Seattle University Collaborative Projects - International Academy of ...

Abstracts of the XXXIIIrd International Congress onLaw and Mental HealthRésumés du XXXIIIe Congrès International de droitet de santé mentaleDavid N. WeisstubChair/PrésidentUniversité de Montreal,Institut Philippe-PinelMontréal, CanadaNH Grand Hotel KrasnapolskyAmsterdam, the NetherlandsJuly 14 th – 19 th , 2013Under the auspices of:International Academy of Law and Mental Health1

PATRONAGEDutch Ministry of Justice2

INTERNATIONAL SCIENTIFICCOMMITTEEDavid N. WeisstubChairUniversité de Montréal/Institut Philippe-PinelHenrik AnckarsäterCo-ChairUniversity of GothenburgNorbert KonradCo-ChairFree University of Berlin (Charité)Machiel PolakChair, Local OrganizingCommitteeForensic Psychiatric Center deKijvelanden, PoortugaalHjalmar van MarleChair, National ScientificCommitteeErasmus University of Rotterdam3

TABLE OF CONTENTSEnglish Language Sessions1. Pre-Conference – Baruch Spinoza: Life, Psychology, and Law2. A 21 st Century Education for the Medico-Psycho-Legal Practitioner:Principles, Research, Methods, and Practice3. Accountability and Moral Responsibility4. Accountability, Responsibility, and Criminal Intent5. Addiction6. Addressing Difference: Recognise and Accept, Don’t Discriminate7. ADHD8. Adult Craziness in Children’s Law Policy: How Debates overChildren’s Welfare and Rights Reveals the Personal Trauma andUnconscious Fears of the Adults9. The Application of Mental Health Care Law in South Africa withReference to the Defence of Non-Pathological Criminal Incapacity– Trends and Developments10. Applied Research in Law Enforcement, Mental Health, and CrimePrevention: Seattle Police Department – Seattle UniversityCollaborative Projects; Development, Implementation, andEvaluation11. Assessment and Treatment of Psychopathy in Clinical Practice12. Assessment, Intervention, and Program Evaluation in a PreventionProgram for Intimate Partner Violence13. Assessment, Treatment and Ethical Issues in Sex Offenders14. Behavioral Approaches within the Criminal Justice System: FromPolicy to Practice4

15. Bio-Psycho-Social Research in Forensic Child and AdolescentPsychiatry16. Bosnian War and its Causalities: The Voices of Concentration CampPrisoners, Refugees, and Survivors17. Bringing Lawyers and Healthcare Professionals Together inTeaching, Decision-Making, and Standard of Care18. Building a Bio-Psycho-Social Response to Intimate PartnerViolence19. Bullying20. Capacity and Incapacity21. Capacity, Incapacity, and Impaired Decision Making – TheChallenges of Providing Support and Protection in the ScottishContext22. Child Abuse: Outcomes & Implications23. The “Choosing Wisely” Movement24. The Clinical, Forensic, and Ethical Pitfalls of the DSM-525. Collaborative Care Arrangement Between Hunter New EnglandMental Health Services & Mental Health Non-GovernmentOrganizations26. Combination of Needs27. Community-Based Compulsory Treatment: Emerging Findings fromthe UK and International Perspectives28. Community Treatment Orders29. Components of Mental Health Courts Influencing Clinical, CriminalJustice and Recovery Outcomes30. Compulsory Community Care31. Conflict and Compromise: Research and Practice in ImmigrationAssessments in Australia5

32. Considerations on Setting the First Canadian Examination onForensic Psychiatry33. Correctional Mental Health in the U.S.A.34. Crime and Psychotic Spectrum Disorders in Greece35. The Crisis Intervention Team Model of Police Response to Personswith Mental Illnesses: Outcomes, Barriers, and Future Directionsfor Research36. A Critical Exploration of Pressing Ethical, Clinical & SpiritualIssues in Acute Psychiatry through to Community Care in Canada37. Critical Issues in the Treatment of Mentally Disordered Prisoners38. CRPD39. Cultural Diversity and Mental Health40. Current Challenges in South American Forensic Psychiatry41. Dangerousness and Social Control: A Continuation42. The Death Penalty43. Decisionally Impaired Older Persons: Challenges and Opportunitiesfor Interprofessional Collaboration44. Dementia45. Developments in Brazilian Forensic Mental Health and its Interfacewith the Law46. Developments of Prison Mental Health Care in the Netherlands47. Diagnostics, Assessment, and Treatment in Psychotic Offenders48. Diminished Capacity and Incapacity in the Criminal Law Context49. DIS-CAT 2.0 A Swedish Prison Project: A Study of Young Violentand Sexual Swedish Male Offenders50. Diversion from the Criminal Justice System: Initiatives in the UKand Australia51. Domestic Violence6

52. Drug Safety and Women’s Health53. Eating Disorders54. Education & Social History55. The Effectiveness of Correctional Interventions with SpecialPopulations56. The Elderly/Aged Persons57. Emerging Practices in Prison and Jail Re-Entry: Managing Risk andPromoting Treatment Engagement58. Employment59. Ethical Implications of an Economic Framework for Mental HealthCare in the Netherlands60. Ethics61. The Evolution of a High-Security Forensic Hospital towards BetterEvidence-Based Practices: Past, Present, and Future Trends; TheExperience of Institut Philippe-Pinel de Montréal62. Examining the Incidence and Consequence of the Involvement ofFemale Staff and Female Inmates in Abuse in Prison: AComparative Perspective63. The Expert Witness as Defendant64. FASD and the Law: The Need for a Targeted Therapeutic Response65. Fetal Alcohol Spectrum Disorders (FASD) and Criminal Justice66. Fetal Alcohol Spectrum Disorder in Modern Society: A Disabilitywith a Difference67. Forensic (Adolescent) Psychiatry, Criminal Responsibility andTreatment Procedures68. Forensic Psychiatry69. The Future Direction of Forensic and Criminal Justice MentalHealth Services70. Hate Crimes7

71. Healing Inhuman Trauma: Obstacles, Successes and New Tools toCreate Civil Society72. Historicizing Mental Health Law and Policy in Japan73. History74. Homelessness75. Human Rights and Mental Health of Women in the Context ofReligious Freedom76. Hybrid Correctional Centre – Mental Health Centre: The SecureTreatment Centre Model77. Impaired Offenders78. Indirect Measures in the Evaluation of the Clinical TreatmentProcess79. Innovation in Mental Health Shared Decision Making Policy,Practice, and Research80. Innovations in Mental Health Care81. Innovative Services at the Front End of the Juvenile Justice System82. Intellectual Disabilities83. The Interface of Older Adults with the Civil and Forensic MentalHealth Services in the United Kingdom84. Interpersonal Care in Psychiatry85. Intimate Partner Violence: Theory and Practice86. Involuntary Admission and Treatment in Norway: Principles andPractice87. Involuntary Outpatient Treatment88. Involuntary Treatment and Hospitalization89. Issues Arising from the Detention of Children with Mental Disorderin Scotland90. Jail and Mental Illness: Designing a Care System Based onEmpirical Evidence and Program Evaluation8

91. Juveniles/Youth92. Law and Emotions I93. Law and Emotions II94. Law and Representations of Social Pathologies95. The Law and Vulnerable Populations96. Law Enforcement and the Police97. Law’s Passions I: Is the Impartiality of the Law Threatened byRecognition of its Emotional Power?98. Law’s Passions II: The Emotions and the Rules of Evidence99. Legal Frameworks, Rights and Care for People Who Lack Decision-Making Capacity100. Legal Issues in Child Abuse101. Legislation and the Effectiveness of Mental Health Law102. Linguistics: Theories of Education and Inter-Relationship103. Longitudinal Follow-Up Studies in Swedish Forensic Psychiatry:Perpetrators of Sexual Crimes and Recidivism104. Longitudinal Follow-Up Studies in Swedish Forensic Psychiatry:Risk Factors, Patterns of Recidivism and Prediction105. Management of Mentally Ill Offenders in the Community: MentalHealth Courts and Beyond106. Medical Errors and Safe Patient Management in Psychiatry107. Medico-Legal Implications of Social Media108. Mental Disorders in German Adolescents High at Risk forOffending109. Mental Health & Death Row110. Mental Health and Law in Korea111. Mental Health Policy and Governance9

112. Mental Health Research with Minors: The Ethical FrameworkRevisited113. Mental Health, Rights, and the Law114. Migration115. The Need for Sustainability and Continuity in Forensic Psychiatry116. Neuroscience117. Non-Pharmacological Treatments of Aggression118. Offender, Offender Behavior, and Collateral Consequences119. Offenders and Inmates120. Overarching Perspectives on Forensic Psychiatry in the Early2010’s121. Personality and Aggression122. Personality and Behavioral Disorders123. Perspectives on Assessing Risk for Sex Offender Recidivism: TheDebate Continues124. Post Traumatic Stress Disorder (PTSD)125. Post Traumatic Stress Disorder and the Law: Civil and CriminalAspects from a North American Perspective126. Practicalities of a Best Practice Use of Force Model when Workingwith People in Psychiatric Crisis127. Pre-Trial Forensic Mental Health Evaluations in the Netherlands128. Prevention of Antisocial Behavior in Children and Adolescents:Ethical, Social, and Philosophical Aspects129. Prevention of Suicide130. Prison Mental Health and Forensic Care in a Changing Society131. Prison Psychiatry I132. Prison Psychiatry II133. Problem-Solving Courts10

134. The Prognosis of Psychiatric Diseases135. Prostitution and Human Trafficking136. Psychiatric and Psychological Autopsy, the Alphen Spree Shooter137. Psychopathology behind Razor Wire: Mental Illness in JuvenileJustice138. Psychopaths: How They Think, Act and Benefit from Treatment, aNeurobiological Perspective139. Psychopathy140. The Quality Circle of Forensic Science: Creating Awareness forthe Forensic Science Area 2020141. Quality of Life in Forensic Mental Health (Medium Secure Units)142. Reduction of Coercive Measures in Psychiatry143. The Research – Policy Interface in Mental Health, SubstanceAbuse, Juvenile and Adult Criminal Justice144. Restorative Justice and Elder Abuse145. Rights, Risk of Harm, & Decision Making Capacity: InternationalResponses to Involuntary Psychiatric Treatment in Light of theCPRD146. Risk Assessment147. Risk and Protective Factors Influencing Criminality for Offenderswith Mental Disorders: Implications for Interventions148. Risk Assessments of Domestic Violence: Perspectives of theCourt, Forensic Science, and Jurisprudence149. Risk Assessment, Social Network Approach, Single Case Statisticsand Music Therapy Related to Forensic Psychiatric Patients150. Sane Enough (for What)? Mental Capacity in CriminalResponsibility and Competence151. Seeking Reform11

152. Self and Other: Conceptual and Empirical Aspects of Identity andDifference153. Sex Fiends, Perverts, Pedophiles, Monstrous Crimes: How ShallWe Understand Policy in the Light of Disgust and Moral Failure?154. Sex Offenders and Public Policy: Bridging Research, Policy, andPractice155. Sexual Assault and Violence156. Sexual Offence157. Shifts in the Provision of Mental Health Care & ManagementInternationally158. The Social Construction of Risk in Mental Health and JusticeSystems159. Specialized Interventions for Persons with Serious Mental Illnessesin the Criminal Justice System: Moving the Field Forward160. Stalking161. Suicide and Assisted Suicide162. Tales of the Unmet Needs: Mental Health in Juvenile Justice163. TBS: Ethics and Treatment164. Terrorism165. Theory and Research in Criminal Psychology I166. Theory and Research in Criminal Psychology II167. Title T.B.A.168. Title T.B.A.169. Torture & Abuse170. Trauma171. Treatment Programs172. Two-Stage Sentencing12

173. Understanding and Improving Use of Community TreatmentOrders174. Using Mental Health Legislation and Coercive Interventions:Dilemmas for Professionals and Service Users175. United Nations Convention on the Rights of Persons withDisabilities: What Does it Mean for Mental Health Law andPractice176. Victimization and Women Offenders177. Victimization, Workplace Aggression, Vulnerable Groups andVictim Rights178. Visual Evidence: Perception, Psychology, Courtroom Practice, andPolicy179. What the Public and the Health Care Profession Today Needs toLearn from Medical Profession Practices which Preceded andAccompanied the Shoah 1939-1945180. Witnesses and Expert Evidence181. Women and Families in Adverse Life SituationsTherapeutic Jurisprudence Sessions182. Achieving a More Therapeutic Health Care System183. Changing the Profession and the Law School Experience – Part I184. Changing the Profession and the Law School Experience – Part II185. A Disability Rights Tribunal for Asia and the Pacific: InternationalHuman Rights and TJ Implications186. Examining Disability Law in Theory and Practice: A TherapeuticJurisprudence Analysis187. Expanding TJ’s Boundaries188. International Human Rights and Mental Health Courts13

189. International Human Rights & TJ190. Judging and Practicing in a Problem-Solving Court: Tips andTechniques191. Justicia Terapéutica: Delincuencia y Drogas192. Justicia Terapéutica y entorno familiar y de pareja193. Justicia Terapéutica y Misceláneas194. Justicia Terapéutica y Salud195. Learning about Human Behavior and Dispute Resolution196. Lessons of TJ for Courts Beyond Problem-Solving Courts197. Manifestaciones de justicia terapéutica en el proceso penal español198. Reconsidering “Injury”: Applying TJ Principles to Litigants inNon-Criminal Courts199. Sustainability of and Lessons Learned from TJ JudicialInnovations200. Therapeutic Jurisprudence and Criminal Court Proceedings201. Therapeutic Jurisprudence and Multisensory Law202. Therapeutic or Anti-Therapeutic? Health Care Policy Choices inthe United States203. Thinking about Victims from a TJ Vantage Point204. TJ & Criminal Procedure: International Perspectives205. TJ and the Judicial Process in Cases Involving Children206. TJ & Higher Education207. TJ and Mental Health Law208. TJ & Victims’ Rights209. TJ, Parenting and Best Interests of the Child in Family Law210. TJ & Restorative Justice: Exploring Linkages211. Understanding and Testing the Theoretical Underpinnings of TJ14

212. Using TJ to Improve the Criminal Justice System I213. Using TJ to Improve the Criminal Justice System II214. The Well-Being of Clients and Victims215. The Well-Being of LawyersFrench Language Sessions216. Les problèmes de santé mentale en milieu carcéral217. La gestion de la perception du risque de violence en psychiatrie :des alternatives à l’atteinte aux droits des personnesSpanish Language Sessions218. Bioética y Toma de Decisiones en la Práctica Médica Asistencial219. Chile: Innovaciones legislativas, mobbing político, y permisosmédicos psiquiátricos: ética institucional, confidencialidad, calidadde las prestaciones en salud220. Chile y Argentina: Indicadores de Abuso Sexual, Parricidio-Filicidio, y aspectos deontológicos de nuevas leyes regulatorias,derechos del estado vs. del paciente221. La Enfermedad Mental y sus Cuidados en las Prisiones222. La Hospitalización Involuntaria y otras Medidas de Coerción223. Legislación, Derechos Humanos y Discapacidad Mental enAmérica Latina y el Caribe, y en España224. Title T.B.A.Italian Language SessionsT.B.E.*15

* T.B.E. – To Be EditedABSTRACTSEnglish Language Sessions1. Baruch Spinoza: Life, Psychology, and LawSpinoza’s Ethics: A Framework for Human-Animal Relations?Anne Benvenuti, Cerro Coso College Zygon Center (anne.benvenuti@gmail.com)In this paper I explore the potential of Spinoza’s Ethics as a framework for conceptualization ofthe theoretical underpinnings of the relationship of humans to non-human animals. Westernphilosophy has long posited a “great divide” between humans and non-human animals, basedprimarily upon the human capacity for rational thought as articulated by Aristotle and furtherconstrained by Descartes and Spinoza in the observation that humans evidence reason throughuse of language. Many ethologists cite Cartesian dualism, particularly Descartes’ formulation ofanimals as machines lacking true internal experience, as the broadly accepted basis for thecommonly held notion that non-human animals are things to be used.The explosion of knowledge in the biological sciences since Watson and Crick’s 1953 discoveryof the structure of DNA, and especially in animal studies since Jane Goodall’s first reports on thechimpanzees at Gombe in 1964, has challenged the long-held assumption that there is a greatdivide between humans and other animals. Numerous studies across a spectrum of animalspecies and scientific interests have found evidence of thought, feeling, intention, and languageamongst non-human animals. Congruent with these findings the biological sciences andespecially ethology emphasize evolutionary continuity. The evolutionary continuity emphasismay be harmonious with Spinoza’s dual aspect monism and particularly with his denial of anyhard and fast boundary between human beings and everything else in nature; and Spinoza’sEthics may offer an instructive viewpoint from which to examine or reexamine the problems andthe possibilities for development of a fresh theoretical approach to human animal relationships.16

Spinoza’s Ethics and Mental HealthDavid Novak, University of Toronto (david.novak@utoronto.ca)The most famous, and by all accounts, the best philosopher to have ever lived in Amsterdam wasBaruch Spinoza (1632-1677). Though we usually consider Spinoza to be a metaphysician, healso had a well thought out ethic, one that spelled out what a harmonious human life could be. Aharmonious human life is one we would consider to be mentally healthy. Spinoza was certainlyinfluenced greatly by the famous adage of the Roman poet Juvenal (who was following an earlieradage of Thales, the earliest known Greek philosopher): “a healthy mind [mens sana] in ahealthy body [in corpore sano].” This is an excellent precedent for Spinoza, since he saw themind and the body to be two aspects of the same unified person, so that one cannot reduce thebody to the mind or reduce the mind to the body. Body and mind must be correlated at everylevel. Though mental/physical (what we would call “psychosomatic”) health is the main concernof his ethic, a person still has more control over their mind than they do over their body,nonetheless. That is why Spinoza’s ethic is meant to be therapeutic philosophy, i.e., it is meant toteach truly thoughtful persons how they can live a fully rational harmonious life. That life is onedirected by a supreme love, and it is a life of a person who learns to overcome love’s opposite,which is not hate but fear. So, concerning that mentally healthy person, Spinoza writes: “A freeman thinks of nothing less than of death, and his wisdom is a meditation on life, not on death.”(Ethics IV/prop. 67) This paper will critically explore what kind of love enables a truly free,healthy person to overcome the fear of death, which for Spinoza is most destructive of aharmonious human life.The I that Is We: Rethinking Moral Agency Without Free Will and in terms ofDiscoveries in the New Brain SciencesHeidi Ravven, Hamilton College (hravven@hamilton.edu)This presentation presents a range of neurobiological and other evidence from the new brainsciences that we must relinquish the notion of free will as the source of moral agency and moralresponsibility. It refers to Damasio’s neural self-mapping and mechanisms of homeodynamicstability, mirror neurons, Panksepp’s seven basic emotional systems as contributory sources ofour human moral capacity. It argues that locate a basic biological striving in a self distributedbeyond our skin into our environments, natural and human. This is why we care about the worldand why it is the arena of our moral concern and of our ideals. As a consequence must rethinkmoral responsibility in terms of the actual scope of its agents --from the individual to the groupand even beyond that to agents that span historical time periods.17

Maimonides and Spinoza: How two thinkers with similar intuitions came to verydifferent conclusionsKen Seeskin, Northwestern University (k-seeskin@northwestern.edu)This presentation explores how two rationalist philosophers seeking to avoid anthropomorphicconceptions of God came to very different conclusions about how to respond to that God.Maimonides' strategy was to stress our ignorance of God. If we cannot know what God is, thenany comparison between God and humans is immediately suspect. Spinoza's strategy was theopposite: to stress that we can know God but that there is no supernatural component to what weknow. The result is that while Maimonides' thought culminates in awe and humility in the faceof something too great for us to comprehend, Spinoza's culminates in a feeling of empowermentas we comprehend how everything follows from the essence of God. In this way, what is forMaimonides the highest virtue becomes for Spinoza a source of pain or weakness.2. A 21 st Century Education for the Medico-Psycho-LegalPractitioner: Principles, Research, Methods, and PracticeChanging Attitudes among Trainees: Whose Job is it?Brad Booth, University of Ottawa (bbooth@theroyal.ca)With the exponential growth of individuals with mental illness coming in contact with the law,psychiatric care for these individuals is at times difficult to find. Many psychiatrists do not haveexperience with the legal system and therefore may avoid treating this group of patients. Toclarify the attitudes of psychiatric trainees, a survey of senior Canadian residents at the nationalpsychiatry review course was conducted. Among the 145 respondents, only 24% had been taughton correctional psychiatry and only 29% had any experience. Nearly 56% had been taught onsexual offenders but only 27% reported having had experience with this population. Nearly 1/3reported they preferred not to deal with forensic issues and 43% preferred not to work withpeople with sexual offences. The data did show that teaching and experience with this populationappears to be a powerful tool in changing attitudes. Being aware of these barriers may assist indeveloping strategies to increase psychiatric service availability.Forensic Nursing Education: International Collaborations andMultidisciplinary PedagogyArlene Kent, University of Saskatchewan (arlene.kent@usask.ca)18

By the end of the twentieth century, forensic nursing educational programs began to appear inthe curricula of colleges and universities. The forensic focus has been a popular career choiceand area of study for many of the health science disciplines. By the mid-1990s, some of theearliest forensic nursing courses were established. Considering that the first Web-based coursewas not launched until 1995 in California (Bates & Poole, 2003), forensic nursing educationmade its online appearance on the global scene relatively quickly. Forensic nursing educators,supported by progressive administrators, used the technology to offer the first online forensiccourse in January of 1997, at Mount Royal University in Calgary, Alberta, Canada (Kent-Wilkinson et al., 2000). Today, courses exist at educational levels that range from certificate todoctoral programs. This presentation will focus on the power of using advanced technology andthe value of international collaborations in the pedagogy of multidisciplinary forensic courses.This session will also highlight findings of Dr Kent-Wilkinson’s research that explored manyaspects of forensic nursing education: definitions of forensic nursing, how forensic nursing rolesare different from other disciplines, the unique knowledge of this specialty, and social factorsinfluencing course development.Sexual Boundary Violations in the Forensic Mental Health MilieuCindy Peternelj-Taylor, University of Saskatchewan (cindy.peternelj-taylor@usask.ca)The ability to create and maintain treatment boundaries with forensic clients has been describedas one of the most important competencies required by clinicians practicing in forensic mentalhealth settings. When mental health professionals fail to establish or maintain therapeuticboundaries, they are at risk of “crossing the line” and becoming over involved with their clients.In practice, over involvement frequently leads to sexual boundary violations. This presentationgives voice to sexual boundary violations as discussed by nurses who participated in aphenomenological study exploring nurse engagement with forensic clients. Illustrated as a “realeye opener”, sexual boundary violations with forensic clients have grave clinical, ethical andlegal implications. And while the responsibility for establishing and maintaining professionalboundaries rests with the mental health professional, some would argue that many forensicclients are skilled at manipulation and exploiting situations for their personal gain, thuscontributing to a blurring of the lines of responsibility when sexual boundary violations do occur.It is hoped that participants will move toward a more complex understanding of sexual boundaryviolations that occur in forensic mental health, which may allow them to better enact theirrelationships with forensic clients. Heightened awareness and understanding of the nature ofsexual boundary violations within forensic mental health settings will, regardless of one’sprofessional discipline, contribute to effective risk management, thereby indicating the need forfurther research. Strategies need to be developed within forensic mental practice that deal withissues surrounding sexual boundary violations before, during, and after they arise.19

Law and Psychiatry Seminar: Meeting the Challenge of Medico-LegalEducation in the 21 st CenturyGlen Luther, University of Saskatchewan (glen.luther@usask.ca)The relationship between lawyers and doctors, especially psychiatrists with whom they workclosely, has been described as tenuous and riddled with miscommunication. The Law society ofCanada has introduced sweeping changes to enhance teaching in the colleges of Law. Beginningin 1976 the University of Saskatchewan has brought together senior law students and psychiatricresidents in a seminar course. This course first ran from about 1976 to 1986 with differentinstructors from those presently involved. The course was not offered for eighteen years and thenwas reintroduced in 2004. From 2004, the course has run yearly for 12-15 weeks betweenJanuary and April with one instructor from each discipline. The joint sessions are 90-120minutes each and revolve around a selected clinical case chosen to represent aspects of topics ofrelevance to law and psychiatry. These participatory and highly interactive sessions focus on atopic of the interface of law and psychiatry and involve a clinical interview, discussion of thelegal criteria and case law, as well as the psychiatric aspects of the case law and the clinical casein question. Participants are also afforded other law and psychiatry related activities andencouraged to attend. These include attendance at a tribunal hearing, visits to a psychiatrichospital as well as interactions with post-license practitioners in the two fields. The format hasreceived very positive reviews and evaluations by participants indicate that they feel prepared tobe involved in the post licensure world of practice, hopefully with better communication skillsand collaborative attitudes. These are essential as they are part of the core competencies expectedof Psychiatrists. The paper will describe the development, methods, practice and benefits of theinter-professional education Law and Psychiatry seminar.Psychology and LawTammy Marche, University of Saskatchewan (tmarche@stmcollege.ca)The primary objective of the undergraduate course in Psychology and Law at the University ofSaskatchewan is to show how psychological research and theory are used in a legal context,particularly in the Canadian legal system, with the goal of examining the role that psychologyplays in promoting justice in the legal system. The course provides a review of theory, content,research, methodology, and controversy in selected areas in the field of psychology and law(e.g., roles of forensic psychologists; police psychology; profiling, detecting deception,interrogations and confessions, psychology of the jury, criminal and civil forensic assessment,social justice). To enhance understanding of the role that psychology and psychologists play inthe legal process, members of the community who are involved in the legal system speak to theclass about their experiences. For the term assignment, students either write a research reportbased on their participation in a community-based research project or they write an amicusresearch brief on a topic of their choosing. By the end of the course, students have a better20

understanding of how the discipline of psychology contributes to the discipline of law and of thechallenges and responsibilities of psychologists in promoting justice within the law.3. Accountability and Moral ResponsibilityEmpathy Disorders and Moral EnhancementIda Hallgren, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(ida.hallgren@filosofi.gu.se)T.B.E.*Free Will, Blame and ResponsibilityFilip Radovic, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(filip@filosofi.gu.se)T.B.E.*Blame Attribution and Responsibility in Violent and Sexual OffendersMalte Johnsson, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(malte.johnsson@gmail.com)T.B.E.*Title T.B.A.David Brax, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(david.brax@gu.se)T.B.E.*21

Delusions and InsightSusanna Radovic, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(susanna@filosofi.gu.se)T.B.E.*4. Accountability, Responsibility, and Criminal IntentThe Concept of ResponsibilityAlva Stråge, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(alva.strage@gu.se)T.B.E.*Insight and Criminal Intent – A Comparative Study of the ConceptsTova Bennet, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(tova.bennet@hotmail.com)T.B.E.*Criminal Intent, Severe Mental Disorder and Unaccountability (The SwedishCase)Christer Svennerlind, CELAM, Center for Ethics, Law and Mental Health, GothenburgUniversity (christer.svennerlind@gmail.com)T.B.E.*22

Criminal Responsibility and Ethics: The Relevance of Susan Wolf’s Account ofSanityGerben Meynen, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(g.meynen@utv.nl)T.B.E.*Hate Crime, Mental Disorder and Criminal ResponsibilityChristian Munthe, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(christian.munthe@gu.se)T.B.E.*5. AddictionHypersexual Disorder in Internet Addiction: Case ReportF. Carabellese, Section of Criminology and Forensic Psychiatry – University of Bari(felicefrancesco.carabellese@uniba.it) (f.carabellese.@criminologia.uniba.it)C. Candelli, Section of Criminology and Forensic Psychiatry – University of Bari(chiaracandelli@gmail.com)R. Catanesi, Section of Criminology and Forensic Psychiatry – University of Bari(roberto.catanesi@uniba.it)G. Rocca, DISSAL, Section of Forensic Psychiatry – University of Genoa(gabriele.rocca@unige.it)This article aims to induce reflection upon the criminogenesis and criminodynamics of sexualoffenses committed through the use of the internet. To this end, we have taken as a starting pointour experience in an expert witness case study. The case that came to our attention was that ofthe production and Web release of pedo-pornographic material, and sexual violence againstunderage disabled children. The offender is a young support teacher affected by a sexual statusclassifiable as a Hypersexual Disorder (Kafka, 1994) in Internet Addiction (Orzack, 2000). Hestarted to spend longer and longer hours navigating the Web and finally became completelyaddicted. His sexual conditions were entirely absorbed by the pedo-pornographic films he saw on23

the internet, and to obtain other films from the pedophiles circle, he was induced to produce newpedo-pornographic material himself, for release on the internet. During the trial, the judgescommissioned an expert forensic psychiatry opinion. The internet can be a “liberating”, rapidaccess method through which to express the symptoms of a condition of “pathological sexuality”(Krafft-Ebbing, 1965). In literature, an “Internet Addiction” has been shown to be correlatedwith some pre-existing personality traits (Kraut et al, 2002; Young, Rogers, 1998).How Do People Change? Results from a RCT on Manualized TreatmentFaye Taxman, George Mason University (ftaxman@gmu.edu)The RNR literature identifies eight criminogenic needs that are dynamic, and that are related tochange. Using data from a randomized trial on treatment options for offenders, this studyassesses the impact of proximal changes in dynamic factors on reductions in drug use andcriminal offending. The study identifies the areas where short-term changes occur using paneldata at 3, 6 and 12 months post randomization. Surprisingly, different criminogenic needsimpact reductions in drug use than offending. And the factors tend to vary depending upon thedegree of substance use disorder. The study findings illustrate the complexity of offenderchange. More importantly the study finds that treatment needs to be more directive regardingareas of change in order to affect offender outcomes.Handling Drug Violations Using a RNR-Based Decision ToolSusan Turner, University of California, Irvine (sfturner@uci.edu)As part of bringing evidence-based practices to parole supervision in California, the Division ofAdult Parole Operations implemented a parole decision making instrument which consideredoffender risk and violation severity in recommending a sanction. Recommended responsesranged from mild (warnings) to reincarceration at the state level. In an evaluation of theprogram, we found substantial percentages of parolees had been released from prison for drugoffenses. This paper discusses how the parole violation decision making instrument was used fordrug offenders and their subsequent violations and whether the recommended sanctions (whichcould include drug treatment) appeared to be related to better outcomes, relative to non-drugoffenders.Substance Misuse, Violent Offending and the LawTony Adiele, Advanced Forensic Psychiatry & Medical Law Service LLC, Cambridge, UK(tony@advancedforensicpsychiatry.co.uk)24

It is a tacit belief amongst members of the public as well as mental health professionals that aconcrete relationship exists between an individual’s misuse of psychotropic substances (bothlegal and illegal) and the individual’s involvement in violent offences either as a perpetrator or asa victim. However whether such a presumed relationship is direct, indirect, positive or negativerequires careful examination. Also, further exploration is needed on whether any such existingrelationship is largely dependent on the specific substance used or combinations thereof. Overthe years, the legal systems obtainable in various countries and continents have manifestlyexercised different approaches when faced with a defendant charged with a serious violent crimecommitted while apparently under the influence of such mind-altering substance(s). Thispresentation will therefore attempt to address these multi-variate and complex issues based oncurrent empirical evidence, forensic psychiatry clinical practice and the English Legal System.Prototypical medico-legal case vignettes will be discussed at the end of the presentation.6. Addressing Difference: Recognise and Accept, Don’t DiscriminateDiscrimination: When is Refusal to Treat Appropriate?Andrew Alston, Flinders University (andrew.alston@flinders.edu.au)Discrimination is based on the recognition of difference. Some discrimination is acceptable, forexample, awarding a prize to the best performer in an exam. Other discrimination is unacceptableand usually unlawful, for example, when it is because of race, religion, sex, sexuality, maritalstatus, pregnancy, age or disability. When a health professional discriminates against a patient,there will usually be a stated reason. There may also be one or more underlying reasons. Usually,it is the underlying reasons and not the stated reasons that identify whether conduct isinappropriate. Examples of stated reasons are: Patient is obese; Patient is a smoker; Patient is analcoholic; Patient’s life style is inappropriate. Examples of underlying reasons are: Reducedchance of recovery; Economy measures; Penalty for bad conduct; Risk to patient; Personaldislike of the patient. When are underlying reasons inappropriate? How can they be identified asthe real reasons for discrimination? What can patients do to avoid inappropriate discrimination orto seek redress when they have been inappropriately discriminated against?Accepting and Rejecting the Street Homeless: Practices of Local AuthoritiesCaroline Hunter, University of York (caroline.hunter@york.ac.uk)Helen Carr, University of Kent (h.p.carr@kent.ac.uk)The paper will look at the mundane exercises of power over the bodies of the street homeless inEngland. We will consider the attempted banning of soup runs and rough sleeping, and the25

washing down of sleeping places. The particular practices in certain London Boroughs willprovide the lens for this. Thus in the City of Westminster there have been recent attempts tointroduce bye-laws to prevent rough sleeping and soup runs in certain parts of the borough andthe campaign against this (see Inside Housing, March 25, 2011). In the City of London anoperation to “wet down” doorways and other places where the homeless sleep was met with a“Rights Guide for Rough Sleepers” (see The Guardian, Wednesday 9 December 2009). We willlook at health and safety concerns, the fear of contamination, the touching of bodies and thetechnologies associated with this, and consider bio-power and risk in the justification of thesepractices. We will look at what prompts exercises of power (for instance commercial needs,political pressures, sporting events, disease etc) and also consider resistance to these controlsfrom religious and charitable organisations, deployment of human rights, and other forms ofprotest.Smoking: Are the Legal Responses Justified?Kynan Rogers, Flinders University (kynan.rogers@flinders.edu.au)Smoking is deeply related to mental health, and smokers face restrictive regulation on theirbehaviour, including support for measures to deny smokers non-emergency treatment. Smokingis a public and private health problem. However, the legal response to smoking is, comparedwith drinking or being obese, disproportionate. In Australia, for example, smokers are over-taxedand increasing prohibitions on smoking are, rather than being scrutinized, criticized for notcoming into operation more quickly. Tobacco is regulated like no other product. The discourse ofsmoking is increasingly normative, yet our legal systems fail to recognize this and continues torely on inappropriate rationales. As a minority, smokers are different, but are they differentenough and in the right way? Upon what bases do we truly regulate smokers? Are these basesconsistent with modern and postmodern theories of justice? And is tobacco control anythingmore than an institutional expression of the dominant social order?Addressing Hoarding: A Principled Approach from Public Health?Michele Slatter, Adelaide University (michele.slatter@adelaide.edu.au)Until quite recently cases of problem hoarding were treated as isolated oddities. They mightinconvenience neighbours, worry local authorities and risk the safety of family but they wereaddressed (or ignored) case by case. However, the last two decades have seen major shifts inboth professional and public awareness. The incidence of problem hoarding is much morefrequent than was earlier believed. Hoarders fit no stereotype. There is no ‘standard appropriateresponse’, no ‘one size fits all’ and no professional monopoly in these cases; best practicerecognises the need for multidisciplinary engagement and support. Although the ‘causes’ ofhoarding are diverse, the lead-up to DSM-5 saw an explosion of research seeking to establish26

Hoarding Disorder. Discussion of hoarding cases is now informed by this broader and moresophisticated understanding. Nevertheless such cases remain challenging especially for localauthorities, driven by conflicting responsibilities, limited resources and uncertain powers.Reform of public health legislation in Australia has introduced another uncertainty into this mix.In developing a risk-based approached the new Acts deploy the flexibility of legislation based oneight guiding Principles that operates through extra-statutory Codes and Guidelines. This paperexplores the implications of this reform for future cases of problem hoarding.7. ADHDADHD and the Juvenile Correctional SystemRobert Eme, Argosy University (reme@argosy.edu)A variety of factors place a juvenile at risk for developing a conduct disorder (CD). One of theseis the most common neurodevelopmental disorder of childhood: Attention Deficit HyperactivityDisorder (ADHD). Hence, it can be expected that ADHD is widely prevalent among males in thejuvenile correctional system and thus should be included in every mental health screening whena juvenile becomes involved with the system as well as in treatment planning. Unfortunately, thisrarely takes place. This presentation discusses the developmental pathway which explains whyADHD is a significant risk factor for the development of CD. It presents research which suggestsa conservative prevalence rate of 25 % for ADHD and provides recommendations for screening.ADHD as a Predictor of Persistence of Serious Violent Offending among Blackand White Young MenHelene R. White, Rutgers University (hewhite@rci.rutgers.edu)Attention deficit-hyperactivity disorder (ADHD) has been linked to delinquency and crime. Fewlongitudinal studies, however, have examined the association between childhood ADHD andlater desistance and persistence of criminal offending. The purpose of this study was to examinewhether childhood ADHD predicts persistence of serious violent offending from adolescenceinto young adulthood and whether this association differed by race. We used data from 894 blackand white men who were interviewed annually from approximate age 6 or age 12 through age 19and 25, respectively, with the younger cohort being interviewed again at approximate age 25.Using self report and official records, men were divided into five groups based on their patternsof violent offending: Non-offenders, Desisters, Late Onsetters, One Timers, and Persisters. Withcontrols for cohort, socioeconomic status, and race, the five groups differed significantly on theirnumber of ADHD symptoms at age 12. Desisters and persisters had higher numbers ofsymptoms than nondelinquents and one-time offenders. Late-onset offenders were in the middle.27

Race did not moderate this association. Although adolescent ADHD symptoms were related tooffending during adolescence, they did not predict persistence of serious violent offending intoyoung adulthood.8. Adult Craziness in Children’s Law Policy: How Debates overChildren’s Welfare and Rights Reveal the Personal Trauma andUnconscious Fears of the AdultsJustice Scalia’s Concept of Childhood and ChildrenAviva Orenstein, Indiana University (aorenste@indiana.edu)The Supreme Court of the United States has frequently discussed the rights, entitlements, andresponsibilities of children. Sometimes these cases are steeped in psychology of children, such asRoper, which held that because of their immaturity and lack of full brain development, peoplecannot be sentenced to death for crimes committed before their eighteenth birthday. In othercases, such as DeShaney v. Winnebago County, where the Court held that a state's failure toprevent child abuse by a custodial parent did not violate the child's rights, or Justice Scalia'sDissent in Maryland v. Craig, where he opposed allowing children to testify about theirmolestation via closed circuit television, the obligations and rights of the adults take precedenceand the child nearly vanishes. The Court's view of children does not merely change over time,but lacks all coherence. Of particular interest is Justice Scalia, lover of hierarchy and father ofnine. Children are often stand-ins for debates and conflicts that trouble the Justices. Ultimately,children are more often treated as property of their parents or pawns of ideological clashes thanas citizens who have rights and need protection.Immunization and InnocenceSydney Spiesel, Yale Medical School (Spiesel@yale.edu)Immunization has been one of the great bulwarks against illness – protecting against personaland epidemic disease – for more than a century. The public health importance of vaccines is sogreat that vaccination of children is often required by law. In 2006 the first vaccine intended toprotect against selected strains of the human papilloma virus (HPV) was licensed in the US. Thefour strains of papilloma virus covered by this vaccine are all mainly transmitted sexually andcause genital warts and cervical cancer and, in addition, various other precancerous andmalignant conditions. Earlier field trials suggested that the vaccine was strongly protective, butonly if given before exposure. The very existence of the vaccine and the recommendation that itbe given early – before there is much likelihood of sexual exposure – led to a bipolar response inparents: some urgently demanded its use and others were outraged at its availability. The early28

enthusiasm of many public health workers for this vaccine led many to push that it be mademandatory, much like most other childhood vaccines; a recommendation that was met withpowerful and, ultimately, fatal resistance. Many parents have a hard time imagining theirchildren as sexual beings and I will argue that a crucial element in the character and direction ofparental and social response has to do with competing images of childhood and, for some, aperception of loss of sexual innocence in the immunized child.Embryos or Infants? Emotional Attachments to IVF EmbryosJody Madeira, Indiana University (jmadeira@indiana.edu)Patients undergoing in vitro fertilization (IVF) often form emotional attachments to the embryoscreated in clinic labs and cryogenically frozen. This paper examines the contours of theseemotional connections, discussing under what conditions certain attachments form and whatconsequences these attachments have for the infertile patients, including deciding upon eventualdispositions for surplus frozen embryos.9. Applied Research in Law Enforcement, Mental Health, andCrime Prevention: Seattle Police Department – SeattleUniversity Collaborative Projects; Development,Implementation, and EvaluationSeattle Police Crisis Intervention Team/Mental Health Partnership Pilot ProjectDevelopment and Implementation of the Seattle Police Crisis InterventionTeam/Mental Health Partnership Pilot ProjectJoe Fountain, Seattle Police Department, USA (joseph.fountain@seattle.gov)Justin Dawson, Downtown Emergency Service Center/Seattle Police Department,USA (justin.dawson@seattle.gov)Dan Nelson, Seattle Police Department, USA (daniel.nelson@seattle.gov)Scott Enright, Seattle Police Department, USA (scott.enright@seattle.gov)In 2010 the Seattle Police Department launched a 24-month pilot project establishing a CrisisIntervention Response Team (CIRT) comprised of members of the Seattle Police Crisis29

Intervention Team partnered with licensed mental health professionals (MHPs) trained in crisisassessment, intervention, and resource referral. The goal of the pilot program is to improvepolice response in situations involving mentally ill and chemically dependent individuals throughspecialized mental health provider response in the field. To date, few jurisdictions haveimplemented programs involving law enforcement/mental health provider partnerships. Thispaper focuses on the history, development, and implementation of the pilot program with focuson the experiences of the CIT Officer and MHP in their collaborative roles within the CIRTPilot. The impact of the CIRT Pilot in changing the nature of police response to the mentally illand in enhancing police-mental health practitioner partnerships in serving the community isdiscussed.Evaluation Results from the Seattle Police Crisis Intervention Team/MentalHealth Partnership Pilot ProjectJacqueline B. Helfgott, Seattle University (jhelfgott@seattleu.edu)Matthew J. Hickman, Seattle University (hickmanm@seattleu.edu)Andre Labossiere, Seattle University (labossiere@seattleu.edu)This paper presents results from an incident-based descriptive evaluation of the Seattle PoliceDepartment’s (SPD) Crisis Intervention Team/Mental Health Practitioner Partnershipimplemented from 2010-2012. The purpose of the evaluation is to measure the value added bythe MHP in cases involving mentally ill individuals and the effectiveness of the CIRT withspecific focus on the role and function of the MHP and the impact of the inclusion of the MHPon the nature of the incident, time to resolution, repeat contacts, and referral to services. Datawas collected from SPD incident and supplemental reports for a 12 month segment of theprogram from January 2011 to January 2012. Key variables included incident location, caseclearance, repeat contacts, linkages to services, and case disposition. Results of analysis ofincident and supplemental reports will be presented and implications for future development ofthe CIT/MHP partnership will be discussed.The Seattle Police Department’s “IF” ProjectKim Bogucki, Seattle Police Department, USA (kim.bogucki@seattle.gov;kim@theifproject.com)The Seattle Police Department’s “IF” project was cofounded, developed, implemented, and iscoordinated by Detective Kim Bogucki from the SPD Community Outreach Unit. The programoriginated when Detective Bogucki went to the Washington Correctional Center for Women(WCCW) and posed a question to the inmates – “If there was something someone could havesaid or done to change the path that led you here, what would it have been?” Afterwards, a30

WCCW inmate asked other inmates to write an essay in response to the question and theprogram was born. There are currently over 700 essays that have been written by womenincarcerated at WCCW. The project has since expanded to include workshops conducted atjuvenile detention centers, middle and high schools, and in juvenile court. The workshopsinvolve Detective Bogucki and former inmates who have participated in the IF project whileincarcerated who share their experiences with the youth and pose the aforementioned question tothem followed by Q&A, breakout sessions, and resource referrals to help the youth with specificissues they are facing addressed in their written response to the question. The project alsoincludes monthly informational topic meetings in the prisons that bring in guest speakers on arange of topics of interest to the inmates. The history, development, and implementation of the“IF” Project will be discussed with a focus on how the project addresses issues of trauma,victimization, and mental health in crime prevention.If There Was Something Someone Could Have Said or Done to Change the Paththat Led You Here, What Would It Have Been? Analysis of “IF” Project EssaysJennifer Sumner, Seattle University (jms1138@psu.edu)Pete Collins, Seattle University (collinsp@seattleu.edu.edu)Elaine Gunnison, Seattle University (gunnisone@seattleu.edu)Jacqueline B. Helfgott, Seattle University (jhelfgott@seattleu.edu)Marne Koerber, Seattle University (koerberm@seattleu.edu)Stephen K. Rice, Seattle University (ricest@seattleu.edu)Sarah Robinson, Seattle University (sarah@theifproject.com)This paper presents findings from qualitative analysis of essays completed by “IF” Projectparticipants. Analysis of 800 workshop essays in response to the “IF” question using qualitativedata analysis software Atlas.ti was conducted. Using the framework of the constructivistapproach to grounded theory, content analyses of the documents utilizing an inductive approachwere used to develop analytic codes from the data. Themes identified that reflect howparticipants answered the “IF” question will be presented to offer an answer to the question, “Ifthere was something someone could have said or done to change the path that led you here, whatwould it have been?” Implications of these findings in the development and extension ofscholarship on general theories of crime, trajectories of offending, and factors and individualenvironmentinteractions influencing criminal behavior patterns are discussed.Results from the Pilot Evaluation of the Seattle Police Department’s “IF”ProjectJennifer Sumner, Seattle University (jms1138@psu.edu)31

Pete Collins, Seattle University (collinsp@seattle.edu)Elaine Gunnison, Seattle University (gunnisone@seattleu.edu)Jacqueline B. Helfgott, Seattle University (jhelfgott@seattleu.edu)Marne Koerber, Seattle University (koerberm@seattleu.edu)Stephen K. Rice, Seattle University (ricest@seattleu.edu)Sarah Robinson, Seattle University (sarah@theifproject.com)This paper presents results from the pilot evaluation of the Seattle Police Department’s “IF”Project, a crime reduction and crime prevention program run by the Seattle Police Departmentthat involves multiple components that bridge law enforcement, corrections, juvenile justice,schools, and community agencies. The core of the program involves a prison-based writingworkshop in which inmates are posed the question, “If there was something someone could havesaid or done to change the path that led you here, what would it have been?” Additionalprogrammatic components involve a monthly prison-based informational topic presentation, andworkshops in schools, courts, and juvenile justice facilities in which ex-offenders who haveparticipated in the prison-based workshops facilitate similar writing workshops for juveniles forthe purpose of crime prevention. Results from a mixed methods evaluation of all components ofthe “IF” Project including evaluation of workshops conducted from July 2012 – June 2013 inprisons, juvenile detention facilities, and schools are presented. Implications of findings forfuture development of the “IF” Project and its effectiveness in crime prevention and inaddressing issues faced by individuals engaged in criminal behavior patterns will be discussed.The Benefits and Challenges of Collaborative Research in Law EnforcementChristine Robbin, Seattle Police Department, USA (Christine.robbin@seattle.gov)Collaborative research between law enforcement and academia has unique benefits andchallenges. The benefits include generation of research questions grounded in current and realworld law enforcement priorities, pedagogical opportunities to enhance student learning throughservice-oriented research, availability of data to researchers to examine issues of practicalimportance, and research resources that would otherwise not be available to law enforcement.Challenges include difficulty in allocating staff for data preparation, management of data, thediscrepancy between the need for immediate findings to address dynamic crime patterns and thetime it takes to design and complete a research study, and difficulties in designing amethodologically rigorous study. Recommendations for addressing challenges and making themost out of practitioner-academic collaboration in law enforcement research are discussed.32

10. The Application of Mental Health Care Law in South Africawith Reference to the Defence of Non-Pathological CriminalIncapacity – Trends and DevelopmentsA Background to the Defences of Pathological and Non-Pathological CriminalCapacity in South AfricaPieter Carstens, University of Pretoria (pieter.carstens@up.ac.za)In this presentation, Prof. Pieter Carstens (in anticipation of the other panel presentations) willoffer an introductory review and broad framework of the South African substantive criminal andmental health care law relating to: the multiple defences of sane/insane automatism; privatedefense (as a ground of justification) and non-pathological and pathological criminal incapacityin specific context of: domestic violence; the HIV/AIDS panic defence; the cultural defence, forexample the belief in witchcraft, ritual, and medicine (“muti”)-murders; the legal and ethicalchallenges faced by expert witnesses (that of psychiatrists and psychologists) in proving ordisproving these defences in the South African context; and a discussion of unique illustrationsin South African case law.The Defences of Pathological and Non-Pathological Criminal Capacity withRegard to Domestic ViolenceMagda Slabbert, University of South Africa (slabbm@unisa.ac.za)Louise Olivier, University of Pretoria (louise@psychupsafaris.com)Domestic violence, also referred to as domestic abuse, spousal abuse, battering, family violence,and intimate partner violence, is referred to as a pattern of abusive behaviours by one partneragainst another in an intimate relationship such as marriage, dating, family, or cohabitation. Thepresentation of domestic violence and battered women syndrome evidence in support of thedefences of pathological and non-pathological criminal capacity will be explained by Prof.Magda Slabbert and evaluated within the context of the battered women who kills her abusivepartner or spouse; the rape charge against President Zuma; and the case against Cezanne Visser(also known as "Adv Barbie"). Recommendations will be made for reform. In the case ofPresident Zuma the psychological and psychiatric parameters will be discussed by Dr. LouiseOlivier with regard to rape victims. Dissociative fugue state will also be discussed in terms ofnon-pathological criminal capacity with a demonstration of the case of Gouws v. the State.33

The Defences of Pathological and Non-Pathological Criminal Capacity withRegard to the HIV/AIDS Panic-DefenceMagdaleen Swanepoel, University of South Africa (swanem@unisa.ac.za)Louise Olivier, University of Pretoria (louise@psychupsafaris.com)Prof. Magdaleen Swanepoel will examine the historical and doctrinal background of the socalledHIV/AIDS panic defense in context of the defence of pathological and non-pathologicalcriminal capacity. There are a variety of strategies that suggest that a criminal defendant shouldbe excused or justified if his violent actions were in response to an HIV/AIDS panic attackadvance. Prior to 2000, 21 states enacted statutes criminalising behaviour that risks thetransmission of HIV or AIDS either sexually or through tissues such as blood or semen. Thequestion of whether the so-called HIV/AIDS panic defence is a manifestation of the temporaryinsanity plea will further be raised by Prof Swanepoel. The status of the victim having beenpossibly infected by AIDS during rape versus the perpetrator will be discussed by Dr. LouiseOlivier.The Defences of Pathological and Non-Pathological Criminal Capacity withRegard to the Cultural DefenceChazanne Grobler, University of Pretoria (chazanne.grobler@up.ac.za)Louise Olivier, University of Pretoria (louise@psychupsafaris.com)Culture exerts a strong influence on individuals’ thoughts, processes and behaviours,predisposing them to act in ways consistent with their upbringing – the so called enculturation ofa person. These beliefs have led to culturally motivated crimes which clash with state law, suchas witch killings in the case of belief in African witchcraft. The question that is raised by Ms.Chazanne Grobler is whether cultural factors illustrate a person with a character that deservespunishment, or whether they point to someone who did not freely choose to commit a crime andwhose motive explains their conduct and excuses (or justifies) it. Ms. Grobler advocates theformalisation of the cultural defence and will consider the nature, scope and application of thisdefence in light of the belief in African witchcraft. She postulates that an accused or defendant'scultural background could negate the essential elements of criminal liability. If convicted, amitigation of sentence can be argued. Although the cultural defence is a multiple defence, shewill explore the cultural defence in context of the element of capacity, specifically with referenceto the existing defences of non-pathological incapacity (in the case of provocation) and thedefence of pathological incapacity. Some cultural beliefs in terms of the Zulu and Sotho tribes(the biggest of the Nguni and Sotho groups) will be highlighted by Dr. Louise Olivier.34

The Role of Psychiatric and Psychological Expert Evidence in Proving orDisproving these DefencesMagdaleen Swanepoel, University of South Africa (swanem@unisa.ac.za)Louise Olivier, University of Pretoria (louise@psychupsafaris.com)Lawyers and mental health professionals often cross swords in cases where a defence ofpathological or non-pathological criminal capacity is mounted. Differences in interpretation andapplication have sparked controversy both within and between these professions. Thesedifferences where these defences are raised will be explained by Prof Magdaleen Swanepoel andDr Louise Olivier. Psychiatrists and psychologists, being so-called "expert witnesses" carry anawesome responsibility. Recommendations they make may impact severely on manyindividuals’ lives. The role of the psychiatrist and psychologist in court in the context of criminallaw will be thoroughly discussed. A finding that the accused lacked criminal capacity can onlybe made on the basis of expert psychiatric or psychological evidence. The court cannot arrive ata verdict on the basis of its own observations. Strauss states that where the evidence submittedfor the prosecution conflicts with that submitted for the defence, the court is of course entitled toconsider that the burden of proving non-imputability rests on the accused. In this regards DrOlivier will discuss the evoking of the plea of posttraumatic stress disorder for lenience at theTruth and Reconciliation Committee at the end of the Apartheid era. In one of South Africa'sleading cases Van Wyk v Lewis, Innes CJ ruled explicitly: "The testimony of experiencedmembers of the profession is of the greatest value ... [The court] will pay high regard to theviews of the profession, but is not bound to adopt them." Therefore the probative value of expertevidence is dependent upon the qualifications, skill and level of experience (competency rule) ofthe expert and the ability of the court to assess this testimony. In the case of Michael v LinksfieldPark Clinic (Pty) Ltd the Supreme Court of Appeal had the opportunity to authoritativelyenunciate the general applicable considerations in assessing expert medical evidence. Adiscussion of these unique illustrations in South African case law will follow by Prof Swanepoel.S v Vosloo will be discussed by Dr Olivier in which the testimony of a neurologist andneuropsychologist was invaluable in proving non-pathological criminal incapacity.Recent Trends in Explaining Abuse within Intimate Relationships: Reflectionson the Discourses of Coercive Control and the Stockholm Syndrome in Contextof the Defence of Non-Pathological Criminal IncapacityGeert Philip Stevens, University of Pretoria (philip.stevens@up.ac.za)Louise Olivier, University of Pretoria (louise@psychupsafaris.com)Abuse within intimate relationships has been a phenomenon of time immemorial. A termcommonly used to refer to abuse perpetrated within intimate relationships denotes the so-called35

