth crime.Moreover, in the case of today’s juvenile delinquents, the harm has already been done and the parents’influence is often very small, if not non-existent.What other factors influence the development of youth crime, and particularly, what role does the peergroup play?How can juvenile delinquents be assisted with effective treatment?We used the ‘hermeneutic, qualitative method’ for this study, which means that by describing andinterpreting current notions and practical material, we can reach an understanding of the phenomenon. Westudied literature on youth culture, upbringing, and both individual and group youth crime. We confrontedthese partial studies and contrasted the given conclusions with descriptions of real-life cases. We have triedto make the lives of the offender, victim, and social worker understandable.The results will be discussed. Tackling group psychopathology would involve close cooperation of the lawwith the police, education, welfare work, and mental health care. We also recommend developing andapplying the notion of ‘performance’ as experience of young criminals.

538184. Treatment Programmes for Treatment Resistant Groups184.1. Western Logic, Adversarial Law, and Juvenile Detention: The Role of ResilienceEdith Henderson Grotberg, George Washington University (egrot@erols.com)The focus of laws concerning juvenile detention (derived heavily from laws concerning older offenders),are largely to determine guilt and punishment. Forensic psychologists, who assess the psychological issuesof offenders, may contribute to determining the kind of punishment decreed to the offenders, however, evenwhen there are different courts for juveniles, the weight of the process is to determine guilt and punishment,using similar laws to justify the punishment.In the United States, a major issue is whether to try a seventeen-year-old youth as a juvenile or as an adult.If tried as a juvenile, the murder sentence would be a life sentence; for an adult, the sentence would bedeath. It is not uncommon for a case to be moved to another jurisdiction where the death sentence ispermitted for juveniles.Focusing on such issues ignores the developmental stage of juveniles and there are implications of suchignoring. Juveniles have not reached their full mental development and therefore are not fully able tocomprehend that what they are doing that might lead to destructive, illegal behavior. Many youth aretrying to establish a self-identity and often take actions that are stimulated by fear of rejection, fear of norespect, and fear of failure. The acting out that leads to arrest and appearing before a juvenile court puts thejuvenile in a situation where he may become overwhelmed by the system as he waits only to get out, nothaving benefited from the punishment.Forensic psychologists who recognize both the developmental and psychological needs of youth are in aposition to provide advice and actions to address these needs. A major contributor to that development isthe promotion of resilience, the human capacity to deal with adversities, to become stronger and moremature as a result. Research and programs demonstrate the effectiveness of the promotion of resilience.184.2. Dealing with Children and Adolescents Who Don't RespondLudwig F. Lowenstein, Southern England Psychology Service (ludwiglowenstein@btconnect.com)In can be very difficult to assess many children and adolescents in order to determine the best treatment forthe problems that lead to their detention. Their behavior often prevents accurate assessments and thereforeprevents the determination of appropriate treatment. Twenty-three therapeutic approaches will bepresented that have been used by the author for over twenty years in a therapeutic community and inInternational School in England. Research and results are summarized.

539184.3. Sentencing and RehabilitationJohn Irwin, San Francisco State University (jirwin4965@aol.com)Barbara Owen, California State University at Fresno (barbarao@csufresno.edu)In the summer of 2004, while there was growing dissatisfaction with the excessive use of imprisonment tocontrol crime, a number of American criminologists and law professors began meeting to discuss Americansentencing practices. Crime rates had been going down for ten years, but the costs of the expanding prisonsystems and state and federal governments’ deficits continued to escalate. In addition, policymakers beganto recognize that hundreds of thousands of prisoners from the bloated prison populations were beingreleased and most of them were being sent back to prison as “recidivists”--many, and in some states, most,of them for petty crimes or violations of parole conditions. There was also the troublesome recognition thatBlacks and Hispanics were being imprisoned at a much higher rate than Whites were. Presently, seventypercent of America’s prison population is non-white. These concerns led to an increase in initiatives toreform sentencing practices. The main purpose of this paper is to describe the background for this currenteffort at sentencing reform and its relation to rehabilitation. This paper will discuss: 1) The Current Stateof Crime, Sentencing, and Punishment in the United States; 2) Crime and Other Factors Contributing to theImprisonment Binge; 3) The Color of Imprisonment; 4) The Costs of Imprisonment and its Impact onPrisoners; 5) Misalignments In Sentencing; 6) Over-Emphasis on Retribution and Incapacitation; and 7)De-emphasis of Rehabilitation. The paper concludes with a discussion of sentencing principles aimed atredressing some of the problems with sentencing practices in the United States.184.4. Preventing Change by Focusing on the Wrong ProblemDennis R. Trent, Midland Psychological Services, Birmingham, England (dtrent@blueyonder.co.uk)Women’s prisons have an inordinately high level of individuals with histories of child abuse. While thismay span all four forms, i.e., physical, sexual, emotional, and neglect, the incidence of physical and sexualabuse well exceeds the normal population. Many times these women will turn to drugs such as heroin andcrack-cocaine in an attempt to block out the recall of past events of abuse. This paper argues that the use ofdrugs is effective from their perspective and the need to attack the cause of the use of drugs is thereforemore important and has a greater likelihood of success than just to focus on stopping the drug usage. Theunderlying dynamics of the effects of child abuse are described along with the common attempts at dealingwith those effects on the part of a female prison population. A programme initiated in a female prison forthe prevention of self-harming women is explored and the effects of it on the members of the programmeare discussed in relation to the abuse. Lessons from the programme are viewed in relation to futuredirections in the treatment of survivors of child abuse and an integrated theory and treatment programmeare put forth. Problems with current treatment programmes are also identified and recommendations forchange are noted.

540184.5. Psychological Evaluations for the Juvenile Court SystemElizabeth S. Bishop, Arbor Psychological Consultants, Ann Arbor, USA (bbishop@umich.edu)Many older children and adolescents who are involved with the juvenile court system in the United Statesare ordered to have psychological evaluations. These evaluations may be used by the court to help withdisposition of cases, especially in terms of recommended treatment. Sometimes evaluations are needed todetermine competency to stand trial or to help in child abuse and neglect cases. These assessments usuallyinclude a detailed history, review of the records, interview with the parent(s) if possible, and a clinicalinterview and psychological testing with the child or adolescent. Testing usually includes individualintelligence testing, evaluation for possible learning disabilities, and both objective and projectivepersonality assessment. In occasional situations, further comprehensive neuropsychological evaluationmay be appropriate; this would be true in cases of head injury or neuropsychological dysfunction.Evaluations may take place at the clinician's office or at a juvenile detention center. Specific tests andprocedures commonly used will be discussed and sample protocols for different types of evaluations will bedescribed. These will include evaluations of children under age 12, evaluations of adolescents fortreatment/placement outside the home, child abuse and neglect evaluations, and evaluations for competencyto stand trial. Some retrospective data may be included from a review of evaluations done for the localjuvenile court system over the past decade.185. Work and Mental Health I185.1. Doctors for Doctors: Clinical and Ethical Aspects of Treating Physicians inDistressTatyana Barankin, Clarke Institute of Psychiatry, Toronto, Canada (tatyana_barankin@camh.net)This presentation will address unique stressors in physicians' lives, as well as barriers to treatmentwhen physicians find themselves in distress. Issues of prevention and building resilience in physicians willbe illuminated. Depression and suicidal management will be discussed, and the issues of transference,counter transference and boundaries addressed. Ethical and legal issues arising when treating physicianswill be covered with an emphasis on reporting issues, confidentiality and third party reports. At theconclusion of this presentation the attendees will be able to :1. Identify and assess physicians in mental distress.2. Provide effective interventions for burnout, depression, suicidality.3. Improve preventive approaches and understand the concept of resilience.4. Appreciate ethical and legal issues in treating physicians.This presentation will also describe a unique program "Doctors for Doctors", developed by the TorontoPhysicians Health Team to recruit and train physicians who will provide treatment to colleagues in distressand create a community of care.

541185.2. Psychological Stress Claims for Workers’ Compensation: Appeal Cases inQuébec (1998-2002)Katherine Lippel, University of Quebec at Montreal (lippel.katherine@uqam.ca)Québec workers’ compensation legislation has entertained compensation claims for psychologicaldisabilities related to acute and chronic workplace stress since the 1980’s and Quebec is currently the onlyjurisdiction in Canada to compensate disabilities arising from chronic stress in the workplace. TheCommission des lésions professionnelles (CLP) is the administrative tribunal having exclusive jurisdictionto hear appeals from the Québec workers’ compensation board (Commission de la santé et la sécurité dutravail or CSST) concerning claims filed under the Act respecting Industrial accidents and occupationaldiseases. This paper reports on results of a study of 357 motivated decisions of the CLP rendered between1998 and 2002 regarding claims for psychological disability alleged to be related to workplace stress.We will present a detailed portrait of the different types of work stressors described in the decisions; thediagnoses associated with the different claims; the types of experts called as witnesses by workers,employers, and the CSST; the nature and duration of the disability claimed and recognised by the tribunalas being associated with workplace stress; the presence or absence of other aetiological hypothesesexamined by the tribunal; and the factors associated with acceptance and refusal of the claims. Depressingand conflict-ridden relationships are among the most frequently cited sources of stress experienced by bothmen and women, and we will examine the nature of these relationships with regard to social position in thefirm (supervisors, colleagues, clients, third parties, etc.).In a previous study that looked at similar data for the period of 1987 to 1994, a gender-based analysisshowed that women succeeded significantly less often than men when claiming psychological disabilitiesand that these differences were particularly important for chronic stress claims. In the new study, this trendis no longer present; however, success is associated with gender in certain types of claims, such as those forpsychological harassment and negative evaluation of work performance. We shall examine some of thesimilarities and differences and look at factors that could explain the changes in the success rates betweenthe two studies. To conclude, we will examine some of the legal and social factors that could becontributing to these differential outcomes and draw on the information gleaned from the data to bettertarget prevention strategies for reducing psychological disabilities associated with workplace stress.185.3. Black and Blue on the Inside: Silence, Domestic Violence, and the AmericanWorkplaceNatasha T. Martin, Seattle University School of Law (nmartin@seattleu.edu)Despite its pervasiveness in American society, domestic violence has been under-discussed as a publichealth problem and particularly as a mentally disabling condition. However, research shows that thenumber of women who suffer domestic violence has reached epidemic proportions. For instance, morethan one and a half million women suffer physical and emotional abuse by intimate partners or formerpartners. Further, domestic violence has enormous employment-related consequences for the victims.Studies confirm that a significant number of all battered women lose their jobs due to issues related to thedomestic abuse. Additionally, for employers, domestic violence results in significant costs in absenteeism,lost productivity, increased health care costs, and turnover, yet domestic violence has not received thesustained attention it deserves under American workplace discrimination law.

542This presentation engages the intersection of domestic violence against female victims and workplacediscrimination law, specifically the Americans with Disabilities Act (ADA). The article explores thefeasibility of the ADA as an avenue of workplace protection for victims of domestic violence by framing“battered women's syndrome” as a mental impairment and thus a covered disability under the Act. Thisinquiry is pertinent particularly because the effects of domestic violence extend beyond physical harm. Infact, there may be little or no visible physical manifestation of the abuse. Notwithstanding the physicalinjury, mental-health related impacts are often crucial, ranging from stress-related illnesses to severepsychological harm, which can disadvantage the victim in a workplace setting. In these instances, the lawencourages silence by the victims who often fear losing their jobs or experiencing other adverseemployment action if their conditions are revealed. While some states have enacted laws providingworkplace protection for victims of domestic violence, there is no federal law providing such protection. In2001, congressional efforts to pass legislation - the Victim’s Employment Sustainability Act (VESA) –failed, and the subject has received little attention since then. Perhaps progress on this issue is thwarted byemployers’ concerns about workplace violence.In sum, this presentation considers generally how American workplace law stigmatizes and silencesdomestic violence victims in their workplace environments. More specifically, this article considers aconstruction of “battered women’s syndrome” as a temporary mental impairment under the ADA, andwhether that construction empowers victims of domestic violence to manage their employment situationsand to challenge unlawful employment practices when they occur. This exploration will incorporate somefeminist critique and critical analysis. It will also confront related cultural, social, and economic realities.This initial work will lay the groundwork to extend consideration of these issues to the international contextthrough comparative analysis in cultures where domestic violence is similarly pervasive and largelyignored as a mental health condition with significant employment-related consequences.185.4. Subject Personality and Civil Actions in the Italian Labour SectorAlessandra Luzzago, University of Pavia (aluzzago@unipv.it)Italy has experienced an increase in civil actions with respect to the labour sector. Many individuals claimto be persecuted in the process of falling ill in the workplace and thus claim damages. The myriad of casesthat have come forward as health injuries, demand the need for achieving a threshold to legally linkcausality with pathology. Although this is a clear legal requirement, the distortions and manipulations ofthese phenomena have given rise to allegations by subjects of being victimized by oppressive actions. It isnecessary from the legal/medical point of view to discern wherein the subjects’ experiences can be linkedto ‘realistic situations’ and where we can justifiably designate paranoid or other delusional formedillusions. This paper explores the concept of ‘subject personality’ and provides objective researchpertaining to this problematic phenomena.185.5. Observations on Investigated Cases of MobbingRoberta Monico, University of Pavia (fabuzzi@unipv.it, aluzzago@unipv.it)This presentation details a study, accomplished by the Department of Legal Medicine and Public Health ofthe University of Pavia, on cases of supposed mobbing, observed in the last five years during medicaljudgments requested either by courts or parts involved.

543The basis of this research lies in the idea that there is a significant difference between clinical diagnosis(e.g. Environmental and Occupational Medicine) and forensic evaluation of mobbing.From a clinical point of view, it is important to evaluate the presence of signs and symptoms, thechronological concurrence, or subjective connection to work environment. In a forensic evaluation, it iscrucial to demonstrate a cause-effect relationship between the supposed prevailing conditions (created byone or more individuals in the working context), and a specific disorder, either for its etiology or for thesymptoms matching. This means that a clinical approach is not adequate and that a mainly medico-legalmethod is crucial to assess if a disorder preexisted.From this perspective, in a correct evaluation method, the purpose is to evaluate the character organizationand temperament, starting from the individual experiences and personal life history. Actually, personalitystructure can dispose the individual to manifest mobbing conditions (dependent and scarcely flexible, inadaptation and personality). It can justify conflicts in the working environment (obsessive, narcissisticpersonality), perhaps leading to mobbing or bossing actions; or it can encourage paranoid elaborations(sensitive and expansive personality or histrionic personality), which have almost nothing to do withmobbing.The intent of this research is to establish the incidence of these different personality structures in theexamined cases.We have used a semi-structured protocol specifically disposed on the knowledge gained from literature.We have considered: social characteristics and personal data of the subjects, their clinical and workingrecord, the value invested by activity in their psychic compound, their coping strategies, the relationbetween the examined person and the supposed victims of mobbing, and the subject’s overall personalitytype as determined from the whole evaluation.The second aim of this study is to establish parameters useful when certifying, during a forensic evaluation,the existence of a mobbing condition.186. Work and Mental Health II186.1. Employment Issues and PTSDMarjorie Cockrell, Cockrell Management Resources, Agoura Hills, U.S.A. (marjoriecockrell@yahoo.com)The initial impact and treatment of PTSD has received much attention with many international situations,as well as the long-term impact on an individual’s ability to function. However, the long-term effectsregarding one’s employment are often neglected. Since an individual’s life is greatly affected by theirability to obtain and maintain employment, the effect of PTSD on employment should not be overlooked.Many individuals are unemployed, underemployed, or unsuitably employed. A comprehensive analysis ofemployment issues of PTSD is often required in forensic cases, workers compensation cases, long-termdisability cases, and other areas that deal with employment and psychiatric disabilities. Symptoms ofPTSD often restrict an individual’s ability to function satisfactorily in the workplace. The relationship ofPTSD and employment will be discussed, as well as recommendations to assess employability, enhanceemployment options, and increase employability. This workshop will provide an understanding of therelationship between PTSD and employability, provide guidelines for more effective reports andevaluations, and discuss vocational assessment of individuals with PTSD.

544186.2. The Harassed Worker in Austria and the Mobbing ConceptBrigitte Schmidl-Mohl, University of Wien (Brigitte.schmidl-mohl@meduni-wien.ac.at)In Austria, the phenomenon of harassment at work (mobbing), started to be a focus of interest in the earlynineties. Since then, specific treatment strategies and a certain kind of case-management done by privatetherapists co-working with members of the unions and a specific Austrian organisation called“Arbeiterkammer” tried to give support to the victims. In 2003, the first book about the legal aspects ofmobbing in Austria was published. For the victims, it is often difficult to succeed in a fight against theirharassers because there is no specific paragraph against mobbing in the Austrian law.186.3. Psycho-Physiological Changes in Stressful Duty over 48 HoursThomas Sycha, University Hospital, Vienna, AustriaReinhard Kitzberger, University Hospital, Vienna, Austria (reinhard.kitzberger@gmx.at)In intensive care units (ICU) and emergency departments (ED), stressful duty and fatigue leads to anexponential decline in physicians’ performance state. (Lacika K, et al.Tetris and physician’s performancestate. The Lancet 1995; 346:516)With this study, we addressed psycho-physiological changes during long (= 48 hours), stressful duty inphysicians at the ICU and ED. Event-related (P300) potentials have been used as objective measures ofcognitive brain function. We measured P300 latency at baseline, 12h, 18h, 24h, 36h, and 40h. Furthersleep quality, subjective performance, stress score, D2, and PASSAT test were performed at thesemoments.Results:• Sleep quality was significantly reduced as compared to the mean of the prior 14 days.• P300- latency was prolonged, but within the normal range, with high inter-individual variability anddependent on the stress- score and sleep quality.• Due to a learning effect, no significant changes were found in the D2 and PASSAT test.• The subjective performance state, as self-assessment, was significantly reduced.• We found psycho-physiological parameters slightly reduced over 48 hours stressful duty of physiciansin ICU and ED. The subjectively perceived decline in physicians’ performance exceeded thesealterations by far.

545186.4. 2005 - The Year for Mental Health and Excellence in CanadaBill Wilkerson, Global Business and Economic Roundtable on Addiction and Mental Health, Toronto,Canada (bill.wilkerson@gwl.ca)This paper will outline a strategy based on business and economic principles to prevent and protect themental health of the labor force and, in so doing, reduce the operational dollar costs and productivity lossesassociated with the rising rates of disability due to mental illness in the global work force.It will discuss in detail the roles and responsibilities of management and labor in the return to work foremployees on disability leave due to mental illness.It will discuss best practices governing a "union-management partnership" in preventing the disablingeffects of depression, anxiety, and substance abuse among men and women in their prime working years.Most particularly, it will specify the duties of unions to accommodate the return to work of their memberseven if this conflicts with a collective bargaining agreement.It will, in turn, outline the responsibilities of unions and governments as employers in the management ofmental disability including its prevention.The Roundtable is an affiliate of the Centre for Addiction and Mental Health in Toronto, Canada, itselfaffiliated with the University of Toronto.This year, the Roundtable is bringing to Canada the Harvard Medical School landmark study intodepression and work performance and is supporting the Canadian Institutes for Health Researchin implementation of the precedent-setting 10-year agenda for mental health in the workplace research.186.5. Perceived Level and Sources of Stress in Baccalaureate Nursing and ObstetricStudentsMohammad Reza Amini, Islamic Kerman Azad University (amini@iauk.ac.ir)In much literature, nursing and obstetrics are identified as stressful professions. A significant portion ofthis stress is related to the clinical setting. Students may perceive stress as a threat, and their learning mightbe hindered. The purpose of this study was to investigate the perception of level and sources of stress onstudents, in various years of the baccalaureate program, by identifying the general level of physiologicaland psychological health, determining the levels of stress experienced by students in various years, and theareas that are perceived as being particularly stressful. The method was a descriptive correlational design.The sample consisted of 315 baccalaureate students of Islamic Kerman Azad University. Data wascollected using two questionnaires--the General Health Questionnaire (GHQ) and the Stress Inventory.Data was analyzed using frequency distributions, t-tests, content analysis, measures of correlation, and ananova test. Results show that more than 50% of the students experience high stress levels and that they areat risk of having a physical or psychiatric illness. Students concern about their future careers and theresponsibilities of partaking in an educational program with a difficult clinical component were the mainsources of stress listed. Other sources of stress were also identified and reported in this article.

546187. Young Offenders187.1. Violent and Juvenile Crime in Japan - New Type of Modern Crime: SelfvalidationTypeJinsuke Kageyama, Tokyo Institute of Technology (jin-k@fa2.so-net.ne.jp)From the viewpoint that homicide is aggression to others and that suicide (especially young male’s suicide)is aggression to oneself, both homicide and suicide can be seen as the most violent types of aggression.One of the purposes of this study is to clarify the changes of the homicide and suicide rates in Japaneseyouths, in association with other social pathology. Another purpose is to clarify the causes for thesechanges in the aggression of Japanese youths.Statistics of Japanese official crime reports (1951-2003) and the Vital Statistics of Japan (1958-2003) wereused. Homicide rates and suicide rates were calculated in Japanese by sexes, age groups, and years.Both the homicide (Figure 1) and the suicide rates in Japanese female youths (especially in the ages 10-30)were found to decrease with the time. Japanese male youths were classified by homicide and suicide ratesinto two groups: 1) Group A/the prewar generation (2 subgroups), and 2) Group B/the postwar generation(3 subgroups) (Figure 4).In recent times, we have seen some unprecedented criminal acts committed by young people in Japan.Indeed, these days it is becoming increasingly difficult to understand the mindset and behavior of ouryounger generations. I believe that in considering violent crime and juvenile crime, the emphasis should benot only on the quantitative aspects, but also on the qualitative nature of the changes. We must understandthe basis that these are crimes of ‘self-validation’ or ‘self-affirmation’, suggesting perpetrators have an‘egopathy’ or ‘empty self’ with a ‘infantile omnipotence’, as caused by, or a reaction to, the over-whelmingmaterialism and information excess of our times.187.2. Street Culture, Group Dynamics, and Delinquent BehaviourJan Dirk de Jong, University of Groningen (jdadejong@yahoo.com)What do we know about delinquent behaviour? We know that predominantly, boys commit delinquentacts, mostly in groups. Statistics also show boys from immigrant backgrounds in deprived neighbourhoodsare disproportionately involved in youth crime. What kinds of groups are these? What cultural influencesare at play in these groups? What happens in such groups that stimulates youth in developing this kind ofbehaviour?Some theories try to explain delinquent behaviour in groups of immigrant youth by pointing in the directionof their ethnic or religious culture. Street culture, group dynamics, and behavior adaptation (by free will orpeer pressure), however, might give us more insight as to how being part of such a delinquent group leadsto involvement in more serious delinquent acts.De Jong has done ethnographic research among groups of mostly Moroccan youth in deprivedneighborhoods in Amsterdam. He will address these issues and compare the group dynamic influences ofboth street culture and ethnic culture on behaviour adaptation in the delinquent groups he studied.