“battered woman syndrome”. The plight of the battered woman who kills her abusive husband orpartner in order to escape from an abusive environment has been and remains a controversialtopic. The defences available to battered women in these situations are limited. A furthercontroversy which recently manifested in the highly controversial decision of S v Visser(unreported judgment) or more commonly referred to as the Barbie-decision, relates to thescenario where the abused woman’s criminal conduct within the abusive relationship is notdirected against the abuser, but against other individuals. Various questions arise as to why theabused individual resorted to such actions instead of turning to the appropriate authorities forassistance such as the police. One of the defences available to an abused woman or individualwithin such settings and within the South African context is the defence of non-pathologicalcriminal incapacity. An abused woman or individual relying on such a defence will inadvertentlyhave to present battered woman syndrome evidence in support of that defence. The psychosocialdynamics of an abusive relationship comprise a much wider purport than merely physical abuse.With reference to S v Visser, the discourses of coercive control and so-called Stockholmsyndrome came to the fore in terms of how much emphasis is placed on psychological abuse.Coercive control and Stockholm syndrome are both alternative theories for explaining the natureand effects of abuse within intimate relationships. Central to explaining the dynamics of thesediscourses is the mental health professional, who will have to assess the impact of such abuse onthe victim in order to assist the court in assessing the validity and merits of the defence of nonpathologicalcriminal incapacity. Research indicates that the mental health professional plays avital and pivotal role in explaining these theories and the various complexities associatedtherewith. Dr Stevens will focus in this presentation on an illustration of the phenomena ofcoercive control and Stockholm syndrome with reference to the highly controversial decision inS v Visser against the backdrop of the defence of non-pathological criminal incapacity. The vitaland essential role of the mental health expert within such a context will be illustrated. Accordingto Dr Louise Olivier it is important in this regard to take note of the Ethical Code of Conduct ofthe Health Professions Council of South Africa with reference to professionals doing forensicwork. She will explain this with special regard to the rule of multiple relationships and the rule ofcompetence.Concluding RemarksPieter Carstens, University of Pretoria (pieter.carstens@up.ac.za)Prof. Pieter Carstens will conclude the session by providing a short summary of the differencesbetween the outcomes of the defences of pathological and non-pathological criminal capacity incontext of the scenarios mentioned above with a specific focus on South African Law.11. Assessment and Treatment of Psychopathy in Clinical PracticePsychopathy and Treatment Outcome36

Evelyn Klein Haneveld, Van der Hoevenklinek, Utrecht, Netherlands(ekleinhaneveld@hoevenkliniek.nl)Although in the past 20 years research on assessment and etiology of psychopathy has increaseddramatically, studies dealing with the treatment of psychopathy are still quite rare and findingsare mixed. Psychopathy can now be diagnosed reliably and validly with the PsychopathyChecklist – Revised (PCL-R), but clinicians are still left with very few guidelines as to how totreat psychopathic patients. In this study, we evaluate the treatment-outcome of a sample of 366forensic psychiatric patients who were admitted involuntarily to the Van der Hoeven Kliniek inthe Netherlands. Since 1997, all patients have been assessed prospectively with the PCL-R.During treatment, risk assessments are conducted repeatedly, including the assessment ofprotective factors. We will present (preliminary) findings on the distribution of PCL-R scores inour sample and their relationship to risk as well as the development of protective factors duringtreatment. Also, we will compare psychopathic and non-psychopathic patients with regard tolength of treatment, treatment drop-out, incidents during treatment and recidivism afterrehabilitation. Finally, we will discuss the implications of this study for clinical practice.Psychopathic Traits in Sex Offenders are Associated with High Oxytocin LevelsWineke Smid, Van der Hoevenklinek, Utrecht, Netherlands(wsmid@deforensischezorgspecialisten.nl)Psychopathic traits in sex offenders are relevant as the combination of sexual deviance andpsychopathy correlates to the most persistent of sex offenders (Rice en Harris, 1997; Olver enWong, 2006). “The clinical concept of psychopathy is generally considered to entail persistentbehavioral deviancy in the company of emotional–interpersonal detachment” (Patrick, Fowles &Krueger, 2009). There is a substantial literature showing that elevated levels of cerebral oxytocinfunction are associated with many prosocial acts including trust, empathy and attachment(Kosfeld et al., 2005; Hurlemann et al., 2010). This would lead to the prediction that there is anegative relationship between psychopathic traits (especially PCL-R facet 1 and 2) and oxytocinlevels. Methods. Urinary oxytocin levels were assessed in 68 males: 22 sex offenders, 23 violentoffenders and 21 non-offender controls, PCL-R scores were assessed in all offenders. Results.Contrary to the expectations, the sex offenders showed elevated oxytocin levels that weresignificantly positively correlated with PCL-R scores (facet 3 and 4). Sex offenders with highoxytocin levels were twice to three times as likely to have a diagnosis of psychopathy.Discussion. We will discuss how elevated oxytocin levels can be related to Patrick et al’s (2009)triarchic conceptualization of the development of psychopathy and sexual offending behavior.Finally, possible underlying neurobiological mechanisms (via suppression of cortisol levels) andimplications for clinical practice (the influence of specific medication and abuse of specificdrugs) will be discussed.37

A Treatment Program for Psychopathic PatientsInge Breukel, Van der Hoevenklinek, Utrecht, Netherlands (ibreukel@hoevenkliniek.nl)In the Van der Hoeven Kliniek, a forensic psychiatric hospital in the Netherlands, approximately25% of the patients score high on the Psychopathy Checklist – Revised (PCL-R). Althoughresearch on the treatment of psychopathy is scarce, we have attempted to implement a programfor these patients, inspired as much as possible by what is known to be effective for seriouslyviolent offenders in general. The What Works principles as described by Andrews and Bontaconstitute the central framework for the program. Treatment is directed at dynamic risk factors,taking into account the responsivity of patients. Other important elements are the Good LivesModel (Ward), the Stages of Change Model (Prochaska and DiClemente) along withmotivational interviewing (Miller and Rollnick), cognitive behavioural psychotherapy and teamsupervision. We will describe how we incorporate these elements into clinical practice andillustrate this with clinical case examples. Furthermore, we will discuss our failures andsuccesses in the treatment of these particularly difficult patients, and attempt to providedirections for further research.Gender Issues in the Assessment of PsychopathyVivienne de Vogel, Van der Hoevenklinek, Utrecht, Netherlands (vdevogel@hoevenkliniek.nl)Jeantine Stam, Van der Hoevenklinek, Utrecht, Netherlands (jstam@hoevenkliniek.nl)Michiel de Vries Robbé, Van der Hoevenklinek, Utrecht, Netherlands(mdevriesrobbe@hoevenkliniek.nl)The assessment of psychopathy in female forensic psychiatric patients is still a relativelyunexplored area. The findings on the widely used Psychopathy Checklist-Revised (PCL-R; Hare,2003) in female samples thus far are not sufficiently convincing to draw conclusions about thesimilarity of the PCL-R structure across gender (Logan, 2009). In this paper, we will presentresults from a Dutch multicentre study on psychopathy and violence risk assessment in femaleforensic psychiatric patients. PCL-R codings of about 300 women will be analysed and related tocriminal and demographic characteristics, as well as to different violence risk assessment tools,including the HCR-20, the SAPROF for protective factors and the recently developed genderspecifictool for female (forensic) psychiatric patients, the Female Additional Manual (FAM; DeVogel et al., 2011). Furthermore, for a subgroup of female patients, PCL-R codings will becompared to those of a matched male sample. Finally, some clinical case examples of themanifestation of psychopathy in women will be discussed and suggestions will be provided withrespect to the gender-sensitive assessment and treatment of psychopathy in women.38

12. Assessment, Intervention, and Program Evaluation in aPrevention Program for Intimate Partner ViolenceTreatment Gains and Losses over Time for Men Who Completed a Program forIntimate Partner ViolenceBrendon Pratt, The Family Centre, Edmonton, Canada (brendon.pratt@the-family-centre.com)The Reaching for a Good Life group has been offered since October 2009. Initial programevaluation data suggests that participation in the program appears to be correlated with positiveoutcomes at group completion. This paper discusses the longer-term impact of the program onparticipants, especially the client’s perception of which changes have been maintained and anydeterioration of growth two years after completing the group program. The initial assessmentbattery was re-administered and participants participated in a semi-structured interview. Thequalitative and quantitative outcome data will be presented. The findings are considered in termsof outcome research about programs for men who engage in intimate partner violence. Thisresearch will look at whether the Reaching for a Good Life model exhibits similar deteriorationof change over time as other treatment models for violent men. Implications for application ofthe Good Lives model in treatment of domestic violence will be explored.An Examination of Personality Characteristics Associated with Attrition from aCommunity-Based Domestic Violence ProgramMartin Weir, Valerian Consulting, Edmonton, Canada (weir138@hotmail.com)Rehabilitation programs for male perpetrators of intimate partner violence suffer fromnotoriously high rates of attrition (Bowen &Gilchrist, 2006). The aim of this paper is to enhanceour understanding of the relationship between personality and the failure to complete suchprograms. Prior to starting a domestic violence group program based on the Good Lives Model(GLM; Ward, Mann & Gannon, 2007), 230 Canadian men completed the PersonalityAssessment Inventory (PAI; Morey, 1991) as part of the intake process. Men who completed theprogram were compared to those who dropped out on the PAI individual scales (Validity,Clinical, Treatment, and Interpersonal), profile code types and conceptual indices. Through agreater understanding of the personality factors associated with attrition from offendingbehaviour programs, mental health professionals will be better equipped to tailor serviceprovision to maintain these men’s participation. Recommendations for improving completionrates in this particular program will be explored. This session will prove to be extremelybeneficial for anyone involved in the delivery of community based treatment of perpetrators ofintimate partner violence including psychologists, social workers and probation officers.39

Profiles of Men Who Batter: Emerging ThemesJill Storcer, Catholic Social Services, Edmonton, Canada(jill.storcer@catholicsocialservices.ab.ca)The desire to understand typologies and characteristics of men who batter has been a prominenttheme in domestic violence literature (Saunders, 1992; Holtzworth-Monroe & Meehan, 2004). Abetter understanding of these men will increase the ability of practitioners to create more relevantand effective interventions, more effectively engage clients in treatment, improve treatmentoutcomes and reduce attrition rates. This presentation will include brief review of the typologyliterature and present the profiles emerging from participants in the Reaching for a Good LifeProgram. Data was derived from the Personality Assessment Inventory (PAI) profiles andindividual interviews completed with each participant. Participants include a diverse group ofmen from various socioeconomic backgrounds and age ranges. Approximately two thirds ofparticipants were not court mandated to participate. How this sample compares to the currentunderstanding of domestic violence is addressed. Implications of these findings on programplanning and development will be discussed.Program Experiences of Men Completing the Reaching for a Good LifeProgramKaren M. Nielsen, Athabasca University (karen.valerian@shaw.ca)This presentation will report the findings of a qualitative investigation into the experiences ofthirty-one men completing the Reaching for a Good Life program. The men were interviewedimmediately after completing the four-month program. The semi-structured interview promptedthe men to consider what was helpful (or not) for them in the program and to reflect on wherethey experienced the most growth. The major themes emerging reflected on program design, thechanges in their interpersonal relationships and areas of personal growth. The use of thisqualitative data in further program design will be discussed.Including the Voice of Participants in On-Going Program Planning in anIntimate Partner Violence Prevention ProgramAnn Marie Dewhurst, Valerian Consulting, Edmonton, Canada (Annmarie.valerian@shaw.ca)Men involved in intimate partner violence prevention programs, like most people in therapy, aremore likely to make progress when they find: a) the content relevant; b) the process responsive totheir needs; and c) participation actually helps them in some way (Duncan & Miller, 2008). To40

ensure that the facilitators of the Reaching For a Good Life Program received consistent andtimely feedback from participants, we employed the Outcome Rating Scale and the SessionRatings Scales (Duncan & Miller). Additionally, to ensure the connection to the Good Life goalsthe men had established during their treatment planning sessions the Good Life histogram(Dewhurst, 2011) was employed at the end of each module as a means of reviewing those goals.The use and value of these tools for intervention planning and program evaluation will bediscussed.13. Assessment, Treatment and Ethical Issues in Sex OffendersNeurophysiological and Neuropsychological Correlates of the Pathway Model ofChild Sexual AbuseMarc Graf, Forensic Psychiatric Hospital, Switzerland (Marc.Graf@upkbs.ch)Marlon Pflüger, Forensic Psychiatric Hospital, Basel, Switzerland (marlon.pflueger@upkbs.ch)Ralph Mager, Forensic Psychiatric Hospital, Basel, Switzerland (Ralph.mager@upkbs.ch)Nadja Händel, Forensic Psychiatric Hospital, Basel, Switzerland (nadja.haendel@upkbs.ch)Benedikt Habermeyer, Forensic Psychiatric Hospital, Basel, Switzerland(benedikt.habermeyer@upkbs.ch)Roland Jones, Cardiff University (jonesrm6@cf.ac.uk)Volker Dittmann; Forensic Psychiatric Hospital, Basel, Switzerland(Volker.dittmann@unibas.ch)Considering that not all consumers of Internet child pornography progress to grooming childrenby means of the Internet or even cross the line to physical child abuse, it would be mostinteresting to study these groups of offenders with regard to the comprehensive pathway modelof child sexual abuse published in 2002 by Ward and Siegert. Are child abusers in contrast toInternet sex offenders just more deviant concerning pedosexuality or do finally deficits inbehaviour control distinct the two groups? In a study funded by the Swiss National Grant wefound specific patterns of differences between those two groups in partially very experimentalbasic research like subliminal visual erotic stimulation in EEG and more established methodslike implicit association test, Go/Nogo-tasks and fMRI. We will present the results of this studyas well as preliminary results from an actual study funded by the Swiss Ministry of Justice anddiscuss the potential consequences for risk assessment and therapy.Antilibidinal Effect of Androgen Deprivation TherapyJoelle A. Troelstra, Van der Hoevenkliniek, Utrecht, Netherlands (jtroelstra@hoevenkliniek.nl)41

T. I. Oei, Tilburg University (T.I.Oei@uvt.nl)The sensitivity to a particular sexual stimulus bears a strong relation with an individual’s sexualpreference and the connection between stimulus and preference. When there is a link, theavailability of testosterone in the brain is necessary to evoke a reaction of emotional `liking`.When, caused by medication, the availability of testosterone has declined relative to the startingvalue prior to treatment, the sensitivity to a sexual stimulus will be reduced. This effect will bestronger when the drop in testosterone availability is more considerable. A sexual thought canalso act as a sexual stimulus. Because the medication reduces the sensitivity to sexual stimuli inthe brain, the response to the stimuli will, however, be reduced; the level of sexual excitementwill be lower. Furthermore, there will be a lower level of - or a lack of - sexual craving and lessor no tendency to become sexually active. Patients using ADT will thus be more in control oftheir behaviors when confronted with a stimulus that - before - could have led to sexualoffending. By increasing the prosocial control of sexual behaviors and by committing oneself toa prosocial lifestyle, the patient will receive more respect from friends, family, employers andothers. It is necessary that the patient agrees with the purpose of the treatment: preventing relapseinto a sexual offence. This is important because, even despite a strong reduction in testosterone,for some a certain degree of sensitivity to sexual stimuli will remain. Thus adherence to theRelapse Prevention Plan, for instance by avoiding high-risk situations such as a swimming poolon a Saturday afternoon, remains necessary. If a patient with ADT treatment thus sets out toenter a high-risk situation, this may still create a considerable risk of recidivism. That is why thetreatment of sex offenders needs more than just an approach with the help of medication.Treatment of Sex Offenders: From Performance Commitment to OutcomeMeasurementTineke Dilliën, Antwerp University Hospital, Edegem, Belgium (Tineke.dillien@uza.be)Kris Goethals, Antwerp University Hospital, Edegem, Belgium (kris.goethals@ggzwnb.nl)Introduction: Routine Outcome Monitoring (ROM) could prove to be a significant added valuefor the forensic field. This is especially true for the treatment of sexual offenders, a field inwhich clinicians bear a great amount of societal pressure to achieve results. Nevertheless, theapplication of ROM is still in its infancy in the forensic world.Aim: Because of the potential benefits in patient care and the contributions to scientific research,the University Forensic Center (UFC) started the application of ROM from January 2012onwards.Method: In a first phase ROM’s practical feasibility is tested by conducting a pilot study. Theresults of this study will be used to guide the actual implementation of ROM in the clinicalpractice of the UFC.Results: Findings of the pilot study (e.g. most suitable instruments for routine use) will be usedas guidelines and best practices for the implementation of ROM in forensic mental health42

services. In addition preliminary treatment results will be presented. The focus lies on how theseresults can be used to maximize treatment outcome. Furthermore, it will be demonstrated howthese data are an addition to the effectiveness research as carried out currently within the forensicsector.Conclusions: If implemented adequately, the routine clinical use of outcome measures is anadded value for the forensic mental health services. In addition to improving individual patientcare, it can also contribute to the effectiveness research as carried out within the sexual offenderliterature.The Basel Treatment Program for Internet Sex OffendersThorsten Spielmann, University of Basel (thorsten.spielmann@upkbs.ch)Marcel Delahaye, University of Basel (key@coat-basel.com)Linda Duris, University of Basel (linda.duris@upkbs.ch)Marc Graf, University of Basel (marc.graf@upkbs.ch)The treatment of Internet sex offenders not only is a duty of forensic psychiatry in case of courtordered treatments but also allows important insights into the development of deviant sexualpreferences as well as inhibiting factors, preventing a progression to hands-on sex offenses.Group psychotherapy with added individual therapy and/or pharmacotherapy when indicatedappears to be most effective and practicable. We will present an overview of now more than tenyears of experience and provide latest results from evaluations.Bioethics of Hormonal Treatment of Sex OffendersPaul Cosyns, Antwerp University Hospital, Edegem, Belgium (paul.cosyns@uza.be)The treatment of sex offenders or patients with paraphilias has always been undertaken through aminefield of clinical and ethical dilemmas. The major ethical issues regarding hormonaltreatment of sex offenders reflect the need for public safety balanced against the best interest ofthe concerned person and the public orientation toward punishment rather than treatment. In thispaper we want to discuss more in detail the following ethical issues involved in this treatmentmodality:• paraphiliac sex offenders referred for hormonal treatment are often the object of someexternal coercion, be it from a court decision or under the pressure of their family,employers or other involved persons. How can we respect the accepted basic principle of‘informed consent’?• who decides for hormonal treatment, a court or a professional?43

• from an ethical point of view, which are all the conditions that must be met to subject theparaphiliac patient or sex offender to hormonal treatment?Which further scientific evidence and research do we need to improve the management of thepharmacological treatment of sex offenders?14. Behavioral Approaches within the Criminal Justice System:From Policy to PracticeThe Penal SystemEdwin Bleichrodt, Erasmus School of Law (vanderwolf@law.eur.nl)T.B.E.*The Measure for Repetitive OffendersSanne Struijk, Erasmus School of Law (vanderwolf@law.eur.nl)T.B.E.*The Measure for Dangerous Mentally Disordered OffendersMichiel van der Wolf, Erasmus School of Law (vanderwolf@law.eur.nl)T.B.E.*Psychological Evidence in Legal PerspectivePaul Mevis, Erasmus School of Law (vanderwolf@law.eur.nl)T.B.E.*44

Psychological Evidence in Psychological PerspectiveHjalmar van Marle, Erasmus School of Law (h.j.c.vanmarle@erasmusmc.nl)T.B.E.*15. Bio-Psycho-Social Research in Forensic Child and AdolescentPsychiatryBiopsychosocial Clinical Practice in Forensic Child and Adolescent Psychiatry:Future perspectivesArne Popma, VU Medical Centre (a.popma@debascule.com)Neurobiological research has provided increasing evidence for the idea that biological factors areassociated with a variety of antisocial behavior in juveniles. Although there are still majorlacunae in our understanding of this association, it seems timely to consider the potential clinicalimplications of the findings that this field of research has generated and will be generating in thecoming years (Popma & Raine 2006). Recent literature will be reviewed and related to specificaspects of (forensic) clinical practice: diagnosis, treatment, risk-taxation, and treatmentevaluation. For example, we will discuss studies in which biological factors have been found topredict treatment outcome in children with disruptive behavior disorders and the effect ofpsychological interventions on biological parameters which are associated with antisocialbehavior (Brotman 2008). In addition, we will reflect on relevant ethical issues.Fearlessness and Brain Functioning in Antisocial Adolescents: An fMRI StudyMoran Cohn, VU Medical Centre (M.cohn@debascule.com)Antisocial behaviour in juveniles has long been recognized as a mental health priority. Suchbehaviour is highly prevalent, related to negative future outcomes, and entails a growingeconomic burden. In psychiatry, persistent and severe antisocial behaviour is diagnosed as adisruptive behaviour disorder (DBD), which is the most prevalent disorder in adolescentpsychiatry. Current treatment effectiveness is limited. In addition to psychosocial factors,neurobiological factors have been shown to influence the development of antisocial behaviour.This proposal focuses on brain functioning deficits related to fearlessness. It has beenhypothesized that the lack of fear contributes to the pathogenesis and persistence of antisocialbehaviour through a lack of anticipation of, and reaction to, social cues with negative45

consequences, e.g. punishment. Currently, while adult brain imaging studies find evidence forthis theory, support for this hypothesis in adolescents is limited to studies with peripheralneurobiological measures. Moreover, longitudinal studies are lacking. Therefore, an innovativelongitudinal imaging study in juveniles with early onset DBD was conducted in which brainfunction parameters reflecting specific aspects of fear, i.e. fear conditioning andreward/punishment anticipation, were related to patterns of persisting versus desisting (transient)antisocial behaviour. Participants (n=150) were drawn from a unique large cohort (n=256) ofdelinquent juveniles in the Netherlands, of whom many have previously been diagnosed withearly onset DBD. Data collection was finished in Summer 2012. As such, fresh data will bepresented from structural and functional MRI analyses that will be performed in 2012/2013.Ultimately, results should extend current knowledge about the underlying brain mechanismspredicting the early pathogenesis and persistence of antisocial behaviour in juveniles and therebystimulate the development of specific and effective treatment strategies.Longitudinal Studies on HPA and ANS Activity in Relation to the Developmentand Persistence of Antisocial Behavior in AdolescentsLucres Jansen, VU Medical Centre (L.nauta@debascule.com)The Hypothalamic-Pituitary-Adrenal (HPA) system and Autonomic Nervous System (ANS)have been frequently studied in relation to antisocial behavior. However, most studies to datehave been cross-sectional, with single measurements of HPA and ANS activity. Evenlongitudinal studies including HPA and ANS activity as a possible predictor for future antisocialbehavior usually have not included repeated measurements of HPA and ANS activity. However,the activity of both systems is not only controlled by genetic/innate factors, but is also influencedby environmental (stress) factors. HPA and ANS activity in mental disorders may thus besusceptible to change over time. Two longitudinal studies on the development and persistence ofantisocial behavior including repeated measurements of HPA or ANS activity in adolescencewill be presented. Also, the stability of HPA and ANS activity during adolescence will bediscussed from a more methodological point of view.16. Bosnian War and its Causalities: The Voices of ConcentrationCamp Prisoners, Refugees, and SurvivorsA Child’s Life in a Refugee Camp: A Survivor RemembersAldijana Alijagic (rubenboers@gmail.com)Ms. Alijagic, now 29, discusses mental health consequences of exposure to violence, trauma, andthe danger of daily life in a refugee camp. “The first time that the war came to my town, we46

woke up to sudden gun shots. It was early morning and the shooting was louder than before. Wesaw most people running into the fields. So did we. When I suddenly heard bullets whistlingthrough the air, I laid down on the ground, carefully protecting my 13-month-old little brotherwith my body. I was 10 years old.”Omarska Concentration Camp: Life as a Bosnian Prisoner of WarHamdija Draganovic, Guardians of Omerska, Rotterdam, Netherlands (rubenboers@gmail.com)Mr. Draganovic survived Omerska, one of three concentration camps in Bosnia and Herzagovina(the others were Keratim and Trnopolje), infamous for the daily brutal torture of prisoners.Life in the Shadow of the Bosnian WarArmin Alijagic (rubenboers@gmail.com)Mr. Alijagic was born during the Bosnian war but grew up in post-war Bosnia where he nowlives and attends high school. His recollections focus on education and preparation for a career ina country ravaged by war.Crimes against Humanity: Speaking for Victims of the Bosnian WarNerma Jelacic, International Criminal Tribunal for Former Yugoslavia, The Hague, Netherlands(rubenboers@gmail.com)Ms. Jelacic is spokesperson for the International Criminal Tribunal for ex-Yugoslavia (ICTY) inThe Hague, and was an inhabitant of Sarejevo during the siege. She lives in The Hague,Netherlands. She has worked as a reporter for The Guardian and before that was employed bythe United Nations.The Horror of the Bosnian War: A Journalist’s InvestigationEldin Hadzovic, Balkan Investigative Reporting Network (BIRN), Sarajevo, Bosnia-Herzegovina(eldin.hadz@gmail.com)47

Mr. Hadzovic experienced the Bosnian war as a Muslim in Serbian territory (Sandzak area). Henow lives in Sarajevo, Bosnia and Herzegovina. He worked as a deputy editor-in-chief for thelargest national daily newspaper in Bosnia (Dani) but presently works as a freelancer, mainly forBIRN (Balkan Investigative Reporting Network) in Belgrade and Novosti, a Zagreb-basedweekly.17. Bringing Lawyers and Healthcare Professionals Together inTeaching, Decision-Making, and Standard of CareInterdisciplinary Teaching Strategies in Mental Health LawLynne Hanson, Queen’s University (lh2@queensu.ca)Renee Fitzpatrick, Kingston General Hospital, Canada (rfitzpatrick@maplefht.ca)Many mental health professionals perceive a fundamental conflict between lawyers andphysicians in the mental health context. Traditionally, lawyers have championed the individualrights of patients, seeking to maximize patient autonomy by protecting their right to bodilyintegrity and self-determination. Conversely, the role of the physician is to act in the patient’sbest interests, ensure their well-being, and provide the best care possible. The authors contendthat these conflicting values are a reality that must be addressed by lawyers and healthcareproviders alike; both tread a fine line, struggling to discern and respect patient self-determinationwhile simultaneously meeting patients’ needs for care and treatment. They suggest that thestruggle to balance these competing concerns may thus be fruitfully addressed via an interdisciplinaryapproach in education and teaching strategies. Law and medicine may be seen asinterlocking pieces of the same puzzle, as law demarcates the legitimate boundaries forintervention and care. Using bright-line tests of capacity and best interests, the Ontariolegislation permits intervention for assessment and care, alongside the ability to treat whereconsent is obtained from the patient or a substitute decision-maker. A patient’s prior capablewish to refuse treatment is upheld and respected where it is applicable in the circumstances.Withdrawal of Life Support and the ‘Best Interests’ TestLora Patton, Consent and Capacity Board, Toronto, Canada (lorampatton@gmail.com)Ruzica Jokic, Queen’s University (jokicr@providencecare.ca)By 2013, the Supreme Court of Canada will have rendered its decision in Rasouli (Litigationguardian of) v. Sunnybrook Health Sciences Centre, [2011] O.J. No. 2984, a case on end-of-lifeissues under the Ontario Health Care Consent Act. Mr. Rasouli’s physicians argued that noconsent was required for withdrawal of life support, claiming that it was not a ‘treatment’ here48

ecause it was futile and of no medical value. The Ontario Court of Appeal held that withdrawalof life support is a ‘treatment’, and that the matter should be decided by the Consent andCapacity Board. There are serious questions to be addressed here as to whether or not anadministrative tribunal is the appropriate forum for the resolution of disputes between physiciansand families at the end of life; the decision will also have important ramifications for incapablepatients generally who depend on a substitute decision-maker to safeguard their health andautonomy. A corollary issue in this case is the interpretation of the ‘best interests’ test, raisingimportant questions about quality of life. Ordinarily, an individual’s choice to refuse treatmentwould be respected, but those who suffer from depression or a similar diagnosis of mental illnessmay not have the same freedom, being more likely to be found to be incapable.Off-label Uses of Drugs: Knowledge Deficits and the Standard of CarePatricia Peppin, Queen’s University (peppinp@queensu.ca)Drugs are approved for use in certain populations and for certain purposes. These limits on usesreflect the testing conducted prior to regulatory approval. Physicians, though, may prescribebeyond these approved uses for other uses, populations, combinations and delivery systems.Such discretion provides a means of introducing further innovation into treatment in a situationwhere safety and efficacy data have been produced and approval granted. What are the risks ofsuch off-label uses? The central risk rests on the inadequacies of knowledge in the fullpopulation for which the product will be used. For example, use of antidepressants in adolescentswas such an unapproved use. Regulatory bodies limit promotion of off-label uses due to itspotential to provide a sense of certainty where unknowns exist and to expand the range ofadverse effects. How should physicians determine their legal obligations in this situation? Inparticular, the standard of care for treatment must be met, as must disclosure of risks andbenefits. The paper will examine this question in relation to the standard of care in other relatedsituations, such as research participation and end-of-life decision-making where the prognosis ishopeless.18. Building a Bio-Psycho-Social Response to Intimate PartnerViolenceViolence and the Brain: Biological Mechanisms that Underlie Violent andAggressive BehaviorKatherine Wyper, University of Alberta (kwyper@ualberta.ca)One of the important factors underlying violent, impulsive, and aggressive behaviour is brainfunctioning. A neuroscientific perspective may be taken to understand and possibly even predict49

violent behaviour (Nadelhoffer et al., 2012). In this presentation, we will discuss the biologicalmechanisms that play a role in violent and aggressive behaviour. In particular, the role of thehuman stress response as well as the executive functioning systems in such behaviour will beintroduced. The fight-or-flight response, how our brain activates and de-activates adrenaline, aswell as how we manage instincts and urges will all be discussed as they relate to violence. Themore complex and higher level executive functioning tasks including decision making, learningfrom experience, and understanding cause-effect reasoning will also be examined in the contextof violent behaviour. Exploration and understanding of these processes will enable us to adopt abiopsychosocial perspective of violence, through which we can better tailor the way we intervenewith violent offenders.A Bio-Psycho-Social Perspective on Interventions for Violent OffendersJacqueline Pei, University of Alberta (jpei@ualberta.ca)In order to most effectively and appropriately provide interventions for violent offenders, it iscrucial to understand the mechanisms underlying violent behaviour. As argued in the previouspresentation, there is a need to reconceptualise our understanding of violence and aggression asbiopsychosocial processes whereby brain systems such as stress response and executivefunctioning play a critical role. From this biologically-informed perspective, the currentpresentation will discuss intervention strategies that address the underlying brain factorsinfluencing violent and aggressive behaviour. Interventions such as meta-cognitive and selfregulationstrategies, mindfulness, and meditation will be introduced and their potential in thetreatment of violent offenders will be explored. We will also discuss how embedding a biologicalperspective into our interventions for violent offenders has the potential to reduce violentresponse patterns and improve outcomes for these individuals.ADHD, Executive Functioning Skills: Implications for a Program for IntimatePartner Violence PreventionGabrielle Fraser, Concordia University College (fraser.gabrielle@gmail.com)Modern theories of attention deficit/hyperactivity disorder (ADHD) emphasize the substantialrole that executive functioning (EF) plays within the disorder. ADHD and its associatedexecutive dysfunctions have been linked in literature to patterns of spousal/partner abuse andbattering. This paper will describe ADHD in the context of EF deficits and how they manifestthemselves in abusive behaviors. Behavior Rating Inventory of Executive Functioning – AdultVersion (BRIEF-A) scores were obtained from 230 Canadian men who were enrolled in theReaching for a Good Life program, which targets abusive behaviors. A statistical analysisrevealed significant differences in areas of EF between men who completed the programmingand those who did not. Further analysis of the BRIEF-A scores also indicates that they can be50

used to predict attrition rates and assist with identifying possible treatment needs of abusive menfor the development of successful intervention programs.Feminist Theory, Offender Rehabilitation Models, Brain and Behaviour Theory,Effective Counselling Practice and Intimate Partner Violence ProgrammingAnn Marie Dewhurst, Valerian Consulting, Edmonton, Canada (annmarie.valerian@shaw.ca)The Reaching for a Good Life program integrates feminist counselling theory, offenderrehabilitation theory, and a common factors approach to effective counselling with men whohave engaged in intimate partner violence. A basic understanding of the biological basis fordecision-making and behavioural control is also integrated into the program. These theoreticalframeworks arise from a worldview which holds that intimate partner violence is a complexphenomenon that must be approached with strategies that meet multiple needs simultaneously. Inthis presentation we suggest that the components that should be integrated into an effectiveprogram for men who engage in intimate partner violence include: a) improving a client’sexecutive functioning skills; b) increasing the client’s awareness of gender inequity and thesocial permission for male aggression against women; c) exploring the client’s personal andcultural values and beliefs to develop those that are incompatible with violence; d) encouragetherapists to use meaningful and engaging change processes that fit with the client’s personalgoals for a good life. This presentation will discuss this theoretical model and its implications foreffective program development.19. BullyingBullying: A Child Psychiatrist’s Qualitative ReflectionMeena Ramani, Nassau University Medical Center, East Meadow, USA(drmeenaramani@gmail.com)Bullying has both physical and mental health consequences. Bullying has been increasinglyrecognized as a serious, but modifiable risk factor in children’s mental health. The mental healtheffects of bullying range from minor symptoms to major psychiatric problems. These may rangefrom poor attention, transient emotional reactions, school refusal, and poor self-esteem to thedevelopment of severe Anxiety Disorders such as Post Traumatic Stress Disorder, PanicDisorder, Major Depression and Substance Use Disorders. Bullying has also been implicated inextreme psychiatric outcomes such as suicides and homicides. Bullying during childhood hasbeen linked to development and persistence of mental health disorders during later life. With theadvent of extensive outreach by internet, bullying has morphed in form over the last decade. It isalso likely to become more pervasive, although mental health effects of cyber bullying are not51

yet systematically well studied. In the age of globalization, many children are increasinglyspending their childhood in multi-cultural societies and the nature of bullying in this group maychange. This presentation will focus on clinical implications of bullying, as observed by a ChildPsychiatrist/Pediatrician over the past two decades. Case presentations will include clinicalobservations from various settings.Cyber-Bullying: Should Bullies be Protected by the Cloak of the FirstAmendment?Meryl Camin Sosa, Illinois Psychiatric Society, USA (msosa@ilpsych.org)More and more children are being seen in in-patient psychiatric units and therapeutic schools asa result of intense cyber bullying. Those are the lucky ones. Others commit suicide because theyfeel so hopeless and alone due to the bullying. Due to the advent of cyberbullying, bullying hasbecome so pervasive that children feel that there is no escape. Home is no longer the protectivesanctuary it once was. While many US states are enacting anti-bullying laws addressing bullyingin schools, these laws, with only one real exception, fail to address omnipresent cyber-bullyingoutside the schoolyard. With no clear cut U. S. Supreme Court ruling addressing this topic, somestates have been reluctant to expand the scope of bullying laws beyond the schoolyard due to thecontention, by the American Civil Liberties Union, that cyber-bullying in the home is protectedby the First Amendment. Opponents of anti-bullying laws have opposed inclusion of parochialschools within the scope of anti-bullying laws. If discrimination against LGBT persons is notallowed in universities, workplaces, and public facilities, why should it be allowed in parochialschools? Legal remedies, other than standard anti-bullying laws, will be explored in thispresentation.Why Are Bully Prevention Programs Failing in US schools?Dorothy Espelage, University of Illinois (espelage@illinois.edu)Bullying is highly prevalent, reduces academic achievement, and results in psychosocialproblems that extend into adulthood (Espelage & Horne, 2008). Despite the costs of bullying,the impact of bullying prevention programs in the US has been disappointing, especially inmiddle-schools. Two meta-analyses found that effects were non-existent or too small to bepractically helpful (Smith et al., 2004, Merrell et al., 2008). A third found that programs reducedbullying in non-US countries by 23% but effects for US studies were significantly lower (Ttofi &Farrington, 2011). It is important that anti-bullying legislation and policies are comprehensiveand enumerate specific characteristics of targets to be protected. Comprehensive policies aboutbullying and discrimination explicitly state protection based on enumerated personalcharacteristics, including sexual orientation and gender identity/expression, race etc. Bullyingcontent is highly associated with homophobic banter (for review see Espelage & Poteat, 2012).52

In addition to their focus on general bullying, prevention efforts and legislation should require afocus on gender-based harassment and violence (i.e., sexual harassment and violence, datingviolence, harassment and violence associated with sexual orientation and/or gender-rolenonconformity).A Call for Public Health Policies for the Prevention of Bullying Related Healthand Safety RisksJorge Srabstein, Children’s National Medical Center, Washington, DC, USA(jsrabste@cnmc.org)There is evolving evidence that bullying is a multifaceted and toxic form of maltreatment,prevalent across social settings, throughout the lifespan and around the world. People whoparticipate in bullying as victims, perpetrators and/or as bystanders are at significant risk ofsuffering from an array of health and safety problems and risks. Most of the legislative initiativesdeveloped around the world have placed the brunt of responsibility for its prevention oneducators and school administrators and have focused on penalties or consequences. Given thesignificant pyschobiosocial antecedents and consequences of bullying, as well as its public healthimplications, there is a need to advocate for the development of public policies that foster theprevention, detection and treatment of bullying related health problems, across social settings,throughout the lifespan and with whole community participation. This presentation will enableparticipants to: appreciate the developing understanding about the nature, ecology, prevalenceand morbidity of bullying; review the range of anti-bullying legislative initiatives enacted aroundthe world; advocate for the development of public policies for the prevention of bullying andrelated health risks, across social settings and along the lifespan, based on a three tier preventionmodel.Bullying and Suicide: Post Hoc Forensic EvaluationEileen Ryan, University of Virginia (er3h@virginia.edu)Bullying has become a recognized problem as evidenced by the surge in research on victims andperpetrators, as well as recent media attention in the US directed at high-profile cases of bullyingand harassment. Although this social phenomenon is identified in many settings, there is littleevidence-based support for successful interventions that generalize across cultures and settings.Interventions may target the bully, the target, and the system in which the bullying occurs.Traditional bullying behavior has moved into the arenas of technology and social networking.Suicide risk, as well as other psychological sequelae, may be increased for both victims andperpetrators. There are protective and risk factors that individuals or systems might possess withregard to bullying behavior and its effects. This presentation will address these issues andprovide a framework for evaluators to objectively examine behaviors in the context of53

performing forensic evaluations in the context of civil litigation after a youth's suicide in whichbullying may have played a role. This presentation will examine some of the challengesassociated with post hoc suicide forensic evaluations where bullying is cited as a "causative"factor.20. Capacity and IncapacityA Therapeutic Approach to Assessing Competence and Capacity in the Contextof Testamentary, Enduring Power of Attorney and Advance Care DirectiveDocuments in AustraliaKelly Purser, Queensland University of Technology (k.purser@qut.edu.au)Jeanne Madison, University of New England (jmadison@une.edu.au)Eilis Magner, University of New England (emagner@une.edu.au)Australia lacks a satisfactory, national paradigm for assessing competence and capacity in thecontext of testamentary, enduring power of attorney and advance care directive documents.Competence/capacity assessments are currently conducted on an ad hoc basis by legal and/ormedical professionals. The reliability of the assessment process is subject to the skill set andmutual understanding of the legal and/or medical professional conducting the assessment. Thereis a growth in the prevalence of diseases such as dementia. Such diseases impact upon cognitionwhich increasingly necessitates collaboration between the legal and medical professions whenassessing the effect of mentally disabling conditions upon competency/capacity.Miscommunication and lack of understanding between legal and medical professionals involvedcould impede the development of a satisfactory paradigm. A qualitative study seeking the viewsof legal and medical professionals who practise in this area has been conducted. Thisincorporated surveys and interviews of 10 legal and 20 medical practitioners. Some of the resultsare discussed here. Practitioners were asked whether there is a standard approach and whethernational guidelines were desirable. There was general agreement that uniform guidelines for theassessment of competence/capacity would be desirable. The interviews also canvassed views asto the state of the relationship between the professions. The results of the empirical researchsupport the hypothesis that relations between the professions could be improved. Thedevelopment of a national paradigm would promote consistency and transparency of process,helping to improve the professional relationship and maximising the principles of autonomy,participation and dignity.Addressing a Lack of Mental Capacity: Courts Authorising the Making of Willsfor Living but Incapacitated Persons in AustraliaFiona Burns, University of Sydney (fiona.burns@sydney.edu.au)54

There will be occasions when a living person will not have the capacity (nor the intention) tomake a will, sometimes meaning that after his or her death the estate will inevitably bedistributed under the intestacy scheme or in a way which may be inappropriate or even perversein the circumstances. In short, the person is alive, but is unable to make a will, although it canalready be seen that the distribution upon death will be unsatisfactory. The hiatus created by alack of basic testamentary capacity became a great concern in Australia during the 1990s. Thispaper will: briefly outline the reasons why law reformers and legislatures decided to give courts(and in some cases other authorities) the power to authorize/make wills on behalf ofincapacitated person; briefly outline the structure and content of legislative provisions, includingthe fact that the person for whom the will is authorized must be alive at the date of theapplication; discuss the kind of situations to which the legislation may apply such as ‘lostcapacity’, ‘nil capacity’ and ‘pre-empted incapacity’; discuss the concept of ‘lack oftestamentary capacity’ utilized in the legislation; the standard of evidence required to satisfy thecourt that the person lacks capacity; the standard of evidence which may substantiate theargument that the person will acquire or re-gain testamentary capacity; the kind of evidencewhich may assist the court in determining the person’s testamentary wishes in the absence ofcapacity; the extent to which (if any) the powers given to courts to authorize wills forincapacitated persons overlap with the powers accorded to protective authorities such asguardianship tribunals/boards and protective commissioners; Discuss whether there are anyinherent ‘dangers’ for abuse under the legislation; and refer to some of the principal cases whichhave arisen under the legislation.Old Shams and Older Victims: Legislative Monitoring and Moderating theDangers Associated with Equity Release in the United States and AustraliaFiona Burns, University of Sydney (fiona.burns@sydney.edu.au)Ageing brings with it two significant problems: its associated health issues (such as poorercognitive capacity); and the economic consequences of ageing such as lower economic growthand the increasing costs of publicly funded pensions and aged care. Equity release products suchas reverse mortgages are considered a viable way of individual seniors bearing day-to-day costsand some of the costs associated with ageing. While reverse mortgages have been touted as asolution for the ageing ‘crisis’, they are complex documents which some seniors have founddifficult to understand. There has been evidence (particularly from the United States) that seniorswho are ill or cognitively reduced (but still having legal capacity) have been subject to predatorylending, misleading advertising, fraud and estate planning scams. The purpose of this paper is toconsider what the major risks and complexities are which reverse mortgages may pose forvulnerable seniors in each jurisdiction (such as misleading advertising, cross-selling, yield spreadpremiums, negative equity, the nature of default, interest rates and administrative fees), takinginto account that reverse mortgages in these jurisdictions may differ, and to compare andcontrast how the governments in both countries have legislatively and administrativelyresponded to the risks created by reverse mortgages with an eye to the whether the processes and55

standards which have (or will be) put into place protect vulnerable elders, such as elders with areduced capacity to understand complex legal documents. It will be argued that public authoritiesin the United States have been proactive (at least in relation to HECM mortgages) relying on awide variety of measures: legislative intervention (such as changes to the Housing EconomicRecovery Act 2008); mandatory counseling; and insurance back-up. In Australia, so far theFederal government has been content to regulate legislatively certain aspects of reversemortgages such as what provisions may or may not be included in the mortgage; and whenenforcement procedures may be taken. Notwithstanding increasing government intervention, itwill be argued that there are still dangers for seniors in both jurisdictions.International Comparison of Legal Frameworks for Substitute Decision MakingGavin Davidson, Queen's University Belfast (g.davidson@qub.ac.uk)Lisa Brophy, University of Melbourne (Lbrophy@unimbelb.edu.au)Jim Campbell, Goldsmiths, University of London (j.campbell@gold.ac.uk)Ann-Marie O’Brien, Royal Ottawa Mental Health Centre (anne-marie.o’brien@theroyal.ca)In this presentation four legal frameworks for substitute decision making for people whosedecision making capacity is impaired will be reviewed and compared. The four jurisdictions thatwill be examined are Ontario, Canada; Victoria, Australia; England and Wales; and NorthernIreland. Some of the key areas of discussion will be the assessment of mental capacity and theinterface between mental capacity and mental health law. Ontario has developed a relativelycomprehensive, progressive and influential legal framework over the past thirty years (Bartlett,2001) but there are some issues about the standardisation of mental capacity assessments andhow the laws work together. In Australia, the Victorian Law Reform Commission (2012) hasrecommended that the six different types of substitute decision making under the three laws inthat jurisdiction need to be integrated and simplified. In England and Wales the Mental CapacityAct 2005 also has a complex interface with mental health law. In Northern Ireland it is proposedto introduce a new Mental Capacity (Health, Welfare and Finance) Bill that will provide aunified structure for all substitute decision making. The presentation will identify key strengthsand limitations of the approaches in each jurisdiction and propose possible ways that furtherprogress can be made in law, policy and practice.21. Capacity, Incapacity, and Impaired Decision Making – TheChallenges of Providing Support and Protection in the ScottishContext56

The Adults with Incapacity (Scotland) Act 2000: Graded Guardianship as a WayForward in Developing a More Proportionate Statutory Response to the Needs ofAdults with Impaired CapacityGeorge Kappler, Mental Welfare Commission for Scotland, UK(george.kappler@mwcscot.org.uk)Welfare Guardianship under the Adults with Incapacity (Scotland) Act (2000) has been a victimof its own success. Use of this power has risen by nearly 60% in the past five years. There arenow approximately 7,000 people on welfare guardianship in Scotland. Alongside this increasehas come a change in the nature of its use. Where traditionally applications were made largely bylocal authorities in exercising their protective role, the reverse is now the case, with 70% of newapplications being made by private parties. There has also been an increase in its use for youngerpeople with learning disabilities. Worryingly, most orders are now approved on an indefinitebasis. The question of when an order should be sought as opposed to when it must be soughtcontinues to be the subject of considerable debate. We now have a situation where, for instance,a 95 year old with severe dementia receiving palliative care in a care home is subject to the samestatutory provisions in terms of the application process and supervisory regime as a 25 year oldwith severe learning disability and challenging behaviour whose care involves considerablerestrictions which effectively constitute a deprivation of liberty. Beyond this, parents who havebeen providing intensive care and support for a severely disabled child since birth haveexpressed feeling demeaned and humiliated when having to appear in court to justify continuingtheir parental role by seeking guardianship powers when their child turns 16. This paper willexplore a possible way forward through the creation of different levels of guardianship withgraded levels of statutory involvement at the application and supervision stages which are moreproportionate to the individual circumstances of the adult.An Exploration of the Understanding and Use of the ‘Impaired Ability’ Criterionfor Compulsory Treatment in the Mental Health (Care and Treatment)(Scotland) Act 2003Jacqueline Atkinson, University of Glasgow (Jacqueline.Atkinson@glasgow.ac.uk)Jacquie Reilly, University of Glasgow (Jacquleine.Reilly@glasgow.ac.uk)The Mental Health (Care and Treatment) (Scotland) Act 2003, introduced in October 2005,brought in a fundamental change to the criterion for compulsory treatment. For the first time inUK mental health legislation a capacity criterion was introduced for short-term and compulsorytreatment orders. This criterion states: “that because of the mental disorder the patient’s abilityto make decisions about the provision of medical treatment is significantly impaired”.Significantly impaired decision making ability (SIDMA) is not the same as “incapacity” underthe Adults with Incapacity (Scotland) Act 2000 but is a “related concept” based on similar57

factors, but with a lower threshold. As such, the law in Scotland “recognises that patients withmental disorder may have impaired capacity which, while damaging their ability to makedecisions, does not render them entirely incapable”. This was seen as being a more ethical andless discriminatory way of dealing with people with mental disorders. There is no precisethreshold for SIDMA which means that there are likely to be different interpretations of it withinand between different professional groups, depending on the circumstances and complexity ofany given assessment. It is important to understand how different groups view this possibilityand what provisions they would expect to make. This paper will focus on the findings of a studywhich focused on assessing relevant professional groups’ (psychiatrists, mental health officers)views about how SIDMA is being applied by professionals, including potential differencesbetween groups and the impact of the inclusion of the criterion on decisions about compulsorytreatment and the setting for treatment.Capacity and the Provision of Support and Protection to Adults at Risk of HarmAilsa Stewart, University of Strathclyde (ailsa.e.stewart@strath.ac.uk)Scotland is unique within the United Kingdom in having consolidating legislation to protectadults at risk of harm. In particular the Adult Support and Protection (Scotland) Act (2007)(ASPA) provides for voluntary and statutory measures to support and protect adults at risk ofharm who have the capacity to make decisions and who have neither a diagnosis of learningdisability nor mental disorder. Since the implementation of this legislation in October 2008 it hasbecome clear that the statutory measures to support and protect adults at risk of harm have beenused sparingly and often only as a last resort with the majority of referrals ending in voluntaryengagement with services. The measures available within the legislation to override the consentof an adult to provide support and protection have been little used. This paper will focus ondiscussing the factors considered in practice to override the consent of an adult within thisunique legal context. In particular the legislative framework and associated codes of practice willbe considered alongside the place of professional judgement in considering the risk of harm andthe requirement for statutory intervention. In addition the issue of undue influence will also beconsidered. The paper will draw upon empirical research to distil the key challenges in practiceof providing support and protection to adults utilising the measures within the ASPA, drawingdistinctions between the various groups of professional staff involved in these endeavours.The Use of Section 13ZA of the Social Work (Scotland) Act: Least RestrictiveOption or Unlawful DetentionGillian MacIntyre, University of Strathclyde (gillian.macintyre@strath.ac.uk)Section 13za of the Social Work (Scotland) Act, 1968 commenced in March 2007 in order tocreate explicit instances where a Local Authority, following an assessment of an individual’s58

needs, can take steps to ensure the individual benefits from services where they do not have thecapacity to make this decision for themselves. Section 13za enables Local Authorities to take“any steps” they believe are necessary to ensure the individual benefits from such services. Theinterface between the various relevant pieces of legislation and guidance including section 6 ofthe Adults with Incapacity (Scotland) Act, 2000 and the European Convention on Human Rights(ECHR) are complex and Local Authorities must ensure that any steps that are taken do notcontravene an individual’s human rights. This relates particularly to Article 5 of the ECHR, interms of deprivation of liberty. This paper will explore the continuing differences among variousprofessional groups in terms of their understanding of what Section 13za allows LocalAuthorities to do. There are mixed views for example when moving an adult who has beenassessed as being “incapable but compliant” into residential care as to whether this represents theleast restrictive option, complying with the principles set out in the Adults with Incapacity(Scotland) Act, 2000, or whether in actual fact this represents a deprivation of liberty. This paperwill draw on data compiled by the Mental Welfare Commission for Scotland on the use ofSection 13za and will complement this with data drawn from focus groups and interviewsconducted with key stakeholders in this field, namely Solicitors, Mental Health Officers andPsychiatrists.The Impact of Significantly Impaired Decision Making on High ReadmissionRates to Hospital: A Psychological PerspectiveNicola Cogan, Lanarkshire NHS Trust, South Lanarkshire, UK(nicola.cogan@lanarkshire.scot.nhs.uk)Polash Shajahan, NHS LanarkshireJulie Langan, NHS LanarkshirePsychiatric hospitalization is a major life event for both patients and families and has significantsocietal costs. It is the most expensive intervention in mental health service provision.Readmission rates have been used to monitor success in preventing, or reducing, unplannedreadmissions to hospital for acute psychiatric services. Repeated emergency admissions to acutein-patient psychiatric units have been variously defined and such individuals have been known as“high readmission” patients. In 2008 the Scottish Government set NHS Health Boards specificHealth Efficiency Access and Treatment (HEAT) targets. Target 3 was to “reduce the number ofreadmissions (within one year) for those that have had a hospital admission of over 7 days by10%”. The Scottish Patients at Risk of Readmission and Admission (SPARRA) is a riskprediction algorithm, developed by the Information Services Division (ISD) Scotland. It aims toidentify patients at greatest risk of emergency admission. The SPARRA for mental disorders hasbeen considered potentially useful in planning healthcare provision and measuring the effects ofservice redesign. This paper will present data on the clinical and demographical characteristics of“high readmission” patients within a NHS Lanarkshire locality. It will draw upon empiricalfindings on how “high readmission” patients were significantly more likely to have CompulsoryTreatment Orders under the Mental Health (Care and Treatment) (Scotland) Act 2003 usedbetween admissions compared to patients with less frequent admissions. Issues concerning59

significantly impaired decision making, risk to self or other, treatment refusal and likely benefitsof treatment are explored. It is argued that, by strategically aiming psychological interventions at“high readmission” patients, a disproportionate reduction in inpatient admissions and unplannedcare could be achieved, therefore providing a good cost-benefit outcome.22. Child Abuse: Outcomes & ImplicationsChild Sexual Abuse and Narcissism: A Case ReportEster di Giacomo, University of Milano-Bicocca (ester.digiacomo@yahoo.com)Flora Aspesi, S. Gerardo Health Care Trust, ItalyMassimo Clerici, S. Gerardo Health Care Trust, Italy (m.clerici@hsgerardo.org)Child Sexual Abuse has a wide range of connotations. Psychiatric implications often includedepression, post-traumatic stress disorder, and self-harming behavior. Moreover it oftendetermines personality correlates (in particular Borderline Personality Disorder). In thispresentation we report an explicative case of the consequences linked to child sexual abuse.Patient: Male, 40 ys, divorced, one son (11 ys). He reports child sexual abuse by both parents (7to 12 ys). Abuses ended when he fought his father with a knife. He worked for an airlinecompany, but was fired for an excess of work absence due to pathology. Since adolescence hepresented obsessive-compulsive behavior, anxiety, mood instability, impulsiveness, flash backs,nightmares, attention difficulties and sleep disorder (linked to the idea of his own death duringsleeping). Clinical diagnoses: Post Traumatic Stress Disorder and Obsessive CompulsiveDisorder (Axis I), and Personality Disorder NAS with obsessive compulsive and narcissistictraits (Axis II). He complains about side effects due to many drugs (different antidepressants,antipsychotics and mood stabilizers), but shows small responsiveness. Test: WAIS-R: I.Q.=105RORCHACH: a personality organized with narcissistic defenses due to relational defects linkedto self and identity definition. SCID-II: Personality Disorder NAS with obsessive compulsiveand narcissistic traits.Child Sexual Abuse: An Irremediable Hurt?Ester di Giacomo, University of Milano-Bicocca (ester.digiacomo@yahoo.com)Alberto Alamia, University of Milano-Bicocca (a.alamia@campus.unimib.it)Federica Cicolari, University of Milano-Bicocca (f.cicolari@campus.unimib.it)Valentina Cimolai, University of Milano-Bicocca (v.cimolai@campus.unimib.it)Massimo Clerici, S. Gerardo Health Care Trust, Italy (m.clerici@hsgerardo.org)60