547187.3. Juvenile Offenders: Are They Bad or Asking for Help?Vala Poloni, University of PaviaCristiano Barbieri, University of PaviaAlessandra Luzzago, University of Pavia (aluzzago@unipv.it)The intent of this work is to outline the parameters of evaluating when a youth can be consideredresponsible for a crime and to determine the best treatment and re-educative approach.Laws in force at this moment in Italy, establish that juveniles under 14 cannot be considered responsible fora crime and admit that juveniles between 14 and 18 can be judged only after their capacity to intend andwill (art. 97 and 98 of the Penal Code) is verified. To activate juridical and rehabilitative interventions, it isnecessary to understand if criminal behavior in juveniles is a signal of discomfort that has to be adequatelydecoded.With this purpose, it is necessary to examine the relationship between the criminal behavior of the youthand the following parameters: maturation phase, sex of the minor, quality of personal experiences, anddegree of integration / development of the identity.Considering the maturation phase, a crime may hide a regressive dynamic, typical of childhood.The sex of offender is also important, because acts of aggression by adolescents towards the opposite sex,such as one’s boy/girlfriend, may have a different value: e.g. defense from abandon/anguish for the female,or search of autonomy in the male.Evaluation of the quality of personal experience explaining the criminal action appears to be primary,because the connotation ascribed to the act affects the preparation and achievement of the crime.The degree of integration/development of the identity of the subject is, at last, the key to evaluate a realitytest of youth before, during, and after the crime.The application of an evaluative method based on the previous parameters guarantees a correct technicaljudgment and adequate rehabilitating interventions; since a youth that breaks the law can be also a personasking for help, for a whole number of causes that have to be investigated and documented.187.4. Psychopathology, Psychosocial and Psychosexual Problems in Male AdolescentSexual OffendersL.A. Hart-Kerkhoffs, VU University Medical Centre, The Netherlands (liesthart@hotmail.com)Background:Research on adolescent (first) sex offenders has identified a subgroup of adolescents who display majorpsychosocial, psychiatric, and/or psychosexual problems. While most adolescent sex offenders do notcontinue their abusive behavior, many youngsters are at risk for repetitive offending. In the presentdescriptive study on juvenile sex offenders, it was the intent to gain better insight into these psychiatric,psychosocial, and/or psychosexual problems.Method:One hundred and eight adolescent sexual offenders (mean age 14.8 ±1.4 years) were studied during referralto the Child Welfare Council, a first line child protection agency. A semi-structured interview regarding

548psychiatric problems (K-SADS-PL), a trauma questionnaire, and the Strengths and DifficultiesQuestionnaire were used. Measurements of the psychosexual problems were done by means of the Sex-BARO.Results:Psychiatric and psychosexual problems are present in a large part of adolescent sexual offenders.Moreover, a considerable group of the sexual offenders demonstrated persistent sexual offensive behavior.Conclusion:Preliminary results will be shown. Implications for future research and clinical practice will be discussed.187.5. Exposure to Community Violence and Violent Delinquency in a JuvenileDelinquent Sample: “A study in Youth Custody Centers of Canada, Belgium andRussia”Robert Vermeiren, University of Antwerp (rvermeiren@europemail.com)Ewout Smit, (ewsmit@hotmail.com)Vladislav Ruchkin, Yale UniversityRay CorradoTheo Doreleijers, Free University of AmsterdamExposure to violence and violent delinquency constitute substantial problems in many societies. Although alink has been suggested between both, this relationship has not been studied extensively in detaineddelinquent youth. Therefore, the current study is aimed at investigating this relationship in different crossnationalsamples of detained adolescents. For this purpose, the Social and Health Assessment, a self-reportsurvey on risk behavior and psychopathology, is being administered to youth delinquency populations indifferent countries (e.g. Belgium, Russia, Canada, Ecuador and Surinam). In this lecture, prevalence ratesof exposure to violence will be reported on, for a number of these populations, as well as the relationship toviolent delinquency. Also, the role of possible mediators, such as levels of post-traumatic symptoms andwillingness to aggression, will be investigated. Finally, cross-national differences will be discussed.

549188. Young Offenders: Diagnostic Assessment188.1. The Implementation of BARO-Assessment/Screening Method with YoungOffenders in the Helsinki City Emergency Office: Experiences from theGrassroots Level.Leo Heikkilä, Forensic social worker, Helsink, Finland, (leo.heikkila@cifinternational.com)BARO-project in Helsinki started in 2001 according the experiences in Holland in the supervision of TheoDoreleijers. Firstly, the entire staff (five forensic social workers and the supervising team of a psychologist,specialized mental nurse and two family therapists) was educated in the use of the interview method. Thepractical work with the interview started in the spring 2002 as a pilot study. The presentation will describethe practices and experiences in implementing a new work tool to social work with its benefits anddifficulties. Both client perspective and social work approach will be presented, too.188.2. Girls Referred to a Community Adolescent Forensic Service over a Three-yearPeriodKenny Ross, Adolescent Forensic Service, BSTMHT, Manchester, England(Kross@gardener.bstmht.nhs.uk)The FACTS Team is a multidisciplinary community based adolescent forensic psychiatry service foundedin Manchester, England with a catchment area covering the entire UK (and increasingly Eire). The teamconsists of adolescent forensic psychiatrists, clinical nurse specialists, an approved social worker, an arttherapist, a clinical psychologist, and administration and clerical staff. Patients seen usually aged between11 and 18 and exhibit high risk forensic behaviours (such as serious aggression, firesetting, sexualoffending and cruelty to animals) in the context of mental health difficulties. The most common diagnosesmade are the various conduct disorders but significant co-morbidity is also seen, for example withemotional disorders, attention deficit disorder, generalised and specific learning disabilities, and pervasivedevelopmental disorders.There is an ongoing database project in which details of all community cases that undergo a fullmultidisciplinary assessment are entered. Information collected includes: demographic data (including age,gender, geographical location, referrer type), needs assessment (based on the Salford Needs AssessmentSchedule for Adolescence [SNASA]), high-risk behaviours (both to self and others), Children’s Act status,Mental Health Act status, Criminal-Justice Act status, and ICD-10 multiaxial diagnosis.Our experience is that referrers focus on different aspects of cases depending on the gender of the youngperson. We often receive detailed information about the self-harming behaviours of females referred toFACTS but relatively little information about their interpersonal aggression. The opposite is the case inmale referrals.This presentation will focus on, and describe the characteristics of the young females referred to ourservice. Some relevant comparisons will be made between the female and male young people referred tothe FACTS Team in order to highlight the differences and similarities between these two groups.

550188.3. What Happened to the BAROed Youth?Eila Sailas, STAKES,Finland (eila.sailas@stakes.fi)During the Helsinki City BARO-project, 117 young offenders have been interviewed and the BARO-resultshave been discussed in a multi-professional team. Of them, 54 delinquents were referred to mental healthservices. In 34 cases there was a suspicion of a psychiatric disorder, most often of depression. In two casesboth psychiatric disorder and substance abuse was suspected. In 18 cases the young offenders were thoughtto be in need of treatment because of alcohol and/or drug abuse. The presentation will give details about theresults of the follow up in the mental health services. The benefits and the difficulties of the BAROinterviewwill be presented.188.4. Prevalence and Patterns of Psychotropic Medication in Youths Residing inRehabilitation Centers in MontrealDenis Lafortune, University of Montreal (denis.lafortune@umontreal.ca)The presentation intends to shed some light on the use of psychopharmacotherapy for youths residing inrehabilitation centers in Montreal, specifically those living in foster care and group homes. Nurses from theMontreal rehabilitation centers’ health services were asked to index the files of all the youths under theircare who were receiving psychotropic medications. The population is made up of 471 boys and 150 girlsand the overall prevalence of pharmaco prescription is 19.6% in summer and 36% in fall. The youngeryouths are more medicated, along with those residing in intensive supervision units for adolescents or thoseresiding in group homes for children under 12 years of age that have been there for a long time. Based onthe cumulative doses of prescribed medications, 70% of participants take weak to average doses (0.5 to 4minimal daily doses), while 30% take strong doses (4.5 to 11 minimal daily doses). The coming of atypicalantipsychotics, more specifically of risperidone, and the emergence of concomitant psychotropicmedications tends to characterize the clinical practices in this setting. Further research on the prescriptionof psychotropic medications is clearly warranted: circumstances surrounding the introduction of themedication, its titration, as well as prescription monitoring. In addition, factors associated with theprescription of concomitant medications and those factors concerning youths receiving strong doses, aswell as the place of medication in the complete residential treatment offered to these youths.188.5. Delinquency And Mental Health; An Analysis Of The Situation In SpainJosep Cornellà, , Government of Catalonia, Girona, Spain (cornella@comg.es)Àlex Llusent Government of Catalonia, Girona, Spain (cornella@comg.es)The situation of the juvenile justice in Catalonia and in other autonomous regions of Spain will be analysed.Especially, there will be a focus on the necessity of correct psychiatric assessment if it concerns a criminalact perpetrated by a minor.The following aspects are analyzed:

551• Psychiatric procedures before the trial.• Psychiatric orientations to the Judges of Juvenile Justice.• Psychiatric attendance in the detention Centers.• Consumption of toxic substances in the detention Centers.• Psychiatric pursuit of the minor that have been object of a judicial sanction.• Aspects that should be improved.Also, the authors will refer to the excellent collaboration that they have found on the part of the juvenilejudges. The situation elicits deficits. But a good climate exists for the work to multidisciplinary work in thepsychiatric attention for the delinquent youth.The authors explain the beginning of the program "Health and School" in Catalonia (from an agreementamong the ministries of Health and of Education) in order to begin a preventative task in the Centers ofSecondary education.189. Young Offenders: Epidemiology and Follow-up I189.1. Psychosocial Outcomes of Boys in Secure Care for Serious or PersistentOffending: Longitudinal FindingsSue Bailey, University of Central Lancashire (ntattersall@gardener.bstmht.nhs.uk)Objective: Describe the psychosocial outcomes of boys in secure care and establish if these outcomes werecorrelated with criminal outcomes.Design: Prospective longitudinal study.Setting: Four secure units in the North West of England.Participants: 97 boys whose average age when admitted to secure care was 14 years, were followed upabout 2 years later, when outcome data was obtained on 81/97 (83%) cases.Main outcome measure: Standardized assessment of mental health, social, and educational needs wereobtained by interview with the young person and corroborated in most cases by information frominformants. All data was then reviewed by an experienced clinician.Results: The average number of needs requiring an intervention at follow-up (mean = 3.4, sd = 3.0) wasmuch lower than before admission to secure care (mean = 8.2, sd = 2.5). Educational and occupationalneeds were particularly well dealt with. However, many mental health problems persisted or worsened.For example, 31% had a need for treatment of substance abuse, a significant increase compared with whenthey were in secure care (percentage difference 21%, 95% CL 9.0% to 32.7%). Anxiety or posttraumaticstress disorders at follow-up were more common (crude odds ratio 11.2, 95% CI 1.4 to 9.3) among thosewho remained in secure care or who went into a young offenders institution during the follow-up (10/43 or23%) than those who did not (1/38 or 3%). No mental disorder predicted subsequent offending.Conclusions: Boys who have been in secure care continue to have a high rate of psychiatric morbidity. Themental health needs of this group are not static but change over time and with varying circumstances.

552189.2. Psychosocial Characteristics of Very Young Dutch First-offendersL. van Domburgh, VU University Medical Centre (l.vandomburgh@debascule.com)Robert VermeirenL. Nauta-JansenC. GelukTheo Doreleijers, Free University of AmsterdamChildren who display delinquent behaviour before the age of twelve have a high risk of developing apersistent pattern of severe delinquent behaviour. In The Netherlands, little is known about thecharacteristics of children below 12 with a first instance of police contact. A more effective recognition ofrelevant socio-demographic, psychiatric, psychological, and crime-related risk factors in this group of childdelinquents may enable better decision-making at an early stage, better referral to appropriate services, andmore effective intervention.In three different police-districts (‘politie regio’s’), 250 children under the age of 12 will be investigatedafter their first registration by the police (T0). Testing includes a structured psychiatric interview, selfreportquestionnaires, and an estimation of intelligence. Both the children and parents will be interviewed.Preliminary analyses have shown a high prevalence of (externalising) psychiatric disorders, lowintelligence levels, and reading difficulties. Children, parents, and teachers reported high levels ofbehavioural and emotional difficulties. No differences could be found by type of offence.It seems difficult to assess risk in young children with a police contact on the sole bases of their offencetype, while severe problems prevail in this group. Therefore, specific risk assessment and screeningmethods need to be developed.189.3. Which Measures are Useful? Results of the Two-year Follow-up of a Twentyfive-yearProspective Longitudinal Study on Delinquent AdolescentsDaniel Gutschner, Institute for Forensic Child and Youth Psychology and Psychiatry, Bern, Switzerland(daniel.gutschner@ifkjb.ch)Theo Doreleijers, Free University of AmsterdamKlaus Schmeck, Universitätsklinikum UlmRobert VermeirenThis presentation shows the results of the 2-year follow-up assessment of our 25-year prospectivelongitudinal study on delinquent adolescents.90 subjects (87% male and 13 % female) of the primary 108 juveniles in the ages of 12-20 were included.The first assessment was made in a multi-informant setting: Standardized tests for intelligence and attentionand a list of other questionnaires (self- and objective reports) were used. Furthermore, structuredinterviews were held to gain information about socioeconomic data and psychopathology (DIPS).At the second time of measurement (2 years later), additional data about the progress of our subjects(recidivism, professional integration etc.) was recorded according to information from juvenile court.

553Recidivism occurred in 64.4% of all cases, whereas the rate of recidivism turned out to be higher inconnection with violent offenses (72%) than with drug (56%) or property offenses (59%). Psychiatricdisorder was classified in 87% of our subjects. This result shows a significant association betweenexternalized disorders and recidivism (chi 2 p

554189.5. Psychiatric Disorders among Incarcerated Boys: A Literature ReviewCoby Vreugdenhil, Juvenile Justice Institution Rentray, Lelystad, The Netherlands(postbus@vreugd.demon.nl)A review of scientific literature will be presented, in order to estimate the prevalence of psychiatricdisorders among incarcerated boys. Only studies with 50 of more male adolescent incarcerateddelinquents, in which at least one psychiatric disorder was assessed with a standardised psychiatricinterview, were included. Most studies reported high, but widely varying, prevalence rates of externalising(substance use and disruptive behaviour) disorders and relatively low rates of internalising (anxiety andaffective) disorders. In addition, high rates of psychotic symptoms and disorders were found. A fewstudies investigated the relationship between psychiatric disorders, violent offending, and criminalrecidivism. No consistent significant relationships were found between psychiatric disorders and violentoffending, nor between psychiatric disorders and criminal recidivism.190. Young Offenders: Epidemiology and Follow-up II190.1. Traumatic Presentations and Behaviors in Youth Exposed to Family MemberHomicidePaul T. Clements, University of New Mexico (pclements@salud.unm.edu)Homicide of a family member leaves more than just bodies behind and leaves survivors to struggle andcope with sudden and violent loss of life, crossing all cultures, races, and both genders. For youth, homicideof a family member may result in more negative post-trauma reactions than loss to natural causes sincedeaths 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 memberhomicide provided insight into themes of bereavement and traumatic stress. A major finding in the studieswas that the witnessing or hearing the news of a family member homicide was a powerful associative factorfor childhood posttraumatic stress disorder and for complicated bereavement. Many issues for bereavedyouth after family member homicide are unique in scope. Serious consequences can occur surrounding ayouth’s evolving moral reasoning, understanding of the consequences of a person’s actions, and thesignificant need for family permanence. Family member homicide can confound all of these developmentaltasks simultaneously. A primary issue is the helplessness of youth at having to watch or listen to the sightsand sounds surrounding a violent act and being unprotected from the full emotional impact of the violence.

555190.2. Assessment of Psychiatric Juvenile Patients Who Are Victims of Sexual TraumasHeidrun Eichberger, Medical University of Vienna (heidrun.eichberger@meduniwien.ac.at)This examination focuses on the assessment of psychiatric, juvenile patients, who had become victims ofsexual trauma. The aim was to find out what impact both their illness and their status as a victim had on theprocess of judging. A representative sample of the overall population (n=188) was each given one of the -in total - six different curriculum vitas of a fourteen year old girl and asked to judge on them. In three casesthe stimulus person was the victim of rape. In addition, a stable psychotic as well as an acute psychoticdisease of the stimulus person were established. Consequently, the results were six test conditions for thedesign: non-victim, acute psychotic stimulus person, stable psychotic stimulus person, victim, acutepsychotic victim, stable psychotic victim. Victims are granted significantly more trauma, significantly lesspositive estimation as well as less devaluation. In the acute case of disease, trauma is estimated to besignificantly higher, positive estimation turns out to be significantly smaller in both cases of disease as wellas devaluation. In all six test conditions, the acute diseased victim gets the highest degree of trauma as wellas the smallest degree of positive estimation; whereas ill victims of sexual trauma are estimated to be lesspositive.190.3. Prevalence of Mental Disorders Among Children and Adolescents in a Germanresidential Care PopulationMarc Schmid, University Hospital of Ulm (marc.schmid@medizin.uni-ulm.de)Lutz Goldbeck L, University Hospital of UlmJakob Nützel, University Hospital of UlmJörg Fegert, University Hospital of Ulm (joerg.fegert@medizin.uni-ulm.de)Multiple risk factors for the development of mental disorders (e.g. abuse, neglect, divorce; geneticpredisposition) are common in children and adolescents in residential care. In this study we assess theprevalence of behavioral and emotional symptoms and mental disorders in a German residential carepopulationThis epidemiological study takes place in 20 residential care institutions including about 689 children andadolescents (age 4 – 18 years, mean age 14,4 SD = 2,94). Our sample comprises institutions of varioussizes and therefore represents a good cross section of the whole “residential care situation” in Germany.A two-step design is performed. First, the children and adolescents and their residential caregivers answer astandard symptom checklist (CBCL/YSR Achenbach). For those participants scoring more than onestandard deviation above the age and gender-related mean of the German population reference groups, astandardized clinical examination is performed to confirm an ICD-10 diagnosis using the DISYPS-KJ(Diagnostik System für Psychische Störungen im Kindes und Jugendalter nach ICD-10 und DSM-IV).The study population reaches high average scores in almost all scales and subscales of the CBCL and YSR,between 1 and 1.5 standard deviations above the mean of the normal control population (means Totals T-Score 64,4;SD = 9,82). There is a high prevalence (over 50 %) of mental disorders. The most frequentdiagnoses are conduct disorder, ADHD with conduct disorder and dysthymia with high rates ofcomorbidity

556Children and adolescents in residential care can be described as a high-risk population. Multiple symptomsand comorbid disorders might indicate the risk to develop a personality disorder. Prospective longitudinalstudies are needed to understand the long-term prognosis. Therapeutic options in cooperation betweenresidential care institutions and child and adolescent psychiatry should be taken including appropriatediagnostic procedures, continued psychotherapy, staff counseling and medication.190.4. Juvenile Offenders with Achievement DifficultiesDeborah Shelton, The Catholic University of America (dssquared@earthlink.net)This study presents the health and mental health status of a random sample of male and female youngoffenders with academic achievement difficulties who were diagnosed with a Learning Disorder.Thirty-eight percent of youth sampled (N=143) were diagnosed with a Learning Disorder. Whencomparing youth with a Learning Disorder to those who did not, few differences were found in patterns ofcriminal behavior or in treatment services received. Non-significant differences were found for medicalconditions, including vision, speech and hearing difficulties, as well as head injuries. Significantdifferences were found in rates of abuse and neglect (χ 2 =13.41, df=2, p= .001) and rates of suspension orexpulsion from school (χ 2 =19.85, df=5, p= .001).The findings of the study confirmed that youth most likely to encounter service gaps are those youthadjudicated as delinquent with multiple health problems, including those with disabilities and likely to dropout of school. Recommendations were made to enhance screening and assessment, particularly for firsttimeoffenders with minor offences and to divert cases where a disability is severe and where the childwould be unable to comply with court orders.191. Young Offenders: Neurobiology of Aggression191.1. Neuropsychological Functioning in Children/Adolescents with Conduct ProblemsMairead Dolan, University of Manchester (mdolan@edenfield.bstmht.nhs.uk)Charlotte Rennie, University of ManchesterResearch suggests that adults with antisocial behaviour and psychopathy have a range of deficits infunctioning in prefrontal-temporo-limbic neural circuitry. To date there has been relatively little research onneurocognitive function in conduct-disordered adolescents characterised based on Callous –Unemotional(CU) traits.We examined the Dorsolateral (DL) pre-frontal functions of planning and set-shifting; the Ventro-medial(VM) functions of behavioural restraint and putative amygdala functions of emotional informationprocessing using a computerized battery.

557Participants were 125 male DSM-IV conduct disordered adolescents in correctional settings and thecommunity in the North West Region of England. Subjects were screened for Axis 1 disorders andlearning disability. Callous-unemotional traits were assessed using the Factor 1 items from the PsychopathyChecklist Youth Version (PCL: YV).Factor 1 scores:Participants with high PCL: YV Factor 1 scores (CU traits) tended to have impairments in planning ability,set shifting and behavioural inhibition. They also had impairments in emotional memory and failed themoral/convention task. This group also performed significantly worse than low CU subjects in theunderstanding of higher order theory of Mind tasks such as the Faux Pas task.These findings suggest that conduct disordered males with CU traits have a variety of deficits in DL, VMprefrontal function as well as deficits in emotional information processing reflecting amygdala dysfunction.191.2. Neurobiology of Disinhibitory PsychopathologyB. Klinteberg, Stockholm University (bkg@psychology.su.se)The neurobiological basis of impulsivity is very well evidenced, not only in groups of patients andcriminals, but also in groups of ‘normal’ individuals. The focus concerns the significance ofneurobiological factors of impulsivity in the development of psychosocial disturbances and forms ofdisinhibitory psychopathology. Early onset alcoholics have been found to display increased scores inimpulsivity and sensation seeking related personality traits and low conformity. Low platelet MAO activityis considered a biological marker of vulnerability for disinhibition and psychosocial deviances, andrepeatedly shown to be strongly associated with high impulsivity. Impulsivity, in turn, is found to be stableover time and constitute a major predictor of adult antisocial, delinquent behaviour as demonstrated in aseries of prospective studies. Of special relevance to this presentation are some longitudinal findings ofearly hyperactive behavior and adolescent norm-breaking behaviors being connected to adult highimpulsivity and forms of disinhibitory psychopathology. Hyperactive behavior was evidenced assignificantly related to subsequent alcohol problems and violent offending, as well as significantlyassociated with psychobiological measures. The connection between impulsivity and neurobiologicalindicators in ‘normal’ adolescents and adults confirms the hypothesis that a biological vulnerability can bepresent in an individual, without the development of any kind of psychosocial disturbance, if there areprotecting resources in the individual or in his/her family or environment.191.3. Neuropsychology of Dependency and DelinquencyBernd Leplow, Martin-Luther-University of Halle-Wittenberg(b.leplow@psych.uni-halle.de)The neuropsychology of delinquency represents a new promising research area with implications which arepossibly relevant in practice. However, as the neuropychologically orientated investigations reported in theliterature failed to yield any consistent findings, the standard version and variations of the Iowa GamblingTask was used in which short and long-term, positive and negative consequences can be presented andsystematically varied en bloque or spread out. In patients with ventromedial brain damage, thedysfunctional tendency to use short-term wins along with the acceptance of long-term losses has come to be

558seen as a core deficit. The results of the author’s research group show that this can also be found inprisoners serving their sentences confined to psychiatric institutions, but that it does not occur in prisonersserving a regular sentence when offenders and control persons are matched according to alcohol casehistory. Correspondingly, dysfunctional decision making strategies were also found in chronic alcoholicsand other psychological disorders, but not in pathological gamblers without alcohol dependency. Thus, theresults appear above all to show a prefrontally determined dysregulation, which is found in the most diverseof disorders. First results in boys with conduct disorder show a similar pattern of results. With regard to theneuropsychology of delinquency, the results indicate that the syndrome of substance abuse and ruleviolation should be given greater attention earlier on in childhood and youth.191.4. The Role of Serotonin in Aggressive BehaviourKlaus Schmeck, University of Ulm (Klaus.schmeck@medizin.uni-ulm.de)C. Stadler, University of FrankfurtF. Poustka, University of FrankfurtObjective: Decreased central activity of the neurotransmitter serotonin has been shown to play a significantrole in the etiology of impulsive and aggressive behaviour. Several approaches have been developed fornon-invasive study of CNS serotonergic activity.Methods: In our first study we used rapid tryptophan depletion (RTD) to decrease central serotonergicactivity in 12 healthy volunteers (6 males, 6 females, 24-31 years). The tryptophan-free amino acid mixturecaused a marked depletion of plasma tryptophan with lowest levels occuring between 3 to 5 hours aftermixture application. In a second study on 9-14 year old children, we investigated serotonergic activity inplatelets, which are accepted as models of the serotonin nerve terminal. Maximum number of platelettritiated paroxetine binding sites (Bmax) and affinity (1/Kd) as well as 5-HT transporter promoterpolymorphisms were measured in 15 aggressive and 14 control subjects.Results: In the first study maximum changes in mood occurred about 10 hours after RTD but only in threewomen with higher aggressive traits who scored significantly higher in arousal, anger and depressed mood,whereas low aggressive women and men with different levels of trait aggression did not show any effect ofRTD. In the second study we found a trend for a lower platelet 5-HT uptake in boys with diagnosis ofconduct disorder. Looking on the data with a dimensional approach we can demonstrate that aggressiveboys with a high level of emotional reactivity showed a significantly lower rate of 5-HT uptake than nonaggressiveboys with low emotional reactivity.Conclusions: Our results are in line with data from previous studies that CNS serotonergic activity isdecreased in subjects with impulsive-aggressive traits.191.5. Cortisol, Heart Rate and Skin Conductance in Antisocial AdolescentsA. Popma, VU University medical centre (apopma@hotmail.com)Patterns of low (re)activity of stress regulating mechanisms, including the autonomic nervous system(ANS) and the Hypothalamus Pituitary Adrenal (HPA) axis, have been found to be related to antisocialbehaviour. Because controversial results have been shown in children and adolescents, the aim of this studywas to further investigate the role of HPA and ANS activity in antisocial behaviour in male adolescents.

559The CAR and diurnal cycle of cortisol were studied in a group of 12-14 year old boys attending adelinquency diversion program (DP; n = 81) and matched normal controls (NC; n=32). Within the DPgroup, a subgroup was formed of boys with a disruptive behaviour disorder (DBD). The CAR wascompared between delinquent boys with and without a disruptive behaviour disorder, resp. DP+, DP- andNC. Furthermore, a subgroup performed a Public Speaking Task to asses ANS (Heart Rate and SkinConductance) and HPA activity in stressful conditions.The DP+ group had significantly lower cortisol levels during the first hour after awakening and a flatteneddiurnal cycle compared with normal controls. During stress the DP+ group showed a different response forboth ANS and HPA indices.Results indicate an association between antisocial behaviour and low (re)activity of stress regulatingmechanisms in male adolescents. Implications for future research and clinical practice will be discussed.192. Young Offenders: Offending Through the Life Cycle192.1. Juvenile Homicide Offenders: Characteristics from Psychiatric Assessment duringCourt Procedures and Later Recidivism RiskMichael Günter, University of Tübingen (michael.guenter@med.uni-tuebingen.de)Silke Eistetter, University of TübingenDaniel Kern, University of TübingenJuvenile homicide offenders are said to have a rather good recidivism risk. This study was aimed at gettingmore precise and differential data on the actual risk of re-offending after 10-30 years.The study included all juvenile offenders charged with homicide or tempted homicide who came to aforensic psychiatric assessment in our department from 1970 to 1994. We compared characteristics fromthe intensive forensic psychiatric assessment after the index offence with later recidivism taken from thecriminal records. Forensic reports were evaluated systematically with an evaluation form. Psychiatric basisdocumentation used nationwide gave additional information.N = 140 subjects could be evaluated. Recidivism with the same offence was very low. Recidivism withother offences was moderate and lower than in other groups of juvenile offenders. Risk factors could bedetected. Sub-groups differing from the main population of juvenile offenders could be described.The risk of juvenile homicide delinquents to re-offend with a similar offence is very low. Sub-groupsshould be given more attention with respect to general recidivism risk. The influence of a longer (up to 10years) detention on recidivism and development remains still unclear.

560192.2. Developmental Disorders and Attachment Styles in Special Needs YoungOffendersG. B. Camerini, University of Modena (giovanni_camerini@unimod.it)M. ZanoliOn a sample of minor young delinquents with antisocial behaviour and/or social problems, aspects ofattachment styles, the eventual presence of developmental disorders and psychosocial risk factors wereinvestigated. A comparison between attachment styles and risk factors was done to determine the origin ofpathological conduct disorders.Two tests were used on the sample:SAVRY: a semi structured interview about the developmental and psychosocial risk and protective factorsevaluation for special needs offenders.SAT: Separation Anxiety Test, by Bowlby and Klagsbourn, revisited by Attili (2000).A comparison between the results of the two tests and a clinical and legal assessment was done.Even with a small sample it was possible to recognize the presence and meaning of different psychosocialand psychopathological developmental risk factors. These elements can be an important contribution forclinical and forensic assessment and for future research related to children and adolescents with conductdisorders who have multi-morbidity and complex needs.192.3. A Methodology for the Study of Personality in Young AdolescentsUgo Sabatello, University of Rome (ugo.sabatello@uniroma1.it)Luigi Abbate, University of RomeRiccardo Williams, University of RomeTeresa Carratelli, University of RomeThe study was suggested from the idea of the authors who, on the basis of recent scientific literature andtheir own clinical experience, propose a complex methodological evaluation on expertise and socialdangerousness in adolescence. The use of SWAP-A200 and AAI (Adult Attachment Interview) areassociated with a more classical methodology such as tests and clinical intake measurement. Themethodology proposed researches a synergy among different instruments that, in different ways and atdifferent levels, investigates personality aspects strictly connected to a clinical perspective of dynamicpsychiatry of adolescents. A short resume of a case of homicide committed by an adolescent will be usedas a guide line for the exposition of the method.

561192.4. With a Little Help from My Friends: Social Capital and the Fear of School CrimeM.R. Nakhaie, University of Windsor (nakhaie@uwindsor.ca)Vincent F. Sacco, Queen’s UniversityA number of high visibility incidents over the last two decades have highlighted the problem of schoolcrime and violence. While incidents, like the shootings at Columbine high school in Colorado, garner thelion’s share of attention, they are statistically rare and in the context of typical media treatments, tend todistract us from the routine character of most school crime. From one perspective, the problem of schoolcrime can be seen to emerge quite logically from the interaction of the demographic structure andorganizational character of educational institutions. Schools after all provide services to groups in thepopulation at greatest risk of offending and victimization. In addition, unlike most other areas of social life,institutional engagement in the case of schools is compulsory for everyone under a certain age. The effectsof school crime extend beyond the direct losses, injuries or emotional harm experienced by victims. Fearand worry about victimization can reduce the overall quality of school life and seriously undermineeducational objectives. For this reason, educators and justice system planners have focused increasingattention on the need to develop effective preventative interventions. Most of these interventions, like zerotolerancereporting policies or school uniforms, have a top-down quality. Considerably less is known aboutthe informal forms of self-help which students employ in order to negotiate dangerous people, places andsituations in school environments. This paper addresses the role of social capital, one of the more importanttypes of safety production resources to which young people have differential access. Data from theCanadian National Survey of Children and Youth are employed to investigate hypotheses regarding theways in which parental and peer relationships and support affect students’ feelings of vulnerability tovictimization in school settings. The paper concludes with a discussion of some of the broader theoreticaland policy implications which emerge from this analysis.192.5. Sleep in Conduct-Disordered YouthNina Lindberg, Helsinki University (nina.lindberg@hus.fi)Increased deep sleep has been associated with antisocial personality disorder, both in male and femaleoffenders. Whether this abnormal sleep architecture reflects specific brain pathology or a delay in thenormal development of sleep patterns needs to be clarified in the future. Antisocial personality is alwayspreceded by conduct disorder before the age of 15. The physiological mechanisms that are involved in thisprocess are still quite unknown. From the perspective of sleep research, the important question is whetherthe deep sleep phenomenon reported in adult persons with antisocial personality disorder can already beobserved in adolescents with severe conduct disorder. We started a sleep study in an institution, whichinvestigated adolescents with conduct disorder problems in autumn 2004. The study results are presented.

562XXIXe Congrès de l’Académie Internationale de Droit et deSanté MentaleSection Francophone6-8 juillet 2005, Université René Descartes (Paris V)Paris, FranceProgramme scientifique

563193. Plénière193.1. Travailler à s’en rendre malade : psychopathologies et travailDr Jocelyn Aubut, Institut Philippe Pinel de Montréal, Université de MontréalChristophe Dejours, Conservatoire National des Arts et Metiers, ParisLes mutations récentes dans l’univers du travail (mondialisation, nouvelles technologies, ré-ingénérie, etc.)ont été associées à une recrudescence non seulement de la détresse subjective chez les travailleurs, maisaussi à une explosion de maladies autant dans le champ somatique que psychique. Les problématiquespsychiatriques constituent la première cause d’invalidité au travail partout en Occident. Cette présentationmettra en évidence les facteurs de blessures psychiques liées au travail, la manière d’entrée en maladie, lesimpacts personnels et familiaux de ces blessures et le rôle du psychiatre dans le diagnostic, le suivi, laréadaptation et la réhabilitation des personnes malades de leur travail. Certains concepts nouveaux serontabordés, tels la chute des murs, le syndrome d’aliénation au travail, les métastases psychologiques.193. Bloc 1, no 1193.2. Symposium:Les réactions émotives du thérapeute face au patient violentAnimateur:Dr Jocelyn Aubut, Institut Philippe Pinel de Montréal, Université de MontréalConferenciers:Gian Carlo Nivoli, Clinica Psychiatrica Univerità degli Studi di SassariLiliana Lorettu, Clinica Psychiatrica Univerità degli Studi di SassariDiscustant:Christian Mormont, Universite de Liege, BelgiqueLes auteurs présenteront quelques problématiques de la relation thérapeutique avec le patient qui a desrécidives de psychopathologie et d’agir violent.Il y a des réactions émotives, dans l’aspect de mécanisme de défense, qui ont comme finalité la gestion del’anxiété ; pourtant lorsqu’elles ne sont pas reconnues et évaluées de façon correcte, les réactions émotivespeuvent devenir un obstacle au diagnostic et à la thérapie : elles constituent un « fardeau émotif » duthérapeute et une « expression iatrogène » de la thérapie. Les auteurs présenteront des vignettes cliniquessur des mécanismes de défense, tels que l’identification, la projection, le clivage, le déni, etc., etproposeront des suggestions cliniques utiles à la formation du thérapeute.

564194. Bloc 1, no 2:194.1. Atelier: La psychiatrie à la rencontre de l’erranceXavier Emmanuelli, Centre de détention Fleury-Mérogis, Paris, FranceMichel Simard, Centre Le Havre, Montréal, CanadaMichel Gervais, C.H. Centre-de-la-Mauricie, Trois-Rivières, CanadaDes malades psychiatriques, incapables ou refusant de s’inscrire dans ce monde en progrès, sont déportésdans des zones de désertification sociale où ne pousse aucun avenir. Certains deviennent ainsi comme des« zombies » hantant les rues des cités. La maladie mentale se conjugue aujourd’hui avec la rupture socialeet l’exclusion, reconfigurant et élargissant les cadres et les enjeux de la rencontre thérapeutique.Au cours de cette conférence, un état de la situation de l’exclusion sociale sur la planète, autant dans sesgénéralités que ses aspects plus spécifiques aux patients psychiatriques, vous sera exposé. Del’enfermement en institution, plusieurs de nos patients sont ainsi passés dans l’enfermement dans l’erranceou au confinement dans un apartheid social. La désinstitutionalisation n’a pas frappé que la psychiatrie, ceraz de marée a radicalement chamboulé le relief de notre civilisation occidentale. Des dimensionshistoriques, spirituelles et sociologiques de cette métamorphose vous seront soumises.La psychiatrie, elle aussi errante et à la recherche de nouvelles frontières, vogue sur les mêmes eaux que lesplus déshérités dont elle doit prendre soin. Nous faisons tous partis du même monde. Le thème de ce 39 ièmecongrès de l’AMPQ, en référant au « psychiatre en relation… » et en invitant les participants à définir unnouveau centre de gravité de cette discipline médicale, y fait d’ailleurs directement allusion. Cette quêted’identité de la psychiatrie pourrait bien trouver son sens et racine dans un bouleversement de la perceptionpar le psychiatre de ses capacités et limites de même que de sa conception de l’organisation du système desoins dans lequel il travaille.Parmi les initiatives déjà en branle pour s’adapter à ces nouvelles réalités, les expériences du SAMU(service d’aide médical d’urgence) social à Paris et du SAMU social international vous seront relatées.Nous vous offrirons un éclairage sur les caractéristiques de ce « prototype-psychiatre » s’adaptant aunouveau monde et des repères pour intervenir dans un univers dorénavant mouvant et socialementdangereux. Des suggestions concrètes pour modifier et améliorer en conséquence l’organisation des soinset services en santé mentale au Québec seront émises.

565195. Bloc 1, no 3195.1. La valeur thérapeutique de la solidaritéJorge Barudy, Centre Exil, Barcelone, EspagnePlus de vingt ans d’interventions auprès d’exilés victimes de violence organisée et, parallèlement à celaavec des enfants et des femmes victimes de violence intrafamiliale, nous a permis d’élaborer un modèle decompréhension éco-systémique de la souffrance humaine. Conjointement, nous avons élaboré desprogrammes d’intervention thérapeutiques qui articulent les connaissances et les instruments professionnelsdes membres de nos équipes, tout en comptant sur les ressources, les compétences et les forces résilientesdes victimes. Nos expériences nous permettent de témoigner du fait que, quelle que soit la méthodethérapeutique employée, son efficacité est en étroite relation avec la sphère des soins, du respect, de labientraitance et surtout de la solidarité que les professionnels sont capables de créer. Notre modèle estalternatif et subversif par rapport à la culture dominante, basée sur la médicalisation, la psychologisation oula psychiatrisation de la souffrance humaine.D’après nous, notre modèle est non seulement le plus cohérent, mais également le plus efficace. Au coursde cette conférence, nous présenterons les bases théoriques de ce modèle et nous illustrerons nos résultatspar des exemples cliniques.196. Bloc 1, nos 4 et 5196.1. Progrès et reculs en santé mentale: l'exemple d'un message d'un hôpitalpsychiatrique sécuritaire.Gilles Chamberland, Institut Philippe Pinel de Montréal, Université de MontréalPaul-André Lafleur, Institut Philippe Pinel de Montréal, Université de MontréalNous décrirons les changements importants survenus dans l'évaluation et le traitement des patientspsychiatriques les plus lourds et les plus dangereux à travers l'évolution récente d'un hôpital sécuritairespécialisé en psychiatrie légale. Les aspects cliniques, législatifs, éthiques, sociaux et administratifs seronttour à tour abordés. On découvrira que l'hôpital sécuritaire, un lieu autrefois peu accessible et d'allureimmuable, est devenu un carrefour en perpétuelle mutation, le pivot du traitement psychiatrique en réseau,où transitent les patients les plus difficiles et le personnel soignant à la recherche d'une formation à la finepointe.

566196.2. Psychiatrie et tabac: bilan d'un projet pilote d'un hôpital psychiatrique sans fuméeJean Hébert, Institut Philippe Pinel de Montréal, Université de MontréalÀ l’automne 2004, la direction de l’Institut Philippe Pinel de Montréal met en place le projet d’un hôpitalsans fumée où disparaîtrait du milieu le tabac incluant les unités de soins.Au cours de cette présentation, nous ferons état de cette expérience hospitalière et discuterons des résultatset des difficultés de cette démarche, surtout en rapport avec les aspects cliniques et pharmacologiquesd’une clientèle psychiatrique en milieu hospitalier sécuritaire.197. Bloc 1, no 6197.1. Symposium: Directives anticipées et contrainte lors de l’hospitalisationpsychiatrique197.2. Perception de la contrainte et du besoin d'hospitalisation lors d'admission enpsychiatrieCharles Bonsack, Département universitaire de Psychiatrie du CHUV, Lausanne, SuisseFrançois Borgeat, Département universitaire de Psychiatrie du CHUV, Lausanne, SuisseDans le public et les médias, l’hospitalisation psychiatrique est généralement associée à un certain degré decontrainte. Pour les patients, la crise menant à l’admission peut aller jusqu’à conduire à un état de stresspost-traumatique. Quel que soit le statut légal de l’admission, le sentiment de contrainte est de ce faithabituel. Il peut prendre diverses formes, et aller de pressions de l’entourage à l’usage des forces de l’ordre.Après coup, voire pendant l’hospitalisation, les patients peuvent aussi considérer que leur hospitalisationétait finalement nécessaire.Méthode : Une étude transversale a été réalisée parmi les patients d’un hôpital psychiatrique suisse afind’examiner leur perception subjective de l’admission, en se focalisant sur le statut légal, ainsi que lacontrainte et le besoin d’hospitalisation perçus. Des données concernant 87 patients ont été recueillies etanalysées. Résultats : 74% des patients considèrent qu’ils ont subi des pressions pour être hospitalisés,qu’ils aient été ou non hospitalisés contre leur gré. 85% pensent que leur hospitalisation était nécessaire.L’hospitalisation non volontaire est associée à une absence subjective d’amélioration.Discussion : Les cliniciens pourraient diminuer les sentiments de contrainte des patients en considérant (1)le besoin d’hospitalisation, (2) le statut légal et (3) le sentiment de contrainte comme des dimensionsdistinctes, et en s’assurant qu’un dialogue a été établi avec le patient dans chacune de ces dimensions. Cedialogue pourrait être facilité par la rédaction préalable de directives anticipées en prévision d’une rechuteéventuelle.

567197.3. Directives anticipées : appréhensions et réalités d'une expérience cliniqueS. Matthieu-Darekar, Département de Psychiatrie Adulte, Lausanne, SuisseV. Chappuis, Département de Psychiatrie Adulte, Lausanne, SuisseC. Richard, Département de Psychiatrie Adulte, Lausanne, SuisseM. Preisig, Département de Psychiatrie Adulte, Lausanne, SuisseF. Borgeat, Département de Psychiatrie Adulte, Lausanne, SuisseNous nous sommes intéressés à analyser l’impact sur la clinique et sur l’alliance thérapeutique del’élaboration de directives anticipées en collaboration entre le patient psychiatrique hospitalisé et l’équipesoignante. Par directive anticipée, on entend l’expression de volontés libres et éclairées d’un individudevant être prises en compte lorsque ce dernier se retrouve dans une situation où sa capacité dediscernement ferait défaut. Ce droit a été reconnu par une nouvelle modification légale datant de janvier2003.197.4. La contrainte en psychiatrie, actualités et perspectivesYasser Khazaal, Département Universitaire de Psychiatrie Adulte, Lausanne, SuisseCharles Bonsack, Département Universitaire de Psychiatrie Adulte, Lausanne, SuisseFrançois Borgeat, Département Universitaire de Psychiatrie Adulte, Lausanne, SuisseLa contrainte reste encore fréquemment utilisée en psychiatrie et tend à être considérée comme unenécessité, légalement autorisée, face à un patient en danger ayant perdu sa capacité de discernement,refusant les soins et mettant en danger sa personne ou autrui. Dans ce cadre, la société attribue au médecinune responsabilité importante. Le processus décisionnel impliqué dans l’exercice de la contrainte est luimêmecomplexe et soumis à des zones de doute. Les différentes mesures associées à la contrainteparticipent avec la maladie au stress vécu par les patients et pourraient compromettre leur adhésion auxoffres de soins. La contrainte exercée, le statut légal et la contrainte perçue sont trois dimensions à intégrerdans notre réflexion. Cette dernière peut est considérée comme une valeur morale étudiée sur un continuumallant de l’absence totale de restriction à différents niveaux de contrainte. Des pressions symboliquementnégatives, positives ou légales sont exercées sur les patients et conduisent à s’interroger sur ledéveloppement d’alternatives à l’usage de la contrainte. L’évolution des relations entre médecins etmalades vers une plus grande participation des patients au choix de leurs traitements implique dereconsidérer ces pratiques, de façon à les limiter à des circonstances exceptionnelles sans pourtantabandonner à leur sort les personnes en danger. L’introduction des directives anticipées dans des loiscantonales Suisses pourrait ouvrir la voix à des modalités de collaboration différentes et mieux acceptéespar les patients.