The phenomenon in object results ubiquitous both regarding victims' gender and socioeconomicconditions. The important consequences linked to what they suffered - either immediately orwith adolescent or adult onset- are mediated by age and family support to trauma reprocessing aswell as by frequency of repetition of the abuse or familiarity with the abuser. These factorsappear to be of primary importance - both at a physical and a psychic level- and may beexpressed in multiple manifestation; it would be impossible to ignore any alarm signals revealingsuspected abuse suffered by a minor. Specific attention will be directed towards short- and longtermconsequences, including Post Traumatic Stress Disorder, personality disorders, depression,substance abuse, as well as perpetuation of the same behavior. In this field, the dramatic lack ofproper training of the professionals who work with minors on a daily basis (pediatricians,teachers, etc.), as well as poor treatment techniques, emphasizes the ugent need for preventionand early intervention.Causing Parental Alienation is a Form of Child AbuseWilliam Bernet, Vanderbilt University (william.bernet@vanderbilt.edu)Parental alienation is a serious mental condition that sometimes occurs when a child's parents areengaged in a high-conflict separation or divorce: the child allies strongly with one parent andrejects a relationship with the other parent without legitimate justification. In some instances,parental alienation is brought about by the indoctrination of the child by the preferred parentagainst the rejected parent. If the preferred parent has indoctrinated the child in a knowing,purposeful, persistent manner to hate and avoid the alienated parent, that behavior should beconsidered emotional or psychological abuse of the child. Although psychological abuse of achild is not currently included in the Diagnostic and Statistical Manual of Mental Disorders, it isincluded in the International Classification of Diseases. There is considerable internationalresearch to support this proposal that causing parental alienation should be considered a form ofchild abuse. The presenter will summarize the work of psychologists, psychiatrists, and legalprofessionals from various countries. In some instances, state and national governments havemade it illegal to induce parental alienation in a child. Also, in some cases, the European Courtof Human Rights has recognized the serious nature of parental alienation.23. The “Choosing Wisely” MovementIs Psychiatry Ready?Antony Fernandez, Virginia Commonwealth University (antony.Fernandez@va.gov)Technological and scientific advances have made the current practice of medicine enormouslycomplex. Along with progress, however, this evolution has come attached with a hefty price tagas well. In recent times, there has been growing concern among medical professionals about61

medically wasteful and futile procedures, the growing problem of health care fraud and themagnitude of their economic impact. In early 2012, nine specialty medical groups in the USAlaunched a movement known as "Choosing Wisely"; this movement, involving approximately350000 physicians, identified 47 medical procedures and treatments widely used in the practiceof medicine, and recommended that these not be used routinely. When this began, Psychiatrywas not one of the fields affiliated with this movement. Diagnosis in Psychiatry is still largelybased on clinically elicited signs and symptoms, and the identification of clinical syndromes. Formost disorders, we still do not have any reliable or sensitive pathognomic tests, and cliniciansimplicitly rely on information obtained from the patient/client., In addition, there is increasingawareness of malingering and the potential for psychotropic diversion and abuse, especially incertain treatment settings. The Choosing Wisely movement is timely, and Psychiatry must join innow.Let's Look at the Evidence for PsychiatryBabu Rankupalli, University of Florida, Gainesville (babu.rankupalli@va.gov)A growing body of research over the last decade has looked at the utilization of treatmentresources and how these affect different clinical outcome measures. Large-scale multicentricprojects have shown that using newer generation medications has no significant clinicaladvantages over older medications on the core symptoms of major mental illness (CATIE,CuTLASS-2). Studies have also shown that different antidepressants are all equally effective inappropriate patients, and the choice of medications is usually guided more by the side-effectprofiles. Other research has shown that polypharmacy is usually associated with a higher risk ofside-effects and interactions, and poorer long-term treatment outcomes. It has also been shownthat non-clinical factors often affect the prescription of antipsychotics and other psychotropics(the PORT study presented at the ICSR, 2009). Often, prescribing practices in the USA involveoff-label use of psychotropic medications; treatment practices are also frequently influenced byeconomic considerations (costs of hospitalization, etc.), industry influences, and fear oflitigation, rather than primary clinical (therapeutic and pharmacological) factors. Thispresentation will outline the various research studies done across the globe that are relevant tothis discussion, and will provide an overview of our recommendations for judicious evidencebasedpsychopharmacological practice in Psychiatry.The Correctional Mental Health Experience: The Proof of the PuddingPratap Narayan, University of California at San Francisco (prat65@hotmail.com)Centorrino et al (2004) reported that patients prescribed antipsychotic polypharmacy receivedhigher medication doses and reported more adverse effects than patients who receivedmonotherapy while the clinical improvement rates were similar in both groups. Pandurangi &62

Dalkilic (2008) in their review of eight RCTs and 66 case reports found no empirical basis forgeneral recommendations regarding the use of particular types of polypharmacy. Mindful of thelikelihood of psychotropic abuse or diversion in a correctional facility, our team at the FresnoCounty Jail instituted a program to improve diagnostic practice, and decrease the possibility ofabuse/diversion of medications. Five specific medications were progressively phased out of theformulary from August 2007 through November 2007. Medications required but not on theformulary were still available using a non-formulary request process. Evaluations werecomprehensive, and included a consideration of malingering in all cases. Staff from a variety ofdisciplines were educated about the program. After an initial increase in requests for mentalhealth services, there were no untoward incidents or adverse outcomes in the long-term. In 2011,we systematically analyzed available data to see what the impact of the changes were, in aretrospective study design. The variables looked at were ones that reflected clinical status, crisiscalls, safety cell placements, and hospitalization (involuntary holds) but that Management had nodirect control over. The findings and implications resulted in substantial savings for thecorrectional facility without compromising quality of care and will be discussed in greater detailduring the presentation.Patient Satisfaction, Costs and OutcomesRaju Paturi, Illinois Department of Corrections, Springfield, USA (drrajupaturi@yahoo.com)Physicians generally try to keep their patients happy, if possible, with the notion that patientsatisfaction can further enhance better clinical outcomes. There have been several recent studieslooking at the treatment outcomes in different disciplines to systematically look at the clinicalimpact of patient satisfaction. Interestingly, however, traditional thinking has not been borne out- whether or not patient satisfaction is a focus of treatment, clinical outcomes have been seen tobe comparable. However, the impact of patient satisfaction appears to be evident in significantlyincreased costs associated with this population. In addition, there is a huge economic burdenassociated with health care fraud in the United States (in 1995, it was to the tune of about 15billion dollars). The overall economic impact of both these phenomena, as they relate to mentalhealth treatment, will be discussed in further detail during the presentation.A Summary of the Evidence for PsychiatryJagannathan Srinivasaraghavan, Southern Illinois School of Medicine (jagvan@gmail.com)There is an enormous need for the profession to sit up and take notice - we are at the crossroads,and the direction we take will decide the future of Psychiatry. The global community does nothave unlimited financial resources, and we are all required to follow the utilitarian principle - thegreatest good for the greatest number. Unfortunately, we are besieged by various influences -legal, political, corporate and economic. The Choosing Wisely movement is a timely63

phenomenon - however, it needs much more widespread acceptance. Professional regulatorybodies need to incorporate these recommendations into their practice guidelines. Mostimportantly, Psychiatry must be at the forefront and blazing a trail. The changes we arerecommending may not be possible in all situations/settings; however, clearly, it works in acorrectional population, and presumably in other closed systems as well. Patient satisfaction is animportant consideration in all treatment, but at what cost? Recent studies in different clinicalpopulations have shown uniformly that patient satisfaction does not significantly improveclinical outcomes, but does increase costs. These issues and other significant questions will bediscussed in detail.24. The Clinical, Forensic, and Ethical Pitfalls of the DSM-5Mind, Brain, and the Nature of PsychiatryRonald Abramson, Tufts University (rona976@aol.com)Psychiatry is the medical specialty that deals with the diagnosis, treatment, and prevention ofmental and emotional disorders of the mind. The mind results from the activity of the organicbrain. Activities of the brain can be objectively observed using the methods of physical science,but the activities of the mind can only be observed subjectively through introspection of one'sself or through empathic communication with another. In the early twentieth century, disordersof the subjective mind were the focus of main stream psychiatry, and psychoanalytic thinkingwas the chief mode of understanding these disorders. However, problems in diagnosticreliability, scientific rigor, and advances in pharmacology and diagnostic imaging have led to ashift in emphasis to biological reductionism. Mental disorders are now defined as "braindiseases" whose criteria are listed in the DSM. The subjective dimension has vanished. Althoughbiological reductionism may seem more scientific, excluding the subjective mind fromconsideration is not scientific at all and may in practice lead to clinical error. Cases will bepresented that will document how exclusive reliance on DSM objective criteria led tomismanagement and put patients at risk.The Diagnostic and Statistical Manuals' Adherence to a Neologistic MedicalModel's Unwitting Contributions to the Stigmatization of Those Given aDiagnostic LabelBurton Norman Seitler, Counseling and Psychotherapy Services-R, Ridgewood & Oakland, USA(binsightfl1@gmail.com)This paper expresses the point of view that formal diagnoses for emotional dilemmas label andscar human beings. Furthermore, such diagnostic categories are relics of an anachronistic,64

antiquated, and inaccurate medical model. This author argues that the medical model isunsuitable for use in attempting to understand the delicate, intricate, and complex entity knownas the human mind, and that to attempt to employ medical/scientific sounding terminology onlyprovides a superficial illusion of understanding someone rather than a genuine in-depthunderstanding of the individual, which can only be accomplished in an interpersonal,psychosocial interaction, one that is not simply cursory. The Diagnostic and "Statistical"Manuals (DSMs) confuse and compound the issue by assuming that once we name something,we now know what it is and we therefore know how to treat "it." Moreover, the term "statistical"in the Diagnostic and Statistical Manuals is a clever "spin" implying that a statistical analysis ofdata has taken place that has produced empirical results that are verifiable and replicable.Nothing is further from the truth.Limitations of the DSM in Clinical Neuropsychiatric DisordersJacob C. Holzer, Pocasset Mental Health Center, Pocasset, Massachusetts(jacob.holzer@dmh.state.ma.us)The purpose of the Diagnostic and Statistical Manual of Mental Disorders is to provide, in part,descriptive information on various diagnostic categories, in order to allow clinicians the ability todiagnose, treat, and communicate about people with various mental disorders (paraphrased fromCautionary Statement, DSM-IV, APA). Among the large number of psychiatric disorders listed,some overlap with clinical neurology, including dementia, delirium, attentional disorders, andmovement disorders. Although this descriptive information can be helpful, the underlyingneurobiology and mechanisms of disease are not emphasized. Different diseases can result insimilar clinical pictures on the surface, yet have major differences in causation, process,interventions, or prognosis. This presentation will provide a critical review of someneuropsychiatric conditions described in the DSM series up to DSM-V, and the potential impacton clinical care and risk management issues for the patient and clinician.Addressing Pharmaceutical Industry Undue Influence on Psychiatric Treatmentin the Internet AgeHarold Bursztajn, Harvard Medical School (harold_bursztajn@hms.harvard.edu)Julian de Freitas, Yale University (julzdefreitas@gmail.com)Brian Falls, Harvard Medical School (brian.falls@va.gov)Omar Sultan Haque, Harvard Medical School (omarsultanhaque@gmail.com)The Internet has allowed pharmaceutical marketing to become more salient than ever before. Itspower to disseminate information has helped the public in many ways, but has also allowed for65

novel conflicts of interest – as when information misleads in order to promote a pharmaceuticalcompany’s marketing efforts, and unduly influences psychiatrists’ prescribing. Such tensions arefurther complicated by the idiosyncrasies of the Internet as a communication medium,challenging traditional bioethical principles intended to safeguard the physician-patientrelationship. We analyze how the Internet influences psychiatric treatment decisions, and how itscharacteristics, coupled with the nature of contemporary psychiatric practice, can leave usersvulnerable to misinformation. We found that drug marketing can mislead across both establishedand novel Internet domains, including search engines, company websites, email lists, blogs,wikis, health information services, and mobile health software. We identify misleading Internetinformational and presentational trends common among these domains. Finally, we explorepotential improvements, including independent evaluation; provision of unbiased information oncommercial sites; warnings on search engine result pages that hyperlinked websites may containmisinformation; identification of misleading search engine results using algorithm; andimplementation of rules regarding conflict of interest disclosure within resources that promotediscussion among typically anonymous individuals.How the American Psychiatric Association’s (APA) Ties to the PharmaceuticalIndustry Bind its Diagnostic and Treatment GuidelinesLisa Cosgrove, University of Massachusetts Boston (lisa.cosgrove@umb.edu)This presentation will use the conceptual framework of institutional corruption as a lens throughwhich to examine the intellectual and ethical crisis in organized psychiatry today. Taking theposition that institutional corruption exists when there are a set of practices (both implicit andexplicit) that create conflicted organizations (Lessig, 2011) – the main mission of theorganization is deflected – it will be shown that “corruption” in organized psychiatry today is notsimply the result of individuals with financial ties to industry. It is not about a few “corrupt”individuals who are hurting an organization whose integrity is basically intact. Although highprofile cases, such as those involving ghostwriting of texts or peer-reviewed journal articles, shiftattention to individuals, institutional corruption is a socio-political problem, not an individualone. Additionally, the analytic framework of institutional corruption is useful in that itencompasses ethical issues and concerns that “conflict of interest” may not. For example, seriousquestions have been raised about the integrity of the Diagnostic and Statistical Manual of MentalDisorders (DSM) and about the trustworthiness of clinical practice guidelines produced byspecialty organizations such as the American Psychiatric Association (APA). This presenter willreport on research addressing the quality of diagnostic and treatment guidelines produced by theAPA. A central question of this presentation is: insofar as institutional corruption distorts truthseeking, what scientific, diagnostic, and treatment truths get most distorted in psychiatry today,and what are the ethical and medico-legal implications of these distortions?66

25. Collaborative Care Arrangement Between Hunter New EnglandMental Health Services & Mental Health Non-GovernmentOrganizationsCollaborative Care Arrangement between Hunter New England Mental HealthServices & Mental Health Non-Government OrganisationsBarbara Stacy, Hunter New England Mental Health, Newcastle, Australia(Barbara.Stacy@hnehealth.nsw.gov.au)As the use of the Recovery concept in mental health results in greater deinstitutionalisation withmore mental health consumers living in the community, a key issue has emerged as to how theHunter New England Mental Health clinicians and the Non Government Organisation supportworkers can work together to adequately improve social inclusion and recovery for mental healthconsumers. This presentation traces the development processes from the simple Team CareModel presented in New York in 2009, through evaluation as presented in Berlin in 2011, to therefined and expanded current Collaborative Care Arrangement proposed for use by front lineservice deliveries. A large number of care providers were involved in preparation of thedocument representing many organisations and reflecting many delivery styles. The documentwas renamed to describe its intent.Collaborative Care Arrangement between Hunter New England Mental HealthServices & Mental Health Non-Government OrganisationsThanh-Nu Reeves, Hunter New England Local Health District, New South Wales, Australia(Thanh-Nu.Reeves@hnehealth.nsw.gov.au)The Collaborative Care Arrangement between Hunter New England Mental Health Services andMental Health Non-Government Organisations was first presented to the IALMH New YorkCongress as the Team Care Model. Since then evaluation workshops and surveys have guidedthe collaboration between Public Health clinicians and the NGO sector resulting in the currenttitle and document. To align with the strategic vision of Australia’s Mental Health Strategy andthe Council of Australian Governments National Action Plan on Mental Health 2006-2011 for amental health system that enables Recovery, the Collaborative Care Arrangement has explicitlyadopted the Recovery concept as the guiding principle. This presentation will demonstrate howthe two mental health sectors have overcome different value-laden applications of the Recoveryconcept toward identifying common ground for effective and efficient collaboration.67

Collaborative Care Arrangement between Hunter New England Mental HealthServices & Mental Health Non-Government OrganisationsTim Fong, Psychiatric Rehabilitation Australia, New South Wales, Australia (Tim.f@pra.org.au)People with lived experience of mental illness often find it challenging to access appropriatesupport services in the community. Community based organisations provide access to a numberof psycho-social rehabilitation programs from which the individual is free to choose. Therelationship between community based non-clinical services and clinical public mental healthservices can be a complex one and navigating ‘the system’ can be challenging. This collaborativeapproach assists the individual and service providers to develop effective Recovery basedinterventions that keep the individual at the centre of their own Recovery. This approach isevolving to one that responds within a Recovery framework.26. Combination of NeedsNaming and Addressing the Role of Traumatic Experiences in the Trajectoriesof the Lives of Homeless African American Female Ex-OffendersSuzette Brann, Reaching Beyond Change International LLC, USA (suzette@drsuzettebrann.com)A feminist lens was used to explore how race, gender, trauma and criminal history coalesced tobecome women’s pathways to crime and homelessness. The study findings indicated thatwomen’s pathways to crime were defined by traumatic childhood experiences, addiction,criminal role models, economic marginalization (the need for income), and damaged self-images.Pathways to homelessness were attributed to traumatic childhood experiences, addiction, lowsocial and human capital, destructive personal relationships, criminal involvement, loss of publicbenefits, and pride. The study findings demonstrate the importance of providing homelessAfrican American women with criminal histories with culturally relevant substance abusetreatment; gender-informed medical, psychiatric, and dental care; counseling that repaired selfesteemand self-image; access to subsidized housing; life skills training; employment readinessworkshops; and spiritual resources to assist them in taking pathways away from crime andhomelessness.What Contribution Can Person-Centred Support Based Approaches Make toDesistance from Offending? The Experience of Women Across a Range ofNeedsRebecca Gomm, Durham University (r.m.gomm@durham.ac.uk)68

Traditional research on desistance from offending has focused on large quantitative studies,which do not account for underlying support mechanisms. Additionally, most of the desistanceliterature subsumes women within the male demographic, meaning that intervention may lackspecificity. Taking a more psychological and person-centred approach can impact positively onindividuals and assist with re-integration into the community. Qualitative research with womenoffenders in London, England, will be outlined, with recommendations for providing morepsychologically informed approaches. Recent literature has indicated that the process view ofdesistance is appropriate for consideration of underlying mechanisms. In contrast to the moretraditional ‘finite’ point of view, it may enable an account of progress made by individuals(Farrington & Kazemian, 2010). Interventions need to be targeted in a differential, timely andflexible manner (Crighton & Towl, 2008). Using process models of desistance, based on theoffender’s experience, may inform this. The potential for using process models of desistance,based on the experience of women offenders, will be outlined.Saving and Changing Lives through Effective Trauma Focused TherapiesKristine Buffington, National Child Traumatic Stress Network, Toledo, USA(kbuffington46@hotmail.com) (419-944-4602)Every human being is born with a beautiful potential to learn, grow, love, and to make wonderfulcontributions to their families, their communities, and society. Sometimes adversities occur inthe lives of children and adults that can harm or interfere with their reaching their full potential,adversities such as child abuse, neglect, exposure to violence, racism, sexism, poverty, andoppression. While these adversities or traumas have the potential to derail child developmentand impact the lifespan, there are things we can do to address traumatic stress and help to saveand transform lives. There are three levels of approaches to address traumatic stress: prevention,trauma-informed system responses, and the use of evidence based trauma focused therapies.This presentation will address highlights of trauma-informed system responses and evidencebased trauma-focused therapies. The National Child Traumatic Stress Network developed aframework of essential elements of trauma informed care for the child welfare system. Theseessential elements are relevant across all systems and can influence a pathway of respectful andlife saving responses. Also highlighted will be Karen W. Saakvitne’s et. al. Risking ConnectionModel and Cohen, Mannarino, and Deblinger’s Trauma-Focused Cognitive Behavioral Therapy.27. Community-Based Compulsory Treatment: Emerging Findingsfrom the UK and International PerspectivesThe Evidence for Community Treatment Orders: An International Perspective69

Andrew Molodynski, University of Oxford (Andrew.molodynski@oxfordhealth.nhs.uk)Community Treatment Orders (CTOs) have been available in some countries for many yearsnow but are relatively new in others and have not been introduced in many. They remaincontroversial to this day with strong opinions expressed on both sides by healthcare professionalsand service users. The heated ongoing debate is at least in part due to the lack of a clear evidencebase regarding their acceptability and effectiveness. The evidence base is quite substantial buthard to interpret and often unclear and/or contradictory. This presentation provides an overviewof the most important studies from different regions of the world with recent advances in ourknowledge about the key questions of effectiveness and tolerability. It looks to ways in which wecan build upon this base to understand these legal mechanisms and their effects in a moresophisticated way.Use of Leverage Tools in Outpatient Mental Health Care in EnglandKsenija Yeeles, University of Oxford (ksenija.yeeles@psych.ox.ac.uk)Research in coercion is not only restricted to legal detention. Patients often perceive theiroutpatient treatment as coercive. The MacArthur Coercion Group study in the USA reported thatup to 50% of outpatients had experienced leverage (pressure to adhere to treatment). The presentstudy aimed to explore the use of leverage tools in outpatient care in England and how it mightvary between different clinical groups, and to compare levels of use with the USA sample.Researchers conducted structured interviews with psychiatric outpatients. Data on the use ofspecific leverage (access to accommodation, financial assistance, criminal justice system andchild custody), patient social and clinical characteristics were collected through interviews andmedical records. A total sample of 417 participants was recruited in outpatient services. Overall35% of the sample reported experiencing leverage. The most common leverage used was accessto accommodation. Reported levels of leverage were lower in England compared to the USA(35% v 51%). Psychosis patients report a higher level of experienced leverage. Use of informalcoercion seems to be routinely spread across mental health services in England and the USA.What Patients and Family Carers Think about Community Treatment Orders: AQualitative Study from EnglandJorun Rugkåsa, University of Oxford (Jorun.rugkasa@psych.ox.ac.uk)As a result of the deinstitutionalisation of psychiatric services, new forms of involuntarycommunity treatment have emerged internationally. Community Treatment Orders (CTOs) wereintroduced in England and Wales in 2008 via amendments to the Mental Health Act 1983 andpermit patients to be treated in the community following involuntary hospitalisation. Aimed at70

the most unwell ‘revolving door’ patients, the intention behind the orders was to improvetreatment adherence in the community. Little is known, however, about the clinical and socialoutcomes of CTOs. This paper reports from in-depth qualitative interviews with a purposivesample of 40 service users and 25 family carers from across England. Findings suggest thatparticipants have mixed views about CTOs, with some reporting that their views had changedover time. Many participants found it difficult to pinpoint the impact that the CTOs had on theirlives, and some felt they lacked information about what they could expect. Our findings add tothe currently limited understanding of CTOs and provide a new perspective on the impact andeffectiveness of this new treatment form by giving voice to the people whose lives it affects themost.Lives Less Restricted: Patients’ Views of Compulsory Community Treatment inScotlandGeorge Kappler, Mental Welfare Commission for Scotland, UK(George.kappler@mwcscot.org.uk)The Mental Welfare Commission for Scotland has an overall safeguarding role for people withmental disorders. We visit people subject to compulsory treatment to monitor the care theyreceive and to ensure their needs are met and their rights protected. The Mental Health (Care andTreatment) (Scotland) Act 2003 introduced compulsory community treatment in Scotland in2005. Many stakeholders had anxieties about this measure. They were concerned that morepeople would be subject to longer term compulsion and that community resources would beinsufficient to meet their needs. The Commission reviewed the cases of people who had beensubject to community compulsory treatment for two years or more. We met as many of thosepeople as possible to hear their views. We wanted to determine how the principles of the Actwere being applied. Most people thought the order had been of at least some benefit. Care andtreatment were generally good and focussed on wider measures to improve quality of life, notmerely ongoing medication. Lack of progress toward employment and lack of strategies towardsrevoking the orders were matters of concern.The Practitioner’s Experience of Community-Based Compulsory TreatmentOrders: A Scottish PerspectivePearse McCusker, Glasgow Caledonian University (pearse.mccusker@gcu.ac.uk)This session will present findings from a small-scale qualitative research project with MentalHealth Officers (MHOs) in Scotland, which will explore their experiences of using communitybasedcompulsory treatment orders in practice (CCTOs). In Scotland, CCTOs have been legallyavailable since 2005, yet there has been limited investigation into their use. MHOs areexperienced social workers with specific legal duties, which include making applications to the71

Mental Health Tribunal Scotland for CCTOs and playing key roles in the ongoing support andmonitoring of service users following the implementation of orders. Central to this is ensuringpatients subject to CCTOs are facilitated access to a range of interventions tailored to theirparticular needs, including education, training and employment. This legal requirement is basedon the principle of reciprocity, recognising the importance of ensuring that restrictions of libertyare accompanied by meaningful follow-up care and support. Therefore, taking a social justiceperspective, this presentation will report on the extent to which CCTOs are used to improvepatients’ quality of life in the widest sense and in ways that go beyond traditional medicaldefinitions of ‘treatment’.28. Community Treatment OrdersAlberta’s Safe Communities Initiative: Highlighting Mental Health and theJustice SystemMargaret Shim, Alberta Justice and Solicitor General, Canada (margaret.shim@gov.ab.ca)Addiction and mental health issues are risk factors related to an individual’s involvement incrime. Criminal behaviour is a complex social problem, and there are no quick or easy solutions.Alberta’s Safe Communities (SafeCom) utilizes a cross-ministry and multidisciplinary approachwith staff seconded from Justice, Health, Education, Human Services and Aboriginal Relations.SafeCom’s mandate is to build capacity for coordinated community based responses to crimeprevention. In addition to Alberta’s Crime Prevention Framework and the Alberta GangReduction Strategy, SafeCom implemented a number of initiatives that span the continuum ofcare to address risk factors and build capacity for coordinated community based responses toaddiction and mental health issues, including: Police and Crisis Teams; Integrated JusticeServices Project; promoting community and police partnerships in innovative crime preventionpilots through the Safe Communities Innovation Fund; increased addiction and mental healthbeds; enhanced addiction and mental health services in correctional facilities; Life SkillsSubstance Abuse Prevention Program for Aboriginal Children and Youth; and Immigrant andRefugee Youth Mental Health Project. Lessons learned from SafeCom’s approach, whichresulted in an increased emphasis on prevention, including addressing risk factors for criminality,especially addiction and mental health issues, will be shared with participants.Integrative Human Services Systems in Low Income Communities to EnhanceMental HealthCarmen Porco, Housing Ministries ABW, USA (cporco@mailbag.com)Developing community learning centers in low income communities focused on education andemployment development enhances the mental health of the resident population. Programs72

dealing with the various stages of human growth and development enable families and childrento utilize services such as head start, day care, after school education sessions, adult educationsessions, family literacy and various counseling services. These enable persons in communities,often without connected services, to quell a sense of hopelessness and avoid greater deteriorationof mental health. Such a model integrated with housing provides the unique institutional settingthat connects the community with the mainstream institutions, and creates the power equalizationthat is often lacking in communities of poverty. By providing holistic family services the modelconnects each member to the different components of meaningful and gainful developmentnecessary to adjust to the normative value core of the dominant society. With such positivedevelopment mental health is elevated. Issues such as child neglect, drugs, crimes and otherdynamics of dysfuntionality are minimized. Connectedness, resource ownership and molding ofbehavior by a staff composed of residents providing the services create the sense of hope andattainment of opportunity that fosters healthy communities.What Is "Impact"? Lessons Learned via a Community-Based Reentry to SocietyProgramDavid R. Montague, University of Arkansas at Little Rock (drmontague@ualr.edu)During the 2011 International Congress on Law and Mental Health conference in Berlin, severalscholarly panels addressed the lack of effective programming for those who are incarcerated invarious parts of the world. This lack of programming is an important reality in that it ties directlyto the various legal systems which advocate rehabilitation, but unfortunately either do not haveresources or choose not to allocate more resources toward such programming. In the UnitedStates, the country with the highest rate of incarceration, such programming is essential indealing with what some call a "revolving door" of recidivism in which former inmates return toprison. To address this phenomenon, a study was completed within the state of Arkansas (in theUnited States) in which several years of such rehabilitative programming were evaluated interms of the "tools" provided to those incarcerated in order to improve their chances of notreturning to prison. What makes this study so unique, is that it was completed at the request ofthe program mentors of this prison's Inmate Leadership Council, to help understand this allvolunteerprogram, made up of facilitators from within and outside the prison. Therefore, thisunsolicited data set is from an official community reentry to society program and takes the formof homework assignments completed by the participants representing various modules oflearning, e.g. financial literacy, conflict resolution, and the impact of incarceration. It is hopedthat this research can add to the global discussion on effective formats for providingrehabilitation for prisoners and therefore strengthen policy discussions on the legal structuredealing with incarceration.Only a Modest Proposal? The Constitutionalisation of Human Rights andSupervised Community Treatment in England and Wales73

Nicola Glover-Thomas, University of Manchester (robert.thomas@manchester.ac.uk)In England and Wales, Supervised Community Treatment (SCT) provides a framework for themanagement of patient care in the community under the Mental Health Act 2007. Its introductionhas generated significant levels of debate, with proponents arguing that a legally mandatedcommunity treatment programme enables and empowers patients. Opponents have argued thatsuch mechanisms instead provide a legitimate means of discriminating against the mentallydisordered. The decision to use supervised community treatment is open to significantprofessional discretion, yet despite this the legal position of the regime adopted in the UK islargely directed by the constitutionalisation of human rights under the Human Rights Act 1998.This has considerably restricted supervised community treatment and raises real dilemmas abouthow useful such a provision can actually be in practice. This position differs considerably fromsimilar regimes in Australasia. This paper considers the original expectations for SCT and itslikely impact on the psychiatric care landscape. Of particular focus will be the limitations thatspring from the entrenched human rights culture that prevails in the UK generally.Law and Social Work: How Collaborations Can Better Serve Students andClientsStephanie Boys, Indiana University (sboys@indiana.edu)Low income clients seeking civil legal services are rarely in need of only legal assistance.Instead, the issues that drove them to seek an attorney typically overlap into multiple mentalhealth and social service needs. This presentation will explain how a newly piloted clinicalpartnership between a school of social work and a school of law enhanced the mental healthoutcomes for clients of the civil legal clinic. The clinic historically served the legal needs of lowincome clients in an urban American community. In 2012, an interdisciplinary collaborationinvolving law and social work students and faculty from both fields was implemented in order toprovide holistic services to clients. The presentation will describe the model, including how theclinic is structured and the roles for students and faculty. Next, preliminary data on clientsatisfaction and mental health outcomes will be discussed. Students’ perceptions of theinterdisciplinary nature of the instruction and services will also be presented. Finally, benefits ofproviding services for clients in a holistic manner will be explored. The clinic has been found toaddress both student learning needs and the needs of clients in the local community.29. Components of Mental Health Courts Influencing Clinical,Criminal Justice and Recovery Outcomes74

It Is a Different Kind of Thing: Treatment Issues and Gender in an EmergingMental Health CourtStephanie Hartwell, University of Massachusetts Boston (stephanie.hartwell@umb.edu)Mental health courts are emerging as an alternative to incarceration for individuals with mentalhealth issues that come before the courts. They are yet another tool in the tool kit related tospecialty police training, jail diversion, and court clinics, offering mental health services in nontraditionalsettings. While each of these tools appears to be theoretically sound, they are also lastresort measures that require empirical evidence of effectiveness and efficacy not just in general,but specifically across the populations they convene and serve. We know very little about theparticipants of mental health courts, particularly relating to their clinical, criminal history, andbackground characteristics. This paper examines all referrals and participants (N=57) in a startup(July 2011) mental health court in Massachusetts with an eye towards treatment issues andgender. There exists a vast literature on gender variation across the criminal justice system fromcrime commission to the mechanisms through which females come in to contact with thecriminal justice system (reasons for committing crime, types of crime) and are subsequentlyprocessed. Attention to gender-sensitive programming across criminal justice jail diversion toolshas been lacking. This paper examines the literature and uses a mixed method approach toexplore early trends in gender related treatment issues for mental health court participants.The Role of Housing in Mental Health Court Graduation and Post-ProgramCriminal RecidivismNahama Broner, RTI International, New York, USA (nbroner@rti.org)Studies have shown the role of homelessness in criminal justice involvement and violence, butfew have focused on the role of MHCs in providing support to attain housing stability or the roleof being housed as a protective factor for post MHC completion re-offending. Over an eight yearperiod, 770 adults were diverted through the Bronx Mental Health Court (MHC) intocommunity-based treatment and wellness supports. This presentation first describes the role ofthe MHC in client housing stability and the relationship of housing stability to graduation and inprogramoffending (controlling for pre-offending, MHC entrance substance use, homelessness,demographic characteristics, and time at risk). Findings are then presented for housing stabilityand being permanently housed at MHC exit as a predictor of 12-month post-MHC criminaljustice involvement (re-arrest, re-offense severity, and days re-incarcerated), controlling fordemographic characteristics, pre-MHC offending, graduation, substance use at time of mentalhealth court completion, and days at risk. Given the increasing emphasis on provision of housingto criminal justice specialized court and reentry populations, it is important to undertand the roleof housing in MHC and its contribution to recidivism reduction.75

An Exploration of Networks among People with Serious Mental Illnesses in theCriminal Justice SystemKelli E. Canada, University of Chicago (kecanada22@yahoo.com)Existing literature supports a reduction in recidivism and increase in service use among mentalhealth court (MHC) participants but there is no empirical support for factors promotingoutcomes, and how MHCs influence participants’ lives is nearly non-existent in the literature.Using mixed-methods, this paper explores MHC participants’ experiences and one possiblefactor associated with outcomes, networks. The qualitative component explores participants’experience with networks while in the MHC. The quantitative component investigates the rolenetwork factors play in treatment engagement and recidivism. Participants in two mid-westernMHCs (n=80) completed a structured interview involving survey questions and empiricallytestedmeasures. A purposive sub-sample (n=26) completed 60-minute semi-structuredinterviews. Two salient themes emerged from the qualitative analysis: 1) peers are criticalcomponents of their network in the context of treatment; and keeping involved in activitiesrelated to recovery (i.e., working at halfway house, taking a leadership role in AA) helped ensurethat their networks were full of people with similar goals; 2) the importance of perceiving thatproviders care and that they are working collaboratively toward shared goals. The quantitativeanalysis supports the importance of network factors in recovery. Density is positively associatedwith treatment adherence and having friends and family who use drugs is negatively associated.Density was not associated with recidivism.Perceptions of Reintegrative Shaming in Mental Health CourtBradley R. Ray, Indiana University – Purdue University Indianapolis (bradray@iupui.edu)Despite differences in geographic regions, teams, and the mix of treatments and servicesavailable, studies consistently find that mental health courts (MHCs) can be successful inreducing re-offending. Social scientific theories offer an excellent way for researchers to explainwhat it is about MHCs that, in spite of their differences, reduces subsequent criminal behaviors.This study suggests Braithwaite’s reintegrative shaming theory as a possible theoreticalexplanation. According to the theory, reintegrative shame is disapproval of behavior, not aperson, which is communicated in a respectful manner, and concludes with a ceremony orgesture that decertifies the offender as deviant and welcomes them back into the community. Incontrast, stigmatizing shame involves labelling offenders as deviant and casting them out of thecommunity. The key prediction of the theory is that stigmatizing shame increases subsequentcriminal behavior while reintegrative shame reduces subsequent criminal behavior. Survey itemsdesigned to measure the theory’s key concepts in a criminal justice context were administered to34 MHC participants immediately following their graduation ceremony. The results show thatparticipants who completed the MHC process were more likely to have experienced reintegrativeshaming than stigmatizing shaming. We argue that despite differences among MHCs, those who76

graduate from a MHC have a reintegrative shaming experience that affirms they are not definedby their deviant behaviors, they are respected, and they have been forgiven and welcomed backinto the community; thus, they gain or renew confidence in themselves which reduces thelikelihood that they will commit a crime.Considering Mental Health Courts and the Spectrum of Mentally DisorderedOffendersWilliam H. Fisher, University of Massachusetts, Lowell & University of Massachusetts MedicalCenter (bill.fisher@umassmed.edu)Empirical research has found that not all mentally disordered offenders are arrested for the sametype of crimes or have the same influences in their offending behaviors. This paper willcategorize mentally disordered offenders into coherent groups useful for multiple analyticpurposes. It will discuss how individuals in each of these groups may be affected by mentalhealth courts and, in particular, by the program components and processes described in thepapers presented in this session.30. Compulsory Community CareIs Compulsory Mental Health Treatment Compatible with Mental HealthRecovery?Allison Alexander, Edinburgh Napier University (a.alexander@napier.ac.uk)The existence of laws allowing compulsory detention and treatment has been questioned bymany for a range of reasons (see Eastman and Peay 1999). More recently in an article for theScottish Recovery Network, Mary O’Hagan (2012) has described compulsory legal powers as‘the elephant in the recovery room’. Those who write about mental health recovery (e.g. Repperand Perkins 2003) emphasise the importance of mental health service users feeling in control oftheir own lives. In contrast, a lack of control is often experienced by people within the mentalhealth system especially if placed there against their will. This presentation will examine whethermodern mental health law with an emphasis on liberal social welfare principles and rights iscompatible with a recovery focused mental health system. With reference to the Mental Health(Care and Treatment) (Scotland) Act the presenter will offer an analysis of whether the Scottishapproach to compulsory detention and treatment and the Scottish policy objective of recoveryfocused practice are fundamentally incompatible.77

Compulsory Mental Health Treatment in New Zealand: An Historical OverviewAlwyn Bondaren, Capital and Coast District Health Board, Wellington, New Zealand(alwyn.bondaren@ccdhb.org.nz)New Zealand has been settled by Europeans since the early 1800s with mental health care takingplace in various inpatient establishments, and later in asylums that were sited in areas farremoved from the cities. The most recent changes took place in November 1992 when by act ofparliament the Compulsory Assessment and Treatment Act ( CAT Act)(1992) replaced the 1968Mental Health Act which has substantially changed the way that compulsory treatment occurs inthis country. I will complete a review of historical literature relating to compulsory treatment inNew Zealand since European settlement. I will discuss the significant changes that have beenintroduced since the most recent Compulsory Assessment and Treatment Act (1992) wasintroduced. I will identify and discuss the roles of Director of Area Mental Health, ResponsibleClinician, Duly Authorized Officer, and District Inspector.The Local Practice of Community Compulsory Care in Sweden: A Study of thePolicy Implementation ProcessUrban Markstrom, Umea University (urban.markstrom@socw.umu.se)During the last decades, a trend has occurred in mental health law in the western world. Stateshave increasingly introduced legislation facilitating compulsory care outside of hospital settings.Community compulsory care (CCC) was introduced in Sweden 2008, after many years ofcontroversy. The aim of this presentation is to describe and discuss results from a studyinvestigating the implementation of this policy and the reform of CCC. Specific focus will be one local service providers and their way of “translating“ policy into local practice. Theimplementation study was conducted as a collective case study in which data was collected fromthree geographical areas in different parts of Sweden. Key persons from social service andmental health authorities were identified and interviewed as staff affected by the CCC reform. Intotal the study consist of about twenty interviews. The analysis is based on policyimplementation theory and research. How do local actors understand and interpret the changes inlegislation and the rhetoric around CCC reform? What does the translation process looks like,and what are the concrete "footprints" from the reform in everyday practice?Conceptual Models of "Risk" and "Capacity" in Community Based CompulsoryPsychiatric Treatment: Results from an Empirical StudyMichael Robertson, University of Sydney (michael.robertson@sydney.edu.au)78

Edwina LightPhilip BoyceAlan RosenChris RyanTerry CarneyBoth “risk” and “capacity” are cited as the basis of involuntary psychiatric treatment. In thesetting of outpatient care, these concepts require more contextualised definition, given that riskof harm or severe impairment of reason are less prominent than in the setting of detention inhospital. In this study, the views of 42 mental health consumers, their carers, clinicians and legaldecision makers were derived by in-depth interviews and qualitative analysis using a generalinductive approach. The study identified a conceptually valid model of risk involving fourdomains: Risk of harm to self or others e.g. suicide or victimisation; Risk of social adversity e.g.homelessness; Risk of excess distress – e.g. symptoms or interpersonal conflict and; Risk ofcompromised treatment. In accounting for “capacity” there were three domains - The capacity tomanage illness; The capacity for self-care and; The capacity to maintain a social role. In regardsto risk in mental health, these findings mirror those of other research findings in that it is abroadly defined construct that is well beyond the limited scope of “harm”, particularly in theviews of consumers and their carers. The model of “capacity” extends beyond traditional medicalor legal models of time and task specific considerations of competence, to acknowledge thecapacity to engage in a life journey of flourishing in a social and interpersonal role. Thelegislative, public policy and clinical implications of the study are discussed briefly.Medication-Assisted Treatment Implementation in Community CorrectionalEnvironments (MATICCE): Preliminary FindingsPeter D. Friedmann, Alpert Medical School of Brown University (pfriedmann@lifespan.org)The Criminal Justice Drug Abuse Treatment Studies II (CJDATS II) is a 5-year researchcooperative funded by the National Institutes of Health, National Institute of Drug Abuse.CJDATS II provides a platform for conducting implementation research in criminal justicesettings, to facilitate the use of evidence-based practices for offenders with drug treatment needs.The MATICCE study protocol engages community correctional systems and community-basedtreatment providers in an implementation intervention that emphasizes staff training on the value79

of medication-assisted treatment, and strategic planning to improve interorganizational linkages.Together, it is hypothesized that these staff- and organizational-level interventions willdemonstrate benefits to offenders as measured by referral rates, treatment receipt, drug useoutcomes, and recidivism. The implementation strategies may provide a model for broaderuptake of MAT, and for balancing public health and public safety priorities in resourceconstrainedsystems. This paper will deliver preliminary findings from the MATICCE study.Organizational- and staff-level findings associated with the implementation of MATICCE willbe discussed. This presentation will focus on the use of a strategic planning intervention and theimpact of organizational- (e.g., commitment from the top) and staff-level (e.g. attitudes towardmedication) factors on achieving interorganizational linkages between community correctionsand local treatment provider agencies31. Conflict and Compromise: Research and Practice inImmigration Assessments in AustraliaPost-Trauma Growth in Middle Eastern Refugees in Sydney, AustraliaCarine Bento, Australian College of Applied Psychology (bento.carine@gmail.com)Chris Lennings, Australian College of Applied Psychology (clennings@lscpsych.com.au)Processing of distress due to traumatic events can result either in psychopathology or personalgrowth or both, depending on socio-cultural and cognitive-emotional factors. However, traumaresearch has given little emphasis to protective factors against mental disorders and the morecommonly reported cases of psychological development in the aftermath of trauma. It was onlyrecently that positive psychological and personal transformation following trauma – betterknown as posttraumatic growth (PTG) – has received much attention. The current study reportson the relationship between posttraumatic growth, intensity of PTSD and the degree of support ina group of 40 Middle Eastern refugees in Sydney, Australia. This study controlled forpsychological morbidity using the K-10 and contrasted case worker and refugee self-assessmentsof growth, trauma symptoms and case management needs. The study also provided Australianvalidations of both the Posttraumatic Growth Inventory and the Arabic version of the K-10, andas far as we know the first Arabic version of the Impact of Events Scale-Revised for adults.Family Violence or Marriage Breakdown – Visa ImplicationsJohn Howard, University of New South Wales (john.howard@unsw.edu.au)Rima Nasr, LSC Psychology, Sydney, Australia (rnasr@lscpsych.com.au)80

Australia has aligned “family violence” provisions of the Migration Regulations with the FamilyLaw Act. It is defined as “conduct, whether actual or threatened … that causes the alleged victimto experience reasonable fear for, or be reasonably apprehensive about, his or her own wellbeingor safety”. However, if a claim of “family violence” is not supported, or a marriage has brokendown without “family violence”, cancellation of a visa is likely to occur, with return of the“sponsored” person to their country of origin. Such outcomes may have severe repercussions,including serious mental health concerns and real threat to one’s sense of safety and security. Aseries of cases will be presented to illustrate the complexity of the assessments undertaken bypsychologists in such matters, while attempting to search for ‘evidence’. This presentation alsoaims to explore the conflict that can occur between legal representatives attempting to use anavailable mechanism for a person to remain in the country and the psychology profession.Finally, implications for professional practice will be discussed.How to Assess ‘Character’? Implications for Migrants, Refugees or AsylumSeekers whose ‘character’ is being QuestionedRima Nasr, LSC Psychology, Sydney, Australia (rnasr@lscpsych.com.au)John Howard, University of New South Wales (john.howard@unsw.edu.au)When charged with certain offences and not a Permanent Resident or Citizen of Australia, the“character test” may be applied. If there are supportable concerns regarding “character”, theindividual may be returned to their country of origin against their will, subsequent to a Courtdetermination of a criminal matter or period of imprisonment. This has serious mental health andother implications both on the individual and their systems (such as children and other familymembers). Additionally, a person may have little in the way of identity or supports in theircountry of origin, particularly if they had not lived in that country for many years and, when theydid, conditions may have been chaotic, dangerous and destructive, with civil conflict ordiscrimination leading to re-location for “protection” or as a “refugee”. Assessments of“character”, including risk for re-offending, are complex and often contested. Psychologists mustnegotiate the assessment of psychological vulnerability or impact, as well as considering thesafety to the Australian community in terms of potential ‘risks’ that an individual poses shouldthey remain in Australia. A series of cases will be presented to illustrate the issues involved,including “risk assessment” and complexity, leading to suggestions for practice.The Child in Immigration Assessments: Relocation, Trauma and the Shatteringof IdentityChris Lennings, Australian College of Applied Psychology (clennings@lscpsych.com.au)81

Children have a most invidious situation in refugee and immigration assessments. They aredependent on their family, but often form the focus for a family’s attempt to stay in a country,hence creating a terrible burden of responsibility in the child. The paper explores the researchliterature on identity, attachment and the impacts of trauma on children, and relocation in thecontext of a case study of the Subcontinent children seeking to exercise the right to remain inAustralia after their parents have been denied a visa. The case study is particular poignant as theunique stressors of the protracted battle to stay in the country led to family breakdown, and thecase study explores the impact on the children of having to choose which parent to support, andwhich to “abandon” in the resulting Family Court battle, contiguous with the Federal Court Visaappeal.Just When You Thought Things Couldn’t Get Worse: Being an InternationalStudent in Australia when the Unexpected HappensLiz Mackdacy, LSC Psychology, Sydney, Australia (lmackdacy@lscpsych.com.au)Some young people arriving in Australia on Student Visas wish to return to their country oforigin on course completion with knowledge and skills to assist them in gaining rewarding jobsand supporting their families. Some wish to remain in Australia upon completion of theircourses. In both cases, unexpected difficulties can emerge to put their studies and visa at risk.These include: unexpected illness; mental health concerns; cultural clashes; falling in love;sexuality; “drama” back home, such as deaths, divorces and economic strain; wrong coursechoices; and so on. Cases will be presented to illustrate the complexity encountered bypsychologists when assessing such matters, against the possibility of visa cancellation andimpacts such as returning home as a “failure” and with serious mental health concerns.32. Considerations on Setting the First Canadian Examination onForensic PsychiatryIntroductionGraham Glancy, University of Toronto (graham.glancy@utoronto.ca)Last year the Royal college of Physicians and Surgeons of Canada finally granted subspecialtystatus to Forensic Psychiatry, the culmination of a 20 year process. It was decided that therewould be no "grandfathering', in other words everybody had to take the exam. Council appointeda committee who with consultation with the College, set about writing an exam. Members of thecommittee will discuss and reflect on this process.82

The Rationale for a Sub-Specialty in Forensic PsychiatryPierre Gagne, Faculty of Medicine – University of Sherbrooke (pierre.gagne@usherbrooke.ca)The involvement of psychiatrists in civil and criminal litigation has sharply increased over thelast decade. The need to limit the use of the title of "specialist in forensic psychiatry" to thosewith special knowledge and clinical experience has generated a movement to create teachingcentres and examination of candidates by the Royal college of Physicians of Canada. Importantacademic and ethical issues are related to the creation of this sub-speciality.Trials and Tribulations of Compiling the Questions for the First ForensicPsychiatry Subspeciality Examination in CanadaJohn Bradford, Division of Forensic Psychiatry – University of Ottawa(john_bradford@sympatico.ca)The trials and tribulations of compiling the new subspecialty examination in forensic psychiatryfor the Royal College of Physicians and Surgeons of Canada have been significant. The RoyalCollege has short answer questions (SAQ) as the format for the examination. The SAQ format isregarded as a valid method of evaluating a higher order of knowledge on a given subject. Theimpression is that SAQ are easier to compile then multiple choice questions (MCQ) but this isnot the case. This presentation will discuss the challenges of the SAQ format as well as thestrengths of this approach.33. Correctional Mental Health in the U.S.A.A Comparison between a Federal (National) Prison System and a StateCorrectional SystemMichael Ahrens, Consulting Psychologist, Marion, USA (d.ahrens3@frontier.com)The presenter has worked nearly 25 years for the United States Federal Bureau of Prisons andover five years for the Illinois State Department of Corrections. He will compare and contrastdifferences between these two, large penal systems. The Federal Prison System is regarded as the“finest correctional system in the world.” It serves as a model for state corrections.Professionalism, correctional programming (rehabilitation), quality health care and soundcorrectional practices are emphasized. The Illinois State Department of Correction is presently ina state of transition, but heretofore is based on a traditional concept of security, restrictive83

environments and incapacitation. Differences in the two correctional systems will be seen in thefollowing topics; classification procedures, training standards, policy implementation, health careprotocols, organizational structure, case management and demographics. High visibility topicssuch as suicide prevention, sexual assault prevention/intervention, health promotion/diseaseprevention and the management of the mentally ill will also be compared.Cutting, Inserting, Swallowing and Hunger StrikesMarvin Fisher Powers, Illinois Department of Corrections, Springfield, USA(forestmeadow@bellsouth.net)Self-harm behavior in a state controlled super maximum prison (Tamms Closed MaximumSecurity Correctional Center) involves inmate mutilation of own body, swallowing or insertingforeign objects into bodily apertures and self-declared hunger strikes. To address this,management involves counseling, pharmacological restraints and therapeutic physical restraints.The mission statement of the prison states, in part, that the Tamms Closed Maximum SecurityFacility (C-Max) has been designated and designed to house the Illinois Department ofCorrections’ most disruptive, violent and problematic inmates. Inmates' approval for placementat the Tamms C-Max will have demonstrated an inability or unwillingness to conform to therequirements of a general population facility. In addition, inmates who have manifested anegative influence on the safety and security of the Illinois Department of Corrections, or mayhave perpetrated criminal activity that threatens the community, may be transferred to theTamms C-Max. The Tamms C-Max will provide extra high levels of security and restrict oreliminate privileges permitted at other Illinois Department of Corrections general populationfacilities.Malingering of Serious Mental Illness in a Closed Maximum Security PrisonCheryl Couch, Illinois Department of Corrections, Springfield, USA (bccouch@hughes.net)This presentation will explore the severity and frequency of malingering by offenders in a closedmaximum security prison in Illinois. In this setting, offenders feign serious mental illness for ahost of reasons which include desire for a transfer, attention by staff and/or social support systemand extra privileges. Types of offenders served along with possible Diagnostic and StatisticalManual of Mental Disorders IV-TR diagnoses will be discussed. A review of the treatmentavailable to malingering offenders as well as the difficulty of assessment and diagnoses of someoffenders in the closed maximum security prison will be presented. Further, a brief discussion ofstaff’s differing opinions of who may or may not be malingering and how this can interfere withmental health treatment will be elaborated.84

Sexual Abuse of GLBT Inmates Seen as Norm in the Prison SettingJohn Reeves, Illinois Department of Corrections, Springfield, USA (jrrdjl@mchsi.com)Even with the implementation of the Prison Rape Elimination Act of 2003 in the United States,there is serious concern that Gay, Lesbian, Bisexual and Transgender inmates continue toexperience sexual, physical and emotional abuse. Oftentimes this comes as a norm of prison lifedue to lack of tolerance and religious beliefs that are brought to the work place by the staffmembers and lack of tolerance, gang related abuse mentality and a view that homosexuals aresexual objects by the prison inmates. Members of the GLBT community in prison are seen as thelowest of the low and therefore become the object of ridicule and abuse. It is reported that prisonstaff frequently do not stop or report this kind of abuse of GLBT inmates because it is perceivedthe GLBT inmates deserves that kind of treatment. There is evidence that GLBT prisoners arestill sexually victimized, either by force or coercion, into unwanted sexual activity, often forprotection, safety or to satisfy the needs of other inmates or staff. This presentation will highlightthat much work yet needs to be accomplished in order to provide GLBT inmates the same safetyand security afforded other inmates. Even with the implementation of the Prison RapeElimination Act of 2003 there continue to be serious issues of GLBT inmates being sexuallyabused by other inmates and staff.Balancing Dual Roles in a Corrections FacilityAngela M. Cowell, Illinois Department of Corrections, Springfield, USA(angelastanning@yahoo.com)This presentation deals with dual role functions within the corrections system, one of these rolesbeing a Correctional Officer in a maximum security prison, where the emphasis is on security.The other role is a Mental Health Professional in a medium security prison where the emphasis isplaced on improving psychological growth of offenders to achieve better reintegration intosociety. While each role has distinct job descriptions and functions this author plans to articulatethe distinct advantages based on the additional qualifications she possesses. There will also bediscussion of potential barriers to smooth functioning based on gender as nearly 90% of securitystaff are males, however a majority of the mental health staff are females.34. Crime and Psychotic Spectrum Disorders in GreeceCriminal Responsibility in Ancient GreeceGeorge Tzeferakos, Athens University (tzefgr@yahoo.gr)85