568198. Bloc 2, no 7198.1. Symposium: Ces patients que certains qualifieraient d’odieuxPierre Lamothe, C.H. Le Vinatier, Lyon, FranceChristian Kottler, C.H. Villejuif, FranceAndré McKibben, Institut Philippe Pinel de Montréal, CanadaLeurs comportements nous révulsent, nous déstabilisent et nous ébranlent. Ils ont violé la voisine, tué leurenfant ou se délectent de leurs comportements sadiques. Et pourtant, ils appellent à l'aide. Que peut-on leuroffrir? Au cours de cette plénière, nos quatre panélistes, trois psychiatres et un criminologue/sexologuerenommés pour leurs travaux et leur expérience en psychiatrie légale, aborderont diverses facettes de larelation thérapeutique avec ces patients particuliers. Il sera notamment question de l'amorce et du maintiend'une relation saine qui soit utile au patient sans être trop néfaste au thérapeute. Nos conférenciers traiterontdes émotions du thérapeute, de sa souffrance et de ses sources de satisfaction, de la préservation de sonéquilibre et de sa propre santé mentale, de ses remises en question et de ce qui peut inciter un soignant àpoursuivre son engagement auprès de cette clientèle. Nous leur demandons quels sont, dans ce contexte detravail, leurs outils thérapeutiques préférés. Les conférenciers prendront la parole à tour de rôle puiséchangeront entre eux et avec la salle.199. Bloc 2, no 8199.1. Symposium: Hospitalisation contrainte199.2. Hospitalisation contrainte et initiation d'une alliance thérapeutiqueMarc Brusselmans, Clinique Fond'Roy, Uccle /Bruxelles, BelgiqueCatherine Bertrand, Clinique Fond'Roy, Uccle /Bruxelles, BelgiqueDans le cadre de la loi belge de la Protection de la Personne des Malades Mentaux du 26 juin 1990, nousproposons de vous décrire les spécificités du contexte bruxellois dans lequel nous travaillons.L’augmentation de l’utilisation de ces mesures de soins contraints et la reconstruction de notre structurehospitalière ont été l’occasion de repenser ce travail avec des patients en hospitalisation contrainte.Nous avons pris l’option de centrer notre travail sur l’accueil dans le sens le plus fort de ce terme, celuinotamment de l’accueil de leur réalité psychique. Temps d’accueil mis à profit par une petite équipe

569polyvalente et spécialisée pour, au côté du patient, explorer ce qui dans sa réalité intrapsychique, dans sonentourage familial et social a fait point d’arrêt et engagé cette hospitalisation sous la contrainte.Temps également mis à profit pour tenter de passer de la contrainte à l’alliance afin d’inaugurer unepoursuite de soins dans un cadre non-contraignant.C’est ce projet pilote à l’œuvre (Hôpital d’Accueil Spécialisé) depuis un an que nous développerons etdiscuterons.199.3. Hospitalisation contrainte : conjugabilité obligée du monde thérapeutique etjudiciaireCatherine Bertrand, Clinique Fond'Roy, Uccle/Bruxelles, BelgiqueMarc Brusselmans, Clinique Fond'Roy, Uccle/Bruxelles, BelgiqueToute hospitalisation décidée dans un contexte urgent et dans le cadre de la loi s’articule de facto entre lemonde judiciaire et le monde thérapeutique.D’avoir à en découdre autour d’une situation souvent urgente et conflictuelle, par nature, nous invite à nouspencher sur cette conjugalité obligée.La mesure de mise en observation « à la belge » place le juge de paix en position de décider de cetteobligation de soins ce qui permet à l’équipe accueillante de tenter d’établir les prémisses d’une alliancethérapeutique.Ce décalage est d’autant plus opérant pour des sujets psychotiques, population sur-représentée dans unservice d’hospitalisations contraintes (= mises en observation).Et retracer pour vous de quelle manière en découle l’élaboration de notre projet thérapeutique dans cetHôpital d’Accueil Spécialisé.200. Bloc 2, no 9200.1. Atelier : Le suicide et le lien : l’étendue de son affaiblissement au Québec et larestauration thérapeutiqueHubert Wallot, C.H. Robert-Giffard, Québec, CanadaDaniel Bordeleau, Hôpital Louis-H. Lafontaine, Montréal, CanadaProblématique: le suicide s’accroît de façon continue, au Québec, depuis le milieu des années 1960. Le tauxquébécois compte parmi les plus élevés au monde. Pour les hommes dans plusieurs groupes d’âge, ilconstitue la deuxième ou la première cause (pour les 15-24 ans) de la mortalité au Québec, et son poidssocial et économique est encore plus important si on considère le nombre des années perdues par les morts

570prématurées par suicide. Le suicide fait plus de victimes au Canada que la combinaison du crime, duSRAS, de la maladie de la vache folle, ou du terrorisme.MéthodesRéviser les causes ’interroger sur les causes de la poursuite de cet accroissement alors que le suicidedécroît légèrement dans les autres provinces depuis les années 70’. Présentation des concepts de Durkheimet tentative d'application en contexte québécois. Éclairage des courbes de suicides par les courbes denatalité, de mariages, de divorces. et de niveau d'occupation..ConclusionLa surmortalité par suicide au Québec n'est pas due à une sur-représentation de la maladie mentale danscette province, ni à une mauvaise organisation des services, mais à des phénomènes sociétaux pour lesquelsdes stratégies préventives purement médicales risquent d'être inefficaces. Commentaire conséquent sur lesmoyens suggérés par le gouvernement pour combattre de fléau.201. Bloc 2, nos 10 et 11201.1. De la sorcellerie à la psychopathie : l'évaluation du risque à l'Institut PhilippePinel de MontréalLouis Bérard, Institut Philippe Pinel de Montréal, Université de MontréalQuelques psychiatres de notre institution sont mandatés à tour de rôle pour évaluer des délinquantsreconnus coupables de crimes violents. L’enjeu est alors de déterminer le risque de récidive violente duprisonnier.Deux approches sont utilisées en parallèle pour y arriver. D’une part, l’évaluation actuarielle (ou au moyende grilles structurées) qui apparaît être désormais une tendance « lourde » en Amérique. D’autre part, uneapproche clinique plus classique qui fait davantage appel à l’expérience et au jugement du médecin aurisque d’être entachée par ses biais ou son « contre-transfert ».Après un bref clin d’œil à l’histoire et avant une allégorie futuriste qui sont un peu les équivalents desfantômes du Conte de Noël de Dickens, cette présentation est un bref survol de notre manière de procéder àces évaluations.201.2. Éthique de l'évaluation de la dangerosité sexuelle : expert ou agent de contrôlesocial?Benoit Dassylva, Institut Philippe Pinel de Montréal, Université de MontréalFrance Proulx, Institut Philippe Pinel de Montréal, Université de MontréalAu Canada, depuis 1997, la loi permet de déclarer des délinquants sexuels « à contrôler » ou « dangereux ».Dans ce contexte, les experts ont à évaluer la dangerosité et la traitabilité du délinquant sexuel récidiviste. Il

571s’agit d’enjeux très importants puisqu’au bout du processus, un délinquant déclaré « dangereux » écoped’une sentence d’une durée indéterminée. Il est donc possible que l’individu soit incarcéré toute sa viedurant non pas pour un homicide commis, mais plutôt pour le danger qu’il représente pour la collectivité.Sur le plan éthique, plusieurs principes fondamentaux s’opposent. Par exemple, il y a conflit entre leprincipe de bienfaisance et celui de l’autonomie de la personne. En fait, il s’agit de l’opposition classiqueentre une conception hétéronomique et une conception autonomique de l’éthique.Nous allons décrire ces différents courants philosophiques en les appliquant à l’évaluation de la dangerositédu délinquant sexuel. Nous utiliserons également divers exemples issus d’autres domaines de la médecine.Plus spécifiquement, à partir de l’état actuel des connaissances, nous analyserons la signification du risquede récidive, telle qu’élaborée par exemple à l’aide d’échelles actuarielles. Nous décrirons les argumentséthiques qui pourraient justifier d’incarcérer indéfiniment un individu considéré à risque élevé de récidiver.Nous décrirons les arguments opposés et les risques de dérive morale dans un tel processus.Concevant l’éthique comme une réflexion rationnelle sur les valeurs sociétales et non comme une règle deconduite définitive, nous ne présenterons pas une conclusion unilatérale, mais espérons plutôt que laprésentation suscitera un échange de points de vue.202. Bloc 3, no 12202.1. Atelier: Si je pense, est-ce que je suis? Considérations théoriques et cliniques ápropose du processus de mentalisationJohanne Cyr, Hôpital Louis-H. Lafontaine, Canada203. Bloc 3, nos 13 et 14203.1. Le suicide à l'époque de la transition : le cas de la RoumanieRodica Mihaela Stanoiu, Le Senat de la Roumanie, Bucarest, RoumanieDans les dernières quinze années, les pays communistes de l’Europe de l’est ont connu des transformationsfondamentales; la vie politique, économique, sociale des communautés et des groupes sociaux a souffertdes vrais chocs déterminés du passage de la dictature à la démocratie, de l’économie socialiste à l’économiede marché. Tout cela s’est répercuté sur l’individu. Peut-être, plus que jamais, l’état anomique desstructures sociales a marqué l’évolution de l’individu.La communication se propose d’examiner combien et comment le rapport entre l’anomie et le suicide amarqué cette époque de transition au début du XXI- ème siècle en Roumanie.

572203.2. Prévention et intervention auprès des personnes suicidaires en milieu carcéralMarc Daigle, Université du Québec à Trois-Rivières, Québec, CanadaLes taux de suicide en milieu carcéral, mais aussi les taux de tentatives de suicide, sont parfoisimpressionnants et ils révèlent certainement un niveau de souffrance auquel il faut porter attention. Lafréquence des comportements suicidaires des personnes incarcérées doit cependant être relativisée. Ainsi,les taux de suicide des détenus seraient semblables à ceux des délinquants vivant en communauté. Ce seraitdonc l'ensemble des délinquants qui seraient à haut risque de mort violente, par suicide mais aussi parmeurtre. En comparaison avec les taux de suicide de tous les hommes vivant en communauté, les taux pourle milieu carcéral demeurent par contre très préoccupants et ils justifient amplement les mesures deprévention qui ont été entreprises. Dans l’éventail des mesures à considérer, le dépistage des individus lesplus à risque est une des étapes les plus importantes. Par delà l’utilisation d’un jugement cliniqueexpérimenté, divers outils sont proposés, notamment des instruments de dépistage concis, comme l’Échelled’évaluation du risque suicidaire (ÉÉRS). De tels outils sont utiles dans un milieu où beaucoup depersonnes sont soumises au processus d’admission alors qu’il y a peu de personnel clinique disponible.L’ÉÉRS a été soumise à un processus de validation dont les résultats sont prometteurs, mais d’autres outilssont également commentés ici.204. Bloc 3, nos 15 et 16204.1. Droits des personnes déficientes mentales et changement de paradigmes dansl'interventionMichel Mercier, Faculté de Médecine – Namur, Université de LouvainLes nouvelles classifications du handicap, la déclaration de Madrid et les politiques de non-discriminationmodifient nos perceptions des droits des personnes handicapées en général, des personnes déficientesmentales en particulier.Il s’agit de changement de paradigmes qui ont eu des retombées sur des attitudes sociales, malgré lespersistances du noyau central des représentations sociales du handicap.Nous aborderons ces problématiques de changements sociaux et leurs impacts sur le droit des personnes, àtravers quelques expériences concrètes dans le champ des interventions auprès de personnes déficientesmentales.

573204.2. Maltraitance et bientraitance : du déni éthique au réductionnisme scientifiqueMichel Mercier, Faculté de Médecine – Namur, Université de LouvainLes concepts de bien et de maltraitance ont fait l’objet de tentatives de définitions scientifiques en scienceshumaines. Les chercheurs se sont penchés sur la bien et la maltraitance dans différents domaines.Notre thèse est que ces concepts relèvent avant tout d’une approche éthique qui doit faire l’objet d’uneétude critique. En effet, la bien et la maltraitance sont des concepts qui se renvoient dans le champscientifique l’un à l’autre de manière tautologique.Nous mettons ce phénomène en évidence dans différents champs d’intervention, notamment l’éducation etla résilience pour déboucher sur des propositions épistémologiques qui tentent d’éviter des réductionnismesscientifiques, afin d’élaborer des jugements éthiques cohérents.205. Bloc 3, nos 17 et 18205.1. Peut-ont guérir le psychopatheJean-Pierre Chartier, École de psychologues de Paris205.2. Le viol pendant les conflits armésRodica Mihaela Stanoiu, Le Senat de la Roumanie, Bucarest, RoumanieLes événements douloureux liés aux conflits armés qui ont lieu dans les dernières décennies d’autant plusceux de l’ancienne Yougoslavie ou le Golfe ont relevé le fait que la population civile constitue la cibleprincipale des agressions sexuelles. Les femmes et les enfants sont habituellement des victimes de ce genred’agression.

574206. Bloc 3, nos 19 et 20206.1. Les résistances des agresseurs sexuels : une question d'autonomieMonique Tardif, Institut Philippe Pinel de Montréal, Université du Québec à MontréalLa situation de contrainte légale qui prévaut chez la majorité des agresseurs sexuels au début d’unepsychothérapie soulève d’emblée pour le clinicien, le travail des résistances. Or, un contexte légal decontraintes heurte les besoins fondamentaux et problématiques de ces patients en regard de leur autonomie.En cela, toute proposition thérapeutique comporte un caractère de défi. Au cours de cet exposé, noussouhaitons amener les participants à mieux : définir les résistances selon que celles-ci se rattachent soit autraitement ou à la personnalité de l’agresseur sexuel; articuler les manifestations de résistances aux enjeuxpsychiques de base des agresseurs; définir des axes d’intervention. Les fonctions ainsi que les principalesmanifestations de résistances seront décrites afin de mieux les reconnaître et d’en saisir les significationspsychiques. Finalement, les considérations relatives au travail des résistances proprement ditess’articuleront autour des étapes suivantes : le thérapeute cherche à atteindre le client afin d’établir uncontact authentique, à amener le patient à accepter de s’engager dans la psychothérapie et à développer larelation thérapeute-patient afin de parvenir à une certaine alliance thérapeutique. Le contenu de l’exposéportera sur des assises théoriques psychanalytiques (Greenson, Wachtel), cognitives-behaviorales(Newman, Beutler) et humanistes (Engle, Hanna et al.). Les théorisations relativement au déni et à laminimisation des aspects délictuels chez les agresseurs sexuels seront également prises en compte (Winn,McKibben). Une conclusion portant sur les besoins fondamentaux et significatifs de ces patients en regardde leur liberté et de leur autonomie ainsi que sur des considérations éthiques sera aussi discutée.206.2. Le silence autochtone à l’égard de l’agression sexuellePierre Picard, Groupe de recherche et d’intervention psychosociale en milieu autochtone, Wendake,CanadaLe silence autochtone à l’égard de l’agression sexuelleLes peuples autochtones, qu’ils soient Premières nations, Métis ou Inuit, ont été témoins depuis denombreuses décennies d’un niveau élevé de violence et d’abus sexuels dans leurs collectivités. Les femmesautochtones et les enfants autochtones en ont été particulièrement affligés.L’historique de la violence sexuelle dans les sociétés autochtones est incomplet, mais il y a tout de mêmechez les experts un consensus général concernant les répercussions du contact avec les Européens sur lessociétés autochtones, c’est-à-dire la déstabilisation et la dévalorisation des valeurs et coutumestraditionnelles, notamment celles se rapportant à la justice, à la morale/l’équité et au respect. Une des suitesde ce contact, peut-être la plus dévastatrice, a été l’érosion des normes, des principes traditionnels et del’effondrement des mécanismes visant à les faire respecter dans les collectivités autochtones.Cette érosion des coutumes et des croyances autochtones traditionnelles, causée notamment parl’établissement des réserves et la mise sur pied des pensionnats, a laissé de nombreuses collectivités sansressource pour éduquer les membres de la communauté sur les habitudes saines de la vie quotidienne.Offrir aux jeunes gens des modèles, des personnes en santé auxquelles ils pouvaient s’identifier, constituaitun moyen éducatif précieux, mais même l’imitation de ces modèles est devenu difficile à mesure que la

575cohésion des membres d’une communauté se détériorait. Beaucoup d’experts ont donc conclu que leprocessus colonisateur commencé il y a des centaines d’années est la cause profonde des nombreuxproblèmes qui sévissent à l’heure actuelle dans les collectivités autochtones.Même si les facteurs historiques sont certes importants à considérer dans l’émergence et le maintien duphénomène de l’agression sexuelle, les conditions de vie actuelles des Premières Nations se placent aussicomme facteurs précipitants. En considérant les indicateurs de qualité de vie, les Premières Nations seretrouvent avec les pires conditions de vie au Canada.(Commission Royale d’Enquête sur les peuplesautochtones, 1993.) Mentionnons notamment que les taux d’alcoolisme et de toxicomanie seraient cinq foisplus élevés que partout ailleurs au Canada, que le niveau de scolarisation est nettement inférieur, que lestaux de chômage sont de deux à trois fois plus élevés ,que les revenus sont inférieurs de 25 % au revenumoyen d’une famille canadienne, que le taux de suicide est cinq fois plus élevé et que les conditions delogement s’avèrent souvent inadéquates. Ces indicateurs constituent des facteurs de risque reconnus etgénéralement associés à l’émergence et au maintien de différentes formes d’abus et de violence. Cesconditions de vie sont accompagnées de symptômes et de problèmes sous-jacents qui sont très souvent liésaux pertes et aux abus subis par les collectivités amérindiennes.La violence sexuelle, longtemps niée dans les collectivités, se révèle être aujourd’hui une importanteproblématique sociale. L’isolement géographique, le peu de ressources professionnelles ,les rôles sexuelsstéréotypés, la petitesse du milieu, les liens très étroits qui unissent les membres de chacun descommunautés et les tabous entourant la sexualité sont autant de facteurs qui ont contribué à maintenirl’isolement des victimes d’actes sexuels tout en assurant l’impunité des agresseurs.Bien que l’incidence de l’abus ne soit pas clairement établie, nous avons réalisé dans le cadre d’unerecherche exploratoire que le nombre de cas officiellement rapportés aux autorités est nettement inférieuraux perceptions qu’ont les intervenants de première ligne quant à l’importance de la problématique.La méthodologie de la recherche menée auprès des intervenants de première ligne dans les communautés,l’instrument de mesure, les variables mesurées quant aux gens et aux communautés, les conditionsd’actualisation de la recherche, les conclusions, retombées et limites seront présentés et discutés.207. Plénière207.1. Enfants et adolescents difficiles : traitements et enjeux sociauxSous la direction du Dr Patricia Garel, Hôpital Ste-Justine, Université de MontréalCette conférence utilisera un reportage télévisuel québécois sur la prise en charge des enfants etadolescents difficiles pour favoriser des échanges internationaux sur les difficultés cliniques, sociales etpolitiques rencontrées dans la prise en charge et le traitement de cette clientèle. La discussion porteraaussi sur l'impact de nos choix de société.

576208. Bloc 4, no 21208.1. Symposium: Évaluation, traitement et récidive des adolescents agresseurs sexuels: l'évolution d'un programme externe de 1992 à aujourd'huiJulie Carpentier, Institut Philippe Pinel de Montréal, CanadaRobert Quenneville, Institut Philippe Pinel de Montréal, CanadaNathalie Auclair, Institut Philippe Pinel de Montréal, CanadaMartine Jacob, Institut Philippe Pinel de Montréal, CanadaLa clinique externe des adolescents agresseurs sexuels du Centre de Psychiatrie légale de Montréal a ouvertses portes en 1992. Depuis cette date, plus de 800 adolescents ont été évalués par une équipemultidisciplinaire. De ce nombre, environ 400 ont été pris en charge à travers une ou plusieurs modalitésthérapeutiques qui sont offertes par la clinique spécialisée. Quel bilan pouvons-nous faire après 12 ans deservices offerts à cette clientèle particulière? Ce symposium regroupant 3 présentations se veut un atelierd’information et de réflexion qui sera séparé en 4 volets. Dans un premier temps, des données descriptivesde la clientèle seront présentées en faisant ressortir les principales caractéristiques familiales, personnelleset délictuelles tout en distinguant les spécificités entre différents sous-groupes. Par la suite, nousprésenterons notre programme de traitement en décrivant les principales modalités thérapeutiques et leurévolution à travers le temps en fonction de notre expérience clinique. Par la suite, nous partagerons lesdonnées préliminaires d’une étude longitudinale sur la récidive des adolescents agresseurs sexuels évaluéset/ou traités au programme externe du centre de psychiatrie légale de Montréal. Finalement, une réflexionsur les perspectives futures face au traitement, au partenariat et à la recherche clôturera le symposium.209. Bloc 4, nos 22 et 23209.1. Criminalité et expertise médico-psychologique : Étude de la concordance desméthodologies utilisées et des diagnostics posés dans un échantillon de 505dossiers pénauxNicolas Combalbert, Université de Toulouse IISylvie Bourdet-Loubere, Université de Toulouse IIDans les cas d’expertise d’auteurs d’actes criminels (adultes), la double expertise, psychologique etpsychiatrique est toujours sollicitée par les autorités judiciaires françaises.Nous avons étudié, selon une double approche clinique et criminologique, un échantillon de 505 dossierspénaux de sujets condamnés pour des crimes commis contre les personnes afin d’observer les similitudes

577ou les dissemblances au niveau des méthodes employées et des diagnostics posés par les expertspsychiatres et les experts psychologues. Ainsi, nous avons examiné de manière détaillée un échantillonhautement représentatif de 1010 expertises conduites par des experts judiciaires psychiatres etpsychologues.L'objectif de cette étude, ne consistait absolument pas à porter un regard sur la validité des allégationsévaluées au travers des expertises, mais plutôt à dégager les différentes approches théoriques etméthodologiques explicites utilisées par les experts et à tester le niveau d’accord inter-juges au niveau desdiagnostics (structural et nosographique) posés.Une discussion des résultats observés permet de s’interroger sur les causes et les conditions d’apparitiondes désaccords et de formuler des recommandations pour améliorer la cohérence de l’expertisepsychiatrique et psychologique des criminels en France.209.2. Modèle de prise en charge de détenus atteints de troubles mentaux gravesPierre Landry, Service Correctionnel du Canada, Ste-Anne-des-Plaines, CanadaObjectifs d’apprentissage : améliorer ses connaissances sur l’organisation des services de santé mentaleofferts en milieu correctionnel – réfléchir sur la cohabitation des enjeux correctionnels et de traitementadapté – se familiariser avec le modèle de prise en charge du CRSM.Nombre de patients psychiatriques, laissés à eux-mêmes, sans ressources adéquates, se retrouvent dansl’engrenage du système de justice pénale et sont pris en charge en milieu correctionnel. Le servicecorrectionnel canadien doit faire face à une augmentation importante du nombre de détenus atteints detroubles mentaux graves, augmentation évaluée à 61% au cours des sept dernières années.Le Centre Régional de Santé Mentale, l’un des cinq centres psychiatriques intégrés au service correctionnelcanadien, a comme mission de répondre aux besoins psychiatriques, évaluation et traitement, et d’assurer laréinsertion sociale sécuritaire de détenus fédéraux de la région du Québec. Plus du tiers de sa populationest atteinte de schizophrénie ou d’un trouble psychotique. Les modalités de prise en charge de ces détenuspatientsferont l’objet de cette présentation. Y seront abordées des questions de nature organisationnelle etclinique dans une perspective de continuité des services. Cette continuité des services s’avère d’autant plusimportante maintenant que le milieu correctionnel doit en effet assumer un grand nombre de détenussouffrant de divers troubles mentaux.La cohabitation des enjeux correctionnels et de traitement adaptés pose un réel défi aux cliniciens. Lemodèle de la prise en charge actuellement développé au Centre Régional de Santé Mentale sera exposé.L’emphase de ce modèle porte sur le traitement cognitif des symptômes résiduels ainsi que sur les déficitscognitifs et sociaux dont les effets invalidants sur le fonctionnement justifient la mise en place d’un moded’intervention complémentaire à l’approche pharmacologique.