Introduction: In ancient Greece, as in all archaic civilizations, the approach to different psychicphenomena was through a cosmogonic-theocratic perception. Mental disorder was mainlyexplained as a divine insanity – “Ἂτη” — the result of hubris. Through this “sacred” perceptionof different phenomena, either natural/psychic or social/political, the rules of social structure andhuman coexistence were forged. Thus, the primitive legal system of the ancient Greeks also hada divine origin, which made any attempt for alterations very difficult. Despite this fact, a gradualchange can be traced peaking in “classical” Athens of the 5 th and 4 th century B.C. During thisperiod, basic legal concepts were formed and the foundations of the elaborate Roman legalsystem, precursor of the modern European system, were laid down.Methods: An extensive review of the literature focused on the development of the ancient Greekpenal code, the evolving perceptions of mental health and disorder in ancient Greekphilosophical thinking, and how these changing concepts can be traced in the ancient theatricalplays.Conclusions: In ancient Greece, with the contribution of important scientists, artists andphilosophers, a gradual shift took place in the concept of crime and criminal responsibility: thetheocratic model was replaced by a more anthropocentric perception of mental health and diseaseand of laws and justice.Mentally Disordered Offenders Judged “Not to be Guilty by Reason of Insanity”:Findings from GreecePetros Ntounas, Attica Psychiatric Hospital, Athens, Greece (petrosdounas@yahoo.gr)There is now robust evidence demonstrating that both men and women with schizophrenia are atelevated risk when compared to the general population to be convicted of non-violent criminaloffences, at higher risk to be convicted of violent criminal offences, and at even higher risk to beconvicted of homicide .The observation that almost half of the homicides committed by people with a psychotic illnessoccur before initial treatment suggests an increased risk of homicide during the first episode ofpsychosis.The relationship between mental disorders and violence is complex. Among the variables thathave been identified as increasing the risk of violence, in addition to psychotic symptoms andsubstance abuse, are socioeconomic status and even the neighborhoods in which persons withmental disorders reside.In Greece according to the being in effect legislation the patients with serious mental illness thatcommitted a serious offence, as e.g. attempt of murder, murder, arson, etc. judged with differentlegal regime from the being in effect penal code. In these patients certain times is applied thearticle 34 of the Greek penal code, that states that the patient with serious disturbance of hisintellectual functions (due to auditory hallucinations, command hallucinations, delusional ideas,etc.) at the moment where he commits the criminal act is judged insane to receive sentence and86

the court orders the keep of patient in a special public psychiatric hospital with a view to receivepsychiatric treatment.We will try to present data that concern the arrangement of hospitalization of patients withserious mental illness that have committed certain serious criminal act and have been judged«not to be guilty by reason of insanity», by the court.Mentally Disordered Offenders in Greek Prisons: Setting up a ForensicPsychiatry Service during the Economic CrisisChristos Tsopelas, Attica Psychiatric Hospital, Athens, Greece (tsopelas@gmail.com)Athanassios Douzenis, Athens University (thandouz@med.uoa.gr)The functioning of penal system and its’ prisons is based on the principles of punishment,security and control and finally rehabilitation and prevention of reoffending. 'MentallyDisordered Offenders' have been recognized as a definite group within criminal justice systemwhile the links between crime and mental disorder although certain are complex and difficult toaccess.In Greece the law accepts that there are instances when a mental disorder may impair theindividual’s ability to differentiate between right and wrong and interfere with free will.( article34 of the Greek Penal Code). If the court accepts that this is the case, the perpetrator isconsidered not guilty of the crime. Mentally disordered offenders should primarily be consideredas ill and therefore exempt from punishment. Mentally disordered offenders are either admittedagainst their will, in General Hospital Psychiatric Units that operate an «open door policy» or inthe psychiatric hospital of the “Korydallos” prison complex.We have tried to build a collaboration of the Forensic Mental Health Unit of the 2 nd Dept. ofPsychiatry, National and Kapodistrian University of Athens with the Ministry of Justice in orderto provide psychiatric service to mentally disordered offenders. We are presenting the initialobstacles, difficulties of providing a stable free service in financial crisis environment, but alsopreliminary quantitative and qualitative research results.Delusional Misidentification Syndromes and CrimeAthanassios Douzenis, Athens University (thandouz@med.uoa.gr)Delusional Misidentification Syndromes (DMS) is a constellation of psychiatric syndromesincluding Capgras and Fregoli syndrome. Characteristic of these syndromes is the delusionalidea that the bodily or psychological identity of the sufferer or others changes dramatically.Individuals with DMS have caused serious bodily harm. Murders are uncommon but not rare.Some of the DMS sufferers misidentify themselves and believe that they are omnipotent. When87

their wishes are not satisfied they respond with threats and attacks. Moreover, most patientspresenting with DMS misidentify individuals that have a great emotional importance for them.This is the reason that some of the victims might be unrelated to the victim but are well knownindividuals from politics or the media. This presentation will discuss recent neurobiologicalfindings for DMS and the association between DMS and violence35. The Crisis Intervention Team Model of Police Response toPersons with Mental Illness: Outcomes, Barriers, and FutureDirections for ResearchThe Crisis Intervention Team (CIT) Program as a Method of Reducing Stigmatowards Individuals with Serious Mental Illnesses among Police OfficersBeth Broussard, George Washington University (bbroussard@mfa.gwu.edu)The extensive entanglement of persons with serious mental illnesses in the criminal justicesystem is a major public health concern and has become an area of action in the lawenforcement, advocacy, mental health, and public health communities. As gatekeepers to thecriminal justice and mental health systems, officer attitudes towards and decisions about personswith serious mental illnesses may have immediate and longer-term consequences for individuals,systems, and communities. In particular, stigmatizing attitudes may result in greater use of forceand greater risk of injury for all involved, lower likelihood of assistance in accessing care, lesswillingness to view the individual as a credible crime victim or take action on his/her behalf,greater likelihood of arrest, and generally less than optimal decisions in responding to mentalhealth-related situations. In this presentation, we will provide an overview of the limited butgrowing literature on programs implemented to decrease stigma towards such individuals amongpolice officers. In particular, we will review the effects of the Crisis Intervention Team (CIT)program on decreasing officers’ stigma, which may improve safety and referral decisions and, inturn, outcomes of persons with mental illnesses who have encounters with the police. For thisreview, we conducted a search using relevant social sciences and criminal justice databases toidentify pertinent articles, reports, abstracts, and dissertations for inclusion. Examination of pastprograms implemented in law enforcement reveal that although educational interventions areeffective in improving knowledge and understanding, those incorporating personal contact moreconsistently decrease stigma. Preliminary research suggests CIT reduces stigma in the areas ofattitudes, attributions, and social distance. A theoretical framework for how CIT likely impactsstigma is presented. Areas for future programmatic and research consideration will also bediscussed, such as possible expansion of the model to other first-responder groups.The Costs and Potential Cost Savings of Implementing the Crisis InterventionTeam (CIT) Program88

Michael T. Compton, George Washington University (mcompton@mfa.gwu.edu)Amy C Watson, University of Illinois at Chicago (acwatson@gmail.com)Research on the Crisis Intervention Team (CIT) model of collaboration between lawenforcement and mental health is growing. One goal of CIT is pre-booking jail diversion, andseveral studies have indicated a possible effect on jail diversion, though effect sizes and studyprocedures have varied greatly. We conducted a thorough review of the literature in order todetermine a current best estimate of a potential effect size describing the difference betweenCIT-trained and non-CIT-trained officers with regard to arrest rates among persons encounteredby officers and suspected to have a serious mental illness. Using this best-estimate effect size, wethen conducted a preliminary, largely theoretical cost analysis of implementing CIT in a typicalpolice jurisdiction, as well as potential cost savings that pre-booking jail diversion might have inthat jurisdiction’s criminal justice system. The potential for cost-shifting from the criminaljustice to the mental health system is discussed. While CIT might lead to cost savings through itseffects on pre-booking jail diversion, further research is needed to clarify both costs and potentialcost savings of this widely disseminated approach.Crisis Intervention Team Training, Emotionally Disturbed Person Call Schemaand Use of ForceCasey Bohrman, University of Pennsylvania (caseybohrman@yahoo.com)A primary goal of the Crisis Intervention Team Model is to improve safety in encountersbetween police officers and individuals experiencing mental health crises. Officers are trained torecognize mental illness and utilize de-escalation techniques to reduce the need to use force inthese encounters, thus reducing the risk of injury for all involved. In this study, we asked CITtrained, non CIT trained and probationary officers (n=147) to rate four emotionally disturbedperson call scenarios on a number of subject and situational characteristics, subject behaviors,and their own expectations, attributions and actions they would take in the scenario. Using latentclass analysis, we identified 2-3 schema for each call type. Schema class was primarilydifferentiated by factors related to level of risk in the scenario (e.g. resistance, subject under theinfluence of drugs or alcohol, age). While CIT training did not predict officer schema, it did haveimplications for whether officers indicated they would need to use physical force. Controlling forofficer schema, we examine the effect of CIT on officers’ endorsement of the need to usephysical force to maintain control of the person with mental illness. Implications for policy,practice and research will be discussed.Potential Obstacles to the Development of Crisis Intervention Teams: Lessonsfrom Efforts at Implementation89

William H Fisher, University of Massachusetts Lowell (william_fisher@uml.edu)Albert J. Grudzinskas, University of Massachusetts Worcester (al.grudzinskas@umassmed.edu)While crisis intervention teams (CITs) have become the gold standard for police based responseto situations involving persons with mental illness, their implementation is not without somedifficulty. This presentation highlights issues identified in consultation with police officials in anumber of communities as well as lessons learned in an unsuccessful attempt to develop a CIT ina large city in the northeast. As a multisystemic response, CIT development requires buy-in notonly from police, but also from local emergency mental health service providers, with whompolice may or may not have a good history. There are also factors internal to police departmentsthemselves. Police officials may be reluctant to develop new specialty units, favoring instead theenhancement of training for all officers. In some cases this reflects officials’ perceptions of thepotential efficacy of CIT, given the geographic and demographic features of their communities.Small departments in rural communities and, conversely, large congested cities may not be idealsettings for CITs. Cost is an additional issue. Police unions may demand that CIT officers, whowill have received enhanced training, be paid at a higher level. Training costs also play a role. Inone large city police estimated that some 40 officers would be needed to cover all three shifts,seven days per week including holidays, and to serve as substitutes for sick or vacationing CITofficers. A related issue is the need to take large numbers of officers off-line for the 40-hourtraining required by the standard CIT protocol and paying overtime to officers substitutingduring those 40 person-weeks. Finally, the patrol officers themselves, especially those with longexperience on the job, may feel that they have developed an approach for dealing with personswho appear to have mental illness and the resources available for managing them.Future Directions for CIT ResearchAmy C Watson, University of Illinois at Chicago (acwatson@gmail.com)The research on CIT to date suggests the model is having some positive effects on improvingpolice response to mental health related calls. CIT training has been shown to improve officerknowledge about mental illness and treatment, increase self-efficacy for responding to mentalhealth crisis calls, and decrease stigmatizing attitudes about mental illnesses. Research suggestsCIT officers may be less likely to use force and be more likely to direct persons with mentalillnesses to psychiatric treatment than their non-CIT counterparts. Some research also suggeststhat CIT may reduce arrests of persons with mental illnesses by diverting them to treatment.Hence there is growing support for CIT as an effective approach to improving police response topersons with mental illnesses. However, there is still much we do not know. For example, howdo does community context and accessibility of mental health services impact CIT effectiveness?How does CIT impact the experiences of persons with mental illnesses in police encounters andtheir longer term mental health service engagement and criminal justice outcomes? This paperwill describe research underway in Chicago that seeks to address these questions. Otherimportant next steps for CIT research will also be discussed.90

36. A Critical Exploration of Pressing Ethical, Clinical & SpiritualIssues in Acute Psychiatry through to Community Care inCanadaWho Gets What? Inequities in Acute Mental Health Care in CanadaKen Balderson, University of Toronto (baldersonk@smh.ca)Resource limitations have been a problem in mental health care even before the unkept promisethat deinstitutionalization would be accompanied by appropriate funding of community-basedservices. Financial pressures on governments leading to decreased health care funding are nowexacerbating these problems. Fewer beds and pressures for decreased length-of-stay have led tochronic backups of patients in Emergency Departments. Whether a patient is admitted to hospitalmay not always depend on clinical need, and often depends on bed flow pressures. Wheninpatient units are full, psychiatric emergency staff may be forced to develop suboptimaldispositions, making discharge plans to relieve ED congestion. A lack of standardization in careprovided to admitted patients may also result in differences/inequities in care received.Psychiatry lags behind other medical specialties in Canada in the standardization of treatmentprovided in acute care settings. This paper examines approaches used in other jurisdictions whichmay lead to increased standardization and improve acute mental health care delivery in Canada.Challenges of Providing Informed Consent in Emergency PsychiatryRosalind Abdool, University of Waterloo (rabdool@uwaterloo.ca)In contemporary bioethics, the principle of autonomy is often at the forefront of decisionmaking.However, there are many psychological limitations and external pressures that makeproviding informed consent a significant challenge. In addition, these limitations and externalinfluences are amplified in emergency situations, where the pressure to make decisions increasessignificantly and there are reduced resources, such as time and the accessibility of familymembers, available to patients to employ regular reflective and deliberative abilities. Mypresentation aims to explore two pressing questions relating to this topic: What additionalchallenges are present in emergency medicine/psychiatry that make providing informed consentparticularly challenging in this context? What measures can be taken to improve respect forautonomy and to facilitate providing informed consent in emergency psychiatry.Can Emergency Psychiatry be Person-Centred?91

Louise Campbell, Clinical Ethics, Limerick, Ireland (louise.campbell@gmail.com)Recent years have witnessed a shift towards a ‘person-centered’ model of healthcare provision.Person-centred care purports to put the patient at the centre of his or her own treatment and toframe treatment decisions in terms of the preferences and needs of patients. A more radicalinterpretation of the concept of person-centered care draws attention to the centrality of a nondirectivetherapeutic relationship, built over time on trust, empathy and reciprocity. The purposeof this presentation is to explore the relevance of these concepts in the context of emergencypsychiatry and to ask whether and to what extent an authentic therapeutic relationship can bedeveloped in a setting which exacerbates the ethical tension between preventing harm to thepatient and promoting a process of participatory decision-making.Human Dignity and Responsibility for the Other: Therapeutic Tools for ThoseWorking with Forensic PatientsChristine Jamieson, Concordia University (jamieson@alcor.concordia.ca)The United Nations Declaration of Human Rights begins with a Preamble that speaks of theinherent dignity of all members of the human family. What does human dignity mean in relationto forensic patients who experience no remorse for crimes committed and yet suffer anguishprecisely because they experience no remorse? In this presentation, we will explore the conceptof human dignity, its meaning and value in relation to the encounter with persons labeled“forensic patients”. Can the notion of human dignity, through the resources of the Judeo-Christian tradition, offer insights to those working with forensic patients? How might anunderstanding of the inherent dignity of all human beings help forensic patients come torecognize their own dignity despite actions committed? The hypothesis of this presentation isthat thinking through the meaning of human dignity will offer a therapeutic tool for thoseworking with forensic patients. Recognition of one’s own inherent dignity is the beginning ofrecognition of the dignity of those we encounter. Responsibility for the other is only recognizedin conjunction with our own sense of human dignity.A Holistic Community Program to Address Metabolic Syndrome through PatientEmpowerment with Demonstrable SuccessJacqueline Duncan, Wayside Centre for Mental Health, Penetanguishene, Canada(jduncan@waypointcentre.ca)In the industrialized world 25-34% of the population are suffering from Metabolic Syndrome, acondition which has been identified to be a precursor for Cardiovascular Disease, Type IIDiabetes Mellitus, Arthritis, Dementia, and some forms of cancer. Metabolic Syndrome is being92

identified in up to 70% of clients suffering from Serious Mental Illness (SMI) as a result ofgenetic factors, social determinants of health, and the use of psychotropic medications. Thispresentation will describe a highly successful out-patient intervention program which ascribes itssuccess to (1) being inspired, driven and moulded by clients with lived experience, (2) beingmanned by staff who are committed, enthusiastic, energetic and compassionate, (3) utilizing acombination of individualized interventions and psychodynamic group interventions, and (4)utilizing visual aids, demonstrations, illustrations, role modeling and lots of repetition to ensurethat information is truly understandable in such a way that clients can make truly informedchoices.37. Critical Issues in the Treatment of Mentally DisorderedPrisonersThe Treatment of Sexual OffendersJohn Bradford, University of Ottawa (john_bradford@sympatico.ca)The treatment of sexual offenders has become highly developed and well documented in therecent scientific literature. The psychological treatment for sexual offenders was welldocumented in the first report of the collaborative outcome data project on the effectiveness ofpsychological treatment for sexual offenders (Hanson et al., 2002). This meta-analytical reviewlooked at the effectiveness of psychological treatment by summarising data from 43 studies (n=9454). Averaged across all studies the recidivism rate for sexual offenders was lower fortreatment groups (12.3%) than comparison groups (16.8%). There was also a reduction ingeneral recidivism. Current psychological treatments, specifically cognitive behaviouraltreatments, were associated with reductions in sexual recidivism (17.4% to 9.9%) and generalrecidivism (51% to 32%). Psychological treatments applied prior to 1980 did not have mucheffect on treatment outcome and recidivism. Pharmacological treatment approaches weresupported by the publishing of the World Federation of Societies of Biological PsychiatryGuidelines for the biological treatment of the paraphilias (Thibaut et al., 2010). This was areview of all available literature from 1969 to 2009 for antiandrogen treatments and 1990 to2009 for SSRI treatment. Each treatment was evaluated according to evidence-based guidelines.These reviews have extensively documented the scientific basis for the treatment of sexualoffenders and the efficacy of evidence-based treatment approaches.Pharmacological Treatment of Impulsive AggressionMatthew S. Stanford, Baylor University (Matthew_Stanford@baylor.edu)93

Aggressive behavior is a major concern in both mental health and criminal justice settings.Although pharmacotherapy is often used in the treatment of the violent individual, no medicationis presently approved by the US Food and Drug Administration specifically for such use. Theresearch literature has implicated several neurobiologic deficits associated with impulsive(reactive) aggression, including reduced central serotonergic functioning, executive dysfunction,and prefrontal deficits. It has been suggested that the neurobiologic deficits specific to impulsiveaggressive behavior may serve as indicators of an ineffective behavioral control system. Areview of the literature finds that several pharmacological agents are effective in reducing thefrequency and intensity of impulsive aggressive outbursts both when used as the primary agentof treatment and as an adjunct to ongoing pharmacotherapy. This presentation will discussempirical evidence for treatment efficacy in impulsive aggression for a broad range ofpharmacological agents.Bringing the Forensic Psychiatrist into the Prisons or the Mentally DisorderedOffenders into Security HospitalsMarc Graf, University of Basel (marc.graf@upkbs.ch)For reasons well known and researched in detail, prevalence rates for mental disorders are muchhigher in prison populations all over the world than in general, not only for prison inmates butalso for prisoners on remand, asylum seekers on warrant for deportation and others. In addition,the proportion of imprisoned people is rising in most countries with an increase in preventativedetention to ensure public safety, leading to longer prison stays, and excessive aging of thispopulation. Therefore forensic psychiatry not only has to deal with the typically young criminalpopulation, vulnerable to becoming mentally ill for social reasons and in a period of life whereincidence of schizophrenia, suicide, drug abuse and most personality disorders are highest, butalso with an increasingly older population with high incidence of affective disorders anddementia. While treatment standards for these mental disorders are largely published andaccepted, and scientific evidence about the screening for mental disorders in prisoners isgrowing, it remains unclear where to treat them: In the prison, in special medical wards in theprisons or in security hospitals. This discussion presents an algorithm based on considerationsabout public safety, criminal proceedings, criminal theory, medical safety and needs, humanrights, ethics and availability of services at the interface between prisons and mental hospitals.Correctional Health Care for WomenMorag MacDonald, Birmingham City University (morag. macdonald@bcu.ac.uk)This intervention will examine the specific experiences of women in prison, focusing onprevious (and continuing) physical and mental abuse, the consequent health care requirements ofwomen prisoners, the policy response and the availability of suitable health care in prisons across94

the EU. This is an important area as in Europe the female prison population is increasingalthough women make up a small percentage of the overall prison population. The mental healthneeds of women prisoners are often complex; they may have histories of abuse, high levels ofdrug misuse and co-morbidity that are compounded by the prison environment. Particularlyserious problems that have been identified for women prisoners are a history of self-harm,worries about children, abuse and homelessness, all factors that impact on mental health. Thefollowing issues will be discussed: the rising number of women being imprisoned in Europeancountries; material relating to the experiences of women prisoners with a history of violence andabuse; ways of defining abuse; key issues facing this group, the genesis of the abuse and whatimpact this has on women accessing health care; material relating to the policy context andcriminal justice response to domestic violence and sexual violence and abuse; useful guidelinesfor managing the issues of violence and abuse; and how EU member states are responding to thedistinct and complex issues faced by women prisoners.38. CRPDSupported Decision-Making in Compulsory Mental Health Law: A ConceptualImpossibility?Mary Donnelly, University College CorkOne of the most decisive normative shifts in the Convention on the Rights of Persons withDisabilities has been the recognition of the right of persons with disabilities to supporteddecision-making (Quinn, 2010; Bach and Kerzner, 2010). While delivering on this right willprovide one of the most significant challenges in realising the potential of the CRPD, at aconceptual level, the shift is not particularly difficult. Persons with significant intellectual,cognitive and/or psychosocial disabilities who need support or assistance in reaching a decisionmust be provided with this assistance and the decision which is then reached must be respectedas an exercise of the individual’s legal capacity.However, more difficult issues arise in respect of supported decision in the context ofcompulsory mental health law. This area of law requires robust support frameworks perhapsmore than any other. However, within a compulsory framework, the decision reached followingthe provision of support may be lawfully overridden. To borrow an analogy, the person gets tovote but there is only one approved candidate. This raises the question of whether supporteddecision-making can ever be delivered upon within a compulsory legal framework for mentalhealth. It may, of course, be argued that compulsion on the basis of psychosocial disorder isalready contrary to the CRPD. However, it is unlikely that we will see a shift away fromcompulsion in mental health in the short term. In the meantime, the question is whether and howthe key normative shift in the CRPD can be realized for persons with psychosocial disabilities.This paper explores both the conceptual challenges and the practical mechanisms required todeliver supported decision in this context.95

Challenges Balancing Law, Services and Civil Society to Advance CRPDSupported Decision-Making ObjectivesTerry Carney, University of Sydney (terry.carney@sydney.edu.au)Fleur Beaupert, University of Western Sydney (Fbeaupert@gmail.com)Many countries have begun to rethink laws, services and civil society roles in advancing theobjective of ‘supported decisionmaking’ enshrined by the Convention on the Rights of Personswith Disabilities. This paper reviews recent experience in Canada, Australia and Britain,including proposals by the Victorian Law Reform Commission, development of personal budgetmodels for services, family decisionmaking, and various pilot programs of innovative newmodels of delivery to different disability groups.Advance Directives: Supporting Legal Capacity under the UN CRPDFiona Morrissey, National University of Ireland (f.morrissey1@nuigalway.ie)The UN Convention on the Rights of Persons with Disabilities (CRPD) requires us to engage innew approaches to decision-making in mental health care and to develop a range of supportstrategies. A spectrum of legal measures will be required to fully implement the supporteddecision-making approach. Advance directives are considered to be appropriate measures forsupporting legal capacity by recognising the 'will and preferences' of the individual. The CRPDprovides an opportunity to clarify and extend the purpose of advance directives and reducebarriers to implementation. The assumption of capacity under Article 12 necessitates thedevelopment of directives which are designed to communicate wishes during mental healthcrises while retaining legal capacity. This form of directive does not categorise a person as'legally incapable' or represent a judgment on their cognitive abilities. The re-conceptualisationof advance directives views them as vehicles for developing capacity and respecting the wishesof the individual in future mental health experiences. A major theme in developing advancedirectives is whether they are made independently or with support. An informal and flexibleapproach will be required to suit various needs and preferences. The various models of advancedirectives which may appropriate for implementation under the CRPD will be considered.Law on Mental Health Consistent with the UN Convention on the Rights ofPersons with DisabilitiesGeorge Szmukler, King's College London (george.szmukler@kcl.ac.uk)96

The 2006 UN Convention on the Rights of Persons with Disabilities (CRPD) sets out key rightsthat citizens with a disability should enjoy in a fair society. People with disabilities arecharacterised as follows: “Persons with disabilities include those who have long-term physical,mental, intellectual or sensory impairments which in interaction with various barriers may hindertheir full and effective participation in society on an equal basis with others”. In respect ofpeople with ‘mental illness’, many of whom are considered as having a (‘psychosocial’)disability under the Convention (depending on the meaning of terms such as ‘long-term’ and‘impairments’ as well as the capaciousness of the category of disabled persons implied throughthe use of ‘include’ in the definition above), legislation such as the Mental Health Act 1983(MHA) (amended in 2007) for England and Wales fails to comply with its principles and isdiscriminatory. The aim of this paper is to examine whether a law governing involuntarytreatment based on impaired decision-making capability (DMC) and applicable to all persons,previously well or unwell, and regardless of the cause of the loss of capability (whether due to‘mental illness’ or ‘physical illness’) would be consistent with the CRPD.Is the 'Fusion' Hypothesis a Cure for Discrimination?Elizabeth Dance, University of Manchester (elizabeth.dance@manchester.ac.uk)It is of great importance that the aims of legislation in this area must be the promotion of patientwelfare and dignity, and non-discrimination. The Fusion approach has been offered as a way ofensuring legislation complies with the promotion of non-discrimination and the recognition thatpeople with disabilities have the autonomy to make their own decisions, by developing aframework covering decision-making for all. With the introduction of the Convention on theRights of Persons with Disabilities (CRPD) the task before us is to determine how the CPRD,alongside ‘Fusion’, will affect mental health legislation and if it will ensure all patients are ableto enjoy their rights without discrimination and are given the opportunity to decide forthemselves. The introduction of capacity-based tests could be a way of ensuring people can maketheir own choices and will reduce discrimination. This paper will discuss the relevancy of suchtests, especially in light of Articles 12/14 of the CRPD and how the concepts they are based uponwill work in a fused mental health law. Overall, this paper aims to highlight the importance ofdiscussions surrounding discrimination and to offer a glance at how things may change in thefuture.39. Cultural Diversity and Mental HealthMeeting the Challenges of Management of Chronic Psychotic Illnesses in anInner City HospitalSeeth Vivek, Jamaica Hospital Medical Center, New York, USA (seethvivek@aol.com)97

Jamaica Hospital Medical Center is an active General hospital with a busy Psychiatric Service.The General Emergency Department handles over 120,000 visits a year. The PsychiatricEmergency Division sees over 5000 visits and consultations a year with over 1600 admissions toits 50 beds. The hospital serves an underprivileged segment of society in New York Cityconsisting of large numbers of minorities. The low socio economic conditions, undocumentedimmigration statuses and instability in living circumstances, result in unique challenges inproviding effective care. In the last 20 years the Medical Center has initiated multiple actions tomeet these challenges. This paper will review some key interventions that include systemic,organizational and educational measures. The author will address the results from successfulprograms and challenges yet to be tackled.Risk and Culture in Forensic Psychiatric EvaluationsChinmoy Gulrajani, Consulting Psychiatrist, New York, USA (gulrajanic@gmail.com)The borough of Brooklyn in New York has a population of two and a half million, making it theseventh largest county in the United States. People living in Brooklyn represent 93 differentethnic groups, 150 nationalities, and speak 136 different languages. About 37 % of Brooklynresidents were born outside the United States and a staggering 23 % identify themselves asneither white (Caucasian, non- Hispanic) nor black (African American) making this one of themost diverse populations in the world. Furthermore, about 25% of Brooklyn residents describetheir ability to communicate in English as “less than very well”. Needless to say, this racial,ethnic and cultural diversity is reflected in the criminal justice system and it is no surprise thatForensic Psychiatrists are posed with several unique challenges not encountered in other settings.This presentation discusses the clinical issues that arise specifically during the forensicpsychiatric evaluation of defendants from the non-dominant population groups. Potential sourcesof error and bias in these evaluations are highlighted by way of anecdotal examples. Evaluatorand evaluee centered factors that influence the outcome of evaluation are discussed. Toconclude, recommendations are made to avoid common pitfalls encountered in the course ofworking with individuals from minority groups.Shades of Violence Against Women in a Rapidly Developing MulticulturalSociety in the Middle-EastSiva Prakash, NMC Hospital L.L.C., Dubai, United Arab Emirates (sprakash@eim.ae)This paper is based on an observational study of variants of violence against women in therapidly developing multicultural society of Dubai, a modern metropolis in the Middle-East. Thesample is drawn from psychiatric services at NMC Hospital – a large multi-specialty hospital inDubai. The sample is predominantly expatriates, a majority of whom are from South Asia. Thepatterns of seeking help, religious, cultural, and social barriers to accessing services, and lack of98

ecourse to legal action are explored and different forms of violence including emotional abuse,and its impact on the victims, discussed. Deviant family and parental pressures are oftenexperienced by young women as tantamount to disenfranchisement; their right to make decisionson important matters in life such as career and choosing a life partner are denied outright. Misuseof psychiatric services is not unusual – in a largely male dominated society gender issues areseen as irrelevant, and the expectation is that psychiatric services will uphold religious andcultural values, even as these result often in marginalizing women. The importance of culturalsensitivity on the part of service providers is critical, and interventions are based on a rationalapproach to bridging the gap. Therapeutic approaches to emotional abuse and violence arediscussed in the cultural context. A high incidence of past sexual trauma is reported among thelarger sample of women seeking help for depression and mood disorders later in life,emphasizing the need for additional intervention directed at this aspect.Challenges in Providing Mental Health Care for Minorities in Australia,Including the Aboriginal PopulationMohan Isaac, University of Western Australia (Mohan.Isaac@uwa.edu.au)T.B.E.*Culture and Mental Health: Perspectives from the United Kingdom and IndiaNitin Gupta, Staffordshire University (nitingupta659@yahoo.co.in)T.B.E.*40. Current Challenges in South American Forensic PsychiatryParental Alienation: A Controversial ConceptVivian Day, Forensic Psychiatric Institute “Maurício Cardoso”, Porto Alegre, Brazil(vivianday@brturbo.com.br)Lisieux Telles. Forensic Psychiatric Institute “Maurício Cardoso”, Porto Alegre, Brazil(vivianday@brturbo.com.br)Maria Regina Azambuja, Public Prosecutor, Rio Grande do Sul, Brazil (mra.ez@terra.com.br)Recently, Brazilian legislation has innovated, trying to reduce litigation related to guardianship99

disputes. In 2008, shared custody was established. Two years later, a new law was created,defining civil and penal consequences when parental alienation is proved. Since then, mentalhealth staff have been asked to attend to situations where there is evidence of psychologicalinterference in the child's or adolescent's development by one of the parents. Richard Gardnerdefined a syndrome of which the most important aspect is avoidance behavior of the child oradolescent toward the visitor parent, induced by a defamation campaign by the parent that retainscustody. This law encompasses psychological evaluation, therapeutic attendance and expertcounsel including diagnosis, evolution and guardianship definitions. However, diagnostic criteriaare not yet well defined, parental alienation cannot be described as a disease or disturbance,opening polemic discussions, and delicate postures must be handled by psychiatric forensicprofessionals.Bullying and Forensic Implications in BrazilAlcina Barros, Forensic Psychiatric Institute “Maurício Cardoso”, Porto Alegre, Brazil.(cininha1981@hotmail.com)Bullying is a specific form of aggressive behavior that has received increased attention. It can bedefined as repeatedly harming or intimidating weaker people and it is commonly reported amongadolescents, especially in the school setting. Bullying in adolescence has been associated withgeneral psychological distress or specific psychiatric disorders and is considered to be a riskfactor for the development of common mental disorders later in adulthood. Of particularimportance is the reported association between bullying and suicidal ideation. In Brazil, thecommission of jurists has approved a proposal to criminalize the practice of bullying. The crime,which will be considered "shameful intimidation" in the draft law, will have punishment rangingfrom one to four years in prison. Based on this proposal, the crime is committed by one who“intimidates, coerces, threatens, sexually harasses, offends, punishes, harasses or segregatechildren or adolescents” using an alleged situation of superiority. The offense can be carried outby various means, including the Internet (cyber bullying). If the crime is committed by juveniles,a socio-educational sentence will be applied. In this context, the forensic psychiatrist can be veryuseful, evaluating bullies and their targeted victims.The Adolescent and the Staff in the Process of Sickness, Care and CureLilian Hagel, Conceição Hospital Group, Porto Alegre, Brazil (lilianhagel@gmail.com)Fernanda Bueno, Conceição Hospital Group, Porto Alegre, Brazil (febueno01@gmail.com.br)Elisa Baldasso, Conceição Hospital Group, Porto Alegre, Brazil (adolescentes@ghc.com.br)Priscila Amaral, Conceição Hospital Group, Porto Alegre, Brazil(priscilacoelhoamaral@gmail.com)100

Mª da Glória da Silva, Conceição Hospital Group, Porto Alegre, Brazil(mariadagloria@ghc.com.br)Fátima Al-Alam, Conceição Hospital Group, Porto Alegre, Brazil (adolescentes@ghc.com.br)]Mental disorders in children and adolescents are prevalent, ranging from 10 to 20% of thepopulation, and 15 to 25% of these present behavioral problems resembling a significantpsychopathology with functional impairment. From a case report of a teenager, the authorspropose a modeling approach for treatment and management of adolescents with severepsychiatric illness. The adolescent, female, age 13, had internal bleeding and a tracheotomy scar.She related that it was due to a car accident in which her mother died, two years previously, andthat her father, an alcoholic abuser, left her with a prostitute when she was 7 years old. When shearrived at the hospital she said she was homeless. With no birth certificate, she was unaware ofher real name and had no schooling. The adolescent presented with several episodes of vaginaland anal bleeding, and hematemesis associated with shock. Multiple transfusions of bloodproducts and central venous punctures were done. Imaging and laboratory tests were normal. Thepatient was caught manipulating the catheter and syringe with blood and admitted that she hadsimulated bleeding. The team was also surprised by manipulation of the patient's attitudes, whichwith severe emotional commitment built an entire fictional life story and caused commotion inthe team, disrupting service. A multidisciplinary intervention was essential in reorganizing thecourse of treatment. Studies show that early intervention may have a significant impact onmorbidity and mortality in adolescence, improving the prognosis for the individual and forsociety as well.Partial Criminal Responsibility in Brazilian Law: Its Foundations andImplicationsPaulo Blank, Forensic Psychiatric Institute “Maurício Cardoso”, Porto Alegre, Brazil(blankp@terra.com.br)Some episodic or accidental issues may occur during a criminal law procedure requiring aforensic psychiatric evaluation in order to elucidate whether the defendant suffers of somemental condition that modifies his or her criminal liability. The Brazilian Criminal Process Codestates in Article 149 that when there is doubt about the mental integrity of the defendant thejudge should order a medical-forensic examination. This procedure requires the existence ofstrong evidence of mental disturbance compromising the defendant’s capacities to comprehendthe illegal act committed, and to behave according to this comprehension. The evaluation maydiagnose mental conditions that modify criminal liability by undermining the defendant’scomprehension of his or her illegal action, and consequent behaviour, without completelyabolishing the criminal liability. This condition is specified at the Brazilian Criminal Code underthe term “semi-liability”, enabling the court to reduce the sentence by one or two-thirds, or todetermine treatment under security measure. Traditionally, mental disorders that fit defendants as“semi-liable” are personality disorders, drug addiction, and intellectual disabilities. Discussionwill include extensions and consequences of diagnosing these mental disorders, sometimes101

implying insanity and sometimes having no effect on mental health, under Brazilian CriminalLaw, based on forensic psychiatric evaluations conducted at the Mauricio Cardoso ForensicPsychiatric Institute, in Porto Alegre, Brazil.Psychopathology and Crime in Women: Assessment of Childhood TraumaHelena Bins, Health Sciences Federal University of Porto Alegre, Brazil(helenabins@gmail.com)Introduction: Childhood trauma (CT) is common in mentally ill women and in forensicpopulations, correlating with criminality, but has been insufficiently studied.Objectives: Evaluate association of CT with psychopathology and antisocial behavior in women,and assess the criminal and psychopathological profile of this population. Method: A casecontrolstudy in 147 female subjects split in four groups: forensic psychiatric inpatients onPsychiatric Forensic Institute Dr. Maurício Cardoso (IPFMC), psychiatric inpatients on HospitalMaterno Infantil Presidente Vargas (HMIPV), convicted women in Madre Pelletier Women'sPrison (PFMP) and controls. The IPFMC group (mentally ill who committed crimes) was used asan index for pairing the remaining groups. MINI PLUS, BIS-11, CTQ and QSD were used. Dataanalysis used SPSS 18.0 (Fischer, chi-squared, Shapiro-Wilkis, one-way ANOVA, post hocScheffé, Kruskal-Wallis and Mann-Whitney).Results: In IPFMC, the most prevalent diagnoses were schizophrenia (47%) and drug addiction(36.8%). In prison, APD (32.4%) and drug addiction (27%). In psychiatric hospital, specificphobia (32.4%) and bipolar disorder (29.4%). The three groups had more CT than control(p

36) Conclusion: The arsonist female pattern obtained corresponded to a single middle agewomen, with a low education level and no profession, with at least one Axis I diagnosis and withan Axis II personality disorder in half of the cases. Affective disorders and acute emotionalproblems (i.e. anger, frustration) appeared to be key background factors in the commission ofarson. The firesetters displayed reactive behavior, and formed their criminal intent under theinfluence of an emotional state. Forensic psychiatrists who assessed the defendants perceivedmost of them (66%) to be mentally insane or to have set the fire under the influence of anextreme emotional disturbance.41. Dangerousness and Social Control: A ContinuationConfine is Fine: Have the Non-Dangerous Mentally Ill Lost their Right toLiberty? An Empirical Study to Unravel the Psychiatrist's Crystal BallDon Stone, University of Baltimore (dstone@ubalt.edu)This article will examine the reverse trend in civil commitment laws in the wake of recenttragedies and discuss the effect of broader civil commitment standards on the care and treatmentof the mentally ill. The 2007 Virginia Tech shooting and the 2011 shooting of CongresswomanGiffords have spurred fierce debates about the dangerousness of mentally ill and serve ascautionary tale about what happens when warning signs go unnoticed and opportunities for earlyintervention are missed. This article will explore the misconception about the role medicationand inpatient civil commitments should play in prevention of dangerousness and undermine thebelief that we can medicate away the needs of the mentally ill. The adverse effect civilcommitments can have on individuals' long-term recovery, future employment prospects andoverall mental, physical, emotional and economic stability can be far-reaching; so minimum dueprocess protections must be carefully guarded. This article contends that civil commitmentdecisions should be based on concrete evidence that the individual is an imminent danger to selfor others and not on a psychiatrists' speculation about future deterioration absent coercedtreatment. Statistical data, collected from a survey of 100 psychiatrists, will be examined todetermine what is most significant to psychiatrists in commitment decisions and highlight theimpact state standards and types of hospital facilities have on psychiatrists' testimony at civilcommitment proceedings. Finally, this article will outline how "need for treatment" and "gravedisability" provisions in commitment standards have stripped away due process protections forthe mentally ill and discuss ways mental health advocates can fight back to reverse this troublingmovement in commitment laws.Social Control and Projections of DangerousnessAnthony Chase, The New Press, New York, USA (zekebrat@gmail.com)103

A significant controversy in the human sciences and philosophy has arisen because muchscholarship remains heavily weighted toward either the general (theoretical elaboration) or theparticular (historical miniatures) without much research and writing in between. A seeminglyminor legal incident (institutional generation of fear and anxiety used to justify violation of laborrights) is examined both in its own right (in detail) and in terms of how it reveals predatorystrategies on the part of agencies of authoritarian social control designed, more or lesssuccessfully, to restrict democratic communication and association as well as codify rules ofstratification in the institution. From the threat of motorcycle gangs taking over defenselesstowns (as if drawn from an American International movie matinee) to the application of shocktherapy to recalcitrant populations in economically-strapped and recession-mired societies, apattern is described which helps clarify old and new authoritarianism as well as the masspsychology of 21st century fascism.“A Citizen of Standing:” New Zealand’s District Inspector in Historical ContextKate Prebble, University of Auckland (k.prebble@auckland.ac.nz)Claire Gooder, University of Auckland (cgoo027@aucklanduni.ac.nz)New Zealand’s Mental Health (Compulsory Assessment and Treatment) (MHCAT) Act (1992)legislates for a District Inspector (DI), whose role is to ensure that mental health consumers heldunder the Act are aware of their legal rights. The New Zealand DI role first appeared innineteenth century legislation. Its historical longevity does not, however, denote that this role hasbeen consistently perceived or approached since its inception. This paper will look at thehistorical development of the DI, focusing in particular on the period 1969–1992, when thepurpose and scope of the role was part of a Mental Health Act (1969) review. This was a time offundamental social and professional change, shifting ideas of psychiatric practice, new locationsof treatment, and growing emphasis on patient/consumer rights. The paper explores how theinteraction between the law and mental health needs, in the context of social and politicalchange, shaped public and governmental expectations of the role.Providing an historical analysis of the DI role adds complexity to our understanding of howperceptions of mental health issues change according to social and political contexts of the time.This has relevance for current mental health law.42. The Death PenaltyDeath Qualification and Predictions of Future Dangerousness Testimony inDeath Penalty TrialsJoel Lieberman, University of Nevada (jdl@unlv.nevada.edu)104

Previous research examining the jury selection process in U.S. death penalty trials hasdemonstrated that death qualified jurors (jurors who are allowed to serve on capital cases) tend tobe more conviction prone and more likely to endorse aggravating factors during the sentencingphase. Research has also shown that death qualified jurors are less likely to effectively evaluateexpert scientific testimony. This research extends these findings by examining the impact ofdeath qualification on perceptions of future dangerousness testimony in a mock jury experiment.Mental health practitioners frequently make predictions in death penalty trials regarding adefendant's future dangerousness. These predictions are typically based on either clinical experttestimony (which refers to an expert's personal opinion and past experience) or a more scientificactuarial expert testimony (where actuarial evaluations are based on empirically verified riskfactors that predict future dangerousness). Participants in the study were "death qualified" andpresented with information about the sentencing phase of a capital trial, in which an expertwitness presented evidence based on either a clinical or actuarial assessment of the defendant.The results indicate that, in addition to death qualification, other interpersonal differences arerelevant to the persuasiveness of dangerousness testimony.Deadly Predictions: The Inability Of Capital Juries To Predict Future ViolenceMark D. Cunningham, Clinical & Forensic Psychology, Dallas, USA(mdc@markdcunningham.com)The U.S. Supreme Court in Jurek v. Texas (1976), applying an intuitive analysis, affirmed thatcapital juries are able to identify those capital offenders who will commit serious violence in thefuture. The capability of capital juries to accurately make these judgments as a means of decidingwhich capital offenders should receive the death penalty has been widely endorsed in both statuteand case law in the United States. Three recent investigations have tested this confidence byretrospectively reviewing the postconviction disciplinary records of three samples of offenderswho faced death penalty sentencing: 1. Federal capital offenders (N = 72, M = 5.7 yearspostconviction); 2. Texas former death row inmates (N = 111; M = 9.9 years death row, M = 8.4years post-relief ); and 3. Oregon capital offenders (N = 115, M = 15.3 years postconviction).For each of the samples, jurors’ predictive performance was no better than random guesses (i.e.,no improvement over base rates), with high error (false positive) rates, regardless of the severityof the anticipated violence. It is concluded that the confidence of legislators and courts in theviolence prediction capabilities of capital jurors is misplaced.The Role of Neuropsychological Assessment in Characterizing Individuals withIntellectual DisabilityJoette James, Department of Pediatrics & Psychiatry and Behavioral Sciences – The GeorgeWashington University Medical Center (jdjames@childrensnational.org)105

The cognitive assessment of individuals with Intellectual Disability is often thought to be simpleand straightforward, and in Atkins cases, a simple manner of administering intellectual andadaptive measures. This presentation will explore the idea that the neurocognitive functioning ofindividuals with Intellectual Disability is actually complex, and accurately characterizing theirneuropsychological strengths and weaknesses can be challenging. The presentation will focus onthe use of specific neuropsychological instruments to characterize fundamental day-to-dayweaknesses associated with low intelligence, such as vulnerability to becoming overwhelmedand difficulties with managing information quickly and effectively when it is complex. Inaddition, the nature of cognitive strengths in individuals with Intellectual Disability and thecircumstances in which strengths are most apparent will be discussed.NeighborhoodsDavid Freedman, University of Colorado (df2379@gmail.com)The relationship between neighborhoods and poor mental and physical health, although studiedfor decades (See, e.g., Faris & Dunham, 1939), now more clearly and strongly linksneighborhoods to mortality, heart disease, cancer, low birth weight, infant mortality, childhoodillnesses, asthma, depression, anxiety, smoking, diet and nutrition, hypertension, heart disease,suicide, accidental injuries, lead exposure, and numerous other illnesses (Diez Roux & Mair,2010; Morenoff & Lynch, 2004).Recently, Sampson (2008) articulated an important conceptual framework for understanding themechanisms by which neighborhoods effect individuals. This framework argues for a dualimport to neighborhoods: first, as the situational context of family and individual life - which haslong been how neighborhoods are viewed (Bronfenbrenner, 1977); but second, as influencing thedevelopmental and enduring early life course that shapes long-term development, behavior andhealth throughout the life of the individual regardless of subsequent neighborhood stability orindividual mobility (Sampson, 2008). In considering outcomes such as mental illness andcriminal behavior, this dual framework suggests important possibilities for understanding andpreventing illness and crime, and therefore, is also important for clinical and forensicneuropsychiatric practice.Freedman and Woods (2012) have taken Sampson’s conceptual framework and examined issuesof ongoing violence, neurotoxins, psychosis. In this presentation, Dr. Woods will discuss thefoundation of neighborhood collective research, and the potential impact this research may haveon the epidemiological approach to environmental factors causing violence and crime.43. Decisionally Impaired Older Persons: Challenges andOpportunities for Interprofessional Collaboration106

Interprofessional Collaboration on Behalf of Older Persons with CompromisedDecisional Capacity: Defining and Developing Core Professional CompetenciesMarshall B. Kapp, Florida State University (marshall.kapp@med.fsu.edu)Issues arise with some frequency concerning the cognitive and emotional ability of an olderindividual to make certain legally significant decisions for him or herself. In confronting theseissues, the professional involvement of both attorneys and physicians (and other health careprofessionals) may be needed: the attorney as the legal representative of the older individual orsome other party who is interacting with that individual, and the physician as a provider offactual information, an expert opinion, or some sort of case management for the older individual.The individual with compromised capacity, as well as others who are engaging in some kind offinancial or personal relationship with that party, ordinarily are best served by effectiveinterprofessional collaboration among members of the different involved professions. However,the level of interprofessional collaboration encountered in dealing with the legal issues that arisewhen the decisional capacity of an older client/patient is questioned often leaves much to bedesired. This presentation will define and suggest strategies for developing, through innovationsin medical and legal education, core competencies for physicians and attorneys that are essentialto improving the level of interprofessional collaboration on behalf of older individuals whosecognitive and emotional condition purportedly compromises their capacity to make certainlegally significant decisions.A Reconfiguration of Interprofessional Collaboration for Specific RetireePopulations: Successful People with Mental and Education-Related DisabilitiesAlison Barnes, Marquette University (alison.barnes@mu.edu)The future of mental illness and personal decision making will unfold in a culture in thedeveloped world with two newly vocal groups of people with mental disabilities. One groupincludes highly effective and intelligent people with chronic mental illness who neverthelessfound the strength to conduct challenging lives and full relationships. Most have spent time “inthe (mental illness) closet” to avoid stigma and virtually inevitable limiting expectationsregarding their capabilities. A growing number have decided to reveal their conditions andstruggles. A second group includes people now in preretirement who were recognized andaccommodated from primary through higher education. Many group members are likely to assertclaims for assistance to maintain their health care and lifestyle choices in spite of the physicaland mental losses that may attend old age. How these expectations might be treated is a topic fordiscussion by scholars and policymakers who wish to give individuals fair and effectiveprotection from discrimination and unwanted interference in their lives. This presentationacknowledges such claims and discusses how a new configuration of professionals might107

facilitate recognition both for the good of the individuals and for society which might continue tobenefit from the wisdom and expertise of such capable people.Using Interprofessional Collaboration to Support a New Decision-MakingModel for Decisionally Impaired Older PersonsMaureen Henry, University of Utah (maureen.henry@utah.edu)Interprofessional collaboration offers a largely unexplored opportunity to improve the quality oflife of decisionally impaired older persons. For decades, decisional impairment research hasidentified elements of capacity and evaluated instruments to measure these elements, to theexclusion of this population’s other needs. Published studies have stated or implicitly assumedthat a finding that an older person is legally incapacitated should shift decision-making to asurrogate. This response assumes that the interests of an impaired individual will be mosteffectively promoted when a surrogate is making major and minor decisions on behalf of theindividual. There are reasons, however, to question this assumption. This presentation willreview capacity assessment literature and synthesize results of studies from various disciplinesthat support the conclusion that the current emphasis on capacity assessment and its associatedtransfer of legal control to a surrogate may impair quality of life. An alternative model wouldemphasize interprofessional collaboration with two specific goals: to identify the strengths ofolder persons and to support to them and their decision companions through the decision-makingprocess. Roles of professionals who will be crucial to an alternative decision-making model,including social workers, nurses, psychologists, physicians, and attorneys, will be described.Reducing Social Disconnectedness and Perceived Isolation Among Older AdultsFor Better Health Outcomes: Could a Mandatory Chronic Disease Registry be aBeneficial Tool?Alina M. Perez, Nova Southeastern University (amp@nova.edu)Among U.S. residents ages 65 and older, 10.9 million, or 26.9 percent, had diabetes in 2010 andan estimated 50 percent had pre-diabetes. Uncontrolled diabetes is the leading cause of kidneyfailure, blindness and lower limb amputations resulting in disability and decreased functioningamong those with the disease. Effective management of diabetes requires compliance withmedication, exercise and dietary regimes. Studies show that among the older population, socialand psychological factors such as social disconnectedness and perceived isolation may impactthe ability of older individuals to comply with medical treatment, resulting in poorer healthoutcomes. In addition, depressive symptoms among the most isolated older adults are found to beassociated with decreased willingness to exercise and with an increase in health-risk behaviors,including smoking and alcohol use. In 2006, The New York City Board of Health implemented a108

mandatory diabetes registry which required laboratories to report all hemoglobin A1C levels ofdiabetic patients to the city’s Department of Health and Mental Hygiene. The department wouldthen contact those patients whose Hg A1C values were indicative of poor diabetes control andtheir physicians, to suggest modifications to their course of treatment. This presentation willexplore the possible benefits of such a registry as: (1) a tool to improve the health outcomes ofdiabetic older adults who also experience social disconnectedness and/or perceived isolation and,(2) an opportunity for interprofessional collaboration in elder care.Clinical Correlates of Impaired Decision Making in Older AdultsNaushira Pandya, Nova Southeastern University (pandya@nova.edu)The ability to make decisions necessary for physical, mental and financial well being is essential,and impairment with this complex capacity puts older adults at risk. They are more vulnerable toabuse, financial and physical mishaps, and even institutionalization and reduced quality of life.Reasons for impaired decision making include acute illness and delirium, dementia, adversemedication effects, abuse, and mood or affective disorders. Presentation of this problem may besubtle or insidious, although at times it is clearly evident. Professionals may see unique facets ofimpaired decision making in their encounters with older adults in the work or social setting. Thispresentation will characterize various medical and psychosocial problems, as well as psychiatricdisorders contributing to impaired decision making. Manifestations of this problem as it relatesto the elder interacting with various professionals will be discussed.44. DementiaDementia Patients, Capacity Assessments and Residence Decisions: Is theMental Capacity Act 2005 Fit for Purpose?Charlotte Emmett, Northumbria Law School (charlotte.emmett@northumbria.ac.uk)This paper comments on how assessments of residence capacity are actually performed ongeneral hospital wards in England and Wales in respect of older people with dementia and howsuch assessments compare with legal standards for the assessment of capacity set out in theMental Capacity Act 2005. Our findings are grounded in ethnographic ward-based observationsand qualitative interviews conducted in three hospital wards, in two hospitals (acute andrehabilitation), within two NHS healthcare trusts in the North of England over a period of ninemonths from June 2008 to June 2009. We also draw from broader conceptions of capacity foundin domestic and international legal, medical, ethical and social science literature. Our findingssuggest that whilst professionals profess to be familiar with broad legal standards governing theassessment of capacity under the MCA, these standards are not routinely applied in practice in109

general hospital settings when assessing capacity to decide place of residence on discharge. Wediscuss whether the criteria set out in the MCA and the guidance in its Code of Practice issufficient when assessing residence capacity given the particular ambiguities and complexities ofthis capacity. We conclude by suggesting that more specific legal standards are required whenassessing capacity in this particular context.Making Best Interest Decisions for Dementia Patients on Discharge fromGeneral Hospital: Do Family and Friends Fulfil an Effective SafeguardingFunction under English Law?Charlotte Emmett, Northumbria Law School (charlotte.emmett@northumbria.ac.uk)In this paper we explore the role of family members and friends in the best interests decisionmakingprocess under the Mental Capacity Act 2005 in England and Wales. We ask whether, inthe absence of Independent Mental Capacity Advocates (IMCAs), close family and friends ofolder people with dementia are capable of fulfilling a safeguarding function when decisions arebeing made about where that person should live on discharge from general hospital. Our findingsare grounded in ethnographic ward-based observations and qualitative interviews conducted inthree hospital wards, in two hospitals (acute and rehabilitation), within two NHS healthcaretrusts in the North of England over a period of nine months from June 2008 to June 2009. Weask: are family and friends there simply in an advisory/supportive capacity or are they often seenas the primary decision-makers by professionals? Does this role accord with the incapableperson’s (P’s) view or the family and friend’s own views and expectations of their role? Is thisperception promoted by professionals? Can relatives and friends really be expected to makeobjective assessments of P’s best interests in the context of decisions about where to live andfulfil an effective safeguarding function? Or are there simply too many competing tensions? Ourconclusions suggest that family and friends can only begin to act as an effective safeguard forthose they care about if communication with professionals is improved and they are involvedmore fully in the hospital discharge planning process.Old Behind Bars: Dementia, Illness and Compassionate Release in US PrisonsJamie Fellner, Human Rights Watch, New York, USA (jamie.fellner@hrw.org)The size of the US prison population – the world's largest – may be stabilizing, but the number ofolder prisoners is increasingly dramatically because of long sentences and limited access to earlyrelease. For example, the number of prisoners age 65 or older has grown by 63 percent since2007. US prison officials are hard pressed to respond to the many needs of prisoners whoseminds and bodies are being whittled away by age, and aging men and women who areincarcerated confront buildings and rules that were designed with much younger prisoners inmind. Provisions for medical parole and compassionate release exist, but they are not utilized110

often enough and authorities are particularly reluctant to release prisoners who have beenconvicted of violent crimes. This presentation will provide an overview of the aging prisonpopulation, responses to dementia, and compassionate release/medical parole provisions.Use of Social Commitment Robots in the Care of Elderly People with Dementia:A Literature ReviewElaine Mordoch, University of Manitoba (Elaine.mordoch@ad.umanitoba.ca)Globally the prevalence of elderly people is rising with an increasing number of people livingwith dementias. This trend is offset with a prevailing need for compassionate caretakers,traditionally taken from a demographic that is currently declining in many societies. A keychallenge in dementia care is to assist the person to sustain communication and connection tofamily, caregivers and the environment. The use of social commitment robots in the care ofpeople with dementia has intriguing possibilities to address some of these care needs. This paperdiscusses the literature on the use of social commitment robots in the care of elderly people withdementia. The contributions to care that social commitment robots potentially can make andcautions around their use are discussed. Future directions for programs of research are identifiedto further the development of evidence based knowledge in this area.45. Developments in Brazilian Forensic Mental Health and itsInterface with the LawSão Paulo Public Policies for Mentally Ill OffendersRafael Bernardon Ribeiro, Santa Casa Medical School & Institute of Psychiatry, University ofSao Paulo (chefiadegabinete@saude.sp.gov.br)São Paulo is the most populous and developed Brazilian state. It has a population ofapproximately 41,692,668 (2011) and is the most powerful state in terms of economy, achievingan IGP of 622 billion dollars in 2009. As expected, this state has the largest prison population:188,518 individuals in 2012. The State Secretary for Penitentiary Administration runs all thecorrectional facilities and forensic units for the mentally ill within the state. There are 3 forensichospitals to assist all this population, encompassing a total of 1095 inpatients (20% abovenominal capacity). Apart from these, there are approximately 350 patients in common prisonwards waiting for a placement in a forensic hospital. According to a recent study in São Paulo,12% of the inmates had a severe mental illness, such as psychosis, depression or bipolar disorder,which makes the situation even more alarming. The public health system works separately fromthe forensic system, although some cooperation is common. One of the main goals to beachieved is integration of this network. The State Secretary for Health had a successful111

experience incorporating the Penitentiary Hospital in São Paulo City, which was delegated to anon-profit partner. The facility improved in all aspects. The aim of this presentation is tointroduce and discuss future plans from São Paulo´s State Secretary for Health for forensicmental health modernization and humanization within the next 4 years.Considerations on the Use of the Rorschach Test in Brazilian ForensicPsychology: Highlights on Anibal Silveira’s Approach as Compared to Exner’sMaria Emilia Marinho de Camargo, Institute of Psychiatry, University of Sao Paulo(mila_marinho@terra.com.br)The Rorschach test is very popular in Brazil, particularly in forensic settings. The forensic use ofthe Rorschach test is mainly based on the Aníbal Silveira school, a theoretical model ofpersonality, coding and interpretation designed by the researcher of the same name. ThisRorschach school was built on extensive research into normal and pathological mental processesand methodological standardization, being the first choice in legal assessments in Brazil. Thecomplete dynamic of personality can be assessed and explored though superior mental functionssuch as memory, cognition, attention, perception, thought, emotions and communication.Cognitive, motor or emotional malfunction that impairs the judgement of reality and ultimatelyexpressed behavior will be reflected in responses to the test and its results. These results willguide decisions from courts and law professionals regarding understanding and selfdetermination,fundamental concepts in Brazilian penal law. The general theory behind AnibalSilveira’s approach to the Rorschach test will be introduced and compared to the Exner theory.Decision Making of Individuals Incarcerated for Commission of Violent Crimes:A Study of Somatic MarkersRogério L. Silva, Institute of Psychiatry Faculty of Medicine – University of Sao Paulo(dr.rogerioleite@gmail.com)Paula Martins, Institute of Psychiatry Faculty of Medicine – University of Sao Paulo(paula.martins@gmail.com)Sergio Paulo Rigonatti, Institute of Psychiatry Faculty of Medicine – University of Sao Paulo(sergioprigo@yahoo.com.br)Despite increased efforts, little is known about differences in decision making of individualsincarcerated for committing violent crimes and even less is known about possible differencesamong their subgroups. Objectives: This study focuses on differences in decision making bymeans of the conductance measurement associated with anticipation of potential decisionsamong Brazilian prisoners in relation to the population and on possible differences between theirsubgroups. Methods: 40 convicted individuals were included, 20 convicted for murder and 20 for112

obbery or extortion. The subjects were submitted to the Portuguese version of Iowa GamblingTask (IGT) while dermal conductance data were recorded. A socio-demographic inventory andan estimated IQ test (WASI) was also applied. Results: Partial results of IGT, the sociodemographicinventory and WASI did not find any statistically significant differences betweenthe groups. No comparison value less than 0.05 was obtained, although subtle differences wereobserved between subgroups. The dermal conductance data have not been analyzed yet.Conclusions: These data will allow renewed interpretations of decision making among thoseindividuals. Importantly, to date, we have found no statistical differences in socio-demographicprofiles or performance between the groups. We believe, however, that this picture may changewhen we include rapists, control groups and the interpretation of somatic markers.Psychiatric Evaluation and Risk Profiles of Forensic Patients in São PauloState, BrazilQuirino Cordeiro, Santa Casa Medical School (qcordeiro@yahoo.com)Introduction: According to the Brazilian Penal Code (1940), which was revised in 1984,mentally ill persons who commit crimes must be evaluated on their ability to understand and/orbehave according to such understanding during the commission of the crime, allowing theseindividuals to be sent to a forensic psychiatric hospital for proper treatment. In São Paulo, thereare three Custody and Psychiatric Treatment Hospitals, with a total of 1,100 vacancies for thetreatment of psychiatric patients. The present study was based on 199 psychiatric evaluations ofrisk cessation in psychiatric patients held in common prison units.Sample: 199 psychiatric patients were evaluated. Data from these assessments were analyzeddescriptively and through association analysis between their psychiatric diagnosis and type ofcrime, criminal repertoire and crime recidivism.Results: Descriptive analysis of the sample (n=199): mean age of 33.85 years, 80.9% single,divorced or widowed, 40.5% arrested once, 26.6% with psychotic disorders and 61.8% withalcohol/drug abuse or addiction, 5% with epilepsy, 17.6% with mental retardation, 1% withpedophilia, 7% with mood disorders, 21.1% with personality disorders, 10.5% with otherdiagnoses. Statistical analysis of the sample showed the following results: regarding the type ofcrime, it was observed that patients with drug abuse or addiction had committed 2.4 times morerobbery crimes compared to patients with psychosis. These patients (drug abuse or addiction)committed 90% fewer crimes against persons compared to patients with psychosis. Regardingcriminal repertoire (prosecution for more than one type of crime), a major association wasobserved between larger criminal repertoires and the co-morbidity of drug abuse or addiction andpsychopathic personality disorder in relation to patients with psychosis. Regarding recidivism, itwas found that the association of drug abuse or addiction and psychopathic personality disorderwas associated with 9.9 times higher recidivism compared to patients with psychosis. Patientswith isolated psychopathic disorder presented 8.0 times higher recidivism compared to patientswith psychosis. Patients with drug abuse or addiction showed recidivism 6.6 times highercompared to patients with psychosis.113

Conclusion: The present study showed that the predominant profile in the sample was male, withhigh average age, low education level and high prevalence of single and separated individuals.The major type of crime committed was robbery, also being the most common amongindividuals with drug abuse or addiction. Among psychotic individuals, the most common crimeswere those against the person. Among psychopathic individuals, there was no preferentialcriminal distribution. Drug abuse or addiction was the most common mental disorder in theinvestigated sample.Brazilian Law and Psychiatric Admissions: The Role of the State Attorney OfficeReynaldo Mapelli Jr., Department of Health, São Paulo State, Brazil(chefiadegabinete@saude.sp.gov.br)In Brazil, until recently, there was no specific legislation regulating mental patients’ rights,psychiatric admissions and state supervision. In 2001, Law 10,216 was enacted, an importantlegal document constituting 13 articles that cover basic civil rights, rights as a patient, the role ofthe state, rules for inpatient admission and discharge and the role of the State Attorney Office asa review body. According to this law, there are 3 kinds of admissions: Voluntary – patientaccepts treatment and can sign a consent form; Involuntary – patient is incapable of signing aconsent form or is not willing to consent for the treatment; Compulsory – admission by courtorder (civil commitment). For any hospital admission, the law requires a qualified consultantopinion and agreement. A doctor must communicate any involuntary admission to the StateAttorney Office in 72 hours, and this procedure can be done using a specific Internet portal. Themain idea behind this regulation is to have a third part following the involuntary procedure untildischarge. This rule generated a database that reflects the epidemiological profile of involuntarypatients treated in São Paulo state. This specific role within the public health system andinformation regarding admissions, as well as complaints and denouncements from citizens,generated more than 10 collective public actions in defence of the mentally ill. These data andactions will be presented and compared to other codes of law and legal systems.Deficits of Memory in Young Sexual Offenders Who Were Victims of SexualAbuse in ChildhoodMery Candido de Oliveira, University of Sao Paulo (meryoliveira@usp.br)Some research on neurobiological theories demonstrates impaired psychological functions asimplicated in criminality development and delinquency. These malfunctions include attentiondisturbance, impulsiveness, antisocial behavior, lack of accuracy, learning disability, low culturalbackground and memory impairment, as well as biological markers such as neurotransmittersand hormones (such as serotonin, thyroid and testosterone). Additionally, parental figures whowere not consistent figures of authority could contribute. New pathways for research emerge114

when these different domains are connected. In the face of the complexity and the lack ofresearch on sexual abuse of young boys in Brazil and the seriousness of possible psychologicaldamages in abuse victims, systemized studies are required to assess this population. One methodis to test memory performance of adolescents who have a history of sexual abuse in childhoodand are serving a sentence in São Paulo’s youth correctional system (Foundation C.A.S.A) forsexual offences (repeating sexually aggressive behavior). The study of memory processesreported in this presentation is based on the hypothesis of memory suppression or recallimpairment that could help explain impairment in social judgment and sexually aggressivebehaviors later in life. These changes in memory could impair the judgment based on learntexperiences and lead to a disarranged and non-consistent way of acting. The failure in socialcognition could result in criminal and anti-social behavior.46. Developments of Prison Mental Health Care in the NetherlandsDevelopment of Prison Mental Health since 2008Jan Gorter, Penitentiary Psychiatric Centre, Amsterdam, Netherlands (j.gorter2@dji.minjus.nl)As a result of the acceptance in 2004 of a motion of the Dutch Senate asking the Government toimprove the connection between mental healthcare in prisons and in free society, aninterdepartmental workgroup was installed. The advice of this workgroup, together withrecommendation number 17 of the temporary parliamentary committee of 2006 on detentionunder a hospital order, led the Ministry of Justice to initiate the “Vernieuwing Forensische Zorg”programme. This programme, among other things, aimed to develop five Penitentiary PsychiatricCentres throughout the Netherlands. In 2009 those centres became operational. In this sessionwe’ll describe the process of developing a psychiatric facility within a prison and doing that‘going concern’, the development of a quality control system and some general characteristics ofthe population. Treating psychiatric patients in a detention situation differs from treatment of thesame patients in free society. The imprisonment itself has an effect of the development andcourse of psychiatric disorders and also on the possibilities in treatment. We would like todiscuss the advantages and disadvantages of treating psychiatric patients within the prisonsystem.Prison Staff Delivering Mental Health CareRob Hollander, Penitentiary Psychiatric Centre, Amsterdam, Netherlands(robert.hollander@dji.minjus.nl)Wendy Weijts, Penitentiary Psychiatric Centre, Amsterdam, Netherlands(w.weijts@dji.minjus.nl)115

Working within a prison mental health facility requires specific skills. In this session we willshare our experience regarding recruitment and education of employees, and present on skillsand qualifications necessary to work with this specific population. Five Penitentiary PsychiatricCentres were opened in the Netherlands in the last 3 years. In the process of recruitment andeducation we encountered challenges opportunities and difficulties worth discussing withcolleagues in prison and general mental healthcare. What are the implications of prison hierarchyfor mental healthcare? While it is the prison directors’ responsibility to provide treatment forinmates with mental disorder, it is the psychologist or psychiatrist that decides what treatment.Prison mental health staff (nurses and trained wardens) co-operate with and are supervised by thepsychologist. Healthcare Law holds them personally responsible for their contribution in thetreatment process. In prison healthcare personnel is subject to both hierarchy and professionalstandards. In the Penitentiary Psychiatric Centre these influences are balanced by dualmanagement on every level of the organisation. The head of the ward and the psychologist joinresponsibility for the ward as a whole, safeguarding professional autonomy of practitionerswithin the necessary strict hierarchy of the detention setting.Results of a Study on the Characteristics of Psychiatric Patients in a PrisonJanneke van Beek, Penitentiary Psychiatric Centre, Amsterdam, Netherlands(j.van.beek@dji.minjus.nl)Major mental disorders increase the risk of violent behavior. A significant proportion ofpsychiatric patients end up in prison and receive treatment there, rather than in a mentalhealthcare institution. This group has histories of non-compliance, is elusive of healthcare and isvery hard to treat even in a mental health facility. To prevent recidivism and fine-tune treatment,more knowledge about this group is necessary. Their stay in prison is an excellent opportunity tolearn more about the characteristics of this psychiatrically and behaviorally severely disturbedgroup of people. We present the findings of research into symptoms and aggression of men andwomen incarcerated in a penitentiary psychiatric centre.Mental Disorders and Psychiatric Symptoms during Imprisonment and theRelation to ReoffendingOscar Bloem, Penitentiary Psychiatric Centre, Amsterdam, Netherlands(o.bloem@dji.minjus.nl)A large number of prisoners suffer from mental disorders and psychiatric symptoms. Little isknown about the course and predictability of these symptoms and co-occurring problematicbehaviour during imprisonment. This study aimed to gain insight into the course of symptomsand behaviour to predict which prisoners need attention or treatment. Factors which relate to thecourse of psychiatric symptoms were studied over time. Furthermore, the effects of transferring116

prisoners to a psychiatric prison ward within prison was studied. Finally, the question of whethercertain psychiatric complaints are related to reoffending were explored. All new arrival remandprisoners and new arrival prisoners on a psychiatric prison ward were studied. Their mentaldisorders were studied and every month psychiatric complaints were measured by bothinterviews and questionnaires. At arrival, prisoners who were admitted to a psychiatric prisonward were diagnosed with more mental disorders, specifically psychotic disorders anddepression. Also, they were experiencing more intense symptoms and were causing moreproblematic behaviour. Within two months of admission, psychiatric complaints no longerdiffered between the groups. The short term results of admission to a psychiatric prison wardseem to be effective for mentally disordered prisoners. Long term effects, specifically inreoffending, were studied and will be presented.Continuation of Forensic Psychiatric Care: Transfer of Mental Care fromPrison to Regular PsychiatryO. M. (Onno) den Held, Penitentiary Psychiatric Centre, Amsterdam, Netherlands(om.den.held@dji.minjus.nl)E. A. (Ton) Boorsma, Penitentiary Psychiatric Centre, Amsterdam, Netherlands(t.boorsma@dji.minjus.nl)Treatment in a regular (forensic) psychiatric setting is paramount, unless…To achieve this goal,the department of Justice and Security finances care within regular psychiatry. Often, a transferof care is not possible. In those cases treatment in our Penitentiary Psychiatric Centre iscontinued. There are many cases where continuation of care is still necessary although a judgedecides that the patient must leave our prison facility. What works? Where are possibilities forimprovement and fine tuning? In this part of the session, the ins and outs of the many possibletransfers of care, will be discussed.47. Diagnostics, Assessment, and Treatment in Psychotic OffendersRole of Dysfunctional Empathy in Violence among People with SchizophreniaMaria D. Bragado-Jimenez, Cardiff University (bragadojimenezmd@cf.ac.uk)Pamela J. Taylor, Cardiff University (taylorpj2@cardiff.ac.uk)This presentation would include a summary from a systematic review on empathy, schizophreniaand violence, and would explore the different components of empathy and their possible role inviolent behaviour among people with schizophrenia and other psychosis.117

The evidence suggests that people with schizophrenia have dysfunctional empathy. Intactempathy has been associated with prosocial behaviour and has been considered a protectivefactor against antisocial behaviour and violence. The dysfunction of the components of empathymight play a role in the pathway to violence among people with schizophrenia and its furtherinvestigation may be worthy.Data from an ongoing longitudinal multicentre study would be presented. This data wouldinclude sociodemographic and psychopathological information from patients with psychosisrecently admitted to both forensic and general psychiatric settings. Self reported empathy andrecent violent episodes during the time of admission are explored among two subgroups ofpatients clustered according the frequency and severity of their historical violence. Preliminaryresults on empathy and recent violence differences between the two subgroups would bepresented. The clinical and legal implications of this study would be discussed.Persecutory Ideations and Delusional Distress in Relation to Aggression and aDimensional View of Psychotic Symptoms/Models in the General PopulationJosanne D.M. van Dongen, Erasmus University of Rotterdam (j.d.m.vandongen@law.eur.nl)Background: People with schizophrenia are more likely to be violent than the people without.Feeling driven to act on persecutory delusions may be one explanation for this, but it remainsunclear why some should act on such delusions but some not. Acquisition of data from peoplewho are very ill is problematic. Our study explores testing of hypotheses on similar ideationaland behavioural associations among healthy recruits from the general population. Aims: To testthe effect of distress induced by persecutory ideas on any relationships between those ideas andaggressive behaviour, and the effect of gender.Method: Twenty-four men and 53 women from the general population participated in this study.The measures of aggressive behaviour were experimentally induced aggressive responding andself-reported personal style, reactive, and proactive aggressive behaviours.Results: Among men, persecutory ideation predicted reactive aggressive responding andaggressive style of behaviour only in those who experienced higher levels of persecutoryideational distress. Among women, with generally lower levels of aggression, the role ofideational distress was more complicated; higher levels of distress mediated against reactiveaggression but were linked to aggressive style. For neither men nor women were there linksbetween persecutory ideation and proactive aggression, regardless of distress.Conclusions: The apparent similarity of associations between persecutory ideation, the distress itmay cause and some forms of aggression to associations between persecutory delusions, thedistress they may cause and actual physical violence, are encouraging for the use of such.118

Are Negative Symptoms of Psychosis and the Deficient Affective ExperienceDifferent Concepts? An Exploratory Study in Chronic (Forensic) PsychiatricPatientsMaarten van Giels, Mental Health Care Westelijk Noord-Brabant, Halsteren, Netherlands(Maarten.van.Giels@ggzwnb.nl)Erol Ekiz, Mental Health Care Westelijk Noord-Brabant, Halsteren, Netherlands(e.ekiz@ggzbreburg.nl)Kris Goethals, Mental Health Care Westelijk Noord-Brabant, Halsteren, Netherlands(kris.goethals@ggzwnb.nl)Hjalmar van Marle, Erasmus University of Rotterdam (Hjalmar@xs4all.nl)Background: The Deficient Affective Experience (DAE) is described as being apredictor of violent behaviour in men recently discharged from forensic psychiatry aswell as in general populations. Furthermore, schizophrenia, and possibly its negativesymptoms as an emotional dysfunction, are also a cause for increased risk for violentbehaviour. However, it is unclear in what way there is a correlation between these twoemotional dysfunctions.Aim: In this study, the aim is to explore the possible correlation between the DAE andnegative symptoms of schizophrenia.Method: Based on an interview and a review of institutional files, the DAE total scoreand facet scores were examined among different forensic and non-forensic psychiatricsubgroups. Subsequently, (partial) correlation and rank order coefficients werecalculated.Results: The personality disordered subgroup showed a significant higher DAE totalscore, as do psychotic patients without a comorbid personality disorder. Forensicpatients have a significant higher DAE total score, compared to patients in generalpsychiatry.Conclusions: Based on few significant correlations between DAE total and facet scoresand negative symptoms items, both appear not to be the same concept. This means thatinterpreting the DAE total score of psychotic patients in general psychiatry should beconsidered with caution.Security and Psychiatry: Adapting Mental Health Services to a “New” Reality –Planning of the First Medium Security Ward in Israel – Learning from theBritish ExperienceTal Bergman Levy, Beer Yaacov Mental Health Center, Israel (bergmantal@gmail.com)119

Introduction: The courts have recently become increasingly involved in the administration ofcompulsory psychiatric services in Israel. Data reveals a gradual increase in the rate of courtordered hospitalizations according to Section 15 of the Law for the Treatment of the Mentally Ill.This trend bears significant implications, particularly relating to the issues of security and safetyin psychiatric hospitalization.Aim: The presentation will present highlights from extensive British experience, focusing on thepotential implications on forensic psychiatry in Israel.Methods: The development of the hierarchy of security in the British psychiatric services isreviewed, beginning in the early 1970s with the establishment of the Butler Committee thatdetermined a hierarchy of three levels of security for the treatment of patients, culminating withthe establishment of principles for the operation of medium security units (Read Committee,1991). These developments were the basis for the forensic psychiatric services in Britain.Subsequently current experience and dilemmas in the process of planning the first mediumsecurity ward in Israel will be discussed.Conclusions: A safe and suitable environment is a necessary condition for a treatment setting.The establishment of separate medium security units or forensic psychiatry departments within amental health facility will enable the concentration and classification of court-orderedadmissions and will enable systemic flexibility and capacity for better treatment, commensuratewith patient needs as well as optimizing the risks relating to this population.Long-Term Outcomes of Patients with Schizophrenia Detained in a ScottishHigh Security HospitalRajan Darjee, The Orchard Clinic, Edinburgh, UK (Rajan.Darjee@nhslothian.scot.nhs.uk)Introduction: People with schizophrenia who commit serious violence are detained in securehospitals. The research presented here investigated the long-term outcomes of patients withschizophrenia detained in a high security hospital.Method: The sample was 169 patients with schizophrenia resident at the State Hospital,Carstairs, between August 1992 and August 1993. In 1992-4 patients and their psychiatrists wereinterviewed and data were collected from case records. Patients were followed up until the end of2001. Records covering the intervening period were examined, and patients and independentinformants were interviewed in 2000 and 2001. A number of structured instruments were used atinterviews and to interrogate case records.Results: Most patients were male, unmarried and from socially disadvantaged backgrounds.Most had been admitted from criminal courts after committing serious offences, half weresubject to restriction orders and a quarter had killed. Most had had psychiatric treatmentpreviously. Comorbid substance dependence and personality disorder were common. Threequarterscommitted at least one act of violence, but less than a quarter caused serious harm.There were almost 2000 violent incidents, mostly in high security. Violence in the communitywas rare. A third had episodic symptoms, a quarter continuous symptoms and a fifth recovery120

with no recurrence. Positive symptoms tended to improve whilst negative symptoms persisted.Substance dependent patients were more likely to be convicted, but otherwise had betteradministrative, clinical and social outcomes. Antisocial personality disorder was associated withviolence during follow-up.Conclusions: Course of psychosis and comorbid personality disorders and substance dependenceare important clinical factors in determining the administrative, forensic and clinical outcomes ofthese patients.48. Diminished Capacity and Incapacity in the Criminal LawContextThe Defence of Diminished Capacity Short of InsanityAllan Manson, Queen’s University Faculty of Law (mansona@queensu.ca)Julian Gojer, Counsel, Neuberger Rose LLP, Toronto, Canada (joseph@nrlawyers.com)Joseph Neuberger, Partner, Neuberger Rose LLP, Toronto, Canada (joseph@nrlawyers.com)Most western criminal justice systems have some form of “mental disorder “or “insanity”defence, based on the M'Naghten rules or other conceptual formulation, which results in anexemption from criminal responsibility. Some jurisdictions also have an intermediate finding,like diminished responsibility in the United Kingdom, which leads to a hospital order without aninsanity finding. But there are many jurisdictions, like Canada, which have no intermediatedesignation for accused persons who suffer from mental disorder but cannot meet the rigourousinsanity criteria. Most criminal law theorists agree that mental disorder short of insanity may berelevant to the issue of requisite intention. However, this theoretical acceptance rarely plays outin practise. The authors argue that criminal law theory makes room for a defence of diminishedcapacity and explore the kinds of psychiatric diagnoses which may satisfy this defence while notleading to a finding of insanity. Using this analysis of possible diagnoses, they formulate a legaltest for translating the psychiatric evidence into a practicable defence.Violent Incidents Against Care Workers in Psychiatry; Judicial Reaction or Not?J.M. Harte, Vu University – Faculty of Law (j.harte@vu.nl)M.E. van Leeuwen, Forensic Psychiatric Hospital Inforsa, Amsterdam, Netherlands(mirjamvanleeuwen@me.com)Mental health professionals often encounter violence caused by psychiatric patients. Accordingto the literature, the possibility of seeking legal action against violent patients has hardly beenstudied or discussed. Moreover, in daily practice there seems to be a lack of clear guidelines andpolicy: incidents are handled in divergent ways. As a first step in the development of guidelines,121

systematic research on the prevalence and nature of violent incidents in psychiatry was carriedout in the Netherlands. By means of a nationwide campaign, health care workers were requestedto fill in a questionnaire on their personal experience with violent incidents caused by patients.The 1534 mental health workers who participated in this research were victims of a total of 2648violent incidents in the past five years. In this presentation, the consequences of these incidents,including injuries, medical treatment and sick leave, are presented, as well as the possiblejudicial reactions, such as reporting to the police, prosecution and conviction. The hypothesesthat only a tiny amount of all incidents are tried in court and that selection of these incidents isquite arbitrary, are discussed."I'm Not an Aid Worker.I'm There to Apply the Law." Lawyers' Experience ofTheir Work in Clinical Negligence: An Interpretative PhenomenologicalAnalysisNoelle Robertson, University of Leicester (nr6@le.ac.uk)Sarah Lawson, University of Leicester (sl314@le.ac.uk)Professionals' whose work entails extensive contact with clients who are traumatised, mayexperience significant emotional difficulties and trauma symptoms themselves. However, therehas been only limited research on such vicarious distress in legal professionals. Lawyers workingin clinical negligence have been neglected despite their exposure to clients' detailed andemotionally-charged accounts of alleged misadventure, and collation of graphic medicalevidence and expert reports to build a case. Such interaction confers a significant emotionaldimension to legal work. In the absence of previous research and to gain rich accounts of howsuch work is experienced and understood, a qualitative study was undertaken. Methods: Five UKlawyers working in clinical negligence participated in semi-structured interviews which wereinformed and analysed using Interpretative Phenomenological Analysis. Findings: Emergentthemes comprised; increased anxiety about own and family's health, cynicism about health caredelivery, rewards and drawbacks of the work, conflict between legal and counselling roles, andfear of revealing distress in the workplace. Discussion: These lawyers disclosed pervasive issuesrelating to heightened affect and difficulties with emotional containment consistent with aspectsof trauma and health anxiety. Recommendations are made to increase awareness of lawyervulnerability and for training and professional support to mitigate potential distress.49. DIS-CAT 2.0 A Swedish Prison Project: A Study of YoungViolent and Sexual Swedish male OffendersYoung Violent and Sexual Male Offenders in Prison – Overview of a SwedishProject122

Björn Hofvander, Lunds University (bjorn.hofvander@med.lu.se)T.B.E.*DIS-CAT Persistent Criminality among Violent Offenders in EmergingAdulthood: the Importance of Early Onset Externalizing BehaviorsMärta Wallinius, Lunds University (marta.wallinius@med.lu.se)T.B.E.*Heritability Factors in Patterns of Substance use Among Young Adult MaleViolent and Sexual OffendersBamchad Behbahani, Lunds University (bamchad.behbahani@skane.se)T.B.E.*A Comparison of Young Adult Male Sexual and Violent Offenders in Terms ofFeeling of Guilt and ShameCarole Weber-Malmberg, Swedish Correctional Services, Kva Kristianstad(carole.webermalmberg@kriminalvarden.se)T.B.E.*A Comparison between Young Adult Male Sexual and Violent Offenders withand Without a History of Intimate Partnership ViolenceAnna-Kari Sjödin, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(anna-kari.sjodin@rmv.se)T.B.E.*123

50. Diversion from the Criminal Justice System: Initiatives in theUK and AustraliaCriminal Justice Mental Health Liaison and Diversion Services: CurrentPractices and Future DirectionsJane Senior, University of Manchester (jane.senior@manchester.ac.uk)Criminal Justice Mental Health Liaison and Diversion services, designed to divert people withmental illness away from the criminal justice system, have proliferated in England and Walesover the last twenty years. They are universally regarded to be a “good thing”, but there is norobust body of research evidence to support the belief that they improve the health, social orcriminal outcomes of people who are in contact with them. The Department of Healthcommissioned the Offender Health Research Network to review current practices around liaisonand diversion and make a number of recommendations for future service development. Site visitsand telephone conferences were undertaken with 21 schemes using a semi-structured interviewschedule. This presentation will identify their referral process, methods of screening, assessmentand onward referral, and outline the problems identified with service provision, funding, coretasks, and inclusion/exclusion criteria. We conclude that liaison and diversion schemes provide aservice for clients who are not always well served by mainstream services, but there appear to beopportunities for service improvement through a standardisation of approach; a national model ofpractice; improved data collection; and more consideration to the conduct of ongoing evaluationsinto service impact and outcomes.Developing Criminal Justice Mental Health Pathways in South LondonAndrew Forrester, South London and Maudsley NHS Foundation Trust, London, UK(andrew.forrester@kcl.ac.uk)South East London contains some of the United Kingdom’s most socially deprived boroughs,with high rates of mental health issues. Since 2008, there has been a focus on improving mentalhealth care pathways for people in contact with the criminal justice system. This presentationwill detail this process, starting with improvements to prison-based care services for people withserious mental illness, moves to enhance services at local courts, complemented most recently bya new wave of services in police custody areas. Throughout, there has been a distinct emphasison multi-agency working, with health agencies partnering with others such as HM Court Service,HM Prison Service, police, probation services, the voluntary sector and health service managersresponsible for commissioning care. Quantitative evaluation and research work will be presented124

from each of the limbs of the criminal justice system and the project’s overall efficacy will bediscussed, with recommendations for future work.Mental Health Screening in Police Custody in England: Developing a ScreeningTool and Referral PathwayHeather Noga, Lancashire Care NHS Foundation Trust, Manchester, UK(heather.noga@manchester.ac.uk)There are many reasons why people end up detained at a police station, some of which aremental health-related. A large proportion of this group would benefit from being diverted fromthe police and court systems altogether, and instead receiving treatment from health and/or socialservices. In the UK, Criminal Justice Mental Health Liaison and Diversion teams are largelyreliant on referrals made by police for mental health assessments. The aim of this project was toimprove current practices surrounding the identification of mental health problems for people inpolice custody, through increasing access to timely and appropriate referrals to mental healthprofessionals. The study incorporated a mixed methodological approach including a review ofexisting screening proceedures, interviews, a delphi consultation exercise and action learninggroups, which included the perpectives of the police, mental health professionals and serviceusers. Upon completion, the project generated a referral decision tool, to be used by non-mentalhealth trained staff to determine whether a detainee in police custody should be referred forfurther assessment and possible diversion. The integration of this tool will refine the referralpathway and increase the chances of a person accessing health and social care services frompolice custody.Health Screening of People in Police Custody: The HELP-PC ProjectIain McKinnon, Newcastle University (iain.mckinnon@ncl.ac.uk)There is a significant amount of health morbidity among police custody detainees. Chronic andacute physical disorders, serious mental illness, substance misuse, elevated suicide risk andintellectual disability are all overrepresented. In England and Wales, the Police and CriminalEvidence Act (1984) confers responsibility for the welfare of custody detainees to the custodySergeant. In a previous study it was established that police screening procedures miss significantamounts of health morbidity and detainees at risk. In a recent study, we developed and piloted arevised screening tool for police custody sergeants within London's Metropolitan Police Service(MPS). This presentation will outline the development of a new police custody screen includingthe results from the pilot. Additionally, recommendations will be made for future changes tocurrent police custody screening procedures.125

An Evaluation of the Police and Community Triage (PACT) InitiativeStuart Thomas, Monash University (stuart.thomas@monash.edu)The Police and Community Triage (PACT) team is a pre-trial diversion program operating inVictoria, Australia. PACT was developed against an operational background which aimed to: (a)improve police responses to people who experience a range of social, welfare and healthproblems and are involved in repeated contacts with the police through ensuring they areappropriately linked to appropriate community services; and (b) reduce their repeated exposureto the police. A pilot phase of this initiative commenced in early 2011 in three police serviceareas encompassing six police stations. This presentation will outline the PACT model thenprovide details of outcomes arising from the first twelve months after its implementation. Viewsof operational police involved and stakeholder experiences of the initiative will be presented anddiscussed in relation to the opportunities that creative partnerships can provide for improving theoutcomes for complex needs clients.51. Domestic ViolenceThe Abuse Connection: Woman, Children, and Pets in a Violent HomeJudee E. Onyskiw, MacEwan University (onyskiwj2@macewan.ca)Despite notable efforts to eliminate violence in families, family violence remains a prevalentsocial problem and a global phenomenon. Violence pervades families in our society. Women areinjured or humiliated by violent partners, children are abused or neglected by parents, and theelderly are maltreated by adult children. Although statistics on different forms of family violenceare collected separately, these different forms of violence do not always exist independently ofone another. Most often, one form of violence is an indicator that another family member is atrisk. While the connection between woman abuse and child abuse has long been recognized,researchers have also observed a connection between the abuse of women and children infamilies and the abuse of pets. The purpose of this presentation is to raise awareness amongprofessionals working with women and children who are living with violence about the interrelatednessamong different forms of family violence and cruelty to family pets. Greaterawareness among professionals from various social service and law enforcement agencies mayresult in a more comprehensive and coordinated approach in their response to family violence.This information may lead to enhanced policies and innovative models of service delivery forindividuals living with this adversity.Being Guided Through the Maze: Women Leaving Domestic Violence126

Lyn Francis, University of Newcastle (lyn.francis@newcastle.edu.au)Women who have experienced domestic violence have higher prevalence rates of mental healthdisorders including depression, anxiety and post traumatic stress disorder than women who havenot experienced domestic violence. Social support has been associated with buffering orprotecting women who have experienced domestic violence from the long term mental healthimpacts of domestic violence. Social support may be informal including friends and family ormore formal helping services such as health or legal workers. This presentation explores somefindings from a narrative research project in Australia about women who have experienced andleft domestic violence. Interviews were undertaken with 12 women who have experienced andleft domestic violence as well as 3 focus group interviews with services whose work includes theprovision of legal support to women who have experienced domestic violence. The formal socialsupports including legal support that women found helpful, or not helpful, will be discussed. Therole of service providers, including the role of legal workers, in providing service to women whohave experienced domestic violence will be examined in light of findings from this researchproject. A discussion of how service provision from the legal and health sector may be enhancedin light of findings from this research will conclude the presentation.Violence Against Women: Examining the Intersection of Legal and MentalHealth IssuesRamona Alaggia, University of Toronto (ramona.alaggia@utoronto.ca)A significant body of research indicates that abused women suffer more negative mental healtheffects than non-abused women. Abused women face serious mental health risks such asdepression, anxiety, post-traumatic stress, and substance abuse. Compounding their mentalhealth issues are legal and policy constraints that impact women's already very difficultsituations. This paper reports on a multi-stage, mixed-methods study utilizing grounded theory tounderstand factors in disclosing intimate partner violence and women's help-seeking actions.Important dilemmas for abused women were identified through an ecological analysis. Forexample, leaving an abusive relationship increases the likelihood that a woman will lose custodyof her children and experience seriously diminished financial stability. However, women whostay in abusive relationships are subjected to child welfare investigations for exposing theirchildren to intimate violence. Whether they stay or leave they are in a dilemma in terms offearing loss of their children. For immigrant women, immigration policies create systemicbarriers resulting in many immigrant women staying in abusive relationships for prolongedperiods of time – accruing serious negative mental health effects because of dependence on theirsponsors, who often are the abusive partner or employer. Discussion of relevant practicedynamics will be facilitated.127

Double Filicide as Retaliation against a SpouseQuirino Cordeiro Jr, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil(qcordeiro@yahoo.com)Isis Marafanti, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil(isis_marafanti@hotmail.com)Maria Carolina Pedalino Pinheiro, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil(mariacaropinheiro@yahoo.com.br)Lilian Caldas Ribeiro Ratto, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil(lilian.ratto@gmail.com)The death of one or more child caused by at least one of its parents is named filicide. This can bedivided into: altruistic filicide, unwanted child, psychotic, accidental and filicide as retaliationagainst the spouse. In the case reported, the father killed his two sons and then attempted suicideafter his wife had left home, as a form of retaliation.52. Drug Safety and Women’s HealthThe Inclusion of Pregnant Women in Clinical Research: Balancing Safety withthe Need for DataBarbara A. Noah, New England University School of Law (bnoah@law.wne.edu)In the past two decades, there has been unprecedented growth in medical research utilizinghuman subjects, with much promise for new treatments that extend life, improve quality of life,and prevent disease and disability. Such research involving human subjects provides thenecessary bridge from scientific theory to practical medicine. Safe prescribing of drug therapiesrequires that researchers design clinical trials to test products for the benefit all persons whosuffer from the studied diseases, not just a limited population. For this reason, it is essential thatclinical trials include women and racial minorities, because these populations sometimes exhibitdifferent patterns of response or adverse reactions compared with white males. Governmentregulations in the U.S. have made excellent progress in including women in clinical research.The latest data demonstrate that women now make up the majority of clinical trial participants.Nevertheless, there is a dearth of sound research data on the safety and efficacy of variousapproved and commonly used medications for pregnant women. At this point, nearly allmedications used to treat illness in pregnant women, including common chronic conditions suchas hypertension, diabetes, epilepsy, and cancer, are used off-label–that is, without FDA approval.Physicians must make prescribing decisions for their pregnant patients without the benefit ofrandomized, controlled clinical trials testing the safety and efficacy of drugs in pregnant women.Serious challenges in study design, institutional review board (IRB) oversight, and research128

participant safety make the thought of research in pregnant women daunting, but it is importantto find ways to test commonly used drugs in pregnant patients. Pregnancy is a commoncondition, even among women who suffer from serious and chronic disease. Researchers must,therefore, design clinical trials for both new and already-approved drugs and therapies that willgenerate data for the safe use of these drugs. Phase IV trials involving careful monitoring ofefficacy and adverse events in pregnant patients who receive approved drugs off-label will alsocontribute to the development of better data on which to base prescribing decisions. This paperwill describe the current status of inclusion of pregnant women in research and will suggest newFDA policies, educational initiatives, and incentives to improve the availability and quality ofdata to support safe drug therapy during pregnancy.Herding WomenDavid Healy, Bangor UniversityIn recent years, a number of authors have advocated the merits of conducting randomizedcontrolled trials (RCTs) of antidepressants in women with nervous disorders during the prenatalperiod, despite growing evidence that these drugs cause birth defects, miscarriages, an increasedrate of voluntary terminations, and possibly lead to increased rates of learning disabilities inchildren born to mothers who take them through pregnancy. This information however is hard tofind. Instead there is a literature extolling the merits of antidepressants and the risks of leavingdepression untreated. It is becoming increasingly clear however that a significant proportion ofliterature like this on the merits of using pharmaceutical agents is ghostwritten. Against thisbackground, ethicists and others making assertions that RCTs are needed risk becoming part ofan apparatus that plays down the hazards of treatment and promotes the use of treatments thatmay be harmful.Antidepressant Use and Depression Screening in Pregnancy: Do BenefitsOutweigh Harm?Barbara Mintzes, University of British Columbia – School of Population and Public Health(Barbara.mintzes@ti.ubc.ca)Modern drug regulation was introduced in response to the thalidomide disaster of 1958-1961. Inthe face of the possible devastating and unpredictable harm, clear evidence of benefit was seen asneeded. For the first time, systematic scientific evidence of effectiveness was required before adrug could be marketed. Thalidomide led to caution with medicine use in pregnancy. Ironically,however, regulatory oversight remains limited, with most drugs used “off-label” in pregnancy.Antidepressants are increasingly used in pregnancy, with rates reaching 8-10% in NorthAmerica. This is despite a growing body of evidence of harm, including miscarriage, cardiacmalformations, poorer neonatal adaptation, and persistent pulmonary hypertension of the129

newborn. Pregnant women are often told they must weigh harm from antidepressant use againstthe harm of untreated depression. This assumes that antidepressants effectively mitigate poorermaternal health and birth outcomes associated with depression. This presentation will unpack theevidence supporting claims of benefit. I also review the evidence supporting depressionscreening in pregnancy. Antidepressant use in pregnancy highlights the failure of currentapproaches to regulation to protect pregnant women from medical interventions without provenbenefits. I conclude with a discussion of why this is occurring and recommendations for change.Off-Label Uses and Women’s Health: Improving Risk Assessment andMarketing ControlPatricia Peppin, Queen’s University – Faculty of Law (peppinp@queensu.ca)Once drugs are approved for marketing, professionals are permitted to prescribe them for otheruses. These uses include prescriptions for other therapeutic purposes, to groups other than thosetested during clinical trials, and in other dosages. A significant number of drugs have proved tohave serious risks that appeared when prescribed for off-label uses. Antidepressant use inchildren and adolescents leading to suicidal thinking and the combination diet drug Fen-Phenleading to heart valve problems are two examples. Gabapentin became a highly profitable drugfor the off-label use of pain relief but its excessive marketing campaign resulted in amultimillion-dollar settlement. The structure of clinical trials contributes to an unequal allocationof risk. Off-label uses of drugs pose particular problems for those groups insufficiently includedand analyzed during the clinical trials process. Because women continue to be under-representedin early stage clinical trials when the drug’s safety and drug dosages are determined, and are alsoexcluded from particular types of trials, off-label uses pose greater risks to women’s health.Short-term trials and small sample sizes increase uncertainty. Marketing of off-label uses, whileprohibited in whole or in part, increases the sales of drugs whose safety and efficacy may belargely unknown. This paper concludes with an assessment of legal remedies to improve riskassessment and provide marketing control.53. Eating DisordersIsolated Health Professionals Working with Isolated WomenKathryn Weaver, University of New Brunswick (kweaver@unb.ca)Daphne Kennedy, School of Graduate Studies - University of New Brunswick(d.kennedy@unb.ca)Eating disorders (EDs), the third most common chronic disease of adolescence and a leadingcause of disability in women, affect approximately 2% of men and 4.8% of women. Unaided, a130

significant number (10%) of women with an ED will die from complications. Accessing help is,however, particularly difficult for those living in rural areas and provinces including AtlanticCanada given the current healthcare climate of fiscal restraint and limited resources. Theresulting lengthy waiting times and lack of varied treatment options, when combined withprevailing public stigmatization toward those with EDs, impede help-seeking and treatmentsuccess. Although the dissatisfaction with treatment services on the part of those seeking help iswell documented in the professional literature, the voices of those who provide ED care andservices are largely silent. To address this knowledge gap, we explored the perceptions andknowledge of Atlantic Canadian allied health professionals who care for clients with ED.Analysis of qualitative semi-structured interviews with social workers, dietitians, personaltrainers, and others revealed their overall sense of feeling unprepared in decision-making. Theanalysis presented important sub-themes including isolation, lack of both experience andemployer support to gain practical educational experiences, and limited evidence-based practiceguidelines. The findings that provide insight into the needs of healthcare providers are useful toenhance existing and develop treatment and prevention initiatives.Overweight and Mental Health in Children and AdolescentsCornelia Thiels, University of Applied Sciences Bielefeld (cornelia.thiels@fh-bielefeld.de)Aim: To study associations between BMI, socio-demographic variables and mental problems inyoungsters.Method: 1057 pupils aged 10 to 17 years completed the Youth Self-Report (YSR) and the EatingDisorder Inventory for children (EDI-C). At least one parent of 874 of these pupils completed theChild Behavior Checklist (CBCL) and the Anorectic Behaviour Observation Scale (ABOS).Teachers completed the Teacher Report Form (TRF).Results: BMI-defined underweight, normal weight and overweight groups did not differ in SES,age or gender. The CBCL, TRF and YSR mean scores for overweight subjects were significantlyhigher than for underweight pupils. The lowest CBCL, YSR and TRF mean scores were foundfor participants with a normal BMI. EDI-C total scores above the >90th percentile were found in13.8% or 18.6% of overweight pupils. The same was true for 5.1% or 8.4% of normal weight and3.6% or 5.3% of underweight participants. ABOS total scores above the >90th percentile werefound in 16.0% or 17.6% of overweight and obese pupils. The same was true for 8.5% or 6.9%of normal weight and 14.3% or 15.8% of underweight youngsters.Conclusions: Overweight prevention policies are necessary because of the physical but also themental risks.How Law and Public Policy Can Impact the Childhood Obesity Epidemic in theUnited States131

Jamie Chriqui, University of Illinois at Chicago, USA (jchriqui@uic.edu)This presentation will review the public policy strategies that are being implemented acrossfederal, state and local jurisdictions in the United States to counter the childhood obesityepidemic. Specific focus will be placed on examining the associations and/or impact that suchlaws and policies are having on affecting the obesogenic environments within which children areliving as well as their association with and/or impact on BMI and related behaviors/risk factors.Specific legal/policy strategies to be discussed include laws and policies at the state, local, and/orschool district levels related to: (1) physical activity including, but not limited to, those related tophysical education and safe routes to school; (2) restricting the availability of foods andbeverages sold outside of meal programs (i.e., “competitive foods”); (3) school district wellnesspolicies; and (4) beverage and food taxes. Examples of the disparate impact of such laws andpolicies on lower income and racial/ethnic minority populations also will be discussed.The Stories of Shame and Resilience in Counsellor Trainees with Experiences ofEating DisordersHelena Dayal, University of New Brunswick School of Graduate Studies – Faculty of Education(helenadayal@gmail.com)Shame is a complex and intensely painful emotion that is accompanied by feeling trapped,powerless, worthless, and leads to withdrawing from others. Shame is associated with the onsetand maintenance of eating disorders. Does shame inhibit student counsellors with eating issuesfrom help-seeking? This research question was asked because shame is possibly a majorcontributor to concealment, acting as a barrier to help-seeking among mental health professionalswith eating issues who are entering the workforce. It is possible that individuals who aremotivated by both psychological distress and need for help but who are ashamed to overtly seekhelp are attracted to helping professions, such as counseling. Counsellors with eating issues mayexperience personal and professional difficulties including counter-transference, overidentification,and feeling overly responsible for clients as a consequence of shame. Resilience toshame can be strengthened through verbalizing events associated with shame, and engaging inmutually empathic, growth fostering relationships. Currently, there is no research that considersthe role of shame as a barrier to help-seeking, or the resilience factors that contribute toovercoming shame in student counsellors. Using narrative inquiry, counselling students withself-perceived eating issues were asked to describe the areas in their lives where theyexperienced shame, how shame influenced support and treatment seeking, and how theyovercame shame. Results from this study can be used to inform university counselling programcurricula and treatment protocol for addressing eating issues. This may help to provide greaterinsight regarding the secrecy of eating issues and the factors that contribute to resilience.132

Perspectives of Eating Disordered Clients’ about Therapeutic Alliance: AQualitative Study Using Critical Incident TechniqueKelly Humber-Kelly, University of New Brunswick School of Graduate Studies – Faculty ofEducation (khumber@umb.ca)A common belief in the research community is that a strong, collaborative working relationshipbetween the client and the counsellor, or therapeutic alliance, is a significant predictor of positivechange for the client. Therapeutic alliance is especially significant when working withstigmatized populations, such as eating disordered clients, who are hesitant to enter treatmentdue to fear of judgment, humiliation, and stigmatization. These fears associated with treatmentcreate a significant barrier which can be broken down through the establishment of an open,honest, trusting therapeutic alliance between the counsellor and client; such a relationship greatlyimproves the productivity of therapy and catalyzes the recovery process. As client perspectiveshave been shown to be more predictive of therapy outcomes than those of the counsellors, thisstudy explored the perspectives of eating disorder therapy clients to discover factors andincidents that influenced the establishment of a strong and productive therapeutic alliancebetween counsellor and stigmatized client. The perspectives of young women who had currentlyor recently received treatment for eating issues within Atlantic Canada were elicited via usingsemi-structured interviews and examined for specific incidents contributing to therapeuticalliance with their counsellor using the critical incidents method (CIT). The findings revealincidents in therapy which aid (or deter) the implementation of an effective working alliance,identify how this alliance influences patient recovery, and provide possible implications forhealth professionals working with this population.The Silent Struggle: Secret Keeping as a Covert Action within Eating Disordersand IssuesKathleen M. Pye, University of New Brunswick (kathleen.pye@unb.ca)Eating disorders and issues are a complex range of mental illnesses which have the potential toresult in significant psychological, physiological, emotional, and social harm. Those with eatingdisorders and issues may be subjected to societal shame and blame; often perceived as selfinflicted,the stigmatizing nature of eating disorders and issues result in many concealing theirillness, choosing instead to struggle in silence. Early recognition and appropriate intervention isvital to the recovery process, yet the secrecy associated with eating disorders and issues preventsdisclosure to potential social supports – including family, friends, and health professionals.Research directed at deepening understanding of the behavioural, emotional, and socialprocesses involved in secret keeping within eating disorders and issues is vital to ensure thehealth and wellbeing of those who struggle. An innovative qualitative paradigm, contextualaction theory (CAT), proposes that human actions are socially constructed and goal-oriented,133

est understood in the context of everyday experiences. By adopting this framework, secretkeeping can be understood as a covert action that is socially constructed between the secretkeeper and those within the individual’s social system. The aim of this study was to examinesecret keeping in the context of eating disorders and issues through an action theoretical lens.This presentation will outline findings from this examination; specifically, the nature of secretkeeping in the context of eating disorders/issues will be discussed.54. Education & Social HistoryWhere Mental Health Meets the Law: Rethinking the Education of AmericanLawyersJennifer Johnson, Behavioral Health Court, California, USAGeorge Woods, Morehouse School of Medicine (gwoods@georgewoodsmd.com)In May of 2012, George Woods, M.D. and Jennifer Johnson, J.D. started a continuing educationseries for lawyers in the United States. Where Mental Health Meets the Law is a comprehensivecurriculum designed to provide attorneys with tools to inform advocacy when mental health is anissue in a case. The United States Supreme Court reasoning in death penalty cases reveals adramatic evolution in thinking about the importance of understanding mental illness. Lawyersnow have a duty to vigorously investigate all aspects of a defendant’s life. According to JusticeO’Connor, understanding social history is central to the “moral inquiry into the culpability of thedefendant.” At the same time, advances in brain science are helping explain the impact oftrauma, poverty, illness and abuse on mental health. The progress in both law and science relatedto mental health is pushing the criminal justice system away from the harsh trend toward massimprisonment of people with mental illness. Many courts embrace the concept of therapeuticjurisprudence and recognize that quality mental health treatment results in enhanced publicsafety and better mental health outcomes for offenders. Although these changes have remainedlargely in the criminal courts, the concepts go beyond the realm of criminal law. Lawyers inmany practice areas encounter clients, witnesses and family members with mental illness. WhereMental Health Meets the Law is an effort to bring the principles learned on the battlefield ofcapital case litigation to a wider audience and to raise the standard of practice for Americanlawyers.Working with a Client Who Has Survived Torture: Barriers and Strategies forLawyers and Mental Health ExpertsDavid Nevin, Nevin Benjamin McKay & Bartlett, LLP, Boise, USA (dnevin@nbmlaw.com)Katherine Porterfield, Bellevue/NYU Program for Survivors of Torture, New York, USA(Portek01@med.nyu.edu)134