578210. Bloc 4, nos 24 et 25210.1. Le traitement pharmacologique imposé, une décision difficile à prendreJean-Luc Dubreucq, Institut Philippe Pinel de Montréal, Université de MontréalAndré Delorme, Institut Philippe Pinel de Montréal, Université de MontréalOlivier Triffault, Institut Philippe Pinel de Montréal, Université de MontréalIl existe une rumeur tenace à propos de la psychiatrie : on redoute encore les internements et les traitementsarbitraires. Cette image caricaturale perdure bien que les faits observés auprès des sans-abri de Montréal etdes personnes incarcérées dans les prisons du Québec témoignent en faveur d’une autre réalité : lespsychiatres ne s’impliquent pas assez auprès des patients les plus difficiles et les plus vulnérables.Au nom de la tolérance envers la marginalité et du respect de l’autonomie, beaucoup de patients nereçoivent pas de soins appropriés et demeurent ainsi dans l’indifférence parce qu’ils refusentcatégoriquement toute intervention psychiatrique. Pourquoi ces patients refusent-ils les soins? Pourquoi cerefus est-il accepté si souvent par les psychiatres?Expliquer une telle problématique n’est pas aisé et nécessite un questionnement au sein de la profession.Plusieurs hypothèses seront explorées en particulier la possibilité que patients et psychiatres puissent êtreinfluencés par une compréhension restrictive de la loi ainsi que par une conception de l’autonomieprivilégiant exclusivement la libre disposition de soi.Après une réflexion éthique et clinique sur la nécessité d’imposer à un patient un traitementpharmacologique pour lui permettre de retrouver sa capacité d’autonomie, quelques repères pour balisercette intervention seront proposés. Le cadre de la loi sera, bien sûr, exploré avec cependant le souci dedemeurer dans la logique du clinicien. Il s’agira alors d’envisager comment la loi peut être au service desbesoins du patient. Enfin, les résultats obtenus auprès de personnes soumises à une ordonnance detraitement seront décrits.210.2. Les traitements sous contrainte en milieu pénitentiaireBruno Gravier, Service de Médecine et de Psychiatrie Pénitentiaires, Université de LausanneMario Navarro, Service de Médecine et de Psychiatrie Pénitentiaires, Lausanne, SuisseLes psychiatres travaillant en prison sont régulièrement sollicités pour prodiguer des traitements souscontrainte à des détenus agités, violents et présentant des troubles psychiques.Cette sollicitation pose de nombreuses questions et suscite un certain nombre de réserves :• au niveau de l’institution pénitentiaire, où elle est source de débats entre équipes soignantes etéquipes de surveillance• dans l’élaboration des politiques sanitaires : dans quels lieux un tel traitement peut-il êtreordonné et effectué ?• au niveau législatif : est-ce une possibilité qu’il faut inscrire dans la loi ou en rester au droitcommun ?

579• au niveau éthique, enfin, compte tenu des nombreuses questions que cette intervention pose.Certaines législations proscrivent une telle démarche au sein même de la prison (France), d’autres latolèrent. Dans tous les cas les débats sont vifs entre les différents partenaires concernés.Le Canton de Vaud a changé récemment sa législation en matière de traitement contre le gré du patient, endétaillant les cas de figures et les modalités de surveillance et de recours. Parmi d’autres mesures, lalégislation impose, en particulier, l’établissement de protocoles précis et adaptés à l’institution. Unecommission des plaintes est, en outre, chargée de surveiller la manière dont ces traitements sont effectués.Son application en milieu pénitentiaire reste floue et rend impératifs la référence à des textes internationauxet le respect des principes cardinaux autorisant une telle attitude thérapeutique (perte de discernement,maladie mentale avérée, dangerosité manifeste, traitement limité dans le temps, etc.).Seule une démarche rigoureuse et validée par les autorités sanitaires peut éviter les dérives et les abus. Àl’inverse, cette question doit être posée pour éviter que des patients restent sans soins, en prison, faute delieux susceptibles de les accueillir.A la lumière d’une revue critique des cas de traitement sous contrainte ayant eu lieu dans les prisons duCanton de Vaud en 2004, les auteurs essaient d’analyser l’influence de la mise en œuvre de protocolesrigoureux dans le contexte pénitentiaire sur le déroulement du soin psychiatrique.La question du respect des droits du patient incarcéré reste primordiale en tout temps, notre communicationinterrogera cette question à la lumière des tensions que génèrent inévitablement de telles situations dans lemonde pénitentiaire.La mise en oeuvre de ces traitements pose, enfin, la question de l’accès au soin des détenus dès lors queleur état psychique nous interroge sur la compatibilité de leur état avec la détention.211. Bloc 4, nos 26 et 27211.1. Étude de la prévalence, dans l'enfance, du trouble d'anxiété de séparation dans unepopulation de femmes adultes souffrant d'un trouble des conduites alimentairesNadine Trudeau, Centre de pédopyschiatrie du Centre hospitalier universitaire de Québec (CHUQ),Québec, CanadaCarole Ratté, Centre de pédopyschiatrie du Centre hospitalier universitaire de Québec (CHUQ), Québec,CanadaJacques Brisson, Centre de pédopyschiatrie du Centre hospitalier universitaire de Québec (CHUQ),Québec, CanadaL’anxiété de séparation (TAS) est une anxiété excessive concernant la séparation d'avec les personnesauxquelles le sujet est attaché (DSM-IV). Elle est diagnostiquée surtout vers le milieu de l'enfance. Enclinique, il n'est pas rare de constater la persistance à l'âge adulte d'éléments d'anxiété de séparation,dans la population de femmes souffrant d'un trouble des conduites alimentaires (TCA).D'un point de vue théorique, il existe, dans les deux troubles, des dénominateurs communs dontla peur d'une démarche vers l'autonomie. La comorbidité « TAS et TCA » a été peu étudiée, jusqu’àmaintenant. Notre projet de recherche s’est penché sur l’étude de la prévalence rétrospective du TASauprès d’une population de femmes présentant un TCA à l’âge adulte. En plus de vérifier cette

580prévalence, nous avons voulu déterminer quelle proportion continuait, à l’âge adulte, de présenter del’anxiété de séparation. Finalement, nous nous sommes interrogés sur l’impact du TAS dans l’enfance, surl’âge d’apparition du TCA et sur sa sévérité.L’échantillon de recherche était composé de 51 femmes adultes présentant un diagnostic de TCA. Desquestionnaires on été utilisés pour mesurer la présence actuelle et rétrospective du TAS. Nous arrivons à laconclusion que la prévalence du TAS dans l’enfance, est plus élevée dans cette population (27,5 %) quedans la population générale (4 %, p=

581212. Bloc 4, nos 28 et 29212.1. Soins infirmiers en Unité de mise en observation (soins contraints)Richard Bastin, Clinique Fond'Roy, Uccle/Bruxelles, BelgiqueOlivier Dubois, Clinique Fond'Roy, Uccle/Bruxelles, BelgiqueCatherine Bertrand, Clinique Fond'Roy, Uccle/Bruxelles, BelgiqueMarc Brusselmans, Clinique Fond'Roy, Uccle/Bruxelles, BelgiqueLe concept-clé de cette Unité est l’accueil, notion d’autant plus importante que la durée du séjour en cetteunité est courte.À l’arrivée du patient et avant le passage du psychiatre, ce sont les infirmiers qui assurent cet accueil par unentretien.Dans le premier temps du séjour, la situation sociale du patient est le canal privilégié qui permet de créerune alliance de soins et de le placer au centre de son histoire. La confiance s’installant peu à peu, les autresressources du patient, sa famille, son lieu de vie, peuvent être abordés, progressivement avec lui, au coursdu séjour.La spécificité du travail des infirmiers est leur collaboration aux objectifs de l’Unité. Cette position donneaux infirmiers(ières) la possibilité d’évaluer les critères légaux de la mise en observation (soinscontraints), de réaliser des entretiens individuels et familiaux, de relayer à l’équipe pluridisciplinaire leséléments qui lui permettront de prendre position face à l’enjeu du séjour du patient : la levée ou laconfirmation de la mesure.Cette approche spécifique entraîne une conséquence directement appréciable pour l’élaboration du travailen lui-même, la diminution de l’agressivité au quotidien, agressivité inhérente à ces situations de soins souscontrainte légale.Dans cette optique, l’accueil est le fondement de ce travail, sa condition aussi. Par leur présence constante,les infirmiers (ères) en sont des acteurs (trices) privilégiés.212.2. Réinsertion des patients dangereux : une façon de faire…Christine Lamarre, Institut Philippe Pinel de Montréal, CanadaLes Services externes de l’Institut Philippe Pinel de Montréal sont composés de deux points de service, leCPLM (Centre de psychiatrie légale de Montréal) et la Postcure. Ces deux sites répondent à des besoinsvariés (évaluation, expertise et traitement) provenant de sources différentes, dans des contextes légauxdiversifiés, mais ils ont en commun le suivi et l’évaluation de patients dangereux présentant des problèmesde santé mentale.Notre pratique s’inscrit presque toujours dans un cadre légal et nous devons composer avec plusieurspartenaires afin de s’assurer une stabilité clinique, à risque réduit, pour notre clientèle et la communauté.Les différents moyens cliniques, mis en place pour optimiser la cohésion du suivi par l’équipe traitante,

582sont constamment réévalués. La responsabilisation du patient est prônée et différents leviers légaux sontparfois nécessaires pour y arriver.C’est dans ce contexte que j’aborderai trois catégories de leviers pour effectuer le suivi des patientsdangereux dans la communauté. D’abord, d’un point de vue administratif, nous verrons comment lesprocessus ont été réorganisés pour faciliter le passage des différents épisodes de soins et la gestion descrises. D’un point de vue clinique, nous démontrerons la priorité accordée à la liaison clinique et les outilsmis en place pour la soutenir. Enfin, d’un point de vue légal, nous décrirons comment le travail departenariat avec nos collègues des réseaux judiciaires est essentiel et contribue à augmenter l’efficacité desservices.Nous progressons actuellement vers des indicateurs cliniques nous permettant de mieux identifier lesbesoins de la clientèle pour ainsi développer des approches réadaptatives plus réalistes.La charge clinique s’est beaucoup alourdie au cours des dernières années et nous devons trouver desmoyens pour atteindre les objectifs de traitement, et ce, avec un minimum de ressources professionnelles.Le développement d’une liaison clinique ciblée et plus efficace à l’intérieur de notre organisation, avec nospartenaires du réseau de la santé, ainsi que des liens étroits avec le réseau communautaire sont des solutionsprometteuses.213. Bloc, nos 30 et 31213.1. Évaluation diagnostique, étiologique et pronostique des adolescents abuseurssexuels : présentation des résultatsLaurence Willocq, C.R.D.S. - Centre Hospitalier Psychiatrique «Les Marronniers», Tournai, BelgiqueClaire Ducro, C.R.D.S. - Centre Hospitalier Psychiatrique «Les Marronniers», Tournai, BelgiqueMarjorie Menghini, C.R.D.S. - Centre Hospitalier Psychiatrique «Les Marronniers», Tournai, BelgiqueThierry Hoagn Pham, C.R.D.S. - Centre Hospitalier Psychiatrique «Les Marronniers», Tournai, BelgiqueL’objectif de cette présentation est d’approfondir les aspects neuropsychologiques des délinquants sexuelsau travers une revue de la littérature. En effet, nous développerons des recherches, principalement menéespar l’équipe de Langevin et collaborateurs à la fin des années 80, de Flor-Henry (1987) et de O’Caroll(1989), de manière à préciser leurs méthodes d’évaluations neuropsychologiques, les variables qu’ils ontcontrôlées ainsi que leurs résultats obtenus. À savoir que les différentes recherches se focalisentprincipalement sur un type de délinquants sexuels (pédophiles versus délinquants non sexuels non violentsou agresseurs sexuels de femmes versus délinquants non sexuels non violents) et qu’il nous sembleintéressant de présenter les résultats de ces différentes recherches conjointement. En ce qui concerne lesrésultats, il s’avère que ceux-ci, en effet complexes, ne se valident pas de recherches en recherches, et quenotamment, actuellement, peu de chercheurs continuent à développer ces aspects. Nous terminerons cetteprésentation par une critique constructive de ces recherches afin, peut-être, de développer à nouveau cethème.

583213.2. Évaluation diagnostique, étiologique et pronostique des adolescents abuseurssexuels-: revue de la littératureMarjorie Menghini, C.R.D.S. - Centre Hospitalier Psychiatrique «Les Marronniers», Tournai, BelgiqueLaurence Willocq, C.R.D.S. - Centre Hospitalier Psychiatrique «Les Marronniers», Tournai, BelgiqueClaire Ducro, C.R.D.S. - Centre Hospitalier Psychiatrique «Les Marronniers», Tournai, BelgiqueThierry Hoagn Pham, C.R.D.S. - Centre Hospitalier Psychiatrique «Les Marronniers», Tournai, BelgiqueL’objectif de cette présentation est d’approfondir les aspects neuropsychologiques des délinquants sexuelsau travers une revue de la littérature. En effet, nous développerons des recherches, principalement menéespar l’équipe de Langevin et collaborateurs à la fin des années 80, de Flor-Henry (1987) et de O’Caroll(1989), de manière à préciser leurs méthodes d’évaluations neuropsychologiques, les variables qu’ils ontcontrôlées ainsi que leurs résultats obtenus. A savoir que les différentes recherches se focalisentprincipalement sur un type de délinquants sexuels (pédophiles versus délinquants non sexuels non violentsou agresseurs sexuels de femmes versus délinquants non sexuels non violents) et qu’il nous sembleintéressant de présenter les résultats de ces différentes recherches conjointement. En ce qui concerne lesrésultats, il s’avère que ceux-ci, en effet complexes, ne se valident pas de recherches en recherches, et quenotamment, actuellement, peu de chercheurs continuent à développer ces aspects. Nous terminerons cetteprésentation par une critique constructive de ces recherches afin, peut être, de développer à nouveau cethème.214. Bloc 5, nos 32 et 33214.1. Grandir en Santé Mentale en Montérégie : une expérience d'implantation d'unréseau intégré de services pour les jeunes 0-17 ans aux prises avec un problème desanté mentale et leurs parentsGeorges Robitaille, Hôpital Charles LeMoyneLucille Bagiel, Association de parents de l’enfance en Rive-Sud, Montréal, LtéeJohanne Trépanier, Agence de développement de réseaux locaux SSSS Montérégie, Longueuil, CanadaAu printemps 2000, se formait un groupe de travail (17 partenaires d’établissements, d’organismes et deministères différents (cf liste détaillée ci-jointe) ayant le mandat de réfléchir sur un concept de réseauintégré de services en santé mentale pour les jeunes 0-17 ans de la région de la Montérégie au Québec).Plusieurs constats avaient conduit à cette démarche : absence de service de santé mentale en 1 ère ligne;éparpillement des services diagnostics pour les enfants présentant un trouble envahissant dudéveloppement; désarroi des parents en quête de soutien; un nombre élevé de jeunes en attente d’évaluationet de services en pédopsychiatrie; durée d’attente très élevée; très faible concertation entre lesorganisations; approches « hospitalocentriques » des problèmes de santé mentale; région socio-sanitaire duQuébec la moins financée en santé mentale pour une population jeunesse aussi nombreuse que celle de

584Montréal. Le modèle retenu et en implantation depuis 4 ans est caractérisé par : la clarification des portesd’entrée via la création d’un guichet unique en CLSC pouvant être utilisé par les jeunes et les personnessignificatives de leur entourage; l’équité dans l’accès quelle que soit la provenance de la demande; ledéveloppement d’une gamme diversifiée de services; le transfert de l’expertise de la 2 e ligne vers la 1 èreligne; l’utilisation optimale de l’expertise pédopsychiatrique dans un contexte de rareté de ressourceshumaines spécialisées; l’autonomie régionale dans l’esprit d’une responsabilité populationnelle. Nouscomptons présenter le modèle « Grandir en Santé Mentale en Montérégie, 2001 », le processusd’implantation dans la sous-région de Longueuil (cf liste sus-mentionnée des membres du comité sousrégional)ainsi que les effets sur les structures, les pratiques organisationnelles, l’offre et la qualité desservices.214.2. Présentation d'un programme de formation pour intervenir en situation de crised'agressivitéRobert Groleau, Institut Philippe Pinel de Montréal, CanadaJean-François Labrecque, Institut Philippe Pinel de Montréal, CanadaIsabelle Racette, Institut Philippe Pinel de Montréal, CanadaLes personnes qui interviennent en santé mentale peuvent être confrontées à des comportements violents.Ces situations sont d’autant plus fréquentes en psychiatrie légale. Dans ce contexte de pratique, lesintervenants doivent composer avec ce potentiel de violence tout en préservant une relation thérapeutiqueavec le patient. Si les intervenants ne sont pas suffisamment formés pour y faire face, ce défi peut devenirune source de souffrances qui aura des conséquences à la fois chez le personnel et la clientèle.Oméga est un programme de formation, enseigné à l’IPPM, pour faire face aux situations de crisesd’agressivité dont l’objectif est de développer chez l’intervenant des habiletés et des modes d’interventionpour assurer sa sécurité et celle des autres. Ce programme repose sur des valeurs et des principes qui sont labase d’une intervention de résolution de crise centrée sur le vécu de la personne. La formation présente unmode d’interventions graduées, qui s’appuie sur l’évaluation du risque, la relation avec le client, le travailen équipe et un langage commun qui facilite la communication et l’intégration de la philosophied’intervention dans le milieu.Cet exposé a pour objectif de situer le contexte de l’intervention à l’Institut Philippe Pinel de Montréal, deprésenter le programme de formation Oméga et de faire ressortir les impacts de l’implantation d’un telprogramme dans une institution. Nous ferons une rapide description de la démarche qui nous a amenés àinstaurer ce programme de formation. Par la suite, nous prendrons le temps de présenter les mécanismes deprotection utilisés par les intervenants pour prévenir ou faire face à une crise d’agressivité. Finalement,nous aborderons le défi que représente l’intégration de cette philosophie d’intervention dans la pratiquequotidienne et le maintien de ces habiletés.

585215. Bloc 5, nos 34 et 35215.1. Suicide en milieu carcéral : modèles et expériences en FranceJean-Louis Terra, C.H. Le Vinatier, Lyon, FranceL’auteur présente les constats et les recommandations suite à une mission effectuée en 2003 sur demandedes ministres français de la justice et de la santé pour améliorer la prévention des personnes détenues.L’expertise s’est faite à partir d’auditions, d’examen de documents français et internationaux et la visite de17 établissements pénitentiaires. Les recommandations au nombre de 17 insistent en particulier sur laformation à l’intervention de crise suicidaire afin d’évaluer systématiquement le potentiel suicidaire dechaque personne détenue suite au constat de la sous détection des crises suicidaires. Un an et demi aprèscette mission, quelques éléments d’appréciation de son impact seront présentés pour les actions entrepriseset le nombre de décès par suicide.215.2. Partenariat Justice-Santé : l'innovation au service des femmes incarcérées.Renée Fugère, Institut Philippe Pinel de Montréal, Université de MontréalJocelyne Brault, Institut Philippe Pinel de Montréal, Université de MontréalDominique Lapierre, Institut Philippe Pinel de Montréal, Université de MontréalKarine Gore, Institut Philippe Pinel de Montréal, Université de MontréalDepuis 160 ans, les femmes sont emprisonnées au Canada. Elles représentent 3% de la populationcarcérale. Les hommes - plus nombreux - ont été privilégiés et leurs besoins sur le plan médical ont étépriorisés. Cette présentation trace, dans ses grandes lignes, l’historique des femmes incarcérées et l’impactdu pouvoir décisionnel sur le développement de services appropriés dans ses composantes bio-psychosociales.Dans un premier temps, la résultante du travail des Commissions d’enquête sera présentée. Une premièredécision politique amène la création d’un comité chargé d’étudier la problématique des femmes etd’identifier leurs besoins.Dans un second temps, nous décrirons la réponse gouvernementale aux recommandations qui s’estconcrétisée par la création d’établissements dotés des programmes nécessaires à la santé et au bien-être desfemmes incarcérées. Ces programmes tiennent compte des droits des uns et des autres dans le cadre d’unpartenariat fédéral-provincial innovateur.Subséquemment à l’ouverture et l’opérationnalisation des établissements - les besoins des femmes de l’Estdu pays n’étant pas toujours satisfaits - une entente entre l’Institut Pinel de Montréal et le gouvernementcanadien a été conclue et l’Unité d’évaluation et de traitement pour détenues fédérales (F1) a ouvert en mai2004.En conclusion, à l’heure des choix, il nous apparaît clair dans le cas présent que le partenariat fédéralprovincialest porteur d’espoir dans le rendu des services aux femmes incarcérées. Des études prospectives

586devront être éventuellement entreprises, dans le but de préciser les résultats du traitement, afin de permettrel’évaluation des programmes et de poursuivre auprès des instances dirigeantes le lobbying nécessaire à lareconduite du financement.216. Bloc 5, no 36216.1. Symposium: Intervention d’urgence en Santé Mentale-Justice : le modèlequébécoisSuzanne Carrière, CLSC des Faubourgs, Montréal, CanadaLouise Riopel, CLSC des Faubourgs, Montréal, CanadaPablo Santos, CLSC des Faubourgs, Montréal, CanadaThierry Webanck, Institut Philippe Pinel de Montréal, CanadaDepuis une vingtaine d’années, des transformations importantes sont apparues dans l’univers des réponsessociales à des conflits qui se situent à la frontière de la santé mentale, de la criminalité et de la dangerosité.Ces nouvelles formes de conflit, de déviance et de transgression s’intègrent difficilement dans les cadresanalytiques et les logiques d’intervention d’une seule discipline, et mettent en évidence l’émergence d’unensemble de tensions sociales urbaines mal connues et mal régulées. Clientèles « inclassables »,problématiques mal définies, gestes dont la compréhension et le contrôle relèvent à la fois de plusieursdisciplines, nouvelles catégories d’intervenants et de stratégies d’intervention, nouveaux encadrementsnormatifs et justifications éthiques, ces transformations traduisent un style de gestion des sociétés libéralespour encadrer ses propres « dysfonctionnements ». Dans cette conférence, nous présenterons les résultatsde recherche traitant d’un modèle novateur d’intervention, l’Urgence psychosociale-justice de Montréal(UPS-J), qui occupe une position d’interface dans une zone carrefour qu’on désigne, faute de mieux, par« santé mentale-justice ». L’UPS-J est désignée par l’État pour mettre en œuvre un double mandat : celui dela déjudiciarisation en santé mentale et celui de l’application d’une nouvelle loi portant sur la protection despersonnes dont l’état mental présente un danger pour elle-même ou pour autrui. Nous nous intéressons auxprocessus de définition d’une nouvelle catégorie de personnes « inclassables » et de nouveaux modes degestion de problématiques limites, notamment dans les pratiques d’intervention d’urgence à l’occasion durecours à l’UPS-J.