Terrorism cases in civilian and military courts may require defense attorneys to work with clientswho have been tortured during their detentions and interrogations, whether by the US or othergovernments. Attorneys face a number of obstacles in developing a functional legal relationshipwith these clients with a history of abuse by the government. Barriers include lack of trust andopen communication, difficulty obtaining a history of the client’s life (including torture history,given psychological symptoms of avoidance) and cultural obstacles due to the perceived oractual cultural differences. Use of a mental health expert to assess a traumatized client’s history,as well as to educate the legal team on the effects of the torture on the client’s ability to trust andperceive information accurately can be essential. In this presentation, a capital defense attorneywith 25 years of experience, including extensive work on the 9/11 cases in MilitaryCommissions in Guantanamo Bay, and a clinical psychologist who is an expert in the effects oftorture and has evaluated several terrorism defendants, will discuss the interplay between mentalhealth and legal issues. Specifically, barriers to a healthy and productive attorney/clientrelationship will be discussed that emerge from an experience of torture and trauma, and specificstrategies of communication that can be effective between lawyers and abused clients will bepresented. In addition, legal issues pertaining to torture in criminal cases, such as suppression ofstatements and mitigation will be discussed.Courtroom Bias toward Culture, Race, Religion, Maltreatment, Torture, GenderDiscrimination, and AbuseJacqueline K. Walsh, Walsh & Larranaga, Seattle, USA (jackie@jamlegal.com)Mark Larranaga, Walsh & Larranaga, Seattle, USA (mark@jamlegal.com)Many capitally charged clients have experienced bias throughout their lives. Their experiences ofbias can be because of their cultural background, race, religion, maltreatment, torture, genderdiscrimination and/or abuse. In order to appreciate your client’s life experiences, it is necessaryto learn about the events that shaped your client’s life and neurological impairments and mentaldiseases from which he or she may suffer so as to understand the lens that he or she sees theworld through. Once knowledge about your client’s limitations is learned, the legal team canwork toward educating the court, prosecuting authority and the jurors, so as to effectivelychallenge bias in the courtroom. In our presentation we will discuss how to protect your clientagainst bias in the courtroom and educate the court, prosecuting authority and jurors so as toevoke empathy for your client.International Manual for CapitalSandra L Babcock, Northwestern University (s-babcock@law.northwestern.edu)135

The Manual of Best Practices in Capital Case Representation aims to provide attorneys withlegal arguments and strategic guidance in their representation of individuals facing the deathpenalty around the world. It sets forth the best practices in the defense of capital cases based onthe experiences of advocates around the world, international human rights principles, and thejurisprudence of both national courts and international tribunals. The manual covers therepresentation of individuals facing the possible imposition of the death penalty from themoment of their arrest until their final clemency application. The manual guides advocatesthrough all stages of the case, including pretrial detention, initial and ongoing investigation,pretrial motions and negotiations, trial, sentencing, and appeals to domestic and internationalbodies.Social and Emotional Learning in an American Inner City Charter SchoolKale Woods, Mercer School of Medicine (kalewds@aol.com)Elias et al first described the quantitative success of teaching emotional and social developmentin order to achieve academic success, particularly in inner city communities (Elias et al, 1997)this quantitative success is based on the recognition that schools are social places and learning isa social process. Nevertheless, race, trauma, poverty, and mental illness test social and emotionallearning programs. This presentation will discuss the marriage and family therapy trainee’slearning experience developing social and emotional learning programs in an inner city SanFrancisco charter school. Kipp charter schools, based in San Francisco, with schools nationwide,has a history of innovative academic programs. Kipp schools also have a history of academicsuccess in communities of historically poor academic success. This presentation will discuss thedevelopmental of Kipp, San Francisco’s social and emotional learning program, starting with adiverse population of 7 th graders. This group became one of the most cohesive grades withmultiple scholarships to the best high schools in the bay area. Methodology and future directionswill also be discussed.Mentorship of a FASD Middle School African American MaleJoel McGill, Merritt Community College (joel.mcgill@gmail.com)Carl Bell, MD, discusses the epidemic of Fetal Alcohol Spectrum Disorder in the AfricanAmerican community in his treatise. Often poorly understood and under recognized, FASD mostoften has not facial features and borderline IQ, rather than mental retardation.Nevertheless, FASD can be devastating cognitively. Mathematic skills and language skills aremost often impaired, leading to academic failure.G.R.O.W. (Global Resilience Outreach Work) is a mentorship and social/emotional learningprogram developed by Angie Wang and Joel McGill to identify at risk youth in Oakland,136

California’s most needy academic settings. G.R.O.W. focused on students who were identified asbeing at risk for cognitive delay, academic impairment, isolation, and possible gang involvement.Jerome Gourdine, the Principal of Fricke Jr. High, screened students and provides Ms. Wang andMr. McGill students to mentor for one year. Ms. Wang and Mr. McGill met with the student’sparents regularly, and met with the student at least once per week. Consultation was provided bya team of neuropsychiatrists and Marriage and Family Therapists.The process of identifying cognitive deficits, recognizing the impact of these deficits in terms ofacademic, social, and practical functioning, and providing support to the student and family inworking through the often ponderous academic setting will be discussed.Options for developing a G.R.O.W. program in inner city school will also be discussed.55. The Effectiveness of Correctional Interventions with SpecialPopulationsExamining the Relative Effectiveness of a Halfway House Program forOffenders with and without Mental IllnessPaula Smith, University of Cincinnati (paula.smith@ uc.edu)Sarah M. Manchak, University of Cincinnati (manchash@ucmail.uc.edu)Most interventions for offenders with mental illness (OMIs) emphasize psychiatric servicesdelivery as a means to reduce recidivism (Skeem et al., 2011), but strong empirical evidenceundermines this model. Mental illness is a weak predictor of criminal behavior (see Andrews etal., 1990; Bonta, et al., 1998), and symptoms lead to criminal behavior in a small proportion ofcrimes (~8-10%; Junginger et al., 2006; Peterson et al.). This evidence suggests a need to revisitthe “what works” question for reducing OMIs’ recidivism. In the present study, we examine6,090 offenders across 44 correctional halfway house programs in Ohio State. We compare theeffectiveness of specific programs (e.g., substance abuse, anger management) and program-levelcharacteristics (e.g., program leadership, staff characteristics, and quality assurance) for OMIsversus non-disordered offenders, as measured by new convictions over a two year follow up.Is it Mental Health or Criminal Behavior? Examining the Differences betweenMentally Disordered and Non-Mentally Disordered YouthBrian Lovins, University of Cincinnati (lovinsbk@ucmail.uc.edu)Edward J. Latessa, University of Cincinnati (edward.latessa@uc.edu)137

In many areas, the juvenile justice system has been a safety net for community mental health.Practitioners of juvenile justice often report that youth in their care are demonstratingsignificantly more mental health symptoms than in past decades. The question is, are these youthpenetrating deep-end juvenile justice programs because they are mentally ill or is it because theyare delinquent? This presentation will explore the differences between mentally disordered youthand non-mentally ill youth who have been committed to long-term secure placements. Using chisquareand logistic regression techniques, this study will examine the differences in regards tooverall composite risk, antisocial attitudes, peers, and family. Based on the results of theseanalyses, policy and practice implications will be explored.A Comparison of Juvenile Drug Court Effective for Youth with Co-Occurring orSubstance Use Only DisordersCarrie Sullivan, University of Cincinnati (carrie.sullivan@uc.edu)Paula Smith, University of Cincinnati (paula.smith@ uc.edu)Christopher Sullivan, University of Cincinnati (sullivc6@ucmail.uc.edu)Leslie Blair, University of Cincinnati (leslie.blair@hotmail.com)Edward J. Latessa, University of Cincinnati (edward.latessa@uc.edu)Studies of the effectiveness of juvenile drug courts have yielded mixed findings. A study ofjuvenile drug courts, funded by the Office of Juvenile Justice and Delinquency Prevention, wasrecently completed in the United States. The study combined evaluations of the processes usedby nine juvenile drug courts with outcome evaluations of their respective effectiveness inreducing recidivism and/or the improvement of other important outcome measures. While theseresults generally advance our understanding of how varying drug court practices impact theeffectiveness of juvenile drug courts, this paper will present differences in findings betweenyouth with co-occurring disorders and youth with only substance use disorders to determine ifyouth with co-occurring disorders can be well served in drug courts. The possible implicationsfor drug courts and mental health courts will be explored.Separate but Equal? Understanding the Impact of Gender ResponsiveTreatment in Correctional SettingsLori Brusman-Lovins, University of Cincinnati (brusmala@ucmail.uc.edu)There is much debate in corrections about the best method for treating and managing femaleoffenders. Generalists argue that there is limited empirical evidence that the method for reducingrecidivism differs for males and females. Those in the gender specific camp argue that thepathway to criminality differs for females, thus treatment for female offenders should vary from138

that of males. This paper empirically examines program characteristics associated withrecidivism reduction for females versus males in community correctional programs. Over 25,000offenders participating in more than 100 programs are examined. Results contribute to thegender-responsive literature that helps guide effective treatment for male and female offenders.Effective Practices in Community Supervision (EPICS) for FamiliesJennifer Luther, University of Cincinnati (lutherjr@ucmail.uc.edu)Research shows that relapse prevention programs that train significant others in cognitivebehavioralapproaches are three times as effective as programs that do not. Family EPICS givesofficers a unique opportunity to build on the application of evidence-based supervision in orderto increase the success of their clients. Officers teach family members of individuals undersupervision to understand, model and support pro-social choices. In this way, communitycorrections officers bolster external support systems. Training officers in Family EPICS includesa two-day classroom workshop, followed by one-on-one field coaching with feedback andbooster trainings. The Ohio Department of Youth Services has implemented Family EPICSwithin three jurisdictions and is planning to roll out the program in two additional jurisdictionsby the end of 2012. Initial feedback from officers and families has been promising. Participantsreport greater collaboration and understanding. Community supervision now has a tool to workwith families toward more effective relapse prevention.56. The Elderly/Aged PersonsPhysical Health Monitoring in Aged Persons Mental Health Bed-Based ServicesRobyn Garlick, Melbourne Health, Australia (robyn.garlick@mh.org.au)Mental health consumers die on average up to 25 years younger than the general population.While those with serious mental illness largely die of the same conditions as the generalpopulation – cancer, heart disease, stroke, pulmonary disease, and diabetes – they develop theseconditions much earlier. Cigarette smoking, obesity, and diabetes are treatable causes of physicalillness and death among psychiatric patients, much the same as in other groups, but factors suchas diet, exercise, misuse of illicit drugs, psychotropic medications, and poor access to generalpractitioners can contribute further to this problem. Poor motivation, compliance and adherenceto treatment due to their mental illness may also play a part. The role of the psychiatric nurse isto promote health. There is a clear National and State policy expectation that physical healthmonitoring will occur but no clear legal framework. A literature review was undertaken ofcommon physical health illnesses in mental health consumers. Then incident reports, unusualevents, and near misses were reviewed for any physical health aspect. This was followed by atraining needs analysis on physical health issues of five residential and three acute units’139

clinicians within Aged Persons Mental Health. From these three areas topics were utilized todevelop an education program for clinicians. The analysis, education program and evaluation areto be presented.Metabolic Monitoring Framework in an Aged Persons Mental Health ProgramRosemary Charleston, Melbourne Health, Australia (rosemary.charleston@mh.org.au)In recent years various reports have identified issues of severe mental illness and metabolicsyndrome as emerging public health issues. It is well recognized that people with a seriousmental illness have poorer health. Obesity, diabetes, stroke and cardiovascular illnesses arecommon physical illnesses in this group and mental health consumers are twice as likely to diecompared to the general population. Primary and secondary health care workers often neglectpeople with a mental illness, compounding this issue. Medication effects, lifestyle factors,physical conditions (pre-existing or developing) and allergies, alcohol and illicit drug use andpsychosocial factors are aspects that impact on mental health consumers' physical health. Diet,smoking, alcohol use and a sedentary lifestyle are examples of these factors. Psychiatricmedication including antidepressants, antipsychotics, anxiolytics and mood stabilizers cancontribute to metabolic syndrome which involves glucose intolerance, insulin intolerance,hypotension and hyperlipidaemia. A framework of physical health screening, documentationforms and policies were developed to monitor for metabolic syndrome. The physical healthscreening included weight monitoring, waist circumference, blood pressure, fasting lipids, andfasting blood glucose. The framework and education outcomes will be further explored in thispresentation.Local Models of Right Preservations: Caring for the ElderlyLois Condie, Harvard Medical School (lois.condie@childrens.harvard.edu)Rights preservation relevant to elderly individuals is formulated in federal and state statutes,administrative policies, and institutional policies and regulations. Carrying out these statutes,policies, and regulations typical remains a local endeavor. Ancillary to these policies andregulations are the efforts of government and nongovernmental organization to help facilitate thepreservation of rights of elderly individuals. This presentation applies a previously developedorganizational system for local models of rights preservation to the needs of elderly individuals.Cross-national models and procedures are described for preserving dignity, establishingthresholds for seeking care, establishing respectful models for seeking guardianships andconservatorships, ensuring safety and security of elderly individuals, respecting cultural normsregarding individual and collective responsibilities, and preserving the individual rights ofelderly individuals in the context of caregiving organizations. Cross-cultural comparisons areoffered as examples of suitable models in light of local norms and economic conditions.140

Physical Health Monitoring in Aged Psychiatric Assessment and TreatmentTeams (Community)Robyn Garlick, Melbourne Health, Australia (robyn.garlick@mh.org.au)This paper provides an overview of recent legal reforms via the fourth and current NationalMental Health Plan (2009–2014). This plan observed that mental health and physical health wereinterdependent and recommended partnerships between mental health, physical health andprimary care services. The plan also comments on the aging population and increased mentalhealth needs in this age group. The importance of good physical health and the role of thegeneral practitioner (GP) were stressed as important, but the plan did not differentiate what theroles were and who had accountability. The Australian National Mental Health Policy for 2008–2012 includes in its vision the desire that consumers with a mental illness should be able toaccess effective and appropriate treatment and acknowledges the interplay between health andmental health, and that each has an impact on the other. Traditionally the focus of case managersin Aged Mental Health has been on coordinating mental health care with general practitionersand other mental health care providers. A significant implementation gap on physical healthmonitoring was noted, in particular to the requirement of an establishment and implementation ofeffective legal frameworks and monitoring mechanisms. This presentation examines a beginningstep of an education package for community clinicians on physical health monitoring. Thispresentation examines and seeks to provide an overview of best practices and challenges facedby clinicians addressed in the education package.Learnings from Coronial Communiques in Aged Persons Mental HealthRosemary Charleston, Melbourne Health, Australia (rosemary.charleston@mh.org.au)The Victorian Institute of Forensic Medicine (VIFM) provides specialist forensic medical andscientific services to the Coroners Court of Victoria (CCOV) to assist with their deathinvestigations. The Institute is responsible for conducting the majority of the medical aspects ofthese medico-legal death investigations. The Clinical Liaison Service (CLS) is a unique initiativeof the State Coroner's Office and the Victorian Institute of Forensic Medicine (VIFM) toimprove patient safety. Two communiqués as a result of these investigations have assisted ourAged Persons Mental Health Program to review local practices, policies and procedures and toimplement education and practices to address the issues identified. These communiqués are theChief Psychiatrist Coronial Communiques and Residential Aged Care Communiques. Under theprovisions of the Mental Health Act 1986, mental health services are required to notify the ChiefPsychiatrist of the death of any patient that is a reportable death within the meaning of theCoroner’s Act 1985. The Chief Psychiatrist reviews findings arising from any coronial inquest orinquiry into these deaths and identifies emerging themes across the service system. Coroners’141

investigations into preventable deaths in Residential Aged Care facilities have a similar process.These summaries draw together the key clinical practice and standards issues for a given periodand highlight areas for ongoing quality improvement action. Some of these findings that haveresulted in education and practice review are presented.57. Emerging Practices in Prison and Jail Re-Entry: Managing Riskand Promoting Treatment EngagementEngagement Processes in Model Programs for Prison Re-Entry for Offenderswith Serious Mental IllnessBeth Angell, Rutgers University (angell@ssw.rutgers.edu)Stacey Barrenger, University of Pennsylvania (slbarrenger@gmail.com)Amy Watson, University of Illinois, Chicago (acwatson@gmail.com)Jeffrey Draine, Temple University (jeffdraine@gmail.com)Linking offenders with mental illness to treatment following prison release is critical topreventing recidivism, but little research exists to inform efforts to engage them effectively. Thispresentation compares the engagement process in two model programs, each representing anevidence-based practice for mental health which has been adapted to the context of prison reentry.One model, Forensic Assertive Community Treatment (FACT), emphasizes a long-termwrap-around approach that seeks to maximize continuity of care by concentrating all serviceswithin one interdisciplinary team; the other, Critical Time Intervention (CTI), is a time-limitedintervention that promotes linkages to outside services and bolsters natural support systems. Tocompare engagement practices, we analyze data from two qualitative studies, each conducted ina newly developed treatment program serving prisoners with mental illness being dischargedfrom prisons to urban communities. Findings show that both programs rely upon the provision ofconcrete, tangible resources as a key method of engaging offenders, and each program providesintensive emotional support during the reentry transition. Nevertheless, FACT and CTI embodydistinct cultures and rituals of reentry, exhibited in their approaches to pre-release engagement,the transition out of prison, and the encouragement of mental health care seeking post release.Examination of the Risk Environment on Community Re-Entry from Prison forMen with Mental IllnessStacey Barrenger, University of Pennsylvania (slbarrenger@gmail.com)Jeffrey Draine, Temple University (jetpak@temple.edu)Beth Angell, Rutgers University (angell@ssw.rutgers.edu)142

Community re-entry from prison is challenging as individuals attempt to meet their basic needs.This process can be difficult for those with a mental illness, and can be further complicated by anenvironment that poses risk towards re-offending. This paper examines the role of the riskenvironment on the re-entry process for men with serious mental illnesses leaving prison. Indepthand go-along interviews were conducted with participants (N = 28) in a randomizedcontrol trial testing the effects of an evidence-based intervention, Critical Time Intervention(CTI). Data were analyzed iteratively using a constructivist grounded theory approach. Resultsindicated that punitive public and social policies limiting or excluding resources to individualsbased on their criminal history posed significant challenges for participants in acquiring basicneeds. The re-entry process was further complicated by continued entanglement with thecriminal justice system, sometimes resulting in a return to jail which disrupted progressionthrough other systems such as health care, entitlements, or work. However, those with familythat could provide concrete and emotional support were insulated from some aspects of the riskenvironment, as their reliance on public services was not as crucial to their basic survival.TITO: An Education and Empowerment Based HIV Prevention Intervention forPeople Leaving JailJeffrey Draine, Temple University (jetpak@temple.edu)Philippe Bourgois, University of Pennsylvania (bourgeois@sas.upenn.edu)Vanessa Woodworth, Temple University (vanessa.woodworth@temple.edu)Jails have been identified as a key intervention point for HIV prevention efforts, but the brieflengths of stay present unique challenges for engagement. This presentation examines a groupbased education and empowerment intervention, Teach Inside Teach Outside (TITO), that aimsto bridge the transition by providing jail in-reach coupled with out-reach post release. Thisintervention is being tested in a two arm randomized trial (TITO vs. counselling) to assesswhether TITO is more effective in encouraging follow up with the intervention after jail releasethan conventional HIV counselling. Preliminary results (n=337) from the in-reach phase showthat the TITO intervention does not show a main effect on post-jail treatment engagement; posthocanalyses show that the most important factors that predict engagement post release includehaving poorer quality of life while in jail, being older at first psychiatric hospitalization, andsocial support from family or friends while in jail. Ethnographic results illustrate the value of theintervention for vulnerable populations who tend to be difficult to engage in services apart fromlegal mandates. Further dialogue between the RCT results and ethnographic results may shedlight on interactions between the intervention and specific social, economic, and health relatedcharacteristics of participants.143

Addressing Criminogenic Risk in Treatment Programs for People with SeriousMental IllnessAmy Blank Wilson, Case Western Reserve University (abw38@case.edu)Kathleen Farkas, Case Western Reserve University (kjf@case.edu)Karen Ishler, Case Western Reserve University (kji@case.edu)Mental health services have struggled to impact criminal justice outcomes among people withmental illness with justice involvement. This struggle has led to a focus on the presence ofcriminogenic behaviors in this population, with some positing that the next generation of servicesmust integrate criminogenic interventions into mental health treatment programs. But little isknown about the nature of criminogenic risk in this population. Data from a study of a re-entryjail in-reach intervention (N=115) for individuals 18-24 with a Schizophrenia spectrum and/ormajor affective disorder and co-occurring substance use disorder were used to examine levels ofcriminal thinking and risk for recidivism. These analyses support the need to integratecriminogenic interventions into services for this population, finding high levels of criminalthinking and risk for recidivism among program participants. For example, participants had highscores on all 8 thinking styles associated with criminal cognitions as measured by the PICTS (tscore above 55), with 3 scales reaching the clinical cut-off point (t score=60). Participants werealso found to be at extremely high risk for recidivism with 86% of the sample receiving scoreson the LS/CMI that indicated high or very high risk levels in this area.58. EmploymentGeneral Protections Pursuant To Fair Work Australia - A New RemedyNada Vujat, Emery Partners, Newcastle & Cessnock, Australia (nvujat@emery.com.au)Over the past six years, Australia has experienced radical changes in industrial relations. TheFair Work Act 2009 (Cth) [FWA] establishes the current national system of industrial relationswhich applies to about 85% of Australian employers. Fair Work Australia commenced on 1 July2009 [Labor Government]. The legislation was intended to increase protections available to thelabour force which were arguably diminished pursuant to the previous WorkChoices regime[Liberal Government]. Part 3-1 of the FWA is titled “General Protections”. This paper exploresthe nature of these new remedies in detail, how the Federal Court of Australia is applying them,and the impact the introduction of such remedies has had and is likely to have upon therelationship between employers and employees.144

What Do You Mean?Monica Broome, University of Miami School of Medicine (mbroome@med.miami.edu)For communication to flow smoothly and to improve outcomes in communication, it is essentialto understand important underlying principles. There are multiple factors that influence how wecommunicate with each other, including but not limited to: nationality, ethnicity, background,class, age, race, culture, and gender. There is now extensive research from the scientific fields ofpsychology, neurology, anthropology, and sociology that show us that men and womencommunicate differently. This presentation will focus on some of the gender differences incommunication. Understanding the different ways that men and women communicate is a keyfactor in understanding what is really being said and increases the odds of getting to the heart ofthe matter. Understanding these gender differences in the workplace will also give needed insightto pre-empt conflict and improve the outcome of meetings and the overall workplaceatmosphere. Understanding these differences may also help with clients and in the courtroom toknow when further questioning is needed to clarify what was said as opposed to what was meant.Using this insight in relationships will prevent strife and decrease misunderstandings. Thispresentation will offer some of the background research and basic principles of genderdifferences in communication, and will offer practical suggestions to increase understanding andimprove conversational outcomes between men and women.Cortisol Concentrations and Workers Self-Reported Mental Health: Are TheyRelated?Alain Marchand, University of Montreal – School of Industrial Relations(alain.marchand@umontreal.ca)Pierre Durand, University of Montreal – School of Industrial Relations(pierre.durand@umontreal.ca)Sonia Lupien, University of Montreal, Montreal – Department of Psychiatry(sonia.lupien@umontreal.ca)The cortisol hormone is a biomarker of stress. One possible use of cortisol measurements inoccupational mental health is to better calibrate mental questionnaires based on subjectiveevaluation. Sound cut-points may be established to scores based on subjective evaluation. Casesand non-cases may be more reliably estimated, as well as developing sound workplacepreventive strategies to intervene on symptoms before they reach an undesired level. However,all of these assume a significant relationship between cortisol excretions and scores on mentalhealth questionnaires. This study aims to model the relationship between three self-reportedmental health outcomes (psychological distress, depression, and professional burnout) andcortisol concentrations by comparing non-working day to working day ones. Saliva sampleswere collected on 132 workers employed in 13 workplaces in Canada. Consenting workers145

provided 5 saliva samples a day (awaking, 30 minutes after awaking, 2 pm, 4 pm, bedtime)repeated 3 times (Saturday, Tuesday, Thursday) over a week. Multilevel regression models wereestimated with saliva samples at level-1, days at level-2 and workers at level-3. Controlling forgender, age, marital and parental statuses, results revealed cortisol concentrations were notsignificantly associated with psychological distress, depression, and burnout scales. Implicationsand limitations of these results are discussed.Mind the Empathy Gap: The Case for Communication Training in HealthcareKathleen A Bonvicini, Institute for Healthcare Communication, New Haven, USA(kbonvicini@healthcarecomm.org)Abundant research evidence in healthcare and medicine has informed us that the manner inwhich healthcare clinicians and teams interact with patients has significant repercussions. Thequality of the interaction has direct effects on patient satisfaction, diagnostic accuracy, patienttrust and their willingness to follow through with recommendations, informed consent,malpractice risk, and the likelihood of making a medical mistake. Of particular interest toattorneys, malpractice carriers, and risk managers is the research evidence linking poorcommunication with liability risk. The major reason behind a patient’s decision to pursuelitigation against a physician is a perceived lack of caring or empathy by the physician. This verypowerful and core skill of empathy is one most valued by patients, yet often lacking in clinicianpatientencounters. Evidence has shown that physicians frequently miss opportunities toacknowledge their patients’ expressed feelings which may lead to a reduction in trust andconfidence felt by the patient.In order to effectively address patient needs and preferences in the current healthcareenvironment, clinicians and healthcare teams require training in interviewing and communicationskills to address behavioral and social influences and incorporate patients in decision-making.The changing needs of society with a strong focus on consumerism and patient empowermenthave emphasized the need to provide clinician and team training to adapt to these changes.Communication training programs can provide insight into patients’ experiences, provide skillpractice for clinicians to effectively respond to patient symptoms, concerns, preferences andemotions, and lay a foundation of trust.Expanding Our Skills for Dealing with Difficult EncountersShakaib Rehman, Medical University of South Carolina (shakmd@hotmail.com)The medical encounter can be extremely rewarding for both patients and clinicians if it goeswell. Every clinician has their share of difficult patient encounters leading to less satisfied146

patients, more frustrated physicians, and more time consuming and less productive encounters.Research has shown that with proper training, clinicians could learn to deal with difficultencounters more effectively. Strategies to enhance participants´ repertoire for coping withpatients who are “difficult” to deal with in a busy practice will be explored practiced involvingmodified role-play, simulation exercises and feedback in this highly interactive session.Objectives:1. To discuss/practice strategies to be more effective and efficient in dealing with difficultpatient situations in a busy practice.2. To learn techniques to improve patients’ satisfaction and reduce our stressTo enhance skills in addressing the behavioral/psychological aspects of medical encounters.59. Ethical Implications of an Economic Framework for MentalHealth Care in the NetherlandsEthical Aspects of Evidence Based Guideline DevelopmentJan A. Swinkels, University of Amsterdam (j.a.swinkels@amc.uva.nl)In the development, implementation and use of evidence based guidelines, moral and ethicalissues are at stake. When forming a guideline working group, there are possible conflicts ofinterest to deal with. Can we trust guidelines, without external judgement (i.e. the AGREEinstrument) and patient involvement? To what extent is it still ethical to follow guidelines?Informed consent for treatment is necessary but depends strongly on the information given. Thereimbursement system also plays a role in implementing and following guidelines. In thispresentation, these problems will be addressed and solutions proposed in an interactive manner.Mental Health Stigma Reinforced by Government PolicyRutger Jan van der Gaag, Radboud University Nijmegen (R.vanderGaag@psy.umcn.nl)In the Netherlands, as in many other countries, the population is ageing, which implies a veryworrying growth in the costs of health care. The impact of the economical crisis led to acutemeasures to contain the explosive growth of Health Care expenses. Tripartite negotiationsbetween the Dutch Ministry of Health, patients and their insurance companies, and professionalsand service representatives led to agreements both in the general health sector in 2011 and themental health sector in 2012. These differential agreements are the consequence of a partitionthat was introduced after World War Two. The agreements focus on slowing down the growth ofexpenses to a guaranteed 2.5% per year (against up to 8% in the past five years). It was alsoagreed upon that patients should contribute more to their health care as first expenses will no147

longer be covered by Insurance Companies. But in June 2011 the government decided thatpatients with mental disorders should contribute even more for their access to services. Hugeprotests with a rally gathering up to 10,000 people followed… but only from within the sector.No politicians or intellectuals, only Medical Associations protested against this state of affairs.Unfortunately this demonstrates that stigmatization of people with mental illnesses is stillprominent in the Netherlands, and the Government enhanced this stigmatization by imposingsuch a unilateral measure – without any opposition in the general population. Luckily all medicalassociations tuned in to give their support, as did all the National Psychiatric Associationsthroughout Europe!Market Oriented Mental Health Care: Ethical DilemmasJack Dekker, VU University (jack.dekker@arkin.nl)The concept of market driven mental health care for patients with serious mental disorder hasimplications that are questionable from an ethical point of view. Market driven ethical treatmentguidelines can suggest cessation of treatment for patients after two ‘no shows’; however, patientswith serious mental disorder often need outreach treatment that continues despite long periods ofno show or lack of compliance or commitment to treatment. In this presentation, the practicalimplications of this new development will be discussed and alternatives will be proposed.Ethical Implications of the New Mental Health Legislation in the NetherlandsRemmers van Veldhuizen, Centre for Certification ACT & FACT, Groningen, Netherlands(remmersvv@hotmail.com)In 2013 the Dutch Parliament will discuss a new proposal for an “Involuntary Mental HealthCare Act”. This is an ambitious effort to manage the problem of involuntary care and treatmentin a way that is acceptable for all parties involved. The innovations in this Act intend to: givemore voice to patients and to families; facilitate stepped care & treatment and support; safeguardlegal positions and security; create a more community based MHC system and a morecomprehensible MH ACT. The aim is less involuntary care and – if needed – more acceptableinvoluntary care. This is a large difference from the former MH Act, which was focusedprimarily to involuntary admission. In this symposium some ethical aspects of this legislativeinnovation will be discussed. Important topics include respecting and restoring patients’autonomy (outpatient commitment), the facilitation of “self binding” and the concept ofreciprocity.148

Equity of Mental Health Care: Moral Implications and Future DevelopmentsChristina M. van der Feltz-Cornelis, Tilburg University (c.m.vdrfeltz@tilburguniversity.edu)In medicine, autonomy of the patient, beneficence of the physician, non-maleficence of thephysician and justice are four leading ethical principles and several Medical Associations as wellas Psychiatric Associations have published Codes of Ethics in which the physician-patientrelationship is considered to be at the heart of medical and psychiatric practice. In recentdevelopments, the patient’s perspective is taken into account more often, i.e. in Shared DecisionMaking and patient preference as leading principles in the choice mental health treatment. Theeconomic framework of mental health care should follow the principle of equity even more in atime of economic recession. If ethical decisions are taken that make it impossible to sustainmedical treatment for economic reasons, unethical injustice in the division of means wouldresult. Therefore, viability and economic sustainability have ethical implications in and ofthemselves. However, ethical decisions should also be based primarily upon sound moral valuesand their acceptability in a given cultural context. Limitation of access to mental health carebased upon economic considerations, as imposed by the government of the Netherlands due tothe economic recession, poses specific ethical challenges, as it intrudes upon the patient-doctorrelationship and the equity of division of means. Moral implications of the influence ofpharmaceutical companies and governmental policies are described and possible solutions onmicro-, meso- and macrolevels are suggested. For an ethical approach to the economy ofpsychiatry, not only should the principle of equity be followed, but allocation of money orresources should always lead toward an ethically sound destination.60. EthicsA Framework for Trustworthiness in the Medical ProfessionKatinka Morton, North Western Mental Health Program, Parkville, Australia(Katinka.Morton@mh.org.au)The importance of trust for the medical profession seems beyond question. There is a growingsociological literature examining the factors which influence levels of interpersonal andinstitutional trust in the medical profession. Trust without the guarantee of trustworthiness isassociated with risk, however. Although there is undoubtedly much trustworthy conduct withinthe medical profession, there has been little attempt to define what trustworthiness is in thiscontext. Philosophy's interest in trust and trustworthiness has been relatively recent, but there arenow a spectrum of descriptions of trust and trustworthiness. In this presentation I examine theavailable considerations of trust and trustworthiness. I argue that it is only one form oftrustworthiness that is appropriately considered for the doctor patient relationship. I define thesestandards in the doctor patient relationship, and present a Framework of Trustworthiness for the149

Medical Profession. I argue that understanding these expectations is crucial both as a normativestandard for conduct, and in considering appropriate responses to unprofessional conduct.Ethics of Psychiatric Expert Opinion in the Area of UncertaintySamuel Wolfman, Law School of Zefat Academic College (s.wolfman@wolfman-law.com)Many psychiatrists submit expert opinions testimonies in courts, regarding causality between thestress involved in a tort case and a psychiatric disease developed after stressful events. Theyeither support the plaintiff claiming cause relationship, or the defense undermining thesignificance of such stress, or claiming that different signs of the disease had been observed inthe plaintiff long before the alleged stressful event. Another area where psychiatrists submitexpert opinion is in labor law cases regarding the question of causality between stress at workand psychiatric disease developed ― allegedly ― after work or military stressful conditions. Inlight of statutory arrangement compensating such disabled, a negative psychiatric opinion mayresult in depriving such sever disabled from any financial support. This paper shall discuss theethics of psychiatrists testifying in the above cases with absolute certainty ― not only in clearcut cases but also in ambiguity and vagueness. As such testimonies may determine the financialfate of such disabled mentally ill for the rest of his/her life and as the real etiology of manypsychiatric diseases is still not fully understood, there are definite ethical questions as to suchabsolute certainty and the place for some humbleness of such experts.The Ethics of Research Involving Victims of CrimeRita Shackel, Sydney Law School – The University of Sydney (rita.shackel@sydney.edu.au)A myriad of ethical issues arise in the conduct of research that involves victims of crime,especially vulnerable victims e.g. children and victims with a disability. The risk ofretraumatisation of such victims is an ethical concern widely recognised by researchers workingin the field. This paper identifies and discusses the main ethical issues that arise in the conduct ofresearch with victims of crime, focusing particularly on especially vulnerable victims and theethical issues that specifically arise with regards to: (i) the expectations that victims have ofresearchers and the ethical responsibilities that such expectations give rise to; (ii) theexpectations of participants and duties of researchers that flow from utililising particular researchmethodologies; and (iii) the potential ethical issues and conflicts of interest that might arise whenthe line between research participation and therapeutic benefits becomes blurred. This analysisdraws on relevant published literature and includes an analysis of data obtained from victimservices websites and relevant government and other institutional protocols relating to theconduct of research involving victims of crime.150

The Role of Empathy in Legal-Psychiatric Assessments: Princess or Cinderella?Roberto Mester, Haifa University (rmester@netvision.net.il)Oren Asman, Zefat Academic CollegeMoshe Kalian, Israel Society for Forensic PsychiatryEmpathy has a well respected position in psychiatry and psychotherapy treatments. However, inthe area of psychiatric assessments for legal purposes the role of empathy is controversial. Tofurther the understanding of the sources of this controversy two issues will be presented anddiscussed: in cases of persons accused of serious crimes, the judiciary in Israel tends not toaccept psychiatric-legal assessments which have been prepared by the accused’s therapist, on theassumption that the therapist may not be objective enough. The court prefers assessments byexperts who do not have a prior professional relationship with the accused. This issue iscontroversial from the ethical point of view and the ethical aspect will be the focus of thispresentation. This subject is particularly problematic in the implementation of the Israeli Law ofDiminished Punishment (section 300/a) in cases of murder committed by persons suffering fromsevere mental disorders. The case of a mother who killed her only child will be discussed forexplanstory reasons – the discussion will be centered on the role of empathy in the preparation oflegal-psychiatric assessments assessments and the ethical issues this generates.Thick Value Concepts and The Pursuit of a 'Pure Scientific' Understanding ofPsychopathySimon Barnes, University of Manchester (simon.barnes@postgrad.manchester.ac.uk)Given the dangers to society posed by psychopathic individuals, it is unsurprising that a greatdeal of public money has been devoted to understanding psychopathy. One of the striking thingsabout psychological criteria for psychopathy is that they typically contain numerous 'thick' valueterms (broadly, evaluative terms like 'courageous' or 'cruel' whose corresponding concepts,unlike those of 'thin' terms like 'good' or 'right', have significant descriptive content). ThePsychopathy Checklist-Revised, for example, requires raters to judge the extent to which aperson exhibits 'glibness', or is 'grandiose', 'callous' or 'manipulative'. The presence of these termsraises questions about the extent to which values may be intrinsic to the concept of psychopathy,and whether they can be 'factored out' as our understanding deepens. In this paper, I consider anumber of different philosophical perspectives on the so-called 'fact-value distinction', and showhow they are relevant to research into psychopathy. I conclude that it seems unwise to pursue a'pure scientific' understanding of psychopathy.151

The Right to Health: A Brazilian Perspective on the Female Prison PopulationRenata Maria Dotta Panichi , Federal University of Health Sciences of Porto Algre(renata.dotta@uol.com.br)Helena Bins, Federal University of Health Sciences of Porto Algre (helenabins@gmail.com)José Geraldo Taborda, Federal University of Health Sciences of Porto Algre(jose@taborda.med.br)Debate on the right to health in prison populations is relatively recent in Brazil. Prisoners havehistorically been considered vulnerable populations, especially those with mental disorders andsubjected to Safety Measure, a kind of criminal commitment (CC) for people found not guilty byreason of insanity, however presumed to pose risks to society. Mentally disordered people underCC have difficulties maintaining family relationships and tend to suffer the effects of this doublestigma as well as of social exclusion, which certainly impair the health and recovery of theseindividuals. In addition, the scarcity of appropriate support to families and the negativestereotypes of mental illness, including a conviction that mental disorders are untreatable, addfurther difficulties to making these individuals rejoin society. Conversely – and paradoxically –the mere confinement of a mentally disordered person to a forensic hospital, with no access toeffective treatment, turns hospitalization essentially into a social control tool. The objective ofthe present work is to describe the results of a survey conducted with 147 women as part of across-sectional, case-control study. The study group comprised 38 patients with mental illnessadmitted to a forensic hospital in the municipality of Porto Alegre, southern Brazil (ForensicPsychiatric Institute Forense Maurício Cardoso). Finally, the work also aims to describe currentlegislation on the right to health in prison populations from the perspective of the BrazilianUnified Health System (SUS).61. The Evolution of a High-Security Forensic Hospital towardsBetter Evidence-Based Practices: Past, Present, and FutureTrends; The Experience of Institut Philippe-Pinel de Montréal40 Years of Evolution at Institut Philippe-Pinel de Montreal: Was There a Placefor Evidence-Based Practices over the Years?Renée Roy, Institut Philippe-Pinel, Montreal, Canada (renee.roy.ippm@ssss.gouv.qc.ca)Forensic institutions follow an ongoing transformation process by which they are constantlylooking to improve evidence-based clinical practices. This enhances assessment, treatment,system management and patients’ care. We will examine the clinical, legal, and organizationalaspects of this transformation process and its impact on patients and staff. Since its creation in1970, Institut Philippe-Pinel de Montréal (IPPM) has been a forensic high-security institution152

that emphasizes development and implementation of new methods for assessment and treatmentof patients presenting violent behaviors related to their mental illnesses, which are oftencomplicated by comorbid addictions. This session takes a critical look at this long-standingevolution at IPPM since its founding, in looking for better practices. Presenters will talk aboutthe past, the present and future outlooks regarding patients, staff and administration. This will bedone from clinical, legal and organizational standpoints. This paper will briefly describe thehistory of IPPM, its initial mission and most important changes over the past 40 years. Reasonsunderlying these changes over time will be addressed. The IPPM’s role in the development ofQuebec Forensic Psychiatry will be discussed as well as its role in Forensic Psychiatry ingeneral.The Transformation of Care Over Time: Organizational Perspectives andCurrent Treatment ProgramsMarion Lepage, Institut Philippe-Pinel, Montreal, Canada(marion.lepage.ippm@ssss.gouv.qc.ca)This paper will discuss organizational aspects related to current intervention and treatmentprograms. Some thoughts will be shared on the evolution of treatments over the last decades. Asin similar institutions around the world, changes have been imposed not only by new knowledge,but also by the arrival of new clienteles, new programmes and new treatments. For example,there were no female patients in IPPM until 1985. Their arrival in the Hospital was seen as apotential source of difficulties arising related to sexual activities between patients, and also to theunder or over-evaluation of women’s violence potential. We will also consider future trends,taking into account our current challenges, in an institution where security always remains a keyissue. This involves providing a safe environment for all patients, for the staff members and forthe general population. Indeed, security is sometimes put forward as a main consideration whennew policies are set. This creates turmoil in the clinical teams. It may cause resistance in theapplication of new rules. Other topics will include the assessment of quality of programmes, therecovery perspective, resistance to new politics and strategies, and new directions in thephilosophy of care. We will also consider the most efficient strategies to implement new policiesand the allies involved in the preparation of those changes. Since formal training and educationhave always occupied an important part of the institution’s mission, this topic will also becovered. The arrival of trainees in an institution by itself is a vehicle of change, questioningroutines and informal rules. Another excellent support for change is research, the results ofwhich will be better adopted by clinical teams if they are kept well informed and involved in theprocess.Clinical Practice over Time: The Maturing of Approach through 40 years ofAssessment and Treatment of Violent Patients153

Tiziana Costi, Institut Philippe-Pinel, Montreal, Canada, (tiziana.costi.ippm@ssss.gouv.qc.ca)This presentation will be dedicated most specifically to the clinical aspects: assessment andtreatment as well as rehabilitation and reintegration into society. Different topics will beaddressed in a more detailed way: assessment, in particular assessment of violent risk withspecialized and efficient tools and instruments, new types of intervention and treatment(Integrated Psychological Treatment, groups for substance abuse and comorbidity,pharmacological innovations, etc.), the adjustment and evaluation required to make sure theycorrespond to our patients’ profiles, and the implementation of new evidence-based programs.These topics will be discussed according to the implications for patients, staff and the institution,as well as the potential for networking with research.The First Forty Years of a Forensic Hospital: The Place Taken by HumanRights and How Far Can We GoLouis Letellier de St-Just, Institut Philippe-Pinel, Montreal, Canada(louis.letellier.ippm@ssss.gouv.qc.ca)This paper will be dedicated to the human rights approach related to mental health issues withina forensic environment. The promotion and protection of the human rights of mentally illoffenders remains a constant challenge. If over the last 40 years, legislation, policies, protocolsor guidelines have targeted concerns such as confidentiality, privacy, voluntary and involuntarytreatment, and seclusion and restraint, attitudes and knowledge still have to change and improve.Being the first forensic institution in the province of Quebec and one of the Canadian pioneers inthe treatment of mentally ill offenders, IPPM had to create an environment that would provide aframework for treatment and support rather than follow the punishment mentality which was thedaily bread in prisons, the source of its patients. Innovation in the approach was the mainobjective at a time when the province was going through evolving social changes. Patients areindividuals. Some, like mentally ill offenders, carry strong stigma. Comprehension as well asresistance to changes brought by a human rights approach will be part of our concerns. Underthe eye of relevant international human rights treaties, this section will notably cover theinfluence of human rights on mental health treatment, the legislation adjustments and thechanges within the judicial system.Future Transformations towards a Forensic Institute: Perspectives andChallengesLouis Letellier de St-Just, Institut Philippe-Pinel, Montreal, Canada(louis.letellier.ippm@ssss.gouv.qc.ca)Tiziana Costi, Institut Philippe-Pinel, Montreal, Canada, (tiziana.costi.ippm@ssss.gouv.qc.ca)154

Marion Lepage, Institut Philippe-Pinel, Montreal, Canada(marion.lepage.ippm@ssss.gouv.qc.ca)Renée Roy, Institut Philippe-Pinel, Montreal, Canada (renee.roy.ippm@ssss.gouv.qc.ca)Forty years ago, forensic mental health policy plans and programmes practically did not exist.Moreover, forensic psychiatry was just beginning to be organized in prisons. Different reformshave contributed to the organization of services for mental health. In the forensic psychiatryfield, we cannot deny that we have improved the access to services, to psychotropic medicationand to better treatment programmes. However, over the past few years, we must admit that wehave faced a certain slowdown in the funding of forensic psychiatry services. Challenges arewaiting for creative projects to ease the rehabilitation for our patients, notwithstanding reducedbudgets. The risk of violence that characterizes our patients’ environment also dictatesorganizational trends and professional behaviours. Still evolving in a high security environment,being recognized as a hospital and therefore promoting ethical values, we have to wonder aboutthe place we give to patient’s control, which is closely linked with the notion of security. Withthese thoughts for background, this paper will bring out the general trends of IPPM’stransformation over time and see how they are related to evidence-based best practices inforensic psychiatry, in particular the latest developments. With their respective experience andknowledge, each speaker will share his or her views on the following questions: Do we reallynowadays offer better care? Has the patients’ situation really improved? What should be ourgoals? What are the benefits of this evolution for patients and clinicians? In conclusion, futureperspectives and challenges will be discussed.62. Examining the Incidence and Consequence of the Involvement ofFemale Staff and Female Inmates in Abuse in Prison: AComparative PerspectiveUncomfortable Places, Close Spaces: Female Correctional Workers’ SexualInteractions with Men and Boys in CustodyBrenda V. Smith, American University (bvsmith@wcl.american.edu)That sexual abuse occurs within the United States correctional system is well known. With thepassage of the Prison Rape Elimination Act (PREA) and the robust data collection efforts thatU.S. Congress required as part of the Act, the contours of sexual abuse and behaviors in custodyare becoming clearer. One of the research findings was that a significant proportion of sexualabuse in custodial settings involves female correctional staff. These findings have been met withdiscomfort bordering on disbelief. Scant scholarship exists which addresses the appropriateresponse to sexual abuse by women; even less addresses sexual abuse by female correctionalworkers. Likewise, feminist jurisprudence on sexuality and desire does little to shed light on themotivations of women who engage in sexual misconduct or abuse, much less women who abuse155

men or boys in custodial settings. Overall, female sex offenders receive less harsh sanctions thanmale sex offenders, they are even less likely to be prosecuted or punished when the victim ismale and in custody.This article describes female correctional staff’s entry and experience in the corrections milieuand how gender, race, class and mass incarceration has complicated their experiences and impactin the corrections environment. Second, the article examines research on the prevalence ofsexual abuse committed by female correctional workers. Finally, the article makes concretepolicy suggestions for addressing abuse in custody by female correctional workers.Does Research on Prison Rape Fail to Address Women within the German PenalSystem?Thomas Barth, JVKB Berlin, Germany (Thomas.Barth@jvkb.berlin.de)Does research on prison rape fail to address women within the German penal system? There arevery few existing international studies that address sexual misconduct of female prisoners, andnone at all about conditions of incarcerated women within the German penal system. Some of therecent surveys on female prisoners indicate the existence of violence against women, rangingfrom sexual harassment to sexual assault. The female prison population in Germany rose by 91.2percent between 1995 and 2006. In 2011, 5.6 percent of the German prison population (68,099 intotal) were women. Thus, the number of incarcerated women at risk of sexual victimization maybe substantial. Women prisoners have a history of sexual abuse almost five times as often as thegeneral population. Nearly a fifth of all incarcerated women are convicted of drug-relatedoffences, which suggests that many of these inmates have a history of drug abuse, some of whichmay be attributable to intravenous drug use that can lead to contraction of infectious diseases likehepatitis and HIV. Additionally, a substantial percentage of incarcerated women suffer frompsychiatric illnesses and are therefore even more susceptible to a wide spectrum of sexuallyharmful behaviours ranging from harassment to assault (including strip searches) to rape.Preliminary results of a survey addressing sexuality and sexual victimization in a women’scorrectional facility in Berlin will be presented.Perceptions of Sexual Safety in US Women’s Jails and PrisonsBarbara Owen, California State University, Fresno (barbarao@csufresno.edu)James Wells, Eastern Kentucky University (James.Wells@eku.edu)This presentation describes the context of sexual violence and sexual safety in a large nationalsample of women incarcerated in US prisons and jails. An earlier study established that violencein women’s correctional facilities was markedly gendered and nested within a constellation ofoverlapping individual, relational, institutional, and societal factors. We learned that violence156

etween female inmates occurred on a continuum, ranging from verbal intimidation to homicide.Violence was most prevalent at the lower end of the continuum and quite rare at the extreme end.Based this mixed method study conducted in 2008, this second phase collected quantitative dataon the perceptions and perspectives of almost 4000 women on various dimensions of prison andjail safety. The survey was designed to address six general areas of conflict or violence: inmateeconomic conflict, inmate sexual violence, inmate physical violence, staff verbal/sexualharassment, staff sexual misconduct, and staff physical violence. Inmates were asked to ratestatements according to the perceived seriousness of the problems they personally encountered intheir current housing units. This presentation will describe the substantive findings of the surveyand provide recommendations for improving policy and practice in women’s correctionalfacilities.Exploration of Laws Regarding the Criminalization of Sexual Contact BetweenClients and Mental Health ProfessionalsJames J. Cassidy, University of New Haven (jcassidy@newhaven.edu)Fadia M. Narchet, University of New Haven (fnarchet@newhaven.edu)The purpose of the presentation is to examine the current trend in American jurisprudence tocriminalize sexual contact between clients and mental health professionals. While civil sanctionsfor sexual contact with clients has long been the subject of civil case law, a current trend isemerging where some jurisdictions are defining such contact as sexual assault. Ethicalprofessional standards often are often implicated, despite the fact that the criminal trial is not aprofessional disciplinary hearing. Issues regarding the client’s consent, the nature of thetreatment, current status of the treatment relationship and the vulnerability of the client are oftenintertwined with complex legal issues. The presentation will explore the jurisdictions that havecriminalized sexual conduct within the therapeutic context and discuss the issues andimplications associated with these emerging laws. Additionally, the authors will examine theextent that these laws exist in countries outside the United States.63. The Expert Witness as DefendantBoard and Malpractice Liability for Expert WitnessesEric Drogin, Harvard Medical School (edrogin@bidmc.harvard.edu)Expert witnesses – including those in the mental health sciences – often consider themselvesimmune to board disciplinary proceedings and malpractice suits, usually due to somecombination of local custom, statutory exemption, and traditionally favorable case law. In recentyears, however, all three of these notions have shifted perceptibly in the direction of increased157

liability exposure in many jurisdictions. This presentation will review patterns of litigation,codified rules, and appellate decisions that are continuing to transform the landscape of modernwitness practice in terms of mounting risk for expert witnesses. Is the “standard of care” anillusory notion when the role of the expert witness arguably does not involve the provision oftreatment or traditional clinical assessment services? If applicable practice definitions do notaddress forensic evaluations or courtroom testimony per se, to what extent is the purview of theboard or the court limited as a result? Attendees will learn practical tips for responding to a boardsummons or subpoena, strategies for collaborating with counsel prior to and during a hearing or atrial, and critical aspects of transitioning from the role of an expert witness in another person’scase to the role of a fact witness in one’s own case.Professional Society Peer ReviewDonald Meyer, Harvard Medical School (donald_meyer@hms.harvard.edu)Psychiatric and psychological experts are often required to testify about a respondent healthcareprofessional’s retrospective mental state and prospective fitness for duty. This calls for the expertwitness to parse the degree to which educational deficiency and mental illness were substantialcontributing factors to any alleged past misconduct, and to offer recommendations forprospective mental health treatment as well as any educational and supervisory remediation ofdiagnosed disorders or deficiencies. Unlike adjudication of malpractice – in which the goal is tomake an injured party whole by financial compensation for negligent harm – the goal of peerreview is to protect the public by serving as an overseer of the quality of the profession. In theUnited States, “peer review” has been statutorily defined as “an action or recommendation of aprofessional review body” that is “based on the competence or professional conduct of anindividual physician” in a fashion that may have a negative effect upon “clinical privileges” or“membership in a professional society.” This presentation examines the mental health expert’srole in professional society peer review, with particular attention to forensic examination,courtroom testimony, and a recent spate of appellate decisions highlighting critical differencesbetween malpractice litigation and administrative adjudication.International Perspectives on the Expert Witness as DefendantJohn Williams, Aberystwyth University (jow@aber.ac.uk)A watershed event in the history of the expert witness as defendant was ultimately precipitatedby the Sally Clark case (UK, 1999). A mother was convicted in this matter of murdering two ofher sons when the prosecution’s pediatrician expert, Sir Roy Meadows, opined that “one suddeninfant death is a tragedy, two is suspicious and three is murder, until proved otherwise.” Thiswitness had incorrectly assumed that there were no genetic or environmental factors affecting thelikelihood of “cot deaths,” and testified that there existed only a one in 73 million chance that158

two such deaths might occur in the same family. An appellate court ultimately quashed thedefendant’s murder convictions. Initially struck off the medical register when the GeneralMedical Council (GMC) concluded that he had “abused his position as a doctor,” Dr. Meadowswon a high court appeal to overturn this ban when it was determined that he had “acted in goodfaith” despite having opined in error. The effects of this series of events are reflected in adecade’s worth of statutory innovations and appellate decisions in jurisdictions throughout theworld. This presentation will provide a comparative overview of international perspectives onexpert witnesses as defendants.“Cold Case” Issues for the Expert Witness as DefendantAlan Clarke, Department of Law and Criminology, Aberystwyth (ahc@aber.ac.uk)The last two decades have witnessed an increasing shift amongst policing organizations in theUnited Kingdom and North America toward utilizing a more formal process of periodicallyreviewing their long-term unsolved cases, to establish whether any new “investigativeopportunities” might have arisen. Originally based upon somewhat ad hoc and innovativeresponses, and used for only a small number of individual cases, these “cold case” reviews haveprogressively established a more defined and coherent methodology for “fixing” the past. Theresulting technological and procedural refinements have enabled other organizations—includingprofessional licensing boards—to delve into matters that until recently would have beenconsidered decidedly low-yield options for identifying malfeasance. In particular, biologicallybased inquiries (concerning, for example, sexual transgressions) and database oriented inquiries(concerning, for example, billing and communications improprieties) have dramatically extendedthe reach of board investigations that address the activities of expert witnesses and otherprofessionals. Empirically grounded studies of the police practices used when conducting coldcase reviews of unsolved homicides illuminate key features of what is termed “retroactive socialcontrol” (RSC). This presentation will identify implications of RSC for what can arguably beconsidered the “policing” function of professional licensing boards regarding the expert witnessas defendant.The Personal and Professional Experience of the Expert Witness as DefendantThomas G. Gutheil, Harvard Medical School (gutheiltg@cs.com)Dealing with the considerable stress occasioned by being the subject of litigation requiresattention to a number of factors in order to prevent the legal process from wreaking havoc withwork, family, and physical and mental health. The core principle in this regard is to preservethose aspects of life that promote wellbeing while allowing for the disruptions that occupying therole of defendant will inevitably produce. Expert witnesses who are being sued often lose thethread of appropriate time management in several observable and preventable ways. Rather than159

filling time, the defendant’s goal should be clearing time. The three activities most likely to beaffected and disrupted by the stress of litigation are paradoxically the most essential topreserving and promoting one’s viability as a legal client: diet, sleep, and exercise. The suedexpert cannot afford to abandon vacations, hobbies, and leisure activities, friends, and familyduring the pendency of litigation. This presentation will focus upon identifying the mosteffective and clinically supportable ways for providing services to – and for persevering as – theexpert witness as defendant.64. FASD and the Law: The Need for a Targeted TherapeuticResponseThe Colliding Directions of Science and the Law in Response to FASDMansfield Mela, University of Saskatchewan (mansfield.mela@saskatoonhealthregion.ca)Fetal Alcohol Spectrum Disorder (FASD), a consequence of prenatal alcohol exposure, isemerging as a significant issue in many parts of the world. The relationship between prenatalalcohol exposure and subsequent involvement with the Law intersects across several domainsincluding antisocial behaviour, criminal activity and violent/sexual offending behaviour. Apartfrom the concerns of accused with FASD offering false confession, reliability of witnesses withFASD and inculpatory behaviour by some FASD affected persons when facing criminal chargesare a few of the interfaces that the law requires scientific methods of psychiatric inquiry to weighin. With insanity statutes and fitness standards set in the background of functional psychoticdisorders, scientific understanding is required for the accommodation of the FASD deficits in theapplication of the law. As governments begin to craft effective responses, and provide servicesto people affected by this disorder, it is prudent to examine the state of current knowledge and todo so with a particular emphasis on the unavoidable collision between medicine, and hence thescience of FASD with the sociological, legal and economic challenges, so as to support thecross-infiltration of ideas, and thereby ensure that the provision of services to persons affected byFASD is handled in a manner which is not only purposeful and supportive, but is also effectivewith the broader societal context. Advances of science can sometimes be misaligned with theevolution of law. Concepts of moral responsibility may be difficult to separate from societalvalues but when premised from scientific circles, fairness, the base tenet of the law, may result asa welcome outcome.How Criminal Courts Can More Effectively Respond to the Adult FASDOffenderLarry Anderson, Provincial Court of Alberta, Canada (larry.anderson@albertacourts.ca)160