587217. Bloc 5, nos 37 et 38217.1. Mesurer la violence d'un patient, un défi à la portée de l'équipe soignante grâce àla grille OAS (Overt Agressive Scale)Julie Bastien, Institut Philippe Pinel de Montréal, CanadaJean-Luc Dubreucq, Institut Philippe Pinel de Montréal, CanadaLa violence, qu’elle soit verbale ou physique, dirigée contre soi, contre des objets ou contre autrui, ne laissepersonne indifférent sur une unité de soins psychiatriques.En raison de son effet agressant, il n’est pas facile pour les intervenants de faire une description détaillée etcomplète du comportement violent. Par ailleurs, au fil du temps, il devient difficile de retrouver rapidementl’information pertinente à travers les notes du personnel soignant.En fait, toutes ces informations peuvent devenir disponibles, facilement et rapidement, grâce la grille OAS.Cet outil informatisé permet la description du comportement violent. Il en précise l’intensité, l’étendue et ladirection. Il permet également de documenter les mesures utilisées par le personnel pour le contenir.Toutes ces données sont précieuses pour travailler en équipe avec un patient violent et sont intégrées auplan de soins. Ainsi, le patient peut avoir une mesure précise et objective de son évolution. De son côté,l’équipe peut déterminer plus sereinement le niveau d’encadrement qu’elle entend mettre en œuvre.Grâce à l’adoption d’un outil commun d’observation et de mesure, l’équipe se donne les moyens d’avoirune grande cohérence dans ses interventions, quel que soit le quart de travail.Enfin, une telle objectivation de la violence et des mesures prises pour la réduire, rend plus facile lacommunication avec les personnes étrangères au monde de la santé. On sait que la psychiatrie est souventsuspectée de prendre des mesures arbitraires. La grille OAS peut alors dépasser sa dimension clinique etdevenir un outil de transparence.217.2. La vérification informatisée de l'atteinte des objectifs thérapeutiques (VIAOT), unoutil d'évaluation clinique pour des patients psychotiques violentsNathalie Auclair, Institut Philippe Pinel de Montréal, CanadaFrédéric Millaud, Institut Philippe Pinel de Montréal, CanadaAndré McKibben, Institut Philippe Pinel de Montréal, CanadaLa dangerosité des patients psychiatriques est liée à une série de facteurs dont les principaux sont desantécédents de violence, un état mental perturbé, des consommations toxiques, des éléments d’impulsivité,des traits pathologiques au niveau de la personnalité, des éléments de rigidité cognitive, une faibleautocritique, une mauvaise alliance et donc une mauvaise observance au traitement proposé. Certainsfacteurs secondaires peuvent également jouer un rôle en tant que facteur de risque ou de protection :l’autonomie dans le fonctionnement au quotidien, la capacité d’entrer en relation, le réseau social etfamilial, la gestion du stress, l’empathie et la capacité à gérer les conflits. La considération de l’ensemble

588de ces éléments est indispensable lorsqu’arrive le temps de prendre des décisions, en particulier lorsqu’ellesconcernent la sortie de l’hôpital ou des mesures judiciaires.L’élaboration et la mise en place de l’instrument VIAOT permet une évaluation systématique desparamètres cliniques importants, permettant de valider l’adhésion au traitement et l’évolution des patientsau fil des mois. Cet outil clinique permet aussi de mettre à profit les observations au quotidien desdifférents intervenants de l’équipe multidisciplinaire, l’utilisation d’un langage commun autant pour lepatient que le personnel, une transparence face aux patients quant à notre travail ainsi que l’identificationclaire d’une partie importante des objectifs de traitement. Dans le cadre de l’atelier, nous présenteronsl’instrument VIAOT, son utilisation dans notre travail clinique depuis son instauration en 2000.218. Bloc 6, no 39218.1. Symposium: Les stratégies de gestion des affects et des fantaisies déviantesutilisées par les agresseurs sexuels pour prévenir la récidiveAlexandre Nicole, Institut Philippe Pinel de Montréal, CanadaAndré McKibben, Institut Philippe Pinel de Montréal, CanadaLa plupart des programmes de traitement pour agresseurs sexuels reposent sur la théorie de la prévention dela récidive (Pithers & Gray, 1996). Ce modèle est une description théorique du processus de récidive quidécrit la séquence de comportements menant à une agression sexuelle (Pithers, 1990; Pithers, Marques,Gibat, & Marlatt, 1993). Le premier élément de la séquence est une situation (conflit psycho-affectif) danslequel son propre contrôle de ses comportements déviants est menacé (Laws, 1989). Il a été démontré queles conflits psycho-affectifs engendrent des humeurs négatives et exacerbent l’émergence de fantaisiesdéviantes et que les délinquants sexuels ont alors recours à des stratégies inappropriées. (Cortoni, 1998;McKibben, Proulx, & Lusignan, 1994; Proulx, McKibben, & Lusignan, 1996; Ward, Hudson, & Marshall,1995). Le modèle de prévention de la récidive vise donc le développement de l’auto-contrôle descomportements sexuels déviants. L’objectif est d’aider les agresseurs sexuels à anticiper et à gérer, à l’aidedes stratégies appropriées, les humeurs négatives et les fantaisies sexuelles déviantes (Pithers, 1990; Pitherset al., 1993).Toutefois, l’association entre l’utilisation des stratégies apprises en cours de traitement et une diminutionde la récidive n’a pas été démontrée empiriquement. McKibben, Proulx et Lussier, 1999, ont été parmi lespremiers à étudier comment les agresseurs sexuels utilisent les stratégies apprises en traitement. Ils se sontpenchés sur les stratégies choisies spontanément par les agresseurs et l’efficacité des stratégies utilisées. Lamême équipe de chercheurs (Lussier, Proulx et McKibben, 2001) a aussi pu démontrer la présence d’unlien entre les traits de personnalité et les stratégies apprises en traitement pour gérer un état général négatifet des fantaisies sexuelles déviantes. Les résultats font en effet ressortir un recours et une efficacitédifférents en fonction de deux profils de personnalité identifiés (dramatique et anxieux).Les études précitées (McKibben, Proulx et Lussier, 1999; Lussier, Proulx et McKibben, 2001), démontrentque les agresseurs sexuels ayant complété un traitement disposent de stratégies pour briser leur cycled’agression, les utilisent, font des choix parmi les stratégies les plus appropriées, maîtrisent les habiletésnécessaires pour gérer leurs conflits et leurs fantaisies déviantes. Les analyses ont cependant aussidémontré que, plus ils progressent dans leur cycle, plus les postulats du modèle de prévention de la récidiveperdent de leur acuité. Les échecs et négligences aux étapes antérieures accélèrent significativement le

589processus de rechute aux étapes ultérieures. Il apparaît donc nécessaire de mieux décrire les processus quimènent le délinquant d’une étape à l’autre.La présente étude repose sur un échantillon de 61 détenus fédéraux, ayant tous participé sur une basevolontaire au programme de traitement en délinquance sexuelle de l’IPPM pour une durée d’un an. Tousont été soumis à deux questionnaires informatisés (RAF et AGEF, McKibben et al., 1999) servant à évaluerles conflits psycho-affectifs, les émotions négatives et leurs fantaisies déviantes mais aussi la façon dont ilsles gèrent. Tel que mentionné ci-haut, jusqu’à maintenant, la présence de liens entre les mesuresadaptatives apprises en traitement et des traits de la personnalité a été démontrée. Il est donc proposé d’unepart, dans une optique de validation empirique de l’association entre les affects et les comportementsdéviants, d’analyser les « parcours » d’utilisation effective des stratégies apprises en traitement ou de lanon-application et d’autre part les liens avec la prévention de la récidive. Ces analyses seront réalisées àpartir de la méthode statistique de l’arbre de classification et de régression (CART), par l’algorithmeCHAID (Chi-Squared Automated Interaction Detector).219. Bloc 6, no 40219.1. Vers une meilleure compréhension du familicideSuzanne Léveillée, Département de psychologie de l'Université du Québec à Trois-Rivières, CanadaJulie Lefebvre, Département de psychologie de l'Université du Québec à Trois-Rivières, CanadaLe familicide est l’homicide de la conjointe ou de l’ex-conjointe et d’un ou de plusieurs enfants. Peud’études ont été faites sur ce type d’homicide souvent associé à l’homicide de la conjointe (uxoricide) oudes enfants (filicide). En 1995, Wilson, Daly et Daniele indiquent qu’il s’agit d’un « crime masculin »,étant donné qu’il s’agit habituellement d’hommes qui le commettent. Selon les auteurs, il y a deux sousgroupesd’individus qui commettent un familicide : les individus en colère qui agissent par mesure dereprésailles et les individus dépressifs qui agissent pour éviter à leur famille (en tant que prolongementnarcissique) de vivre la honte ou la peine. Ewing (1997) indique que ces individus présentent des affectsdépressifs, des traits paranoïdes, font face à un stress extrême (ex. : séparation, perte) et consomment alcoolou drogues. De plus, le besoin de contrôle est particulièrement important. À partir des données recueilliesau Bureau du Coroner de Québec, il y a eu 15 familicides commis par des hommes sur le territoire de laprovince de Québec entre 1989 et 2000. Selon une analyse préliminaire, il s’agit tous d’hommes (100%)qui ont en moyenne 44 ans, 67% se sont suicidés, 60% étaient séparés de leur conjointe ou en processus deséparation et 47% avaient fait de la violence conjugale contre leur conjointe. L’objectif de ce travail estd’approfondir, à partir de ces données, la compréhension de ce type de passage à l’acte.

590220. Bloc 6, no 41220.1. Schizophrénie et crimes intra familiauxA. Houidi, Service de Psychiatrie légale, Hôpital Razi, Manouba, TunisieA. Trad, Service de Psychiatrie légale, Hôpital Razi, Manouba, TunisieM. Ben Jebara, Service de Psychiatrie légale, Hôpital Razi, Manouba, TunisieH. Troudi, Service de Psychiatrie légale, Hôpital Razi, Manouba, TunisieR. Ridha, Service de Psychiatrie légale, Hôpital Razi, Manouba, TunisieLes schizophrènes sont les malades les plus énigmatiques et les plus imprévisibles, ils sont considéréscomme étant parmi les patients les plus dangereux. Cette dangerosité est confirmée par la plupart desétudes récentes et elle aurait pour particularité de viser l’entourage familial dans deux tiers des cas. Qu’enest-il en Tunisie des crimes intra familiaux perpétrés par des sujets atteints de schizophrénie? C’est à partird’une étude rétrospective de dossiers de patients schizophrènes hospitalisés dans le service de psychiatrielégale de l’hôpital de Razi, suite à crime commis dans le milieu familial, que nous avons essayé de dégagerleurs caractéristiques épidémiologiques, cliniques et criminologiques en vue, d’une part, de les compareravec les données de la littérature et de relever d’éventuelles spécificités socioculturelles et d’autre part,dans l’objectif de dégager des éléments prédictifs permettant de mettre en place des mesures préventives dupassage à l’acte.221. Bloc 6, nos 42 et 43221.1. Aspects neuropsychologiques des délinquants sexuelsClaire Ducro, C.R.D.S. - Centre Hospitalier Psychiatrique «Les Marronniers», Tournai, BelgiqueThierry Hoa Ng Pham, C.R.D.S. - Centre Hospitalier Psychiatrique «Les Marronniers», Tournai, BelgiqueL’objectif de cette présentation est d’approfondir les aspects neuropsychologiques des délinquants sexuelsau travers une revue de la littérature. En effet, nous développerons des recherches, principalement menéespar l’équipe de Langevin et collaborateurs à la fin des années 80, de Flor-Henry (1987) et de O’Caroll(1989), de manière à préciser leurs méthodes d’évaluations neuropsychologiques, les variables qu’ils ontcontrôlées ainsi que leurs résultats obtenus. À savoir que les différentes recherches se focalisentprincipalement sur un type de délinquant sexuel (pédophiles versus délinquants non sexuels non violents ouagresseurs sexuels de femmes versus délinquants non sexuels non violents) et qu’il nous semble intéressantde présenter les résultats de ces différentes recherches conjointement. En ce qui concerne les résultats, ils’avère que ceux-ci, en effet complexes, ne se valident pas de recherches en recherches, et que notamment,

591actuellement, peu de chercheurs continuent à développer ces aspects. Nous terminerons cette présentationpar une critique constructive de ces recherches afin, peut être, de développer à nouveau ce thème.221.2. Étude comparative des représentations sociales du suicide en fonction de laprégnance de l'exposition sociale à un mode opératoire spécifiqueSylvie Bourdet-Loubere, Université de Toulouse IINicolas Combalbert, Université de Toulouse IISuite à deux études exploratoires sur les représentations sociales du suicide en population généralefrançaise et auprès d’un échantillon d’élus locaux français, cette recherche tente de montrer l’influence dela surexposition sociale à un mode de suicide spécifique (la précipitation dans le vide) sur la structure et lecontenu des représentations sociales du suicide.Cette étude compare donc la structure et le contenu des représentations sociales du phénomène suicidaireauprès d’un échantillon de 200 sujets socialement surexposés à la précipitation, issus de la populationcadurcienne (Lot), où le taux de suicide par précipitation est largement supérieur au taux national versus unéchantillon de 200 sujets issus de la population toulousaine, où le taux de suicide par précipitation estcomparable à celui de la France (soit environ 6%).Les données ont été recueillies à partir d’un test projectif de mots et d’un questionnaire d’opinion.Les résultats révèlent une structure du champ représentationnel identique concernant l’objet social« suicide » pour les deux groupes de sujets au niveau du noyau central de la représentation. Par contre, onnote des différences entre les deux échantillons au niveau des éléments composant le système périphériquede la représentation. En effet, les Toulousains donnent des réponses renvoyant à un phénomène socialabstrait alors que les Cadurciens évoquent davantage des éléments « de vécu » renvoyant à une réalitéd’environnement concrète et tangible. Par ailleurs, le questionnaire d’opinion indique une surestimation del’incidence du phénomène suicidaire aux niveaux départemental et national pour le groupe surexposé à laprécipitation. De même, ces derniers présentent une plus grande proximité psycho-affective avec laproblématique suicidaire et ont tendance à juger plus sévèrement les politiques de prévention aux niveauxdépartemental et local. Enfin, pour les sujets du groupe surexposés au suicide par précipitation, on notequ’ils ont davantage tendance à reconnaître une « spécificité » au suicide par précipitation par rapport auxautres modes opératoires quand les Toulousains semblent davantage assimiler les divers modes opératoirescomme relevant d’un même phénomène suicidaire.

592222. Bloc 6, no 44 et 45222.1. Les enjeux liés à l'évaluation et l'orientation d'urgence des prévenus présentantdes troubles mentaux, à la Cour du Québec (CQCCP) de MontréalThierry Webanck, Institut Philippe Pinel de Montréal (Urgence Psychosociale - Justice), CanadaL’Urgence Psycho-Sociale-Justice (UPS-J) intervient, à la Cour du Québec (Chambre Criminelle et Pénale)de Montréal, auprès de prévenus qui semblent présenter des problèmes de santé mentale. L’objectif estd’évaluer ces personnes pour les orienter vers des services ou des ressources appropriées. C’est aussi unservice conseil aux décisions que sont appelés à prendre les intervenants légaux (avocats, procureurs etjuges).L’intervention de l’UPS-J est effectuée dès le début du processus judiciaire, généralement lors de l’enquêtesur la remise en liberté, soit environ 48 heures après l’arrestation. Il ne s’écoule généralement que quelquesheures entre la demande d’intervention et la décision relative à l’orientation du client.La présentation portera sur le contexte de l’évaluation ainsi que sur les enjeux cliniques et légaux liés, entreautres, à la gestion du risque dans l’optique d’une remise en liberté.Suivra une description et une analyse des orientations privilégiées en fonction des paramètres légaux,cliniques et environnementaux qui influencent l’évaluateur et les différents acteurs du tribunal.Nous conclurons, en examinant les forces et les limites de ce genre d’intervention, autant pour le prévenu,que pour le tribunal et la société.222.2. L'Art de protéger, comment valider aujourd'hui les détentions civiles des pesonnesdont l'état mental présente un danger pour elles-mêmes ou pour autruiPierre-Marc Couture-Trudel, Université de Montréal, CanadaJean-Luc Dubreucq, Université de Montréal, CanadaCette présentation décrira les diverses caractéristiques du régime québécois de détention civile, instaurédans le but de protéger les personnes et leur entourage en cas de danger provoqué par l’altération de leurétat mental. La fragmentation des régimes de protection fera l’objet d’une critique juridique et clinique.Ensuite, nous aborderons le critère de dangerosité retenu par le Législateur pour ce régime particulier deprivation de liberté. Celui-ci impose tant aux cliniciens qu’aux juristes, une conclusion de type binaire : il ya ou non présence d’un danger, alors que dans les faits la notion de danger est bien souvent pluscomplexe… Afin de tenir compte de cette réalité clinique, mais aussi des contraintes de la loi, nousproposerons une distinction didactique entre le critère objectif de danger physique et celui plus subjectifd’une atteinte à la santé vue comme un état de bien-être de la personne. Puis, une analyse dichotomique duprocessus décisionnel sera suggérée. Distinguer la détermination d’un danger de celle d’un besoin deprotection, permettra de mieux appréhender le dilemme éthique présenté par le régime actuel. Enfin, nousexaminerons l’influence des valeurs actuelles, notamment de l’autonomie et de la bienfaisance, surl’évaluation des situations cliniques et sur l’interprétation de la loi. Les enjeux éthiques seront décrits et

593déboucheront sur un questionnement aujourd’hui crucial : qui prendra la responsabilité des personnes dontl’autodétermination est en péril?223. Bloc 6, no 46223.1. Symposium: Programme d’hospitalisationJocelyne Morissette, Institut Philippe Pinel de Montréal, CanadaJonathan Lambert, Institut Philippe Pinel de Montréal, CanadaÀ titre d’hôpital sécuritaire suprarégional, l’Institut Philippe Pinel de Montréal offre des servicesd’évaluation et de traitement à l’ensemble de la population québécoise. Depuis 1987, le management depatients difficiles, présentant à la fois une pathologie psychiatrique et un potentiel de violence, fait l’objetd’un programme spécifique de contrats de service avec les hôpitaux de l’ensemble du territoire. Plus de 60patients sont accueillis chaque année dans le programme.L’atelier proposera d’abord une présentation des caractéristiques spécifiques au programme de contrats,notamment les types de demandes, leur contexte clinique ainsi le profil de la clientèle. Nous discuterons parla suite des différentes modalités d’évaluation et d’intervention développées par notre programme.Le cadre légal québécois sera brièvement présenté, comme toile de fond à une discussion portant sur uneutilisation judicieuse des leviers qu’il propose en clinique. Nous exposerons aussi les caractéristiques de laprocédure de liaison auprès des hôpitaux demandeurs, procédure qui comporte des volets de formation etde «coaching », mais qui se veut principalement un lieu d’échanges visant la continuité des soins.Finalement, nous tenterons de dégager les indicateurs de performance du programme, en discutant decertains résultats préliminaires, ainsi que des orientations à privilégier.223.2. Plénière223.3. Mondialisation des industries du sexe et libéralisme : les effets de la légalisationde la prostitution.Sous la direction de M. André McKibben, Institut Philippe Pinel de Montréal, CanadaInvité:Richard Poulin, Université d'OttawaAvec le triomphe des valeurs libérales dans le processus actuel de la mondialisation, le sexe tarifé a connu,dans les dernières décennies, une expansion considérable ; la soumission aux règles du marché et aux lois

594libérales contractuelles d’échange entraîne une acceptation de plus en plus grande de l’acte marchand quidonne accès, contre une somme variable d’argent, au sexe de personnes. Pour un nombre important d’Étatset d’organisations, la prostitution est devenu un « métier comme un autre » et, même pour certains, un «droit ». Depuis le début du nouveau millénaire, on note d’ailleurs qu’un nombre important d’États alégalisé la prostitution.Après la présentation de données sur l’ampleur de la prostitution et de la traite d’humains à des fins deprostitution, les liens entre la légalisation de la prostitution et la traite des femmes et des enfants,conséquence logique de l’expansion de cette sphère d’activités «commerciales», seront présentés. Enfin,l’impact des tendances politiques internationales libérales à l’œuvre depuis la Conférence de Beijing en1995, dont l’enjeu concerne aussi la normalisation de la prostitution et de la traite à des fins de prostitution,sera mis en évidence.224. Bloc 7, no 47224.1. Symposium : Discernement et récidive. L’évaluation de la dangerosité.224.2. Analyse comparée des notions de Discernement, Jugement, Aptitude etResponsabilité criminelle en droit pénal français et canadien : Le problème deplus en plus prospectif et international de l'évaluation et de la gestion expertalesdu risqueDenis Morrison, Département de psychiatrie, Université de SherbrookeÀ la fois le discernement, le jugement, la responsabilité, la capacité ou l’aptitude en droit pénal français ouromain ou en Common law britannique, américaine ou canadienne ne sont aucunement des concepts voiredes notions médicales, non plus médico-légales non plus psychiatriques ; elles sont à la fois à l’intersectionéthique, légale ou philosophique. On demande cette fois à l’expert médical d’en débattre, ce qui constituequelque peu une aberration. Paul Appelbaum avait déjà donné l’opinion qu’il fallait s’abstenir de répondreà la question ultime…L’autre but, peu avoué, mais très connu en milieu anglo-américain est de sanctionner auprès du tribunall’existence ou non d’un risque (appelé autrefois dangerosité), de le qualifier et de le quantifier en plus de lecirconscrire dans des contextes et de mises en situations données ou potentielles… Il faut donc en plusd’évaluer le risque de donner une opinion sur sa gestion en fonction de facteurs statiques etdynamiques…L’expert, de plus en plus, risque de se substituer au juriste, surtout en code pénal, moins enCommon law à cause du système adversaire. L’autre but pourrait être de nature davantage répressive, avecle resserrement de la composante punitive et du pouvoir dissuasif de la sentence. Cela nous renvoie quelquepeu aux anciens objectifs de l’expertise dite pré-sentencielle à trois volets, soit déterminer la nature del’affliction, s’il y a traitement et surtout si l’individu est dangereux ou pas. Le but ultime de toute expertisedevient la protection de société contre l’individu à risque. L’extrême, en milieu canadien, devientl’expertise du délinquant à long terme et, bien sûr, du délinquant dangereux avec risque d’incarcérationindéterminable et absence de toute intervention thérapeutique puisqu’à la fois non traitable et traitementreporté de toute façon en bout de ligne, si l’on reconnaît qu’un tel traitement existe…

595224.3. Dangerosité criminelle, dangerosité psychiatrique. Analyses épistémologiques etcliniques des aléas du discernementNielle Puig-Verges, Université Paris VIII, Hôpital La Salpêtrière, Paris, FranceEn France, la question de la distinction entre dangerosité psychiatrique et dangerosité criminelle oucriminologique se pose périodiquement en référence à l'expertise psychiatrique. Dans nos travaux cliniquesprécédents, nous avions considéré qu’il pouvait être effectué une différenciation pertinente, dans la mesureoù celle-ci créait une rupture par rapport aux préjugés sur les troubles psychopathologiques et permettaitd’effectuer des propositions plus adaptées sur les prises en charge socio-éducatives et thérapeutiques.Réexaminée selon la démarche de l’épistémologie clinique comparative, la notion de dangerosité renvoie àdes interrogations et à des prises de positions qu’il est nécessaire d’élucider. Alors que pour lejuriste,« l’état dangereux » est souvent synonyme de trouble mental et peut entraîner la non responsabilité,un traitement en milieu spécialisé et une mesure d'exclusion du champ social, pour le clinicien le potentielde nocivité sociale d'une personne n’est en aucun cas réductible au trouble psychique; cette notion occulteaussi le fait que le malade peut être dangereux pour lui-même autant que pour autrui.Apprécier la dangerosité dans ses diverses composantes suppose donc que nous examinions lesreprésentations auxquelles elle renvoie dans l’imaginaire collectif , mais aussi dans divers champsdisciplinaires. Au plan individuel, nous la corrèlerons aux composantes du Discernement (dégagées par nostravaux) ainsi qu’à la capacité d’apprécier les limites et d’anticiper les risques. L’état du discernement doitensuite être analysé dans une perspective prospective, anticipatoire, c’est à dire en dégageant ce qui évoqueune dangerosité actuelle ou ce qui signalerait un risque éventuel de récidive.224.4. L'acte pathologique et la question du discernementDenis Charles Morin, psychiatre honoraire des hôpitaux, Médecin conseil du Préfet de Police de Pris,Expert particulier de l’Instruction au T.G.I. de Paris, FranceEn France, la pensée rationnelle, socle du Droit, range les actes humains en trois classes, l’acte ordinaire,l’acte délictueux et l’acte pathologique. Pour délimiter la frontière séparant l’acte délictueux de l’actepathologique, il a successivement été fait appel à plusieurs défaillances touchant d’abord le bon sens, puisinvoquant un état de démence, et enfin une altération du discernement.Qualifier un acte de pathologique suppose actuellement une évaluation du pouvoir de discerner. Dans lescas évidents, cette appréciation relève du bon sens des fonctionnaires de police. Dans les autres cas, elledoit s’appuyer sur un avis éclairé, censé mesurer la qualité du discernement de l’auteur de l’acte, comme sila faculté de discerner pouvait comporter un degré.L’auteur montrera qu’en clinique, les mobiles des auteurs s’ajustent imparfaitement à ce modèle.

596224.5. Dimension criminologique du discernement. Les limites de l'expertisepsychiatriquePierre André Delpla, Service de Médecine Légale, Hôpital de Rangueil, FranceEn comparaison de sa précédente version (article 64), l’article 122-1 du nouveau Code Pénal Français (envigueur depuis mars 1994) a opéré un double changement :• - il a reformulé, d’une part, l’hypothèse où les troubles psychiques ou neuropsychiques d’unauteur d’infraction exonéraient ce dernier de sa responsabilité pénale, au motif que son« discernement » ou le « contrôle de ses actes » étaient abolis ;• - il a introduit, d’autre part, dans la loi elle-même un nouveau cas de figure où le mis en causebien qu’atteint de troubles mentaux, restait punissable malgré l’existence -au moment des faitsqui lui sont reprochés- d’une « altération du discernement » ou d’une « entrave au contrôledes actes », dont l’impact sur la peine et son régime est laissé à l’appréciation de la juridictionde jugement.Si, dans le premier cas, le rôle de l’expert psychiatre reste –du moins dans l’esprit- balisé par la pratiqueantérieure (relative à « l’état de démence au temps de l’action »), il en va tout autrement dans le second oùle psychiatre –technicien auxiliaire du juge- manque cruellement de repères à la fois en amont –lesréférences nosographiques classiques n’étant pas applicables en l’état- et en aval, dans l’ignorance où il setrouve de l’utilisation que feront les magistrats et les jurés de ses conclusions.Une véritable réflexion s’impose donc aux praticiens de la psychiatrie médico-légale, pour contribuer àdonner à un dispositif législatif encore récent et dont la portée reste difficile à apprécier, toute son ampleuret sa véritable dimension criminologique.224.6. Répétition de l'acte et aggravation du parcours transgressif des abuseurs sexuelsMarc G. Schweitzer, Hôpital de La Salpêtrière, Paris, FranceL’instauration en France du Suivi Socio-judiciaire et la possibilité d’Injonction de soins pour les auteursd’infractions sexuelles, introduits la loi du 17 juin 1998 relative à la répression des infractions sexuelles et àla protection des mineurs, ont contribué à une situation nouvelle au plan des obligations et des procéduresaussi bien pour les auteurs concernés que pour les professionnels impliqués.Cette possibilité de mettre en place une injonction de soins pour une personne auteur d’infraction sexuelle,donne une dimension autre à l’expertise psychiatrique qui ne se réduit plus à la question de l’articulationentre niveau de discernement et les troubles psychiques repérables au moment des faits incriminés.L’évaluation dévolue à la démarche expertale repose sur l’analyse psycho-biographique et criminologique,ainsi que sur l’analyse psychopathologique, l’acte et de la transgression. Le constat de la répétition de l'acteet l’aggravation du parcours transgressif des abuseurs sexuels ont contribué à développer les projets deprévention. L’obligation imposée par la loi de se prononcer sur l’indication de soins, impose maintenantaux professionnels de se préoccuper des moyens à mettre en œuvre pour éviter la répétition de l’acte ; nousintroduisons ainsi une dimension prospective, tout en sachant que nous pourrons difficilement maîtrisertoutes les composants favorisant la récidive.De nouvelles demandes sociales affluent qui tendraient à faire de l’expertise un élément de la mise en placed’un nouveau dispositif de contrôle socio sanitaire , ce qui nous paraît contestable.

597225. Bloc 7, no 48225.1. Symposium : Deux exemples d’utilisation d’échelles d’évaluation du risque chezles adolescents avec trouble du comportement.225.2. L'évaluation du risque de violence chez les adolescentsTiziana Costi, Institut Philippe Pinel de Montréal, CanadaL’évaluation du risque de violence est au centre des préoccupations de plusieurs cliniciens travaillant dansle domaine de la psychiatrie légale, toujours à l’affût de nouveaux instruments pouvant raffiner leurjugement clinique et structurant leur évaluation, tout en leur donnant des pistes pour mieux gérer le risqueet mieux intervenir. Cela est d’autant plus important lorsqu’il s’agit d’adolescents. Pour cette populationégalement, des nouveaux instruments ont récemment été introduits pour améliorer l’évaluation du risque deviolence. Un des ces instruments est le SAVRY (Structured Assessment of Violence Risk in Youth), quiconstitue l’équivalent du HCR-20.Notre présentation portera sur l’évaluation du risque de violence chez les adolescents, avec la descriptiondes différents instruments utilisés, spécialement le SAVRY. Des données recueillies lors des évaluationsdans une unité d’expertise et traitement d’adolescents seront abordées et une discussion portera sur lesapports de cet instrument (grille d’entrevue) dans l’évaluation et la gestion du risque pour cette population,ainsi qu’une comparaison avec d’autres instruments similaires. Cette deuxième partie de la discussionpourra se faire en collaboration avec monsieur Richard Lusignan, chef du service de criminologie del’Institut Philippe Pinel de Montréal, dont la présentation traite de l’utilisation du HCR-20 chez lesadolescents.225.3. Étude, selon le HCR-20, des relations agresseur-victime(s) d'un grouped'adolescents québécois violentsRichard Lusignan, Institut Philippe Pinel de Montréal, CanadaJacques D Marleau, Institut Philippe Pinel de Montréal, CanadaLa présente étude porte sur les résultats obtenus au guide d’évaluation du risque de violence HCR-20 par108 adolescents agresseurs, évalués au programme des adolescents de l’Institut Philippe Pinel de Montréal,entre février 1998 et avril 2003. La relation entretenue entre l’agresseur et sa victime fut utilisée commecritère de classement. Spécifiquement, deux types de relations ont été retenus à des fins de comparaison : lavictime membre de la famille ou connue ainsi que la victime inconnue.Les 108 adolescents admis à l’IPPM ont fait l’objet d’une évaluation individuelle et d’une rencontrefamiliale. Un guide d’évaluation du risque de violence HCR-20 fut complété pour chacun des adolescents.Quelques items ont été modifiés afin de mieux rendre compte de la situation particulière des adolescents.Des différences statistiquement significatives apparaissent à la fois au niveau du score total obtenu auHCR-20 ainsi qu’au niveau de deux sous-échelles : la sous-échelle historique (H) et celle de gestion du

598risque (R). Également, cinq items du HCR-20 paraissent particulièrement aptes à distinguer les deux sousgroupesd’agresseurs : premier acte de violence commis durant la jeunesse (H2), échec antérieur de lasurveillance (H10), attitudes négatives (C2), exposition à des déstabilisants (R2) et manque de soutienpersonnel (R3). Ces résultats indiquent une aggravation des facteurs de risque de violence chez lesadolescents qui agressent des victimes inconnues lorsque comparés aux adolescents qui victimisent lesmembres de leur famille ou des personnes connues. Ces résultats entraînent des conséquences importantesau niveau des interventions cliniques à visée préventive et thérapeutique.226. Bloc 7, no 49226.1. Symposium: La notion de responsabilité : carrefour entre le droit et la santémentaleChristian Mormont, Université de LiègeEdouard Delruelle, Université de LiègeMarc Preumont, Université Libres de BruxellesLa responsabilité est une notion polysémique qui se trouve à la croisée des champs légal etpsychopathologique. De surcroît, cette notion concerne autant les justiciables que les professionnels quenous sommes.En effet, il y a peut-être lieu de distinguer les différentes dimensions, pénales, morales, psychologique de lanotion de responsabilité et de tenter de préciser quels sont les recoupements ou les liaisons qui peuvent êtreopérées entre elles.De plus, au travers de la notion de responsabilité, le débat peut être ouvert sur une certaine contaminationdu champ de la santé mentale par la morale. La promotion de l’aveu et du « plaisir coupable » dans lecadre de l’aide contrainte en est un autre exemple.Ne fut-ce que dans le cadre expertal, nous avons vu ces derniers temps de nombreux psychologues accepterde répondre à une question dont ils affirmaient, d’autre part, qu’elle ne les concernait pas, celle de laresponsabilité du justiciable. La responsabilité étant, ici, assimilée à la notion de conscience et de contrôlede ses actes voire à l’exercice de son libre arbitre.Mais, à l’autre pôle, la responsabilité est également celle de l’intervenant et pose la question de sonengagement, engagement par rapport aux usagers des services, mais engagement également par rapport aucorps social qui détermine sa fonction et rétribue son action.

599227. Bloc 7, nos 50 et 51227.1. Coment appliquer les droits du patient dans le secteur de la santé mentale?André M. Allard, Hôpital Psychiatrique du Beau Vallon, Namur, FranceEn tant que citoyens et citoyens-sujets en risque de recevoir des soins, nous sommes très sensibles à laphilosophie sous-jacente à cette loi : respect des Droits de l'Homme, valeur fondamentale et vitale pournotre société.Nul doute que nos comités d'éthique hospitaliers apprécieront cet effort d'organiser un dispositiflégislatif en faveur de nos patients. Mais, en tant que cliniciens, nous devons tempérer cet enthousiasmeet regretter le manque de précisions de certaines notions ou même l'inapplicabilité de quelques notionsau champ de la santé mentale. Nous illustrons combien de questions restent sans réponse pour cesecteur.Une telle législation va-t-elle pouvoir changer nos pratiques ? Y aura-t-il modification positive deshabitudes de notre société, pour qu'elle en arrive à gommer des stéréotypes à l'égard du malade mental,changer sa perception de la maladie mentale?227.2. L'expérimentation sur la personne humaine : l'approche législative belgeEvelyne Langenaken, Faculté de droit, Université de LiègeLe 7 mai 2004, la Belgique a adopté un régime légal complet pour les expérimentations humaines. Cetteloi, entrée en vigueur le 1 er mai 2004, a mis fin à une situation paradoxale où une pratique expérimentaleavancée coexistait avec une insécurité juridique importante (consentement éclairé, exigence d’un bénéficethérapeutique, protection des incapables, etc.), le champ législatif en la matière étant jusque là composé detextes épars et souvent confus. Le domaine d’application de la loi est étendu et, au-delà del’expérimentation médicamenteuse, vise toute investigation menée chez la personne humaine en vue dudéveloppement des connaissances biologiques ou médicales. La loi tente de circonscrire avec précision etde réglementer le rôle de chacun des intervenants à une expérimentation menée sur la personne humaine ;une attention particulière est portée au rôle des Comités d’éthique. Elle prévoit un régime particulier deprotection des mineurs et des majeurs incapables de donner leur consentement à la participation à desexpérimentations. Le législateur a enfin eu le souci de réglementer les différentes étapes de la conduited’une expérimentation, envisageant de manière large les cas de figure pouvant survenir de sa mise enœuvre à sa conclusion. Notre exposé propose un aperçu global de ces nouvelles dispositions législatives,ainsi qu’une première analyse en rapport à sa cohérence avec un principe qui nous paraît devoir guidertoute réflexion juridique en cette matière : le droit à l’autodétermination de la personne sur son corps.

600228. Bloc 7, nos 52 et 53228.1. Le piège de l'imageJean-Dominique Leccia, Université McGill, Montréal, CanadaNotre modernité occidentale est construite autour d'un impérialisme de l'image qui fonctionne commemodèle et comme support de réalités souvent fragiles et/ou menacées. Notre pratique professionnelle, maisaussi les faits divers, nous indiquent à quel point toute altération de ce modèle de miroir précipite souventdangereusement les déroutes narcissiques et identitaires.Nous illustrerons notre propos par des exemples pris de chaque côté du miroir. D'abord les icônes, les starsincapables de négocier le passage entre leur ego médiatique et la réalité. À l'autre bout de la chaîne, lesbanlieues ou les ghettos, mais aussi les groupes dont l'image est stigmatisée et qui, en l'absence de modèlegratifiant, engage leur corps en première ligne pour exprimer leur désarroi.La psychiatrie, habituée à des folies plus structurelles, est désarmée face à ces manifestations psychiquesopérant au rythme de l'image. La fragilisation des identités spatiales, tant physiques que médiatiques,associée aux dissolutions des frontières entre la réalité et l'image engendrent des déséquilibres mentaux. Lespectre clinique est large, il s'étend depuis la vague dépressive planétaire jusqu’au véritable chaos et dérivesindividuelles.228.2. Favoriser la santé mentale par un leadership intégralMaude Laberge, Université de MontréalHugues Cormier, Université de MontréalLa présente communication a pour objectif d’explorer la proposition qu’un type particulier de leadership -leleadership intégral- puisse promouvoir la santé mentale en agissant de manière à diminuer lesenvironnements naturel et social propices au déclenchement de troubles mentaux. Devant l’ampleurconsidérable des problèmes de santé mentale et l’accroissement de leur présence dans le mondecontemporain, il est ainsi proposé qu’un leadership dit intégral -parce que notamment centré sur ledéveloppement du bien commun - puisse contribuer : à atténuer le fardeau global des maladies mentales, àaméliorer les conditions de vie des personnes vivant avec une maladie mentale de même qu’à favoriser leurintégration au sein de la société. Après avoir caractérisé le concept de leadership intégral (notamment àpartir des travaux de Abraham H. Maslow), différents facteurs pouvant influencer la santé humaine sontrévisés afin d’identifier des cibles d’action prioritaires pour ce type de leadership. Enfin, à titre illustratif dulien potentiel entre leadership intégral et santé mentale, quelques-uns des faits saillants du leadership exercépar Jimmy Carter pendant et après sa présidence des États-Unis sont soulignés.

601Author IndexAbbate, L., 560Abdool, S., 308Abdous, B., 435Abma, T., 431Acker, C., 113Acuña, M.C., 474Adams, R., 249Addison, S., 366Adelson, N., 248Agrali, S., 500Agrawal, P., 498Akuffo, A., 333Alderdice, J., 383Aldige Hiday, V., 145Alexy, E.M., 92Allard, A.M., 599Allodi, F., 243, 318Alston, A., 58, 60Alvares, S., 71Amana, C., 62Ambrosini, D.L., 39Amering, M., 40Amidjaya, I., 512Amini, M.R., 545Amor, T.J., 233Anckarsäter, H., 128, 129, 130Anders, S.S., 517Anechiarico, B., 445Angelari, M., 170, 174App, T., 447Appelo, M., 535Arboleda-Florez, J., 453Arboleda-Flórez, J., 236, 474Arlebrink, J., 483Aroian, K., 341Arrigo, B., 440Artemyeva, V., 523Ash, G.R., 284Attia, S., 310Aubut, J., 563Auclair, N., 576, 587Aulich, L., 187Austin, W., 407Awmiller, C., 316Aydin, C., 110Aylwin, S., 400Backer H.S., 389Bagiel, L., 583Bahdi, R., 42Bailey, S., 275, 428, 551Bakkalci, M., 246Bakkum, T., 154Bal, P., 237Balarajan, R., 334Balderson, K., 309Balke, N., 501Bandes, S., 526Baneke, J., 198Barankin, T., 540Barbieri, C., 452, 471, 547Bar-El, J., 207Barel, Y., 85, 304Barlow, S., 439Barnes, A., 36Barnow, S., 450Baron, R.C., 327Barr, W., 234Barratt, E.S., 434Barth Menzies, K., 465Bartlett, P., 323Barton, T.D., 295, 518Barudy, J., 565Basser, L., 225Bastien, J., 587Bastin, R., 581Bath, E., 532Battelli, F., 70Bauer, A., 303, 304, 305Bay, M., 259Beckett, J., 251Beckett, R., 280Beeghley, L., 232Beermann, E., 25Belkin, G.S., 414Belsasso, G., 494Benefield, N., 355Bennett, B., 413Bennett, C., 178Benson, S., 328Bentley, P., 515Bérard, L., 570Berendsen, E, 365Berg, J., 44Berghmans, R., 433Berman, A., 206Bertrand, C., 568, 569, 581Bess, G., 328Beverley, L., 362Beyer, K.R., 306Bijttebier, P., 389Bilke, O., 220Bilsky, W., 108Birgden, A., 519Birmingham, C.L., 167

602Bishop, E.S., 540Blaauw, E., 405, 435, 469Blanck, P., 326Blank, A., 164, 165Bleich, A., 411Blitz, C.L., 165Blue, I., 132Böck, G., 487Bogaerts, S., 460Boland, F., 197Boland, J., 50Bolis, M., 474Bonsack, C., 566, 567Bordeleau, D., 569Borgeat, F., 566, 567Borgeat, F., 567Bouman, Y.H.A., 139Bourdet-Loubere, S., 591Bourdet-Loubere, S., 576Bowen, P., 240, 319Boyadjiev, B., 180Boyarin, J., 286Boydell, K., 476Brand, E.J.P., 204Brands, M., 514Branney, P., 441Brault, J., 585Breuk, R.E., 188Brewer, J.K., 101, 248Bridgewater, P.D., 213Brimer, E., 197Brimse, A., 129Brinded, P.M.J., 401Brisson, J., 579Broer, J., 365Brophy, L., 77, 78Brouwers, R., 535Brown, D. P., 479Browne, N., 126Brunner, J.L., 331Bruß, E., 423Brusselmans, M., 568, 569, 581Bruzzone, R., 69, 70, 71, 72, 73Bullens, R., 535Bulten, E., 405Burdova, I., 257Burns, F., 170, 172Burns, K.A., 166Burris, J., 55Burton, A.O., 342Busch, K., 512Buzzi, F., 346Cai, W., 107Caires, M.A.F., 453Caldwell, M.F., 533Calhoun, G.B., 189Calogero, A., 64Camerini, G. B., 560Camilleri, P., 439Campbell, J., 23, 78, 133Canbek, O., 193Carlstedt, A., 128, 129Carmic, N., 299Carmichael, P.A., 264Carney, T., 168Carpentier, J., 576Carratelli, T., 560Carrière, S., 586Carroll, A., 102, 424Carson, S., 259Cartwright, C., 508Castro Fonseca, A., 219Caulfield, T., 140Celenza, A., 350Chaimowitz, G., 91Chamberland, G., 565Chaplow, D.G., 401Chappell, D., 522Chappuis, V., 567Charland, L.C., 25Chartier, J.P, 573Chase, D., 517Christie, N., 457Chu, T., 184Churgin, M.J., 448Clark, D. C., 480Clarke, J., 218Clements, P.T., 43, 554Cockrell, M., 543Coffin, J.C., 114Cohen, M.L, 55Cohen-Kettenis, P.T., 220Coleman, T., 362Combalbert, N., 576, 591Compton, W., 489Compton, W., 16Constance, A., 32Constanze, G., 280Conticelli, A., 66Coombes, L., 441Cormier, H., 600Cornellà, J., 550Coronel, L.C.I., 194Corrado, R., 548Costi, T., 597Côté, G., 418, 435Cotton, D., 363Coupet, S., 527Couture-Trudel, P., 592Craissati, J., 358, 457Creighton, S., 267Crichton, J., 426, 428

603Crisilla, L., 367Crowley-Cyr, L., 462Crozier, I., 114Crustolo, A.M., 186Curtin, K., 379, 380, 381Cutcliffe, J., 494Cutcliffe, J.R., 132Cuyjet, M., 480Cuzzocrea, V., 278Cyr, J., 571Czerederecka, A., 48D’Silva, K., 357Daalder, A., 459Dąbrowski, S., 181Daering, A., 177Dahlgren, L., 477Daigle, M., 418, 435, 572Dalla Ragione, L., 392Darjee, R., 426, 427, 428Das J., 390Dassylva, B., 570Dauer, E.A., 56Davidson, M., 426Davis, M.R., 416Dawe, S., 486, 488de Andrade, Y., 529De Fazio, L., 468De Freitas, K., 162de Jong, J.D., 546de Jonge, J.M., 374, 375De Keyser, E., 507de Kogel, K., 397De Luca, R., 64de Vogel, V., 423Deacon, A., 422Dean, K., 421Deborah Chase, 517Declercq, F., 460Decoene, S., 389Deenen, J.M., 158Deeney, R.M., 140Dejours, C., 563Deliens, L., 507Delorme, A., 578Delpla, P., 596Delruelle, E., 598DeRanieri, J.T., 93Des Rosiers, N., 212Deschenes, E.P., 207, 215Devereux, J.A., 74Dhaliwal, G., 123Dhir, A., 320Di Marco, F., 71Di Nunzio, M., 66Diamond, J.A., 284Diaz Pintos, G., 414DiChiara, G., 12Dickey, W., 297Dinerstein, R.D., 255Dittman, V., 311Dittmann, V., 30, 31Dixon, A., 218Dlugacz, H., 315Doddemma, E., 397Doepfner, M., 391, 392Dolan, M., 556Domek, G., 228Dönisch-Seidel, U, 139Dönisch-Seidel, U., 398Donnelley, J., 513Doreleijers T., 390Doreleijers, T., 220, 429, 548, 552Dorfman, D., 316Doron, I., 174Douard, J., 102, 449, 450, 456Douw, F., 442Doyle, C., 356Dozortseva, E., 222Dozortseva, E.G., 49Draine, J., 164Drake, C., 424Drappo, L., 392Dreisbach, V., 81Dressing, H., 472Drost, M., 135Drozdek, B., 368du Planty, G., 393Dubois, O., 581Dubreucq, J., 578, 587, 592Ducro, C., 582, 583, 590Dudeck, M., 450Dudeck, M., 99Duff, A., 176, 386Duffy, D., 379Duffy, D. M., 380Duffy, D.M., 380, 381Duggan, C., 354Duhamel, C., 529Duijst, W., 345Duits, N., 277, 390, 429Durham, M.L., 236Dvorak, A., 487Dyall, L., 248Egger, I., 500Egli-Alge, M., 223, 280Eichberger, H., 371, 555Eistetter, S., 559Ekblad, S., 504Elsner, K., 201Emens, E., 299Emmanuelli, X., 564Encandela, J., 337, 338