The adult criminally accused person who is affected by Fetal Alcohol Spectrum Disorder(FASD) is in need of special responses and handling throughout the process of criminal justice.This paper considers, in the context of the current status quo, how trial judges may consider andrespond to the special circumstances of a person affected by FASD as they appear before theCourt, from the time of first appearance through to conviction and sentencing. It also suggestshow case management and a more integrated set of agency support activities may contribute tomore effective outcomes.The Trial Judge’s Perspective: Creative Sentencing and the Adult FASDOffenderPeter Ayotte, Provincial Court of Alberta, Canada (peter.ayotte@albertacourts.ca)The presence of Fetal Alcohol Spectrum Disorder (FASD) in a convicted offender presents aspecific and special challenge to the trial judge. In Canada the stated principles of sentencinginclude preservation of the rule of law, the enhancement of public safety, denunciation,deterrence, retribution, incapacitation through physical separation, rehabilitation, the promotionof individual responsibility including recognition of victims and the harm committed or resultingfrom criminal acts, and finally, reparations for the harm endured by victims. These purposes areexpressly set out in s. 718 of the Criminal Code. In addition, the dominant statutory principle inCanada is proportionality. While the enumerated principles of sentencing must be dulyconsidered, the sentence must be “proportionate to the gravity of the offence and the degree ofresponsibility of the offender”. This is prescribed by section 718.1 of the Criminal Code. Withthese principles and strictures in mind, when the offender is affected by FASD, the judge shouldconsider the offender’s ability to actually comply with the terms of the sentence. To facilitatethis, an effective sentence should involve a variety of agencies and community members, to giveassistance to the affected offender so as to promote his or her management and response to theterms of the sentence. In this way, the affected person is aided by the terms of the sentence,rather than being merely punished or worse, subjected to a set of requirements which he or shewill most likely fail to adhere to or effectively manage.The Challenges Facing Social Services and Corrections: FASD Sufferers asInmates and When Supervised by Community CorrectionsE. Sharon Brintnell, University of Alberta (sharon.brintnell@ualberta.ca)Karen Cotton, Alberta Justice & Solicitor General, Edmonton, Canada(karen.cotton@gov.ab.ca)Fetal Alcohol Spectrum Disorder (FASD) necessitates a planned, targeted and programmedresponse by corrections agencies and officials. Persons subject to the jurisdiction of corrections,161

as inmates, probationers or parolees who are affected by FASD present a variety of behavioural,cognitive and other problems, as well as a set of behaviours that absent knowledge and trainingtend to trick or confuse corrections and social services staff and officers into making assumptionsabout that person’s ability to respond to commands or control requirements, all of which requireorganized and planned programs, handling and programming. These require education andtraining of corrections personnel, and policy direction and coordination. In addition, there is aneed for interaction with the Courts, and all justice system actors, to ensure that FASD is takeninto consideration throughout the process of the administration of justice.Future Possibilities: FASD and Therapeutic JusticeNeil C. Skinner, Provincial Court of Alberta, Canada (neil.skinner@albertacourts.ca)Fetal Alcohol Spectrum Disorder (FASD) presents significant cognitive disability, and relatedand co-morbid conditions and behaviours in those persons affected by it. These, and othersymptoms and characteristics result in real and unavoidable barriers to the ability of an affectedindividual to effectively interact with the justice system (and virtually all other institutionalsettings in modern society) such that recognition and a purposeful and integrated response arewarranted. In criminal justice the normal manner (and associated governing legal principles andpractice) through which accused persons are dealt with serves to exacerbate the circumstancesfaced by an accused person affected by FASD, and for convicted offenders, particularly themanner in which those persons will respond to the Court and participate in the process. Theresult, without a new and targeted response, is inevitably problematic, for the individual and thecommunity. There is a solution however, which is founded on principles of therapeutic justice,and which is informed by a variety of established alternative court procedures, includingproblem-solving courts, therapeutic jurisprudence and non-adversarial justice.65. Fetal Alcohol Spectrum Disorders (FASD) and Criminal JusticeGrowing International Awareness of FASD in Legal SettingsKathryn Kelly, University of Washington (faslaw@u.washington.edu)People with FASD vary in terms of the severity of their physical or cognitive symptoms, but theyall exhibit poor judgment, are impulsive and lack social skills. As a result, youth and adults withFASD are very likely to end up in jail or prison, for offenses ranging from minor to the mostserious. Until recently, the majority of youth and adults with FASD went undiagnosed in thelegal system, but that is beginning to change. Several Bar associations in Canada, the US andelsewhere have passed, or are considering, policy statements regarding FASD offenders, andlegal training programs on the topic have been proliferating. These developments are discussedat length in this presentation.162

Cognitive and Social Deficits Associated with FASDNatalie Novick-Brown, University of Washington (natnovickbrown@gmail.com)FASD is a somewhat hidden disorder, and as a result most attorneys, and many mental healthexperts, will fail to recognize that they may have a client who has FASD. This presentation willspell out for attorneys and experts the physical signs, social history indicators, and psychometricscore patterns suggestive of FASD. Particular emphasis will be placed on associated neurocognitive(e.g., executive functioning) and adaptive behavior (e.g., suggestibility) deficits andhow they contribute to a diagnosis. Actual case material will be used to illustrate the roles ofdifferent professionals, and the advantages of such professionals working together as part of aninterdisciplinary team.How Lawyers Can Use FASD to Seek Lesser or Alternative SentencesWilliam J. Edwards, Los Angeles County Public Defender, Los Angeles, USA(wedwards@pubdef.lacounty.gov)A diagnosis of FASD can be critical in convincing both prosecutors and judges to considerdiverting criminal defendants from severe criminal charges or sentences. Using actual caseillustrations, this presentation will show how declarations or testimony by experts knowledgeableabout FASD can be used to put together a case for legal incompetence, for reduced criminalculpability, or for non-penal treatments, such as supervised community living placements. Thekey ingredient in such an effort is telling a story that humanizes the defendant and reframes hisor her behaviors in more sympathetic terms, as reflecting brain damage caused by exposure toalcohol in the womb.FASD as a "Common Sense Deficit Disorder"Stephen Greenspan, University of Colorado (stephen.greenspan@gmail.com)The reason why FASD is an important mitigating factor in a criminal case is because it allows anattorney to reframe offending behaviors as “dumb, not bad.” People with FASD behave in theinterpersonal realm essentially as if they have intellectual disability (ID), even when their IQ istoo high to qualify for that diagnosis. People with neuro-developmental disorders, such as bothFASD and ID, have an absence of “common sense,” defined as ability to recognize social orphysical risk. Examples from actual criminal cases are used to illustrate this point. Just as somecivil agencies provide a “brain damage waiver” allowing people with FASD to access163

developmental disability services regardless of full-scale IQ, courts should provide the sameprotections to people with FASD that they currently provide to offenders who qualify asintellectually disabled.66. Fetal Alcohol Spectrum Disorder in Modern Society: ADisability with a DifferenceWhat is FASD: How is it Diagnosed and Assessed?Monty Nelson, University of Alberta (montyn@telus.net)The features and biophysical, psychological and neurological characteristics of Fetal AlcoholSpectrum Disorder (FASD) are the subject of this presentation. The structure of the 2005Canadian Guidelines for Diagnosis (based on initial guidelines from the United States) will bepresented, with a particular emphasis on the cognitive assessment and features of Adults withFASD. Although some of the facial and medical features may or may not be present, thecognitive symptoms of FASD may be the most significant in the person’s life. While thediagnostic process includes verification of prenatal alcohol exposure, post natal risk factors, anda medical evaluation of the individual’s facial features and growth, the neuropsychologicalevaluation is often the lengthiest part of the assessment. A review of the neuropsychologicalassessment process will be provided, as well as a discussion regarding typical suggestions forintervention in the adult population.FASD in the Life of a Patient: FASD and Primary Health CareHasu Rajani, University of Alberta (hrajani@ualberta.ca)Fetal Alcohol Spectrum Disorder (FASD) affects the patient across his or her lifespan. Thepresentation usually varies with age and is related to alcohol being a risk factor for birth defects,behavioural disorders, and learning disorders. The individuals have issues related to mentalhealth, addiction, employment and housing. There is a high correlation between FASD diagnosisand risk of interaction with the justice system. These effects of FASD on the individual present avariety of, and as the person ages, a changing set of challenges for the health care provider andfor supporting agencies and literally all public bodies, which the FASD patient will or mayinteract with throughout their lives. This paper considers the manner in which a primary healthcare network may effectively handle patients who are affected by the disorder, and whyinnovative responses are not only desirable but also necessary.164

FASD Prevention, Education and ResponseTheresa O’Riordan, N.W. Central Alberta FASD Network, Edmonton, Canada(toriordan@fasdnetworknwc.ca)Fetal Alcohol Spectrum Disorder (FASD) requires significant and targeted public informationand educational resources and campaigns as a core mechanism for prevention of this tragicdebilitating condition. Among essentially all forms of biophysical disability and mental disorder(with the exception of substance abuse as defined in DSM-IV), FASD is entirely preventable.FASD is also unique in that it is irreversible and non-responsive to curative treatment or therapy.When these features of FASD are coupled with its incidence and prevalence, the need forpreventative education is undeniable. This paper examines strategies for effective education andan integrated approach to prevention. As one example, the Canadian Prevention Frameworkdescribes four levels of FASD prevention: (1) raising awareness for the whole population; (2)discussing alcohol use with all girls and women of childbearing age; (3) reaching and providingspecialized care and support to girls and women who use alcohol during pregnancy; and, (4)supporting new mothers with alcohol problems.The Economic Burden of FASD to the Legal, Health, Education and SocialSystemsEgon Jonsson, Alberta Institute of Health Economics, Edmonton, Canada (ejonsson@ihe.ca)Fetal alcohol spectrum disorder (FASD) refers to a range of physical, cognitive and behavioralimpairments caused by prenatal exposure to alcohol. The brain trauma caused by alcohol to thedeveloping fetus is irreparable, lifelong, and devastating for the individual, the family, and othercaregivers. In Canada, one out of every one hundred newborns is affected by fetal alcoholspectrum disorder. An individual with FASD is also at high risk for a number of secondarydisabilities and negative outcomes, including homelessness, alcohol and drug abuse, infectiousdiseases (such as HIV, hepatitis C and tuberculosis), unemployment, mental illness, dropping outof school, family and placement breakdown, and involvement with the criminal justice system. Amajority (60%) of individuals affected by FASD come into conflict with the Law. FASD alsocomes with significant costs to society for health, social, educational, justice and correctionalservices. Most individuals with FASD require extensive support throughout their lives for socialassistance, special education, health care, and other services. The annual total cost of FASD inthe province of Alberta is conservatively estimated at $575 million. The cost of FASD in Canadais estimated to be $7.6 billion in 2009 dollars.165

Policy Framework for a Multilateral Response to FASD: The Alberta 10 YearPlanKurt Sandstrom, Alberta Justice and Attorney General, Edmonton, Canada(kurt.sandstrom@gov.ab.ca)Over 23,000 Albertans have Fetal Alcohol Spectrum Disorder (FASD). The social and economicimpacts of the disorder directly or indirectly touch every citizen. FASD has a devastating andlife-long impact on individuals and communities across the province. Drinking alcohol duringpregnancy can cause irreversible brain damage to an unborn child. Those with the disorder oftenneed support throughout their life coping with challenges associated with health and mentalhealth problems, addictions issues, learning difficulties, and involvement in the justice system.The incidence and prevalence of Fetal Alcohol Spectrum Disorder (FASD) among the Albertapopulation necessitated a planned and integrated cross-Ministry response by the Government ofAlberta. This presentation reviews the development of the Alberta 10-year FASD Plan and itsimplementation to date. The strategic plan was designed as a direction-setting document toprovide a broad framework for the coordination, planning and delivery of relevant FASDservices across Alberta. Development of the plan engaged community partners and federalgovernment agencies responsible for FASD initiatives.67. Forensic (Adolescent) Psychiatry, Criminal Responsibility andTreatment ProceduresThe Relationship between Neuropsychological Functioning and PsychiatricDisorders in ChildrenEllemieke Nederlof, Puttershoek, Netherlands (enederlof@psydrechtsteden.nl)Annemarie van der Ham, Tilburg University (avdrham@gmail.com)Over the last decades, increasing evidence has emerged suggesting that psychiatric disorders arenot only associated with genetic, environmental and personality factors but are also stronglyrelated to neuropsychological functioning. Certain profiles of cognitive functioning andimpairments appear to both predispose the development of psychiatric disorders and affect theircourse. The research on this subject has predominantly focused on ADHD, disruptive behaviordisorders, autistiform disorders, bipolar disorders and schizophrenia, corroborating theirassociation with certain neuropsychological dysfunctions. However, their specific role, as well astheir relation with other psychiatric symptoms, have remained largely unclear. In addition, littleis known about the effectiveness of treatment or training of these neuropsychologicaldysfunctions. In spring 2012, a longitudinal study was launched to explore the relation betweencertain profiles of neuropsychological functioning and the development and course of psychiatric166

symptoms, and investigate the effects of neuropsychological training. All children between 6 and18 years who were referred to an ambulatory care setting for psychiatric treatment were assessedboth psychiatrically and neuropsychologically. Psychiatric symptoms, intellectual functioning,attention, inhibition, visual and verbal memory, planning, processing speed, verbal reasoning,abstract reasoning, cognitive flexibility and coordination were measured. Participating childrenwill be followed up to age 25. In the present article, results of the first year of the study will bediscussed.DBT in an Outpatient Forensic Setting: Report of a Pilot StudyLouise M.C. van den Bosch, Consulting Psychologist, Deventer/Leiden, Netherlands(wiesvdbosch@concepts.nl)The literature of the last twenty years shows that cluster B personality disorders, and especiallyborderline personality disorder (BPD), have become a population of interest for researchers andclinicians. The development of evidence based treatment programs has resulted in a lessnegativistic attitude towards treatment of these patients even when they suffer from comorbidproblems like substance abuse (van den Bosch & Verheul, 2007). Unfortunately it seems that thispositive development has not extended to forensic borderline patients. Over the last 15 yearsonly 1 study could be found that focused on effectiveness of treatment of BPD patients inforensic settings (Bernstein and Arntz, 2009). Forensic borderline patients seem to be consideredas a specific subtype of borderline personality disorder. Sociodemographic data, process data andtreatment data of borderline patients from an outpatient general psychiatric program, anoutpatient substance abuse program and outpatient forensic psychiatry were compared. Resultswill be shown. The conclusion of expanding evidence based treatment programs to all borderlinepatients, including forensic psychiatric patients, seems justified.Intellectual and Neurocognitive Functioning in Relation to the Development andCourse of Delinquent Behavior: Results from the Pittsburgh Youth StudyAnnemarie van der Ham, Tilburg University (avdrham@gmail.com)Ellemieke Nederlof, Puttershoek, Netherlands (enederlof@psydrechtsteden.nl)Karel Oei, Tilburg University (t.i.oei@tilburguniversity.edu)In her influential theory of offending, Moffitt (1993) differentiates between life-course persistentand adolescence-limited offenders, which she proposes each have a unique etiology and course.The origin of the life-course persistent trajectory of offending is believed to lie in the interactionbetween a child’s dispositional liabilities, in particular innate or acquired neuropsychological andneurological deficits, and a disadvantaged developmental environment. Adolescence-limitedoffending, on the other hand, appears to emerge in otherwise healthy, normally developing167

individuals and is considered virtually normative. A third, low-level chronic trajectory ofoffending was more recently identified (Moffitt, 2002). Its antecedents and correlates haveremained understudied, yet preliminary findings suggest that this group may also becharacterized by neuropsychological impairments (Raine et al., 2005). Using data from thelongitudinal Pittsburgh Youth Study, the present study examined the differentialneuropsychological correlates and antecedents of the life-course persistent, adolescence-limitedand low-level chronic trajectories of offending. Measures of verbal and spatial IQ, verbal andvisuo-spatial memory, verbal fluency, cognitive flexibility and sustained attention and clinicalsymptoms of inattention and impulsivity were collected and compared between groups.Significant group effects were demonstrated, independent of the potential confoundinginfluences of ethnicity, substance use, head injury and psychosocial adversity. Both the lifecoursepersistent and low-level chronic groups of offenders showed intellectual andneurocognitive impairments when compared to the adolescence-limited group of offenders and anon-delinquent control group. Differences were most apparent on verbal IQ, sustained attentionand impulsivity indices.The Psyche of Women who Commit Neonaticide: A Psychological Study ofWomen Who Kill Their Newborn ChildrenK.J. de Wijs-Heijlaerts, Netherlands Institute for Forensic Psychiatry and Psychology(k.de.wijs@dji.minjus.nl)Neonaticide occurs when a biological mother takes the life of a newborn child within 24 hours ofits birth. It has been practised in all eras and in all cultures, mostly either because of harsh livingconditions, such as poverty and scarcity of food, or in order to dispose of unwanted (deformed,illegitimate or female) newborns. In this day and age neonaticide is committed by relativelyyoung, somewhat emotionally childish women and is characterized by keeping the pregnancyhidden from the environment for fear of discovery, and after delivering the child taking its lifeeither actively or passively. The mother then continues with everyday life. In a time whencontraceptives and abortion are available, such a crime provokes not only revulsion andindignation in society, but also calls forth incomprehension and raises many questions about thepersonality of the culprit, her background, her environment, a possible motive and whether thesekind of cases can be prevented. In this study we researched the existing literature on neonaticideand made an overview of the most important findings in order to answer the aforementionedquestions. Limitations in the current literature are discussed and new research topics areproposed.Criminal Responsibility and “Legal Self” ApproachGerben van de Kraats, Consulting Psychiatrist, Utrecht, Netherlands (gbvdkraats@ziggo.nl)Karel Oei, Tilburg University (t.i.oei@tilburguniversity.edu)168

Gerben Meynen, Tilburg University (g.meynen@uvt.nl)The question of how criminal responsibility should be understood and implemented in forensicpsychiatric assessment is still unanswered. What capacities must agents possess in order to becandidates for moral or legal responsibility? Is free will relevant with respect to criminalresponsibility? Juth and Lorentzon (2010) proposed to replace the concept of free will with theconcept of autonomy and conceived the assessment of criminal responsibility in terms ofdecision-making processes. Hirstein and Sifferd (2010) argue that these processes are directed atprefrontal executive functions and call the set of executive processes “the legal self”. In thispresentation we discuss this “legal self” approach to criminal responsibility. What defines the“legal self”, and is this legal self concept of help in answering the question of criminalresponsibility in the practice of forensic psychiatric assessments? By presenting some casereports in which legal principles are implicitly directed at the executive processing capacities ofagents, we try to evaluate the clinical applicability of this “legal self” approach.68. Forensic PsychiatryChallenging DischargesJohn L. Young, Yale University (johnlmyoung@msn.com)Forensic inpatients do not necessarily share in the trend towards decreasing lengths of stayexperienced in civil mental hospital settings. The purpose of this presentation is to reflect onexperiences gained through focused efforts (some of them successful) to transfer patients from amaximum secure setting they no longer require. The obstacles to discharge are readilyunderstandable. Aside from legal requirements, they include difficult medical problems,challenging mental disorders, and imposing physical size and strength. Not uncommonly atransfer is arranged only to fail within a day or two, confirming the conviction that the patientcannot be discharged. Outside institutions play a crucial role; several organizations must beinvolved simultaneously. Long and frequent meetings cannot be avoided and it may be necessaryto revise plans midway more than once. Measures that can overcome these obstacles includeadministrative support and a critical mass of treating staff members willing to challenge somestrong socio-cultural influences. A great deal of patience is required to engage sufficientwillingness to repeat incrementally small steps in order to challenge prevailing assumptions.Creativity can help to support a gradual wearing away of physical and mental barriers. Therewards of success are immense for all concerned.The Applicability of Neurofeedback in Forensic PsychotherapyRon van Outsem, Bouman GGZ, Netherlands (ronvanoutsem@casema.nl)169

In this presentation, possibilities for the incorporation of neurofeedback into the repertoire offorensic psychotherapy are explored. After a brief description of the method, an overview of theempirical evidence of its efficacy in specific areas of treatment is presented. This evidence isthen translated into possible applications of neurofeedback in various areas of offender treatmentincluding domestic violence, various other forms of violent and anti-social behavior, certainforms of sexually abusive behavior, and criminal behavior of an obsessive compulsive nature. Itis stressed in this presentation that neurofeedback is still a relatively new subject of empiricalresearch in most areas of treatment. To date, robust evidence of its efficacy exists only for thetreatment of Attention-Deficit/Hyperactivity Disorder (ADHD) and Substance Use Disorder(SUD).The Optimation in the Process of Getting Privileges During Therapy in ForensicPsychiatryChristina Maass, University of Rostock (christina.maass@uni-ulm.de)Kristina Wedler, University of Rostock (wedlerkr@med.uni-rostock.de)Relapse prevention through rehabilitation is one of the central tasks of treatment in forensicpsychiatric hospitals. To practically prepare for the release of patients and their reintegration intosociety, graduated stages of liberalisation are allowed during the process of therapy. A positiveprognosis therefore presents the essential condition of receiving such parole. The aim of thisstudy (granted by the Ministry of Social Affairs Mecklenburg-Western Pomeranian) at theHospital for Forensic Psychiatry in Rostock was to optimise the existing decision base for thegranting of liberalisations during treatment in a forensic psychiatric hospital. Moreover, theplacing of liberalisations should be arranged in a more effective and time saving way. Based on adetailed literature analysis, suitable prognostic tools were highlighted. In addition, on the basis ofan employee survey, strengths, weaknesses and chances of the currently used checklist wererevealed. Every employee who was involved in the therapeutic process of a patient had to fill outthis checklist. The optimised and renewed checklist is compared to the “old” one with regard toeffectiveness, time saving and the appearance of incidents during times of paroles, and thesecomparisons are discussed. The findings of a final employee survey regarding the practicabilityof the new checklist will also be presented.Murders as the First Criminal Episode for Schizophrenic Patients in Japan'sNew Forensic Psychiatric Service under the Medical Treatment and SupervisionActShingo Yoshioka, Higashi Owari National Hospital, Nagoya, Japan(yoshisn@eowari.hosp.go.jp)170

In Japan a new forensic psychiatric service was established under the Medical Treatment andSupervision Act in 2005. This service covers only serious criminals such as murderers or rapistswho have no or diminished criminal responsibility due to their severe psychiatric illness. Ourhospital has a special unit and specially designed therapeutic programs for their rehabilitation.We treated 101 inpatients under the system from Dec. 2005 to Jul. 2010. 85% of them are have amajor diagnisis of schizophrenia, and 20% are confined for murder. Twelve cases of murderinvolved patients diagnosed with schizophrenia, for five of whom the homicide was their firstcriminal episode. Two of the five had received no psychiatric treatment at all prior to theiroffence, while two others experienced sudden relapses on the day of the offence leading to themurders. These patients have adhered to outpatient treatment plans and maintined fairconditions.We will report on their psychopathology.The Peculiarities of a Psychiatric Inpatient Unit in a General Forensic Hospitalin the State of Sao PauloCamille Chianca Rodrigues, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil(Camille_chianca@yahoo.com.uk)Quirino Cordeiro Jr, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil(qcordeiro@yahoo.com))Anne K. Maia, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil (annekmaia@yahoo.fr)Lilian Caldas Ribeiro Ratto, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil(lilian.ratto@gmail.com)Jacqueline Hatsuko Tamashiro, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil(jhatsu@gmail.com)Natalia Timerman, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil(natimerman@hotmail.com)Edineia Zanuto, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil(edizanuto@uol.com.br)This presentation will describe a psychiatric inpatient service in a general forensic hospital,managed by Santa Casa for 3 years. It is a general hospital that provides care for the penitentiarypopulation in Sao Paulo State (around 180,000 individuals). There are 8 psychiatric beds,although the number of inpatients is often over the limit. The criteria for admission are divided inthree main categories: acute psychiatric illness; being at risk of hurting him/herself or others;impossibility of staying in the original prison unit. The conditions are: to present a severe mentalillness such as a psychotic episode or depression, with or without withdrawal syndrome; and alsoside effects due to psychotropic medications. The life risk is evaluated in those at high risk ofsuicide, self-harm, hetero aggressivity or victimization. In the second semester of 2009 737outpatients were booked for consultations, but only 520 were evaluated; among those, 22 becameinpatients. In 2010, there were 1642 consults booked, 1077 were evaluated and 66 became171

inpatients. In 2011, there were 1550 consults booked; 930 were evaluated and 56 becameinpatient. In the first 4 months of 2012, 451 were booked, 294 were evaluated and 32 becameinpatients.Multi-Disciplinary Teams’ Perceptions of the Effectiveness of BreakawayTrainingRichard Mottershead, University of Chester (r.mottershead@chester.ac.uk)Philip J. De Prez, Glyndwr University (p.drez@glyndwr.ac.uk)Introduction: Breakaway training is a 30 year old mandatory training programme for themanagement of violence and aggression (NICE, 2006) and is defined as ‘a set of skills to helpseparate or breakaway from an aggressor in a safe manner’ (p.7)’. It was originally created forthe prison service but was adapted and has become widespread within independent and NHSmental health services (Rogers, 2007). Whilst previous research has focused on the quantitativeelements of Breakaway training (Rogers, 2006, Dickens et al 2009, Mott et al 2009) there hasbeen little coverage of the more focused views of those at the centre of the training: ‘the staff’.Aims: To ascertain staff views and opinions on whether Breakaway training is fit for purpose. Todiscover whether breakaway training has been effective for participants in previouslyencountered challenging incidences. To explore whether the various individual practitionerswithin the multi-disciplinary team have similar or varying experiences and views of Breakawaytraining and to identify from the views of the participants any areas in their experience whereimprovements in training could be made. Method: Themes that appeared to be paramountfollowing the semi-structured interviews were analysed using grounded theory and were used toassess the perceived effectiveness of the Breakaway training experience by the participants.69. The Future Direction of Forensic and Criminal Justice MentalHealth ServicesImproving Prison Healthcare ServicesAndrew Forrester, South London & Maudsley NHS Foundation Trust, King’s College, London,UK (andrew.forrester1@nhs.net)Over the last 15 years, there has been considerable development and change within prisonhealthcare delivery in England and Wales. The principle of equivalence has been used as a guideto enable much of this change and has been adopted as an underlying theme in a range of policydocuments that have assisted in setting the overall strategic vision. Partly as a consequence of172

this, prison mental health in-reach teams were introduced across the prison estate, aiming toprovide the same services inside prisons as are also provided in the community. The policybackground is discussed and local prison research is presented to demonstrate the process ofchange. The composition and effectiveness of the resulting services is described, includingevidence confirming high levels of unmet need and clinical complexity, with a recurrent findingthat many people access mental health services for the first time through criminal justice systemcontacts.Prisoners Have a Right to HealthTim Exworthy, St Andrew’s Healthcare, King’s College, London, UK (tim.exworthy@kcl.ac.uk)The “right to health” is an important international principle that applies to all, however prisonersin many countries are known to receive sub-standard services. The concept of equivalence hasbeen used to guide service development in England and Wales and as a result there have beenclear and well described improvements. However, there is increasing recognition that thelimitations of equivalence may now have been reached and that the introduction of a newframework would be timely. One such framework, the AAAQ framework (i.e. available,accessible, acceptable and good quality) is described and its international transformativepotential is discussed.An Evaluation of Mental Health Provision to a Local Court in South LondonChiara Samele, King’s College London (informedthinking@gmail.com)Although there have been considerable improvements in prison healthcare arrangements inEngland and Wales in recent years, service provision across the other limbs of the criminaljustice system has lagged behind. Lord Bradley’s review of people with mental health problemsor learning disabilities in the criminal justice system (Department of Health, 2009) outlined someof the current difficulties and made wide-ranging recommendations for change. In South EastLondon, many changes have taken place within criminal justice mental health services sincethen, and one particular case example, at a busy urban local Magistrates’ Court, is presented.Service design and activities are described, and a newly introduced partnership with a voluntarysector provider is discussed. The AAAQ framework (i.e. available, accessible, acceptable andgood quality) is also used to describe service progression.What is the Price of Quality in Criminal Justice Mental Health?173

Ann Biddle, South London & Maudsley NHS Foundation Trust, London, UK(ann.biddle@slam.nhs.uk)It is well established that individuals in the criminal justice system present with a wider range ofunmet healthcare needs than the general population. In England and Wales, some have called forincreases in funding to make up the short-fall, while others have called for services to berebalanced in order to allow existing funding resources to be reallocated. In times of relativefinancial austerity and economic downturn, it is increasingly naive to think that money will bespent on offender health simply because it is the ‘right thing to do’. Instead, the future is likely tobe one in which service evolution proceeds through a marrying of research ideas and businessapproaches. Services that are likely to succeed best are those that will be able to demonstrateclear outcomes that are of benefit to both society and the individual, including health economicsbenefits. Evidence for the longer term effectiveness of financial outcomes within servicemanagement is presented.Ensuring Quality Healthcare Service Delivery within a Crowded and RapidlyChanging Macro-EnvironmentJill Lockett, South London & Maudsley NHS Foundation Trust, London, UK(Jill.lockett@slam.nhs.uk)In England and Wales, the national health service contains two main sections - primary care (themain point of entry into healthcare for most individuals, through General Practitioners) andsecondary care (after an onward referral is made by a primary care professional). Primary CareTrusts (PCTs) have played a central role in delivering primary care services and have alsocommissioned the vast bulk of secondary care services. The 151 PCTs control the majority of thebudget of the NHS. However, the macro-environment is rapidly changing (economically, legallyand politically), with the introduction of Foundation Hospitals and Academic Health SciencesCentres, the new concept of ‘any willing provider’ and a move towards protocol based medicineand bench-marked practice. Tendering is likely to play an increasingly important part in thefuture and the implications for existing forensic services (including medium and low secureservices) and for criminal justice mental health, as an emerging area, is discussed.70. Hate CrimesNormalising Racism: Insights from a Mixed Methods Study of Muslims inIrelandAmanda Haynes, University of LimerickJames Carr, University of Limerick174

T.B.E.*Hostility, Prejudice, Bigotry, Hate: What Exactly is a ‘Hate Crime’?Jennifer Schweppe, University of Limerick (Jennifer.schweppe@ul.ie)‘Hate crimes’ is the term used to describe crimes committed out of an underlying prejudice onthe part of the offender against the victim’s social group. However, while there is a generalacceptance of the term in the literature, and we instinctively understand what it means, thequestion as to what exactly is being punished is unclear. This paper will examine exactly what isbeing prosecuted in ‘hate crimes’, seeking to understand what hostility, prejudice, bigotry andhate mean from a psychological perspective. It will go on to assess what the legal understandingof the terms is, and how the terms have been interpreted by the courts.Title T.B.A.Mark Walters, University of SussexT.B.E.*71. Healing Inhuman Trauma: Obstacles, Successes and New Toolsto Create Civil SocietyTrans-Generational Aspects of Trauma: A family issueGabriel Diaconu, McGill Group for Suicide Studies, Bucharest, Roumania(gabriel.diaconu@douglas.mcgill.ca)Thomas Wenzel, Consulting Psychiatrist, Vienna, Austria (drthomaswenzel@web.de)One confusing aspect in the actual conceptualization of Post-Traumatic Stress Disorder (PTSD)is that it is an individual illness. That is, a person develops PTSD in reaction to events to whichthe person experiences helplessness and terror, and later well-characterized symptoms appear,such as reliving nightmares, avoidant behavior, persistent neurovegetative activation, etc.Converse to individual symptoms, we may expect PTSD to manifest itself at the group level –should the event concern communities that suffer extraordinary situations, such as war traumaand displacement. The Universities of Vienna, McGill, Pristina, and Kosovo, along with the175

Karolinska Institute, under the UNICEF banner and with the help of the Kosovar InternalMinistry have mounted a collaborative effort to establish PTSD salience at the group level withinrepatriated children and their families. Mental health of children (n = 164) and their primarycaregivers (n = 131) were ascertained by extensive interviews and standardized questionnaires.PTSD caseness was found in 29% of children under the age 14, and in 30.4% of those above age14 – almost every third child. More severe PTSD caseness was present in at least one of theparents 64.5% of the time – almost 2 out of 3. Parent PTSD was 7-fold more prevalent in caseswhere the child met criteria for Post-Traumatic Stress. We suggest that family PTSD mayconstitute a risk factor for PTSD in offspring, independent of major depressive disorder – butcontingent on continuous exposure to traumatic triggers such as displacement – and that furtherresearch is needed.Reflection of Legal and Social Consequences on Mental Health Condition ofVictims of Ethnic Cleansing in GeorgiaMariam Jishkariani, RCT/EMPATHY, Tbilisi, Georgia (centre@empathy.ge)The main goal of this study was to evaluate the effectiveness of interventions in cases of victimsof ethnic cleansing in Georgia, using multi-profile medical file and several PTSD-focusedpsychological inventories. Based on observations in 2011, n = 413 victims were observed.Among them, 302 experienced traumas of ethnic cleansing and torture during war conflicts inChechnya and in occupied territories of Georgia. Data analysis revealed 266 cases of physicaldisturbances were observed together with psychological problems (88 % of 302). Althoughmulti-profile treatment and rehabilitation were provided, legal redress was not achieved. In allcases, mental problems have wavelike dynamics with tendencies for chronic changes inpersonality. Correlations between trauma and stress-related disorders have been observed inmany clinical studies, but studies on the reflection of legal redress on the dynamics of stressrelateddisorders were lacking. We conclude that legal redress is a significant and importantfactor for full recovery. Consequently, legal assistance should be considered an integral part ofpsychological rehabilitation. Research should address comparative study between those personswho have suffered war crimes, crimes against humanity and human rights violations who didreceive legal redress and those who still have not had legal validation of their suffering.Media Interventions to Correct Wrongs and Facilitate ReconciliationMarten W. deVries, Maastricht University (m.devries@maastrichtuniversity.nl)The goal of this contribution is to highlight media processes and products to heal trauma and tostruggle against torture, social inequality and man-made disasters. A dynamic, sometimesdelicate, interrelationship exists between broadcast and social media and the human mind andcommunity life. Media is one cornerstone of modern life that has evolved and actualized its176

potential as an essential, major innovative tool to help respond to trauma, improve well being,and correct wrongs in populations. Broad reach and interactivity of conventional and new modesprovide immediate awareness of social injustice; with synergy to galvanize political action andthe will to change policy. A media interest group/partnership develops ‘meaning’ in the processof dealing with shared trauma, and creates fresh opportunities (“opens space”), so vital incorrecting wrongs related to social violence and torture. Interactions between those whoexperience the trauma, concerned citizens, scientists, and mental health and communicationsprofessionals shape the media intervention. Survivors are active co-producers, not passive“objects" of the message. Embedding media in diverse communities improves accuracy,validates participants, and, thereby, accelerates and enlarges critical information exchanges thatcan alter attitudes and improve behavior. Strong alliance with truth and commitment to civilsociety are essential for healing. Around the globe, grass roots and broadcast organizationsemploy social media, news, entertainment, talk and drama/soap formats to forge reconciliation,confront evil and facilitate social cohesion. Examples to illustrate media’s role to improve coexistenceafter ethnic violence and trauma in Rwanda and Kenya include the dramatized docusoap/webapproach. These range from broadcasting prime time to mobile units and discussiongroups in rural areas.How do you Know When It’s Torture?Barry H. Roth, Harvard Medical School (broth@bidmc.harvard.edu)The forensic psychiatric expert’s assessment of torture survivors who manifest PosttraumaticStress Disorder and apply for refugee asylum is a paradigmatic example of the interface ofpsychiatry and the law. While it is necessary to acknowledge the utility of current dominant andwell-established protocols, it is also imperative to note and correct their failures and limitations.This paper illustrates a model which simultaneously comprehends and designates the negativedimensions of the humanitarian catastrophe of torture and brings forth monumental and profoundpositive strengths of character which sustain survivors. Cases drawn from two decades ofevaluations of torture demonstrate this innovative update of mainstream medical-scientificpractice. A reproducible and easily communicated heuristic model respects clinical variables andreports the interactivity of individual psychological factors with the cultural/political nexus. Aconsistent pattern emerged from review of country reports, survivor affidavits, interviews andforensic reports and testimony to the court. Ordinary means led to extraordinary findings whichmade it possible to incorporate and supersede previous paradigms that have defined torture andnarrowly designated psychological ability to respond due to an illness-based mentality. Torture isa crime of specific intent – to deconstruct and shatter the human connections of their subjects.Survivors had the force of human ties to sustain them. Necessary and legitimate methods achievevalid examination and forensic reporting. Professionals have the force to do right – verifiableobjective means nurture justice and social progress.72. Historicizing Mental Health Law and Policy in Japan177

Mental Health Services in Japan: A Historical OverviewYoji Nakatani, University of Tsukuba (yojinaka47@yahoo.co.jp)Junko Koike, Jichi Medical University (koike@jichi.ac.jp)This paper will illustrate the development of mental health services in modern Japan, dividing itinto three stages. (1) Despite the enactment of the first law dealing with the mentally ill in 1900,their condition continued to be gloomy through the first half of the twentieth century due to anextreme paucity of psychiatric facilities. The majority of patients were cared for by their familyusing a seclusion room in patients’ own homes ─ shitaku-kanchi (domestic confinement). Somepatients were given folklore medicine in temples or shrines. (2) Beginning in the 1950s, custodialcare developed with drastic growth in psychiatric hospitals and beds, prompted by governmentpolicy to encourage the building of mental hospitals through subsidies as well as by increasedaccessibility to medical treatment through the implementation of national health insurance. (3)Since the 1980s, harsh criticism against human rights violations in mental hospitals led thegovernment to establish new mental health legislation putting an emphasis on community-basedcare. From a comparative view, Japan is unique in having pushed forward with hospital-centeredpsychiatric treatment while deinstitutionalization developed in most Western countries.Particularities of Japanese mental health services with regard to global trends will be discussed.Between Legality and Illegality: Folk Therapy for the Mentally Ill in ModernJapanAkira Hashimoto, Aichi Prefectural University (aha@ews.aichi-pu.ac.jp)Following the Meiji Restoration in 1868, the Japanese government prohibited superstitiousremedies and illegal confinement of the mentally ill in order to “modernize” or “Westernize”psychiatry. However, it was not easy for people to change their beliefs and customs, and most ofthem depended on folk therapy. As it was difficult to draw a hard line between legality andillegality, folk therapist practices were not fully controlled by the law. As a result, some practicescontinued as before and were even praised by medical doctors who recognized the “scientific”effectiveness of traditional remedies, although some practices were sharply criticized for theirmoneymaking activities or for human rights violations. However, during the course of themodernization of psychiatry, folk therapy needed to change to survive. Some religiousinstitutions for folk therapy were successfully converted into modern mental hospitals, but otherssooner or later disappeared. By showing several examples of traditional practices in thispresentation, we will explore how folk therapy was dealt with in the context of mental healthpolicy and law in modern Japan.178

Establishment of the Treatment of Mentally Ill People Practiced in ModernJapan: Continuity and Discontinuity of Edo-Period Treatment of Mentally IllPeopleKazuko Itahara, Osaka University of Health and Sport Sciences (itahara@ouhs.ac.jp)Laws regarding the treatment of mentally ill people first appeared in Japan during the Edo Period(1603–1868). Mentally ill people were treated in three ways. Some were incarcerated in a cell intheir home after the municipal authorities were officially notified; this type of treatment wasreserved for people who would inherit the position of head of their family and others of superiorstatus within their family or community. Those of inferior status could be incarcerated in a prisonfollowing a request to public officials. Mentally ill people who could not be cared for by theirfamily or community were incarcerated, with no supervision, in a facility for sick travelersmaintained by members of the hinin, or outcast class. These mentally ill people assumed hininstatus when incarcerated. The Meiji government, which sought to modernize Japan, wasestablished in 1868 following the collapse of the Edo Shogunate. Although the treatment ofmentally ill people changed with the advent of the Meiji government, it continued to drawsignificant influence from Edo-Period laws and the feudal caste system. Here, we examine thechanges to laws concerning mentally ill people during the Meiji Period (1868–1912), focusing onthe characteristics of the treatment of mentally ill people in modern Japan and the processes bywhich attitudes changed.The Prohibition of Mental Patients from Using Public Services in Modern JapanMiki Kawabata, Ritsumeikan University (mikikwbt@gmail.com)This report examines the legal prohibition of mental patients from public services in modernJapan, focusing on local regulations of the Meiji era. Previous studies have addressed clauses innational laws prohibiting mental patients from obtaining certain licenses, but they have notfocused on clauses in local regulations prohibiting mental patients from using certain facilities orservices. Based on documents of prefectures throughout Japan, this research establishes that themain facilities or services from which local regulations of the Meiji era prohibited mentalpatients were public baths, carriages and rickshaws. Besides mental patients, these regulationsprohibited drunken people and unsupervised old people or children. The regulations wereenacted from 1883 by many local governments, in rural areas and big cities, such as Iwate,Osaka, Kyoto and Okayama. The first facilities or services from which a regulation prohibitedspecified people were public baths in Iwate prefecture in 1883. The next were rickshas, fromwhich unsupervised mental patients and people with infectious diseases were prohibited in Osakain 1885. The third were carriages, from which mental patients and people with infectiousdiseases were prohibited in Osaka in 1886. In this presentation, I will discuss the background tothese various prohibitions.179

Alternative Medicine for Mental Patients: The Case of GanryujiAi Miura, Baika Women’s University (a-miura@baika.ac.jp)Alternative medicine for mental patients was in use in many parts of Japan even after the mentalpatient custody law was enacted in 1900. This law made confinement of mental patients possiblein their family homes and some people believed alternative medicine to be more effective thanmental hospitals. In the Ganryuji placed in Tamba City, Hyogo Prefecture, alternative medicaltreatment was being used ("water treatment using the waterfall" and "prayer based onBuddhism") at the beginning of the 20th century. But Japan in the early 20th century wasprogressing inevitably toward war due to its social and international situation, and alternativemedicine became unstable while confinement of mental patients was strengthened. This led tothe establishment of Kora Mental Hospital, situated near Ganryuji, in 1937. It is notable that thishospital continued to use alternative medicine. Alternative medical treatments continued in thehospital until at least 1940. Traditionally, modern western psychiatry had been in conflict withalternative medicine. But this presentation will illustrate the case of Ganryuji and discuss howalternative medicine and western psychiatry established a complementary relationship to oneanother there.73. HistoryNational Socialist Psychiatry in the German South-West: InternationalInvolvement of Agents and International Perspectives on Nazi GermanyThomas Müller, University of Ulm (th.mueller@zfp-zentrum.de)This presentation focuses on the methods, objects and projected outcome of a research project inthe making. Results of pre-studies and framing investigative analyses will also be presented. Theaim of this project, conducted by a larger group of researchers under the presenter’s guidance, isto learn more about the regional specificity and history of what have come to be named “nationalsocialist psychiatry”, “euthanasia” and the relation to the “Holocaust”, i.e. the Shoah. The regionunder study is Wuerttemberg, in the SouthWest of the German Reich, a former Kingdom (until1918) and today a part of the federal state of Baden-Wuerttemberg. Prerequisites, major stepsand consequences of the German history of psychiatry during National Socialism in this regionare under scrutiny and seen through the scope of “centre and periphery”. Embedded in a largerframework of academic contributions on the matter by international scholars, this research aimsto study both common ground and diverging aspects of the history of South Western psychiatryin national comparison as well to detect international activities of historical agents.180

The Treatment of Slaves as Human in Colonial New EnglandWilliam E. Nelson, New York University (william.nelson@nyu.edu)According to the law of colonial Virginia, slaves were chattels ― "considered," according to the1730 case of Tucker v. Sweney, "no otherwise than horses or cattle." In colonial New England,in contrast, slaves were treated as human beings. One key example makes the point. In Virginia,slaves were not permitted to marry, but female slaves were encouraged to have sex, to reproduce,and thereby increase the wealth of their masters. In New England, on the other hand, black slaveslike free white people were punished if they engaged in sexual activity or produced childrenoutside of marriage. My presentation will focus on this as well as other differences in thetreatment of slaves ― differences that reflected New Englanders' recognition of their slaves'humanity. How can one account for this difference? The answer is not an economic one: NewEnglanders worked their slaves as hard and exploited them every bit as much as did Virginians.Rather, as I hope to show in my presentation, the answer lies in law and in the realm of ideas.Mental Degeneracy, Eugenics and the Honeymoon Homicide of 1936Paul A. Lombardo, Georgia State University (plombardo@gsu.edu)In April, 1936, sixty year old bachelor farmer Dan Shine married his twenty-four year oldhousekeeper Pearl Hines. When Dan's body was found only five days after the wedding, thecause of death appeared to be suicide, but within hours his bride was charged with murder.Pearl's mother Minnie was the notorious head of a family that included seventeen other children.The degenerate ways of that "mentally deficient" clan were so infamous that a student at the stateuniversity made them the focus of her thesis. For the next year, newspaper articles and detectivemagazines described the trials that followed for Pearl and her accomplices. Other documentscaptured the aftermath of criminal proceedings, as Pearl's siblings were sterilized to remove thepotential for another generation of criminals. This paper will analyze the "honeymoon homicide"and its aftermath. The episode demonstrates the resilience of eugenic mythologies about"problem families" and a theory of hereditary degeneracy that harkened back to RichardDugdale's 19th Century book The Jukes, still used in this late 1930s true crime saga to framepopular understandings of crime, poverty, mental defect and social disorder.Psychiatric Power and Practice in 19th Century State Asylums: Newcomer v.VanDeusenMary deYoung, Grand Valley State University (deyoungm@gvsu.edu)181

In 1874 Dr. Nancy Newcomer was committed against her will by her son-in-law to theKalamazoo Asylum for the Insane in Michigan. Her behavior, allegedly, had been erratic andemotional. Although a physician herself, she was unable to convince the medical superintendent,E.H. VanDeusen, that she was not insane; indeed, her efforts to do so only strengthened hisassessment that she was. As a result, she remained in the asylum for many months until herdischarge. Three years later, in a case watched with great interest by powerful asylumsuperintendents across the United States, Newcomer successfully sued VanDeusen for falseimprisonment. Although the Michigan Supreme Court reversed the lower court decision aftertaking testimony from scores of family members, asylum staff and patients, the Newcomer casebrought into medical, legal and public discourse questions about the nature of insanity, thenegotiation of diagnostic labels, and the ways in which psychiatric practice and power were bothconstituted and resisted in state asylums. This paper uses a Foucauldian perspective to analyzethe contemporaneous discourse on the Newcomer v. VanDeusen case in the psychiatric and legalliterature as well as in the newspapers which enthusiastically reported on it. Three of Foucault’smost potent concepts will be used to further that analysis: “disciplinary power,” or the tacticalfunctioning of power; “confession,” or the ritual for the production of truth; and “subjectivation,”the construction of one’s own identity as subject to someone else’s control.74. HomelessnessThe Paradox of Military Training: Survival on the Streets among HomelessVeteransSusan L. Ray, Western University (slray@uwo.ca)Introduction: Little is known about homelessness among Canadian Forces (CF) and AlliedForces (AF) Veterans. The purpose of this secondary analysis of the first national study onhomelessness among Veterans of the CF and AF was undertaken to explore whether homelessveterans’ survival on the streets is helped or hindered by their military training.Methods: An interpretative phenomenological approach was used as the methodologicalframework for the study. Although all 54 transcripts from the primary study were selected, 15were chosen for secondary data analysis because these participants spoke extensively about theirlives on the streets. The transcriptions were analyzed to identify common themes until anunderstanding of homeless veterans’ survival on the streets was attained.Results: Military training as a double edged sword for homeless veterans is the overarchinganalytical interpretation that emerged from the analysis. Two subthemes: Military trainingprepares veterans for survival on the streets; and military training to defend oneself withaggression if necessary can make transitioning to civilian life difficult illustrate the paradox thatemerged.Conclusion: These differences of attitude and experience for homeless people with a servicesbackground contain messages for providers of services to homeless veterans. Health care serviceproviders need to recognize, validate and respond to the effects, positive and negative, of life in182

the armed forces for homeless veterans in order to provide the best care. Building upon theirstrengths attained during their military training and education about conflict resolution andassertiveness are some of the implications emerging from this study.From Welfare to Well-Being: Turning Things Around Among HomelessVeteransWilliam H. Milroy, Veterans Aid, London, UK (ceo@veterans-aid.netJay A. Mancini, The University of Georgia (mancini@uga.edu)The intersections of resilience and vulnerabilities comprise the everyday life of homeless people,are affected by their past experiences, and are predictive of their future prospects. Very ofteninterventions directed at homeless people have more failure than success. However, we contendthat interventions often do not account for the contexts of homeless people’s lives, fail toembrace community capacity to support positive change, and lose sight of the resilience that canbe mobilized, at both an individual and a community level. We present systematic researchevidence, and clinical evidence, that demonstrates these resilience and vulnerabilitiesintersections. These data on the health and well-being of homeless individuals, emanate from anintervention and prevention initiative in East London, one that shuns a welfare approach tomoving individuals from social exclusion to social inclusion, and embraces an approach focusedon well-being. Our change process framework includes four primary elements: gatewayinterventions, unpacking, getting sorted out, and graduation. Within these elements, interventionpractices and processes are described, including “swift” intervention, re-learning life skills,building trust, and transitions to new environments and new ways of viewing everyday life. Bothquantitative and qualitative survey and interview data are presented that speak to contexts andprocesses of change, including self-efficacy, community connections, and rejoining thecommunity; in addition, clinical observations are included to provide case study information onprocesses of moving toward social inclusion.75. Human Rights and Mental Health of Women in the Context ofReligious FreedomThe Intersection of Women’s Rights, Religious Freedom, and Civil LawAnne Benvenuti, Cerro Coso College (anne.benvenuti@gmail.com)This presentation provides an overview of several conflicts related to human rights and religiousfreedom with illustrative examples from around the world and from various religious traditions.Particular focus will be given to instances wherein conflict between religious motives and civillaw impacts the human rights and mental health of women. I will address ways to engage183

conflicts between religious freedom and human rights, both within religious traditions, andbetween religious motives and civil law, given that these conflicts may impede human rights,especially the rights of women. Finally, I argue that a global human rights agenda is logicallyand morally necessary and that religious freedom should be exercised within such a vision andnot in competition to it.Veiled Muslim Women: From Cause to EnemyZahra N. Jamal, University of Chicago (znjamal@uchicago.edu)Post-9/11 laws and policies established in the name of national security in the United States havechanged significantly charitable practices among American Muslims. This in turn has hadnegative effects for veiled American Muslim women who have gone from being a “cause” ofAmericans to their enemy. As Muslim Americans have increasingly put monetary and humanresources into addressing mosque defacement, hate crimes, No Fly lists, racial and religiousprofiling, law enforcement campaigns that signal entrapment, and other human and civil rightschallenges that have been defined by a predominantly male Muslim religious leadership, therights and needs of Muslim women – whose mental and physical health have been particularlytargeted in the American context – are marginalized and overlooked. These women faceincreased need for mental health, anti-bullying, and civil liberties support. With a dearth oforganizations to serve their needs, though, this group remains underserved and at risk. There areopportunities for organizational development and collaborative partnership building to servetheir needs. This talk unpacks these important recent shifts and highlights opportunities toaddress the acute needs of American Muslim women.Educating the Next GenerationJigna Shah, University of Chicago (jigna@uchicago.edu)Today's young people have grown up in a world in which technology, travel, and mass migrationhave reshaped global human religious and cultural encounters as never before. The education ofthis new generation with regard to intersections of religious freedom, human rights, and mentalhealth (of women and/or of others denied basic dignity and bodily integrity) presents particularchallenges. In some contexts this challenge is linked to the widespread removal of religion frompublic discussion (or privatization of religion), resulting in a sometimes surprising "religiousilliteracy" among the young, who prize a sense of themselves as spiritual but care little for whatthey perceive as inherently flawed institutionalized religion. In other contexts it is related to aresurgence of fundamentalisms that stifle rigor in inquiry and that re-erect barriers betweenself/group and diverse others. In both cases, there exists a "disconnect" or fragmentation ofunderstanding with regard to issues related to tensions between the common good, the impositionof religious values, and the recognition of universal human rights, including the mental health184

consequences of such recognition or lack thereof. This paper explores attempts in universitycontexts to reconcile such conflicts or tensions by means of a spiritual perspective (inclusive ofsecular humanism), with the underlying goal of producing a new generation of leaders whounderstand the relationship of healthy religious behaviors and attitudes to individual andcommonwellbeing.Religious Freedom and Violence against WomenElizabeth Davenport, University of Chicago (ejld@uchicago.edu)There is great variance around the world with regard to law providing women with protectionfrom and response to violence in domestic and other contexts. This variance offers a tellingopportunity for a close examination of intersections of religious freedom, human rights, andwomen's mental health. Religiously-motivated attitudes and acts may sometimes advance thecause of human rights, but too often appear to undermine both individual rights and the commongood, as happens when religious voices call for disparate treatment of women and men (forexample, in determining marriageable age, or in law rooted in the belief that heralding the rightsof women necessarily undermines religion or "the family"). The mental health consequences forthose denied equal treatment under the law are well documented, and violence against women iswidely understood to be a fundamental violation of women's human rights. Yet religiousfreedom is frequently held to trump such rights. This paper asks what it would take for religiousjustifications for infringement upon the integrity and dignity of women to be consistentlyrejected, and whether the limiting of religious expression that threatens the common good is notonly desirable but feasible, even in diverse cultural/legal contexts.76. Hybrid Correctional Centre – Mental Health Centre: TheSecure Treatment Centre ModelOverviewColin Cameron, Royal Ottawa Health Care Group, Ottawa, Canada(colin.cameron@theroyal.ca)The Secure Treatment Unit (St. Lawrence Valley Correctional & Treatment Centre) is a 100 bedhybrid Correctional Centre - Mental Health Centre whose mandate it is to serve adult maleoffenders serving a provincial sentence (less than two years) identified to have serious mentalillness from accross Ontario. This facility is the result of a contractual agreement between theMinistry of Community Safety and Correctional Services and the Royal Ottawa Health CareGroup. The staffing ratio is 70% health care professionals vs 30% correctional staff. Dr.Cameron's introduction will provide an overview of this unique facility, including looking atsome of the overall clinical outcome and recidivism data.185