604English, K., 520Erikson, M., 356Evans, C., 216Everitt, B.J., 13Evers, T., 464Fardella, J., 26Farrell, S., 79, 88Faulkner, S., 79Fegert, J., 555Feindel, M., 76Fennesz, P., 371Feria, M., 497Feringa, H.A., 400Ferriani, E., 232Fever, K., 249Fidone, M.C., 471Field, S., 40Fields, T.H., 395Figueiredo, B., 44, 214, 492Finegan, J., 29Fioritti, A., 232Fischer, M., 215Fischetti, M., 66Flanagan, N.A., 100Fleming, J., 410Foeken, K., 136Foerster, K., 277Foley, T. P., 456Ford, E., 353Fornaro, G., 442Forrester, K., 60Forsman, A., 128, 129, 130Forsting, M., 202Freckelton, I., 56, 83, 310Frederick Amar, A., 94Freeland, A., 88Freeman-Wilson, K., 522Freeman-Wilson, K., 17Frei, A., 30, 311Freidl, M., 506Frenken, J., 536Frey, R., 344Freyberger, H.J., 99, 450Friedel, E., 321Friedman, D.K., 42Friedman, D.R., 41Friedman, G., 207Friedman, R., 102Friedman, R.I., 450Friedmann, P., 490Friedmann, P. D., 18Friedrich, M.H., 371Fritzler, R.B., 518Frodl, P., 155Frolik, L.A., 36Froming, K.B., 103Frommer, N., 401Frottier, P., 436Frühwald, S., 436Fugère, R., 585Fuhrman, B., 24G. van Gorp, W., 495Galeazzi, G., 468Galietta, M., 271, 272Galli, V., 183Gammelgard, M., 419Ganzini, L., 507García Averasturi, L., 470Garcia, L., 195Garel, P., 575Gaskell, R., 446Gass, P., 472Gavaghan, C., 162Gavey, N., 441Geiger, B., 207, 215Geller, J., 84Geluk, C., 552Genefke, I., 497Geppert, L., 488Gervais, M., 564Gierowski, J.K., 48Gilchrist, E., 148Gill, P., 32Gillner, M., 99, 450Gioacchini, E., 68Gizewski, E., 202Glaister, J., 260Glaser, B.A., 190Gledhill, K., 316Glover-Thomas, N., 234, 235Goethals, K.R., 137Goldbeck, L., 555Goldberg, L., 19Goldberg, S.G., 324Goodstein, L.D., 52Gore, K., 585Gorman, T., 361, 408Gould, K.K., 317Graf, M., 30, 31, 311Gramingna, R., 312Gravier, B., 578Gray, G., 530Gray, J.E., 21, 75, 84Greathouse, S., 61Greenberg, J.A., 262Greene, E., 271Greenfield, D.P., 102, 450Greenslade, J., 186Greeven, P G.J., 398Gregurek, R., 369Gretenkord, L., 424Gretton, H., 532

605Grey, H., 110Grigor, J., 224Grinshpoon, A., 303, 304, 305Grisso, T., 275, 443Groenen, A., 468Groleau, R., 584Groscup, J., 271, 272Grotberg, E.H., 538Grünberger, J., 487Guerreschi, C., 72Gumpert, C., 199Günte, M., 222Günter, M., 277, 559Gurrera, M., 145Gustavson, C., 130Gutschner, D., 223, 393, 429, 552Hadjipavlou, S., 357Hadley, T., 342Haessler, F., 94Haier Levi, Y., 303Haled, R., 303Hamerlynck, S., 220Hampel, C., 364Hampel, G.,, 198Händel, N., 30Handelman, M., 88Hannan, B., 120Harder, H., 132Hárdi, L., 502Harding, W., 233Hardy, D.W., 122Hartford, K., 144, 145Hart-Kerkhoffs, L.A., 547Harvey, R., 340Hasegawa, T., 268Hashiloni-Dolev, Y., 265Hashizume, K., 372Havemann, P., 463Hawkins, P.J., 86Hazlett, G., 313Hazlett, H., 314Healy, B., 78Healy, D., 115Hébert, J., 566Hebert, M.R., 217Hedlund, B., 465Hedrick, C., 282Heer, M., 312Hegendörfer, G., 179Heide, K.M., 54Heikkilä, L., 549Hellblom Sjogren, L., 196Herdoiza-Estevez, M., 396Herrmann, F., 349Hertling, I., 487Heslop, L., 145Hill, J.L., 163Hinrichs, G., 376Hirschfield, A., 523Hodgins, S., 418, 435Hodgkinson, P., 127Hogue, T., 357Hoke, C., 292Holdman, S., 237, 409Hollander, A., 41Holmes, D., 92Hooijschuur, A., 192Hoover, D.B., 240Hopkins, C.Q., 520Hora, P.F., 517Hotopf, M., 37, 39Houeland, T., 306Hougen, H.P., 499Houidi, A., 590Houston, P., 464Hovens, H., 369Howells, K., 355Howie, P., 218Huchzermeier, C., 377, 378, 423Huizenga, H., 204Hummel, P., 279Humphries, D., 340Hustoft, K., 306Hutchinson, T., 402Hutschemaekers, G., 432Inciardi, J., 490Inciardi, J. A., 17Inge Genefke, 497Ingvarson, M., 168Ipperciel, D., 27Ireland, J.L., 438Irwin, J., 539Isasi, R.M., 141Jackson, S., 133Jacob, M., 576Jacobs, S., 376Jacobson, R.B., 302Jacobsson, L., 477Jacobsson, M., 41Jaffe, H., 496Jahn, K., 108James, D., 146, 468Janssen, W.A., 431Janus, E.S., 452Jasanoff, S., 19Jebara, M.B., 590Jetzes, M., 192Jiang, S., 104Jing, Z., 491Jinian, H., 111Johnston, J., 252Johnstone, G., 177

606Jones, R., 216Joshi, V., 332Jung, P.B., 263Jung, S., 459Kachigian, C., 122Kageyama, J., 546Kahana, J., 258Kalatiaia-Heino, R., 45Kalinowsky-Czech, M., 49Kallert, T., 179Kandelia, S., 126Kane, E., 353Kanter, A.S., 225Kaplan, L., 288Kasper, S., 344Kastrup, M., 243Kates, N., 186Kavanagh, D., 486Kedote, M., 412Keller, R.C., 300Kemp, S.F., 261Kennedy, A., 505Kennedy, B., 364Kennedy, H., 33, 379, 380, 381Kennedy, M., 34Kern, D., 559Keys, M., 319Keywood, K., 142Khan, P., 90Khazaal, Y., 567Killeen, M., 325Kimsma, G.K., 507King, W., 288Kingswell, W., 488Kisely, S., 79, 81Kiss, C., 31Kitchener, P., 167Kitzberger, R., 544Kjellin, L., 138Kleijwegt, M., 281Kleinpeter, C.B., 207Klinteberg, B., 557Knopp, M., 330Knudsen, K.., 339Kochansky, G.E., 349Kodituwakku, P.W., 106, 249Koehn, C., 133Koenraadt, F., 155Köhler, D., 376Kojimoto, M., 268König, F., 436Konrad, N., 95, 438Konradsson, P., 206Koob, G., 11Koplin, A., 226Korr, W., 337Koss, M.P., 520Kottler, C., 568Kouratovsky, V., 536Kovera, M., 61, 273Krauss, D., 274Krauss, D.A., 272Krautgartner, M., 502, 506Kriegler, J.A., 372Krischer, M., 391, 392Kriveloya, A., 337Kruger, A., 244Krüger, T., 202Kruttschnitt, C., 307Kuehnle, K., 53Kühne, A., 50Kühner, C., 472Kulwicki, A., 341Kuyvenhoven, J., 406La Fond, J.Q., 521Laberge, M., 600Labrecque, J.F., 584Lafleur, P., 565Lafortune, D., 550Laishes, J., 437Lamarre, C., 581Lambert, J., 593Lamothe, P., 568Landry, P., 577Langenaken, E., 599Lapierre, D., 585Larsson-Kronberg, M., 484Lasker, R.D., 384Lasry, A., 207Laudy, D., 412, 414Laugharne, J., 253Laugharne, R., 253Lavorato, M. C., 104Lawson, L., 448Lawson, W.B., 343Lawton-Smith, S., 82Lazorthes, D., 580le Grand, B., 257Leccia, J., 600Lee, D.H., 272Lefebvre, J., 589Lehmkuhl, G., 391, 392Lehnecke, K.M., 152Lehoux, M., 274Leiper, R., 358Lemmens, T., 413Lendemeijer, B., 432Lenoff Zatzman, C., 525Leo, R., 106Leo, S., 67Leplow, B., 557Lepri, G., 278

607Lesch, O.M., 487Leutz, S., 277Léveillée, S., 589Levenberg, D., 384Levett, L., 273Lewis, O., 240, 241, 322Leygraf, N., 202Lezra, J., 297Liao, L., 266Lieberman, J., 272, 274Lindberg, N., 561Linden, A., 57Lindqvist, P., 199Linegar, P., 364Linehan, S., 379, 380, 381Linehan, S.A., 380Linzmayer, L., 487Lippel, K., 541Liss, H., 99Llusent, A., 550Lodewijks H., 390Lodewijks, H., 388Lohner, J., 437, 438Lord, G., 292Lord, K., 293Lorettu, L., 563Loughnan, A., 444Lowenstein, L.F., 538Lu, S., 183Lubit, R., 52, 373Lucas, M., 229, 230Lucire, Y., 467Lund, C., 130Lurie, S., 87, 329Lusignan, R., 597Lutjenhuis, B., 258Luzzago, A., 452, 471, 542, 547Mackay, R., 118MacKenzie, R., 473Maclean, A., 21MacPhee, C., 364Maden, T., 359Madsen, L., 366Maeve, K., 211Magner, E.S., 451Majodina, Z., 335Malingrey, F., 418Mallia, P., 415Malmquist, C.P., 233Manning, N., 354Manson, A., 74Manzi, G.S., 69Marcoux, I., 510Margolin, J., 304Markwell, H., 309Marleau, J.D., 597Martin, F., 402Martin, N., 173Martin, N.T., 541Martin, W.M., 111Marzi, L.M., 274Mastronardi, V., 63, 64, 66, 67, 68Matravers, M., 387Matschnig, T., 436Matsubara, S., 269Matthews, D., 356Matthieu-Darekar, S., 567McAdam, J., 403McArthur, M., 439McCay, A., 103McClelland, R., 161McCutcheon, J.P., 118McDermott, B., 422McDonald, J., 190McEwan, T., 473McGrady, L.B., 238McGuire, J., 196McKenna, B., 85, 216McKenzie, R., 469McKibben, A., 568, 587, 588, 593McLellan, T. A., 15McNamara, D., 447McPherson, S.B., 326, 513McSherry, B., 239Meier, R., 260Melamed, Y., 411Melega, V., 232Mendelson, D., 57Mendelson, G., 75Mendini, A., 63Menghini, M., 582, 583Mercier M., 572, 573Merikangas, J.R., 125Merson, J., 466Mester, R., 85, 304Mewhinney, K., 171Meyer, P.N., 121Millaud, F., 587Miller, A., 222Miller, E., 332Miller, J.G., 457Mills, M.J., 51Ming, C., 183Mirzaei, S., 246, 247Mishara, B.L., 493Modena Group on Stalking, 468Moeller, A., 105Molewijk, B., 433Monette, R.A., 286Monico, R., 452, 542Monks, S., 379, 380, 381, 382Moore, J.M., 149

608Moore, P., 241Morgan, C.A., 314Morgan, M., 440Morin, D.C., 595Morissette, J., 593Morland, I., 262Mormont, C., 563, 598Morrison, A.M., 148Morrison, D., 594Morrissey, J., 463Mortier, F., 508Morton, L.H., 528Mossallanejad, E., 530Mullins, M., 242Mulvany, J., 143Murphy, J., 388Murray, G., 395Muschang, V., 416Musisi, S., 503Muthu, Y., 513Mychajlowycz, R., 99Myers, J., 328Nachmany Albeck, D., 303Nadelson, C.C., 210Nader, M.A., 13Nakatani, Y., 269Nakhaie, M.R., 561Nardi, B., 65Nauta-Jansen, L., 552Nauta-Jansen, L., 220Navarro, M., 578Nelson, C., 344Nemetz, T., 87Newman, L., 403Newnam, S., 186Neylon, N., 151Nicole, A., 588Nieuwold, M.,, 489Niklaus, P., 393Nilsson, H., 130Nilsson, T., 128, 129Nivoli, G., 563Noble, J.H., 255Nordström, A., 478Norton, L., 373Nourse, V., 298Novak, D., 290, 509Nützel, J., 555O’Brien, A., 78, 79, 88O’Brien, A.J., 83O’Brien, N., 14O’Connor, M., 271, 272O’Hagan, P., 168O’Neill, E., 33O’Reilly, R., 21Öberg, D., 484Oei, K., 152, 153, 155, 156, 204, 205, 535, 536,537Ofshe, R., 106Ogden, T., 186Ogloff, J.R.P, 416Ogloff, J.R.P., 473Oh, R., 339Ohene, S., 113Ohn, T., 207Ohnesorge, J., 298Olive, M.E., 125Oluboka, O.J., 91Onchev, G., 180Oolders, H., 158Ordan, H., 207O'Reilly, R.L., 75Organ, P.G., 334Orkopoulos, M., 253Ortiz, E., 112Östman, M., 478Overdijk, M., 434Owen, B., 215, 539Paap, K, 165Pacheco, A., 214Pagán, V., 280Paiva, C.A., 44, 492Palassis, S., 514Palermo, G.B., 53Palmstierna, T., 200Paquette-Warren, J., 186Parker, M., 510Parsons, S., 59, 367Parzen, M., 116Passweg, V., 500Pathé, M., 473Patton, L.M., 23Paul, T., 202Pegoraro, R., 19Penn, J.V., 276Penrod, S., 195Peppin, P., 57Perera, U.C.P., 498Peres Day, V., 149Perez, E., 310Perlin, M.L., 317Perron, A., 92Persons, N., 54Persons, R.W., 54Peternelj-Taylor, C., 97Petrila, P., 146Petrunik, M., 454Pham, T.H., 417, 419, 582, 583, 590Philipse, M.W.G., 425Phoenix, A., 209Picard, P., 574Pilch, F., 383

609Plattner, B., 553Plyley, C., 89Pogorzelski, W., 165Pollard, K., 359Poloni, V., 547Pomilla, A., 68Ponizovsky, M., 305Pontius, A.A., 147Popma, A., 558Porter, S., 231Pot, M., 345Poustka, F., 558Powell, M., 467Prause, W., 506Preisig, M., 567Preston, N., 79, 81Preumont, M., 598Preuss, U., 223, 280Prior, P.M., 244Proulx, F., 570Puig-Verges, N., 595Pullan, S., 96, 99Pullman, D., 142Purcell, R., 467, 473Putkonen, H., 307Quanbeck, C., 421Quenneville, R., 576Qurashi, I., 46Racette, I., 584Radford, M.F., 37Raitt, F., 348Ramskogler, K., 487Ramskogler, K., 492Rasio, E., 169Rasmussen, M., 241Rasmussen, M.A., 323Rasmussen, N., 115Rasmussen, S., 504Ratté, C., 579Rauxloh, R.E., 336Reaume, G., 318Recordon, P.J., 525Recupero, P.R., 62Redding, R.E., 195Reddy, R., 127Reed, T., 466Rees, G., 38Reiner, W.G., 266Reinfried, L, 344Reinhold-Hurley, B., 376Rennie, C., 556Renteln, A.D., 117Resinger, E., 216Resinger, E., 146Resinger, E., 344Rhodes, L.A., 499Ricci, G.R., 283Ricci, P. L., 289Rich, R., 338Richard Lusignan, 597Richard, C., 567Riches, V., 453Ridgway, D.A., 51Ridha, R., 590Rigonatti, S.P., 453Rijk, A., 461Riopel, L., 586Rioux, M., 226, 321Robbins,T., 12Roberts, K.A., 470Robertson, R., 195Robitaille, G., 583Rodney, P., 28Rogaleva, L., 223Römer, K.D., 31Ronner, A.D., 528Roosenschoon, B., 160Rosca, P., 303, 305Rosenshield, G., 287Rosenthal, E., 227Ross, K., 549Roy, P., 364Ruchkin, V., 221, 548Ruden, A.M., 150Rutherford, A., 458Rutledge, E., 33Ryan Hart, T.A., 150Ryan, E., 443Rymaszewska, J., 181Sabatasso, S., 346Sabatello, U., 560Sacco, V.F., 561Sadowsky, J., 119Sahin, U., 246Sailas, E., 550Saletu, B., 98Sallmén, B., 482Sánchez-Caro, J., 62Sandland, R., 209Santana, S., 101, 189Santos, P., 586Saul, B., 385Saunders, J., 486Schalast, N., 201Scharfetter, J., 216Scharfetter, J., 146Scharfetter, J., 344Schedlowski, M., 202Scheela, R.A., 93Scheftsik, M., 462Schepker, R., 108, 110Scherf, M., 242

610Scheubmayr, S., 216Schiffer, B., 202Schmeck, K., 558Schmeck, K., 429, 552Schmelzle, M., 223, 280Schmid, M., 555Schmidl-Mohl, B., 544Schmidt, P.M., 294Schmidt-Felzmann, H., 20Schneider, E., 212Schneider, V., 96Schofer, J.W., 295Schoonberg, J., 348Schultz, W., 11Schulze, B., 475Schutgens, E., 399Schuthof, G., 153Schwab-Stone, M., 221Schwartz, S.J., 256Schweitzer, M.G., 596Scully, P., 256Seddon, N., 359Segal, S.P., 80Segraeus, V., 485Seidl, C., 404Seifert, D., 202Sekhukhune, D., 230Seki, F., 173Serafim, A.P., 453Sevecke, K., 391, 392Sexton, T.L., 187Shamian, J., 29Sharav, V.H., 255Sharpe, G., 335Sharples, J., 329Shearer, R., 191Shelton, D., 556Shepherd, N., 430Sheridan, L., 472Sherman, J., 481Siddique, S., 210Siegel, J., 166Simalchik, J., 531Simard, M., 564Simms, K.E., 394Simpson, S., 216Sing, J.J., 117Sinn, T., 446Sivasubramaniam, D., 175Sjodin, A., 128, 129Sjöström, S., 41Skeem, J., 200Skene, L., 509Skipworth, J., 401Skufca, J., 89Slaby, A., 494Slatter, M., 59Smit, E., 548Smith, G.P., 22Smith, M., 79Smye, V., 116, 137Solan, L.M., 290Solodova A., 258Solomon, E.P., 54Soltys, S.M., 124Somers, S.B., 175Sørensen, B., 496Soucy, L., 364Southwick, S., 315Spence-Laschinger, H.K., 29Spencer, J., 26Spencer-Carver, E., 213Spitalnik, D.M., 254Spitzer, C., 99, 450Spybey, M., 359Srinivasaraghavan, J., 121Stadler, C., 558Stahlberg, O., 128Stanislaus, A., 124Stanoiu,, 573Stanoiu, R.M., 571Stark H., 264Starkman, B., 345Starling, J., 218Steele, J., 426, 427, 428Stefurak, T., 190Stephens, R., 337Stetler, R., 128Stevenson, C., 133Stewart, D., 89Stitt, L., 145Stone, D., 336Stone, M.H., 151, 300Stopsack, M., 450Stowell, B., 187Strano, M., 69, 70, 71, 72Strnad, S., 98Struijk, A., 153Stuart, H., 475, 479Studer, L., 455Stupperich, A., 360Susan Bandes, 527Svensson-McCarthy, A., 245Sycha, T., 544Syse, A., 324Sytsma, S.E., 263Tägnfors, U., 129Tait, T., 168Takayanagi, I., 270Tancredi, L., 20Tancredi, L.R., 352, 493Tardif, M., 574

611Tavanti, M., 112Taylor, G., 291Taylor, S., 82Telles, L., 191ten Wolde, A.C., 259Teran Suarez, J.M., 511Terra, J., 585Thain, G.J., 294Thaman, S., 76Tholen, F., 365Thom, R., 228Thomas, C.R., 276, 444Thomas, L,, 34Thompson, A.H., 476Thompson, T.C., 351Thomson, L.D.G., 426, 427, 428Tilse, C., 171Timmins, D., 35Tivendell, J., 365Tizzani, E., 65Toib, A., 119, 444Toker, M., 109, 203Tolson, G.H., 482Torres-González, F., 181Tóth, M., 205Trad, A., 590Trent, D.R., 539Trentelman, M., 489Trépanier, J., 583Triffault, O., 578Troudi, H., 590Trudeau, N., 579Trudo Lemmens, 412, 413Tschan, W., 470Tucker, W., 97Tuinier, S., 203, 206Türkmen-Barta, L., 280Turkovic, S., 370Turner, T., 90Tyszkiewicz, M., 430Urcelay, J.R., 360Valeriy, M., 404van Beest, R.H.P., 159Van de Veen, S.L., 516van den Brink, R., 192, 365van der Meer, C., 159van der Pol, R., 156van der Wal, G., 507van der Werf, B., 409van Domburgh, L., 552van Essen, F.J., 157van Gorp, W., 52van Hummel, E., 157van Kalmthout, A.M., 204van Lankveld, J., 135van Maren E. J., 389van Marle, H., 137, 406van Os, T., 157van Outsem, R., 278van Rensburg, B. J., 229van Rensburg, B.J., 229Van Rybroek, G.J., 534van Veldhuizen, J. R., 160Vasquez, J., 238Vecht-van den Bergh, R., 347Vees, S., 277Vermeiren, R., 47, 220, 221, 548, 552Vezzoni, C., 22Victoroff, J., 131Vieira Filho, A.H.G., 453Villanova, M., 63, 64, 66, 67Vingilis, E., 24, 186Vlahov, D., 16, 491Vocci, F. J., 15Völkl-Kernstock, S., 371Volkow, N., 13Volpert, T., 19Vreugdenhil, C., 533, 554Waldman, E., 524Walker, J., 519Wallace, R., 282Wallot, H., 569Wallsten, T., 138Walsh, B., 408Walsh, E., 420Walsh, J., 371Walter, H., 487Walther, M., 223Wandel, L.P., 293Wang, G.J., 18Wang, X., 192Ward, T., 194Waring, D.R., 412Warren, J.I., 308Waters, T.F., 523Watson, W., 386Weagant, B., 55Webanck, T., 586, 592Webster, C., 27Weinkove, J.V., 229Weinrich, M., 377Weinstein, J., 352Weinstein, R., 351Weisman, R., 387Weissman, M.M., 134Weisstub, D.N., 268, 270, 288, 493Welsh, J., 247, 506Wenzel, T., 98Wenzel, T., 503Wenzel, T., 506Werckle, G., 455Westerborg, M., 153

612Wexler, D.B., 526White, P., 105Whittle, N., 45, 109Widdershoven, G., 433Wienerroither, E., 98Wiersma, D., 192, 365Wilcox, D.T., 368Wilde, Z., 524Wilf, S., 285, 301Wilk, P., 29Wilkerson, B., 545Willemsen, J., 461Willenbacher, B., 47Williams, N.H., 331Williams, R., 560Willocq, L., 582, 583Wilson, J.P., 370Wilton, J., 163Winick, B.J., 521Winthorst, W., 365Witztum, E., 304Woellner, R., 143Wolff, N., 166Wolowitz, D., 349Wolpert, A., 283Woods, C., 459Woods, G.W., 409Woods, K., 330Woods, M., 250Woodworth, M., 231Wool, R., 97Wright, B., 379, 380, 381Xiao, J., 79, 81Yelpaala, K., 296Young, J.L., 208Young,, R., 486Zanoli, M., 560Zaqoud, R., 505Zeedyk, S., 210Zetler, J., 143Zhang, E., 182Zuckerberg, J., 318