Assessment and StabilizationSarina Messina, Royal Ottawa Health Care Group, Ottawa, Canada(sarina.messina@theroyal.ca)This presentation will describe the approach and work of the STU’s Assessment andStabilization Program. The ASU runs on a 25 bed maximum secure unit which acts as thegateway to the facility receiving virtually all STU admissions. The program adopts a Risk, NeedsResponsivity Model to assessment and treatment. Acutely ill residents are stabilized, and whenappropriate are transferred to one of the other STU Programs for further treatment. Therapeuticinterventions will be described, including approaches to stabilize psychosis, DBT group andReadiness for Treatment group.Treatment of Seriously Mentally Ill Sexual OffendersBrad Booth, Royal Ottawa Health Care Group, Ottawa, Canada (brad.booth@the royal.ca)Trans-institutionalization is the phenomenon of the movement of mentally ill individuals frompsychiatric hospitals to the prison system, an unforeseen and unfortunate result of the deinstitutionalizationof the 1970s to 1990s. This movement of mentally ill individuals to theprisons has also been seen among individuals who commit sexual offences. This group ofmentally disordered sexual offenders (MDSOs) is unique and requires specific interventionsaimed at both their mental illness and their sexual offending. Despite some challenges with thispopulation, there are effective approaches available. This presentation will discuss the sexualoffender sub-unit at the STU, and outline the frequency of mental disorders and pharmacologicapproaches in the MDSO population.Aggressive Behaviour ModulationDiane Watson, Royal Ottawa Health Care Group, Ottawa, Canada (diane.watson@the royal.ca)This workshop will review the approach and work of the STU Aggressive Behaviour ModulationProgram, including how RNR Principles are adopted in assessment and treatment. The 3 phasedmodel of the program will be described, along with evidence based psychopharmacologic andpsychotherapeutic treatment interventions for dysfunctional anger and impulsive aggression. Theapplication of Rational Emotive Behaviour Therapy principles along with other groupinterventions in this patient population will be discussed, Practical tips for dealing with186

dysfunctional anger, impulsive aggression and treatment impeding behaviour within aCorrectional facility will also be provided.Working with Trauma DisordersColin Cameron, Royal Ottawa Health Care Group, Ottawa, Canada(colin.cameron@theroyal.ca)This presentation will begin with a review of the prevalence data on trauma and posttraumaticstress disorders in correctional populations, and evidence that suggests trauma to be a significantfactor contributing to criminogenic risk. Not surprisingly we found a high prevalence of traumaand trauma disorders in offenders being admitted to the STU such that RNR principles wereadopted to develop a 25 bed Trauma Disorders Program. The workshop will include a briefreview of the evidence based treatment guidelines for PTSD, and how we have incorporatedthese into our approach to treatment, including psychopharmacology, and individual and grouppsychotherapy. Particular time will be spent sharing our experience with DBT in this population.Our approach to assessment and evaluation will also be shared along with some outcomemeasures.77. Impaired OffendersHow Soon is Too Soon? When Is Someone Who Kills, but Is Found to be NotCriminally Responsible, Ready to be Integrated into the Community?Donald R. Gardner, Provincial Court of British Columbia, Canada(dgardner@provincialcourt.bc.ca)Vince Li was charged with murder after a brutal slaying of a fellow bus passenger near Portagela Prairie, Manitoba in July 2008. He was later diagnosed with schizophrenia and found notcriminally responsible for the victim's death. In May 2010, the Provincial Review Board ruled hecould leave the hospital for supervised excursions. His treating psychiatrist expressed theopinion that there was no evidence Mr. Li harboured any delusional beliefs. The prosecutor'soffice did not oppose the application for community supervision. Mr. Li's lawyer stated that wascommitted to ensuring he get better with a goal of being reintegrated back into society. This caseraises the issue of balancing the public safety with the rehabilitation of someone with adiagnosed mental illness.187

Foolish Homicide in Brain-Impaired Offenders: Impulsivity, Gullibility andUnawareness of RiskStephen Greenspan, University of Colorado (stephen.greenspan@gmail.com)Foolishness involves a failure to anticipate risk of negative consequences. A homicide can bedescribed as foolish when it is out of proportion to provocation (killing someone for making aninsulting comment) or likely gain (a robbery that nets $30); when the offender does notunderstand the degree of risk to the victim (aiming for the shoulder, but severing an artery;causing suffocation from locking someone in a trunk); when the crime is undertaken as a resultof manipulative pressure from another person (believing false accusations about the victim);when the violence is an automatic reaction (without any reflection); when the offender has nounderstanding of how to avoid being apprehended (leaving obvious evidence at the scene of thecrime); or, in many cases, a combination of all of these. People with brain-based disorders have ahigh likelihood of engaging in foolish crime, including homicide, even when their intelligence isrelatively intact. Several actual cases of foolish homicide in brain-impaired offenders will bedescribed, and analyzed in relation to a model of “foolish action” that has four explanatoryfactors: (a) situation (social pressure, threat); (b) cognition (inability to read cues or understandrisk); (c) personality (impulsivity, dependency); and (d) state (anger, fear, inebriation). Thismodel and these cases will be used to propose and illustrate a comprehensive psychologicaltheory of mitigation and culpability.Developing Psychological Informed Criminal Justice Environments IEddie Kane, University of Nottingham (eddie.kane2@btinternet.com)Victoria Baldwin, University of Nottingham (Victoria.baldwin@nottshc.nhs.uk)Over the past 3 years there has been a significant political focus in the United Kingdom onindividuals with mental disorders who are detained within the Justice system. This has led to aseries of policy responses that have been developed in order to address the needs of theseindividuals. In 2011 six psychologically informed planned environments (PIPES) wereintroduced in the UK Justice system. These pilot schemes were designed to offer staff additionaltraining to help them develop a more psychologically based understanding of their work. Thisunderstanding enables them to create a safe and supportive environment that can facilitate thedevelopment of those who live there. PIPES are designed to have a particular focus on theenvironment in which they operate, actively recognising the importance and the quality ofrelationships and interactions. They aim to maximise ordinary situations and approach them in apsychologically informed way. PIPES look at the social context and interactions of theindividuals who live and work there and stress the importance of the relationships whichunderpin daily living in what are often pressured environments housing individuals who havelived a life of exclusion from these common interactions. Of the six pilots four were developed188

within prison environments and two within community justice environments. This paper reviewsthe rationale and development of these pilots, the interventions deployed and the workforce anddevelopment challenges and the training strategy used to address them including the use of theKnowledge and Understanding Framework for personality disorders commissioned by theDepartment of Health and Ministry of Justice in 2007.Developing Psychological Informed Criminal Justice Environments IIEddie Kane, University of Nottingham (eddie.kane2@btinternet.com)Victoria Baldwin, University of Nottingham (Victoria.baldwin@nottshc.nhs.uk)Over the past two decades in the United Kingdom there have been initiatives designed to divertoffenders with mental health problems away from the criminal justice system into moreappropriate services within health and other agencies. These have generally been ad hocinitiatives and subject to closure or significant reduction by local service commissioners at timesof financial constraint. The services also tended to be local initiatives and no national pattern ofcoverage developed. The importance of diverting individuals with mental health problems out ofthe criminal justice system continued to be widely supported across political parties and thepublic sector agencies responsible for both health and justice but in reality little or no investmentwas made and organisational boundaries continued to present real barriers to effective change.In 2010 the then Labour Government published the Bradley Report which made wide rangingrecommendations for reforms at the health/justice interface. The new coalition governmentadopted the recommendations of the Bradley report in full in 2011 and also announced asubstantial new investment (£59 million) in further developing these services. In 2012, acollaborative of the National Association for the Care and Rehabilitation of Offenders(NACRO), the Centre for Health and Justice, University of Nottingham, Revolving Doors andThe Centre for Mental Health were commissioned to assess and further develop a hundredexisting liaison and diversion pilots and develop a template to commission a further group ofpilots to ensure that national coverage of these services. This paper will report progress on thisinitiative including a review of best practice evidence and training needs.Marijuana Embalming Fluid and Legal Implications for Insanity and Fitness toStand Trial AssessmentsCecilia H. Leonard, SUNY Upstate Medical UniversityTony Adiele, Advanced Forensic Psychiatry & Medical Law Service LLC, Cambridge, UK(tony@advancedforensicpsychiatry.co.uk)Embalming fluid (EF) applied to marijuana cigars or cigarettes, with or without the addition ofphencyclidine (PCP) has many names such as “fry”, “water” or “wet”. Under the influence of189

these substances, individuals might appear psychotic and engage in violent behaviors. The user’spresentations may also mimic a psychotic disorder or a delirium. The Courts often requestassessments to determine whether such a defendant is fit to stand trial. Drug-induced variablechanges in mental state often result in stark discrepancies between serial examinations over aperiod of time. The initial clinical assessment and the diagnosis may vary significantly fromsubsequent evaluations depending upon the timing of the assessment, the type(s) of substance(s)ingested as well as the pharmacokinetics of the substance(s). All of these substances usedindependently are known to induce changes in mental status. However, the combination canproduce a more potent and prolonged effect. Also, despite abstinence, the user may havepersistent symptoms of psychosis and the individual may be diagnosed with a mental disorderdespite abstinence. This may complicate their Fitness to Plead and Stand Trial assessments,diagnosis of a mental order and the use of settled insanity as an affirmative defense. In thispresentation, we will review the pronounced psychopathological effects of the marijuanaembalming fluid on the defendant user and the legal ramifications.78. Indirect Measures in the Evaluation of the Clinical TreatmentProcessThe Application of the Implicit Association Test for Measurement of ImplicitTheories/Cognitive Distortions in Sexually Violent Forensic PsychiatricInpatientsThijs Kanters, FPC de Kijvelanden, Rotterdam, Netherlands (Thijs.Kanters@hotmail.com)This paper concerns a study on the implicit theories/cognitive distortions in sexually violentforensic psychiatric inpatients. We investigated the cognitive distortion “children as sexualbeings” in sexually violent inpatients (rapists and child abusers), non-sexually violent inpatients,staff members and students. Two IAT’s were used: a neutral IAT (flowers, insects, pleasant,unpleasant) and a child/sex-IAT (child, adult, sex, and not sex). The IAT-scores of the inpatientswere related to scores on risk assessment instruments and self-report questionnaires aboutaggression, personality and attitudes towards women. From the literature, we expected that childabusers would have a stronger association between children and sex than both rapist and controlgroups, and that the strength of the child-sex association would be correlated with risk ofrecidivism. During this paper the results of our study will be presented. Consequences of theseresults for the development of an effective treatment program will be discussed.Behavior Change in Forensic Psychiatric Inpatients during their Stay inHospitalRuud H.J. Hornsveld, FPC de Kijvelanden, Rotterdam, Netherlands (r.hornsveld@tiscali.nl)190

This paper concerns a study in which we investigated the treatment effects on the behavior ofviolent forensic psychiatric patients during their stay in hospital. For that purpose, 237 inpatientswere measured between 2003 and 2011 bi-annually by the staff on the ward with the aid of theObservation Scale for Aggressive Behavior (OSAB). As a start, we compared the patients’subscale scores during the successive bi-annual measurements. During a period of five years,scores on the Irritation/Anger, Anxiety/Gloominess, Antecedents, and Aggression subscales werefound to increase, then decrease, then again increase and finally again decrease. Scores on theProsocial Behavior subscale increased gradually over the course of time. A significant relationbetween PCL-R scores and aggressive behavior on the ward was found only during the first twoyears of stay. We concluded that a structured and controlled environment has a strong influenceon the behavior of violent offenders. Consequently, the relevance of risk assessment in a closedsetting is discussed.The Use of the Implicit Association Test in Differentiating between CognitionsRelated to Reactive and Proactive AggressionAlmar J. Zwets, FPC de Kijvelanden, Rotterdam, Netherlands (almarzwets@hotmail.com)This paper concerns a study in which we investigated whether certain cognitions shoulddifferentiate between offenders and students, and between reactively and proactively aggressivepatients. By using an Implicit Association Task (IAT) we analyzed cognitions in a group ofviolent forensic psychiatric inpatients and a group of students. We used two IAT's: a violent IAT(pleasant, unpleasant, peace, and violence) and a control IAT (pleasant, unpleasant, flowers, andinsects). IAT-scores were compared between both groups. We expected that the inpatients wouldhave a less negative association to violence than the students. Scores of reactively aggressivepatients were compared with those of proactively aggressive patients. From the literature, weexpected that patients who show proactive aggression have a less negative association toviolence on the IAT. Other factors which might have influenced these results, like psychopathy,were taken into account. During our presentation the results of our study will be presented.Consequences of our results for the development of an effective treatment program will bediscussed.79. Innovation in Mental Health Shared Decision Making Policy,Practice, and ResearchWhat Helps and Hinders Shared Decision-Making in Mental Health Services?Miles Rinaldi, South West London & St George’s Mental Health NHS Trust, London, UK(Miles.Rinaldi@slwstg-tr.nhs.uk)191

The objectives of recovery focused mental health services differ from the objectives oftraditional, “treatment-and-cure” health services. The latter emphasizes symptom relief andrelapse prevention. In recovery focused services, symptomatic improvement is important, andmay well play a key role in a person’s recovery, but quality of life, as judged by the individual, iscentral. As a consequence, within mental health services shared decision-making is broader thansimply making a decision to take medication or not. Shared decision-making needs to be appliedacross all decisions from treatments and interventions to decisions about where to live andwhether or not to work. The ambition to embed shared decision-making by people who usemental health services along with the attitudes and practices of psychiatrists across the lifecoursewill be presented. Lessons learnt from the application of shared decision-making inroutine practice of a large inner London mental health trust will be discussed.Organisational Change, Recovery and Shared Decision MakingAnne Markwick, Hertfordshire Partnership NHS Foundation Trust, Hertfordshire, UK(anne.markwick@hertspartsft.nhs.uk)In order for mental health services to become Recovery orientated we need to move fromrelationships biased towards traditional professional expertise to more equal relationships biasedtowards the person’s own self knowledge, sense-making and personal goals in the context oftheir whole life. These relationships will be based much more on a coaching and consultativeapproach than that of the traditional medical approach. Professionals will become a resource tobe used rather than the expert at the centre of treatment. Shared decision making is central to thisapproach. The qualities of practitioners who are able to work in this way include curiosity andbelief balanced with an ability to provide opportunity, challenge and encouragement against abackdrop of empathy, humanity and authenticity. This provides the context for “holding thespace” for Recovery. In her experience of leading organisational change towards a Recoveryorientation, and her original research on this issue, Anne Markwick suggests that this processparallels that required of practitioners. Thus in order to develop Recovery orientated practitionersand organisations we need to be able to “hold the professional space” – walking the walk ofRecovery at all levels. This presentation will outline and analyse current key projects in recoveryoriented organisational change in the UKIntroducing Shared Decision Making in Psychiatric Medication Management asPart of a Recovery AgendaElina Baker, Devon Partnership NHS Trust, Exeter, UK (elina.baker@nhs.net)192

Recovery based practice is being widely adopted by mental health services in the UK. Whilethere has been a commitment to implementing broad values and principles there is also a need toclearly specify how these can be applied in specific areas of practice. In order to establishrecovery based practice guidelines for prescribing and medicines management, our project drewon published descriptions of recovery supportive practice, a local survey of the views of peopletaking medication and their supporters and attempts to operationalise agreed recovery principles,such as working in partnership, supporting personal responsibility and exploring personalmeanings. Our recommendations included re-conceptualising medication as one of manypossible recovery tools that people can actively use to support their wellbeing rather than atreatment determined by an expert professional. This requires mental health professionals adopta shared decision making approach to medicines management.In order to support the implementation of the project recommendations, we have developedreflective practice workshops for prescribers to explore barriers to and supports for shareddecision making. We have also explored ways of supporting people taking medication toparticipate meaningfully in the decision making process. As well as presenting our guidelines,we will present the experience of carrying out this work, the results of evaluation and reflect onfactors which both support and impede the implementation of recovery based practice in relationto prescribing and medicines management.Initiating Shared Decision Making in Psychiatric Medication Management as anEvaluated InterventionShulamit Ramon, Anglia Ruskin University (shula.ramon@anglia.ac.uk)Sheena Mooney, Cambridge and Peterborough Partnership Foundation Trust, Cambridge, UK(sheenamooney@yahoo.com)We will present a National Institute of Health Research (UK) funded research project focused onparallel preparation of psychiatrists, care co-ordinators, and service users who have experiencedpsychosis, to actively engage in the process of shared decision making (SDM) focused onpsychiatric medication management, accompanied by a pre-programme and a post-programmeevaluation. The project philosophy follows that of Deegan et al (2010) in approachingpsychiatric medication as an aspect of personal medicine. Embracing this philosophy requires amajor change in attitudes and everyday practice by all participants, for reasons to be highlightedin this presentation. SDM has become a key UK policy across the health system (Department ofHealth, 2011: Liberating the NHS: Greater Choice and Control), and has particular significancewithin the mental health sub-system. The first evaluated pilot intervention in the UK in thisimportant yet highly sensitive area of mental health, the project is delivered in a partnership inwhich the initial consultation phase and the training programmes are led by both professionalsand service user trainers. Key findings and their significance will be outlined.193

Implementing SDM as Part of the First Phase of Care Planning within theIsraeli Psychiatric Rehabilitation ServicesYaara Zisman-Ilani, The University of Haifa (yaaraz@windowslive.com)In recent years, there has been growing awareness and emphasis on patient involvement inmedical treatment decisions, commonly referred to as shared decision making (i.e., SDM)(Charles, Gafni, & Whelan, 1997, 1999). To date, SDM in healthcare has primarily been studiedamong patients with physical illnesses. Recently, research on SDM in mental health has alsobegun (Duncan, Best, & Hagen, 2010), mainly among people with schizophrenia (Hamann et al.,2006) and depression (Loh et al., 2007; Loh, Leonhart, Wills, Simon, & Harter, 2007). AlthoughSDM can be seen as a basic principle of many effective psychiatric rehabilitation practices(Curtis, 2008), to date, research has focused exclusively on medication use (Duncan et al., 2010).The potential importance of adapting the principles of SDM to recovery-based practices inmental health and to the field of psychiatric rehabilitation (such as employment and housing) hasbeen recently emphasized (Deegan & Drake, 2006; Deegan, 2007; Drake, Deegan, & Rapp,2010) but not yet implemented. In this session, I will present the development and theimplementation of a new SDM intervention aimed at improving the assessment phase of therehabilitation process of people with serious mental illness (SMI) in Israel.80. Innovations in Mental Health CareShort Term Risk Assessment in Acute Psychiatric Wards: Reflections on a FiveYear Research and Practice Development Project in the NetherlandsRoland van de Sande, Hogeschool Utrecht (roland.vandesande@hu.nl)E. Hellendoorn, Bavo-Europoort Mental Health Trust, Rotterdam, NetherlandsA.E. Wierdsma, Erasmus University of RotterdamE.O. Noorthoorn, Radboud University NijmegenH. Nijman, Hogeschool UtrechtC. van der Staak, Hogeschool UtrechtC.L. Mulder, Erasmus University of RotterdamShort term risk assessment by psychiatric trained staff appears to be strongly driven by tacitknowledge. In the Netherlands approximately 30% of all aggressive incidents in acute wardsresult directly in a seclusion intervention. A set of validated instruments is integrated in a CrisisMonitoring Model. In a cluster of randomized clinical trials the following hypothesis wasreviewed: structural and frequent applications of risk sensitive observation instruments enablethe staff to improve their risk management arsenal in order to reduce severe aggressive incidents194

and coercive interventions. For this purpose the Broset Violent Checklist, Kennedy-Axis V,Brief Psychiatric Rating Scale, Scale of Dangerousness and the Social Dysfunctioning andAggression Scale were used. The hypothesis was that this Crisis Monitor model may improvequality in decision-making during the entire admission episode. All consecutively admittedpatients were included in the study (n=596). The experimental units and control-units had similarseclusion rates before randomization. In addition, reported aggression incidents in both researchclusters were comparable. At the experimental wards aggression incidents were reduced to 78%,whereas in the control wards an increase of 12% was identified. [Chi-square = 21, 3; (1)p

other interventions have been exhausted. In Australia, the reduction and potential elimination ofrestraint (and seclusion) practices and adverse events have been identified as a key nationalpriority area for increasing safety and reducing harm in mental health care (National MentalHealth Working Group, 2005). This is in line with the United Nations (1991) Principles on theProtection of People with Mental Illness, which specifies that physical restraint and seclusiononly be used in extreme cases. In Australia, the use of seclusion in acute psychiatric units hasdecreased, influenced by national initiatives to reduce their practice. Despite calls fromgovernments and consumer organisations to eliminate or reduce restraint and seclusion, usagehas increased in settings such as Emergency Departments, ambulances and general hospitalwards. This paper will report on data collected in South Australia about the use of restraint andseclusion in a range of hospital settings (Emergency Departments, ambulances, acute psychiatricaged care settings and acute psychiatric wards) and the context in which they occur. Legal,ethical and clinical perspectives will be examined to explore why, in a climate of “leastrestrictive treatment” environment and consumer focussed philosophies, the use of containmentpractices is increasing, particularly in settings where such practices only recently came intoexistence.New to Forensic Education ProgrammeHelen Walker, The Forensic Network, Carstairs, Scotland (helen.walker6@nhs.net)The New to Forensic educational programme has been developed for use across all forensicservices in Scotland. It has been designed to meet the needs of all staff who are both new to andalready working within forensic mental health services. Its objectives are targeted to both clinicaland non-clinical staff. The programme follows the patient's journey through the mental healthand criminal justice systems. It covers mental disorder, legislation, psychiatric defences,assessment and treatment, risk of harm to others, services, attitudes and boundaries,multidisciplinary working, users and carers, community, learning disability, and prison services.It is self-directed and practice based, and uses a problem-based approach. Over a 3 year period,trainers and mentors have been trained to deliver the programme by members of the School ofForensic Mental Health and all services have adopted the programme as a core educationalinitiative. Findings from the programme evaluation indicate a significant improvement inlearning following engagement in the initiative.81. Innovative Services at the Front End of the Juvenile JusticeSystemRestorative Justice ServicesGordon Bazemore, Florida Atlantic University (bazemor@fau.edu)196

One of the most recent innovative services being provided to juvenile justice and related youth isfocused on the increasingly popular approach known as restorative justice. Juvenile justicesystems, schools, and other programs involving youth currently use restorative justice practicesas an alternative both to punitive practice, and/or to treatment alone. Restorative justiceprocesses first attend to the stakeholders involved in a crime or incident that harms others –including, first, the crime victim, the offender, and supporters of both. Restorative processesfocus on repairing the harm done to victim, community and offender. Rather than simplypunishing, or treating, the offender in this process is offered a new form of non-punitiveaccountability, the goal of which is to make amends for harm done rather than passively “takethe punishment.” This discussion presents examples of innovative restorative justice services in avariety of contexts and locations.Detecting and Treating Sexually Transmitted Diseases among ArrestedJuveniles: Lessons from a Multi-Agency-Research CollaborationSteven Belenko, Temple University (sbelenko@temple.edu)Richard Dembo, University of South Florida (rdembo@usf.edu)Newly arrested juvenile delinquents are at high risk for sexually transmitted diseases (STDs), yetthere have been few attempts to implement screening, prevention, or treatment services for theseyoung at-risk persons. Because delinquent youth are at high risk for STDs, most are quicklyreleased to the community following arrest, and access to health services is minimal, thispopulation represents a considerable public health risk. This paper describes the results of aninnovative research protocol to connect a county health department with juvenile justice agenciesso that delinquent youth are offered STD testing and treatment shortly after arrest. Most of theyouths agreed to be tested and two-thirds of those infected were able to be contacted and treatedby the county health agency following release from custody. We discuss the organizational andsystems barriers to expanding and sustaining this type of cross-systems collaboration.Some Effective Approaches to Identify and Address the Needs of Troubled YouthHaving Contact with the Justice SystemRichard Dembo, University of South Florida (rdembo@usf.edu)Identifying and intervening with troubled youth having contact with the justice system is aneffective way to reduce the issues they and their families are experiencing, and improve their andtheir community's quality of life. In the past few decades, I have been involved in a number ofsuch efforts, some of which will be discussed by my colleague panellists. In addition to thesejoint efforts, I have been involved in the design and implementation of a Family EmpowermentIntervention (FEI) project involving newly arrested youth, a truancy intervention project, and a197

Civil Citation program in Hillsborough County, Florida. The first two clinical trials spin offactivities at the Hillsborough County, Juvenile Assessment Center (JAC), a centralized intakefacility receiving and processing arrested youth (itself an innovative development), which hasbeen in operation since 1993. I plan to provide a brief history of the JAC, then review theimplementation and outcome assessments of the just-noted services. Collectively, they holdmuch promise for creatively reframing the way in which the juvenile justice system operates.Stronger Families: Engaging and Retaining Youth Involved in the JusticeSystem and their Families in the Mental Health/Substance Abuse Interventionand Treatment ServicesNancy Hamilton, Operation PAR, Inc., Pinellas Park, USA (nhamilton@operpar.org)Operation PAR’s 42 years of providing a continuum of comprehensive mental health andsubstance abuse services from engagement and assessment through intervention and treatmenthas underscored the need to address adolescent substance use and abuse issues. The use ofevidence based assessment and services increases engagement rates of youth and their familiesinto the continuum of prevention, intervention and treatment services. This presentation willpresent an overview of the use of the valid and reliable Global Appraisal of Individual Needs(GAIN) to screen and assess youth involved in alcohol and substance abuse including thoseyouth involved in delinquency who are brought by law enforcement to the Juvenile AssessmentCenter. Participants will receive an overview of the process used to train and certify staff inMotivational Interviewing and other evidence based practices. These trained professionals areskilled at engaging youth and their families into the treatment process. The use of manualizedtherapies and evidence based curricula such as Motivational Enhancement, Cognitive BehavioralTherapy and Seeking Safety, a trauma curriculum, improves outcomes, increases retention andimproves the satisfaction of the youth and families served. An overview of the evidence basedpractices used will allow participants to relate specific aims of these practices with the positiveoutcomes achieved by youth and their families.How Florida Is Preventing Youth from Sinking Deeper into the Juvenile JusticeSystemWansley Walters, Florida Department of Juvenile Justice, Tallahassee, USA(Wansley.Walters@djj.state.fl.us)Secretary Walters is responsible for a state agency of 3,200 employees serving youth andcommunities throughout Florida. She is leading comprehensive reform at DJJ to make it thenational role model for juvenile justice administration. Under her leadership, DJJ is investingmore resources in the front end of the juvenile justice system to ensure that youth receive the198

ight combination of services and sanctions, in the right place at the right time. Key reformpackage elements include: Diversion: The expansion of civil citation and other innovativediversion practices will stem the flow of first-time misdemeanant youth into the system.Historically, Florida has spent millions of dollars on interventions for low-risk youth who wouldprobably never re-offend. Detention Reform: Statewide detention reform, including thedevelopment of real alternatives to detention, will fuel continued reductions in unnecessary andinappropriate detention. Reduced detention over the past several years has allowed DJJ to closehundreds of beds, yielding a cost-savings of more than $25 million. Right-Sizing ResidentialCare: The past several years have also revealed significant inefficiencies at the deep-end ofFlorida’s juvenile justice system, with far too many low-risk youth confined in expensiveresidential institutions. They consume scarce resources that could instead be invested incommunity-based sanctions that hold youth accountable, protect public safety, create jobs andpromote healthy futures for children. Community-based sanctions are more effective at reducingjuvenile crime and cost much less than correctional institutions.82. Intellectual DisabilitiesResearch on Freedom Restrictions: Quality GuidelinesVivianne Dorenberg, VU University - Medical Centre & Free University - Faculty of Law(v.dorenberg@vumc.nl)In recent years there have been several research programs to guide care providers in workingwith the legal framework for psychiatric care and the care for people with intellectual disability.Mostly, the focus is on creating quality guidelines to reduce restrictive measures. Incollaboration with the Free University (medical centre) and the University of Tilburg, theHogeschool Leiden is currently doing research on restrictive measures in the care for youngpeople with mild intellectual disorders (MID). Young people with MID represent a difficultgroup of clients. They have an increased risk for all kinds of problems, from psychiatric to severebehavioral problems. This makes aggression and therefore the need for restrictive measures verycommon among these clients. But the variety of the problems also indicates multidisciplinarycare, possibly in more than one care sector, which means that care providers are confronted witha wide range of laws and regulations. The first part of the research project (September 2011 -April 2013) showed that care providers experience difficulties with the legal framework.Therefore, the project set out a number of quality guidelines to raise awareness and to helpreduce (the need for) restrictive measures. The presentation will focus on these guidelines.Low IQ and Risk Measurement: The Use of Instruments for Risk Taxation in theMentally RetardedRonald Visser, Klinisch Psycholoog, Amsterdam, Netherlands (ronald.visser@sheerenloo.nl)199

Prediction of violence risk has become more accurate in the last 10 years because of the use ofchecklists/instruments. Clinical diagnosis alone has proven to be less valid than the use of astandard checklist combined with clinical evaluation. Structured Professional Judgement (SPJ)has now become “good practice”. In this presentation we will focus on the population of light,moderate and severely mentally retarded (IQ

Jane McCarthy, King’s College London (JMccarthy@standrew.co.uk)In the UK, intellectual disability (ID) is not routinely screened for within the criminal justicesystem. The consequence is that people with ID may not be directed to the most appropriateprison location or departments to receive the support they need. This study aims to establish theextent of ID among prisoners at a local prison in London, UK. Prisoners arriving at the prisonwill be screened and follow-up diagnostic assessments carried out. The study will explore thecharacteristics of prisoners with ID; the extent to which they have additional mental healthproblems and examine their prison pathways and healthcare resources they use. In addition to ID,participants will be screened for autism spectrum disorder (ASD) and attention-deficithyperactivity disorder (ADHD). All those screening positive for any of these disorders willassessed for additional mental health problems and substance misuse. Participants’ prisonpathways of in terms of resources required and locations used in comparison to the generalprison population will be explored. The study is currently at the recruitment stage. Data on ratesof recognised and previously unrecognised ID, ASD and ADHD will be reported along withpreliminary results on characteristics and comorbidity.Aging in Place: Neurocognitive Impact of Long Term Prison Sentences andLegal ImplicationsStacey Wood, Scripps College (swood@scrippscollege.edu)Longer sentences at both the state and federal level have resulted in a large and growing agingpopulation in US prisons. Human Rights Watch estimates the number of inmates over 55 at125,000 and growing (Humans Rights Watch, 1/27/2012). Many of these older inmates faceincreased risks of cognitive decline secondary to histories of low educational attainment,psychiatric disorders, substance and alcohol abuse, trauma histories, head-injuries, and poorpremorbid medical care. In addition, we argue that the prison environment itself may be anindependent factor that increases the incidence of dementia secondary to low levels of cognitivestimulation, poor medical care, poor diet, and psychological trauma. Further, demographically,prison populations are at higher risk for hypertension, diabetes, and cardiovascular disease priorto incarceration and these risks become amplified in the prison environment. In fact, a recentreport indicated that prison inmates demonstrated accelerated aging, appearing 10 - 15 yearsolder medically resulting in classifications of inmates over age 50 as older in 15 states (VERAInstitute of Justice, 2010; HRW 1/27/2012). This presentation will review the literature onaccelerated aging in the prison population with an emphasis on implications for neurobehavioralassessment and legal decision-making.Neurobehavioral Examination of the Forensic ClientGeorge Woods, Morehouse School of Medicine (gwoods@georgewoodsmd.com)201

David Freedman, University of Colorado (df2379@gmail.com)Stephen Greenspan, University of Colorado (stephen.greenspan@gmail.com)There is a growing awareness among mental health practitioners that many mental disorderspreviously believed to be primarily behavioral in nature, reflecting character and environment,are actually grounded in brain mal-development or brain disorder. This growing awareness,influenced by the advent of new diagnostic procedures and measures, is also found amongforensic practitioners. In this presentation, I describe some of the elements involved inconducting a neurobehavioral assessment of cognitive functioning, particularly in capital cases,organizing this material in terms of the professional disciplines – social work, mitigationinvestigation, psychological, and medical – with which these methods are mainly identified. Thepresentation concludes with a brief discussion of how to integrate the multiple areas of expertiseto create an accurate understanding of the neurobehavioral functioning and capacity of thesubject.83. The Interface of Older Adults with the Civil and ForensicMental Health Services in the United KingdomScottish Mental Health Law and Older PeopleDavid Findlay, NHS Tayside, UK (david.findlay@nhs.net)The Mental Health (Care and Treatment) (Scotland) Act 2003 (MHCTA) operates alongside theAdults with Incapacity (Scotland) Act 2000 (AWI). Both are firmly based on clearly articulatedprinciples and can involve complex areas of interaction though use of MHCTA is more closelydocumented and fully recorded. MHCTA saw a move from Sheriff Court hearings to a tribunalbased system and this presentation will explore subjective aspects of that shift for both olderpeople and involved professionals as well as considering trends in levels of detention andcompulsory treatment across age ranges and diagnoses. It will touch upon less frequently usedoptions, such as the Care Programme Approach (CPA), and subsequently emergent legislation,such as the Adult Support and Protection (Scotland) Act 2007 (ASPA). Specific mention will bemade of MHCTA’s role in dementia and seemingly lower profile in both delirium specificallyand the general hospital setting overall. An overview of the “Shrieval” process will be given inthe context of Scotland’s entire tribunal system being subject to review. The emphasis will be onthe diverse ways in which a bureaucratic, legalistic process adds value to the everyday care ofolder people’s mental health problems.202

Incapacity Legislation and its Use for Older Adults in ScotlandDonald Lyons, Mental Welfare Commission for Scotland, Edinburgh, Scotland(donald.lyons@mwcscot.org.uk)The Adults with Incapacity Act for Scotland was passed in 2000. It provides a definition ofincapacity, a set of principles that must be followed and a graded series of financial and welfareinterventions. The number of new applications, especially for welfare powers, continues to rise.Deprivation of liberty issues and the provision of medical treatment for physical health remainsignificant problems. Some recent legislative changes have helped. Proposals for further reformare aimed at ensuring compatibility with human rights law, while trying to ease the burden onhealth and social care practitioners and the courts.Civil Mental Health Detentions for Older Adults in One Scottish Health RegionGary Stevenson, NHS Fife, UK (gstevenson@nhs.net)This presentation examines the emergency and short-term civil detention of older adults in oneScottish region under successive mental health legislation, with the data collected primarily byclinician-based interviews. Results indicate an initial rate of 68 increasing to 141 detentions per100,000 of the respective over-65 year age populations, a two-fold increase. Compared to theearlier patient cohort, the later cohort had higher rates of over 85-year-olds with organic mentaldisorders and higher rates of progression to six-month compulsory detention and treatmentorders (CTOs). New data will be presented on outcomes at 2-year follow-up for all adults in theregion detained on CTOs, comparing the older adult to the younger adult (under 65-year old)cohort. The observed higher rates and longer periods of detention may reflect changes in clinicalattitudes and legal requirements from a previous reliance on the common law doctrine ofnecessity to the requirements of a more legalistic framework, and may signal future clinicalrequirements, given the aging population, pointing towards the need for earlier recognition andmanagement of clinical issues in an attempt to minimize the “necessity” of clinico-legalintervention.Older People and the Criminal CourtsGraeme Yorston, St Andrew’s Hospital, Northampton, UK (gyorston@standrew.co.uk)Older people often get a raw deal from the criminal courts – both as victims and as perpetratorsof crime. In the past older people who were the victims of violent, sexual or property crime wereoften seen as unreliable witnesses, and prosecutors were reluctant to pursue convictions. In 2009203

The Crown Prosecution Service in England and Wales launched an initiative to address thisproblem and the progress that has been made since then will be discussed. Over the past decadethe number of older adults in UK prisons has increased eight fold. The prevalence of seriousmental health problems is higher than in younger prisoners, and these often go unrecognised.Existing secure psychiatric facilities have been reluctant to admit older adults because ofconcerns about their vulnerability to aggression from younger patients, so a number of specialistsecure mental health units for older adults have been developed in the UK in the independentsector. Many of the assumptions that underpin forensic psychiatry and Mental Health ActPractice in the UK apply less well to older adults, however, and this will be discussed against thecontext of emerging secure services for older people.A Survey of Older Adult Patients in Special Secure Psychiatric Care in ScotlandRobert Gibb, The State Hospital, Carstairs, UK (robertgibb@nhs.net)A retrospective survey design was employed. Patients admitted to The State Hospital aged 55 orover and patients who reached their 55 th birthday as inpatients between 1 st January 1998 and 31 stDecember 2007 were included. Thirty-six patients were identified over the relevant time period:The most common diagnostic category in our sample was psychotic illness (63.9%). withdementia accounting for another 11.1% . The average length of admission was 14.2 years (range21 days – 40.3 years). The average number of medical diagnoses on admission was 1.2 (range 0-5), rising to 2.4 (range 0-7) at discharge or end of study. Twenty-two patients (61.1%) hadmobility problems and there were 7 cases (19.4%) of sensory impairment. Services must ensure asuitable environment with robust access to physical health care and recreational activities forolder adults in secure mental health settings. This presentation will also examine other issuespertaining to Forensic mental health practice with Older Adults.84. Interpersonal Care in PsychiatryExploring the Other, Otherness, and Othering in Forensic Psychiatric andCorrectional NursingCindy Peternelj-Taylor, University of Saskatchewan (cindy.peternelj-taylor@usask.ca)Forensic clients are members of a highly stigmatized and stereotyped population. How nursesview those in their care, “the other”, and more importantly, how they engage the other, is asignificant concern for nursing. In forensic and correctional environments, it is not uncommonfor nurses and other health-care practitioners to depersonalize their patients and clients throughtheir use of language. Referring to patients and clients as “inmates,” “cons,” “psychopaths,”“schizophrenics,” or “monsters” not only evokes stereotypical images, but, more importantly,204

casts the individual into the role of other. Othering is generally viewed as a negative form ofengagement, one that is contrary to ethical nursing practice. Through the exploration of relationaland contextual factors contributing to this phenomenon, the author argues that othering is acontemporary practice issue of moral significance – one that addresses the provision ofcompetent and ethical nursing care, and one that requires ongoing dialogue within the forensicand correctional nursing communities. Although this analysis of othering represents only aglimpse of how nurses work and care for individuals in forensic and correctional environments,it may challenge nurses (and other health care providers) to situate themselves within thisdialogue as they reflect upon, relate to, and refute othering. In doing so, they will be betterpositioned to work in a competent and ethical manner with individuals who have come intoconflict with the law.Subtle Coercion and Moral DistressKim Lutzen, Karolinska Institutet (kim.lutzen@ki.se)Contemporary research focused on every-day ethical decision making in various mental healthcare environments provides convincing results for the suggestion that moral distress has adverseeffects on the client-care provider relationship. A common yet simple explanation of the originof moral distress is rooted in the notion that a person’s beliefs, or convictions, of what he or shethinks is the right thing to do are impossible to implement. In mental health care, this situation isnot unusual, mainly, because what the client prefers is not always congruent with the treatmentcare plan. The aim of this presentation is to argue that different ways of using subtle coercionmay be a consequence of moral distress; compromising the principle of autonomy in the name ofdoing what seems to be “good” for the patient/client. I will also argue that subtle coercion mayalso be a primary consequence of the care provider´s lack of autonomy.Revisiting Relational Ethics as a Fitting Ethic for Forensic PsychiatryWendy Austin, University of Alberta (wendy.austin@ualberta.ca)This presentation will revisit the argument that a relational ethics approach to the ethics offorensic psychiatry has more to offer than that an approach based strictly on principlism.Informed by qualitative research results of an interdisciplinary study funded by the SocialSciences and Humanities Research Council of Canada, “Ethical relationships in forensicpsychiatric settings,” the challenges of practicing ethically at the interface of justice and healthcare systems will be addressed. The dominate requirement for security and custody in suchsettings shapes care and treatment and requires an approach to ethics that can guide actions in theeveryday reality of forensic clinicians. Although forensic psychiatry has been named as a “moralminefield,” mainstream bioethics has yet to offer much guidance as to ethical responses to thecomplexities inherent to this practice specialty. Relational ethics, encompassing the core205

elements of engagement, the interdependent environment, and uncertainty/vulnerability, seeks toidentify the fitting response to an ethical question, rather than the right or the good. It has thepotential to meet the need for an appropriate ethic for interdisciplinary forensic psychiatry teams.Comparisons between Psychiatrists’ and Mental Health Nurses’ DecisionMaking in Civil CommitmentAnthony O’Brien, University of Auckland (a.obrien@auckland.ac.nz)Clinician perception of use of mental health legislation has been suggested as contributing tovariation in rates of civil commitment. Variation has been reported in a number of jurisdictionsinternationally and is evident in New Zealand. The primary aim of this study was to develop andtest the psychometric properties of a questionnaire designed to measure clinician perceptions ofuse of mental health legislation. Secondary aims were 1) to test the hypothesis that cliniciandifferences in perceptions of use of legislation are associated with the rate of committal of theirmental health service, and 2) to test the hypothesis that nurses and psychiatrists show differencesin clinical decision making. Two instruments were used to measure clinician perception ofmental health legislation in nine New Zealand health districts. Districts (n=9) were selected torepresent those with high and low rates of use of civil commitment. Clinicians (n=168) wereasked to rate clinical vignettes thought to be typical of those in which mental health legislationmight be considered. A 24 item survey of attitudes to civil commitment was developed andtested using exploratory factor analysis. The study used a purposive sample of mental healthnurses (n=98) and psychiatrists (n=70). This paper will focus mainly on the comparisonsbetween psychiatrists and nurses and will discuss the implications for the functioning ofmultidisciplinary teams and for decision making in relation to mental health legislation.85. Intimate Partner Violence: Theory and PracticeThe Aetiology of Intimate Partner Violence and Implications for Practice andPolicyLouise Dixon, University of Birmingham (l.dixon.1@bham.ac.uk)Nicola Graham-Kevan, University of Central Lancashire (ngraham-kevan@uclan.ac.uk)Purpose: This review critiques popular theoretical accounts of intimate partner violence (IPV). Itprovides a synthesis of methodologically sound research to understand how this social problemis best conceptualised and the implications for practice and policy. Background: Practice andpolicy in the domain of IPV is often informed by opinion and research driven by a genderedperspective, despite the wealth of evidence supporting the need to further explore and respond tothe spectrum of IPV from a gender inclusive perspective. Theory underlying hypotheses about206

the nature and aetiology of IPV is important as it informs professionals how they can bestrespond to reduce or eliminate this problem. Therefore, it is crucial that practice-led initiativesare driven by theory that is supported by good quality empirical evidence.Key points: The theoretical perspective and resultant methodology used to investigate IPV canaffect how the aetiology and nature of this behaviour is understood. Policy makers, academicsand practitioners should be aware of the need to examine the methodological rigour of research,before applying its findings to prevention and intervention. A wealth of quality research hasconsistently found evidence for a complex aetiology of IPV, used by men and women, which canoverspill into the parent-child relationship.Conclusion: The use of a gender inclusive approach to guide research and practice into IPV iswarranted. Evidence based practice is essential if the field is to move toward developingstrategies to effectively combat family violence.The Functional Relationship between Alcohol and Intimate Partner AbuseLiz Gilchrist, Glasgow Caledonian University (liz.gilchrist@gcal.ac.uk)Alasdair Forsyth, Glasgow Caledonian University (alasdair.forsyth@gcal.ac.uk)Lana Ireland, Glasgow Caledonian University (lana.ireland@gcal.ac.uk)Alcohol has been identified as a common feature of intimate partner abuse (IPA), viaintoxication at the time of abusive events, and as a correlate of abusive relationships. Alcoholproblems are linked with higher likelihood of physical and psychological abuse and the injuryassociated with intoxicated violence tends to be higher. Surprisingly little is known about howthis association functions. Much of the reluctance to investigate this area has been due to a focuson societal level explanations for IPA and, at the individual level, a desire to avoid allowingperpetrators to use alcohol as an excuse. This study will a) explore the links between alcohol(AUDIT scale) and relationship conflict and abuse (CTS-2) with follow up qualitative interviewsto explore the meanings of any relationships found, across a range of individuals who vary bysocio-economic status and level of relationship conflict. This presentation will present the initialdata from this study and discuss implications for theoretical models of IPA and for interventions.Personality Profiles of Male Desisters from Physical Partner ViolenceKate Walker, Coventry University (walkerk3@coventry.ac.uk)Sarah Brown, Coventry University (sarah.brown@coventry.ac.uk)Erica Bowen, Coventry University (e.bowen@coventry.ac.uk)207

A proportion of men who use violence in a relationship do desist over time although themechanisms responsible for this remain unclear. The objective of this paper was to examine andcompare the personality profiles of those who reported they have desisted from, persisted in ornever engaged in violence against an intimate based on the Revised Conflict Tactics Scale. Thedesign was between subjects. Due to the prevalence of personality disorders in perpetrators ofIPV an analysis of the sub-scales of the Millon Clinical Multiaxial Inventory-III usingMANOVA was conducted on data from desisters, persisters and the control group.Approximately 40 desisters and 40 persisters were recruited from those attending voluntarytreatment programmes in the community or those referred for treatment through probation. Asimilar size control group was recruited. Initial findings suggest that higher percentage ofoffenders had personality disorders compared to controls. There was also evidence of differencesin some of the sub-scales between the desisters and persisters with desisters evidencing morescores at clinical level. The findings indicate the need to screen for personality disorders prior totreatment, as the needs of these individuals are likely to differ significantly depending on thenature and severity of the disorder. Research now needs to be extended to include other measuressuch as attachment styles and self-control. Comparisons can then be made to examine how thesediffer between desisters, persisters and those who do not use violence in a relationship.Strengthening Probation: The Development of a Brief Solution-FocusedIntervention for Perpetrators of Intimate Partner ViolenceEmma Holdsworth, Coventry University (Aa7076@coventry.ac.uk)Erica Bowen, Coventry University (e.bowen@coventry.ac.uk)Riana Taylor, Wiltshire Probation Trust, Swindon, UK(riana.taylor@wiltshire.probation.gsi.gov.uk)The drive towards evidence based practice in the UK has led to the development of a range ofaccredited, government-mandated programmes delivered in probation and prison services whichare notoriously costly and resource intensive. Moreover, such interventions are typically aimed atmedium or high risk offenders thereby addressing the needs of only a proportion of maleperpetrators who use violence in relationships. This has led to a call for brief, non-accreditedprogrammes to meet the needs of this overlooked population. This presentation will provide anoutline of the development of one such innovative programme in a UK Probation Trust, drawingupon principles of brief solution-focused therapy. The rationale for the approach taken and theresulting intervention will be detailed. Preliminary findings regarding the acceptability andimpact of the programme will also be provided.Changing Attitudes toward Dating Violence in Adolescents (CAVA): TheDevelopment of a Serious Game-Based Primary InterventionErica Bowen, Coventry University (e.bowen@coventry.ac.uk)208

Matthew Mawer, Coventry University (m.mawer@coventry.ac.uk)Emma Holdsworth, Coventry University (aa7076@coventry.ac.uk)Emma Sorbring, University of the West (emma.sorbring@he.sv)Bo Helsing University of the West (bo.helsing@he.sv)Eline Leen, University of Erlangen (eline.leen@fim.uni-erlangen.de)Paul Held, University of Erlangen (paul.held@fim.uni-erlangen.de)Valère Awouters, Limboug Catholic University College (valere.awouters@khlim.be)Sebastiaan Jans, Limboug Catholic University College (sebastiaan.jans@khlim.be)Attempts at evidence-based tertiary intervention for intimate partner violence perpetrators arenotoriously contentious, with questionable empirical evidence of their ability to effectivelyreduce violence in relationships. Consequently, there is an international drive to develop primaryprevention strategies, aimed at targeting general adolescent populations at a point where intimaterelationships are becoming important. This presentation will detail the development of a highlyinnovative serious game-based intervention which has modified typical schoolroom curricula foruse through a computer-mediated approach. The foundations of the intervention will be detailed,excerpts of the intervention will be showcased and preliminary findings of the acceptability andimpact of the intervention will be examined.86. Involuntary Admission and Treatment in Norway: Principlesand PracticePredictors of Involuntary Hospitalization to Acute PsychiatryKjetil Hustoft, Stavanger University Hospital, Stavanger, Norway (khu2@sus.no) (+4790998510)Tor Ketil Larsen, Stavanger University Hospital, Stavanger, NorwayBjorn Auestad, University of StavangerInge Joa, Stavanger University Hospital, Stavanger, NorwayJan Olav Johannessen, University of Stavanger & Stavanger University HospitalTorleif Ruud, Akershus University Hospital & University of OsloIntroduction: There is little knowledge of predictors for involuntary hospitalizations in acutepsychiatric units.209

Method: The Multi-center study of Acute Psychiatry included all cases of acute consecutivepsychiatric admissions in twenty acute psychiatric units in health trusts in Norway, The datawere registered during the admission process, including rating of Global Assessment ofFunctioning and Health of the Nation Outcome Scales.Results: Fifty-six percent of the patients were referred for voluntary hospitalization, 44 percentwere referred for involuntary hospitalization. In a regression analysis we found that the strongestpredictors for involuntary hospitalization were contact with police, referral by physicians whodid not know the patient, contact with health services within last 48 hours, not living in ownapartment or house, high scores for aggression, level of hallucinations and delusions, and contactwith an out-of office clinic within last 48 hours and low GAF symptom score. Involuntarypatients were older, more often male, non-Norwegian, unmarried and had lower level ofeducation. They more often had disability pension or received social benefits.Conclusion: Involuntary hospitalization seems to be guided by the severity of psychiatricsymptoms and factors “surrounding” the referred patient. Important factors seem to be malegender, substance abuse, contact with own GP, aggressive behavior, and low level of socialfunctioning and lack of motivation. There was a need for assistance by the police in a significantnumber of cases.Involuntary Hospitalization of First-Episode Psychosis with Substance AbuseDuring a 2-year Follow UpAnne Opsahl, Sørlandet Hospital, Kristiansand, Norway (anne.opsal@sshf.no) (+47 90932859)Thomas Clausen, Norwegian Center for Addiction Research (SERAF), University of Oslo &Sørlandet Hospital, Kristiansand, NorwayØistein Kristensen , Sørlandet Hospital, Kristiansand, NorwayIvar Elvik, Stavanger University Hospital, Stavanger, NorwayInge Joa, Stavanger University Hospital, Stavanger, NorwayTor K. Larsen, Stavanger University Hospital, Stavanger, NorwayObjective: To investigate whether substance abuse (alcohol or illegal drugs) in patients withfirst-episode psychosis (FEP) influenced treatment outcomes such as involuntary hospitalizationduring follow-up.Method: First-episode psychosis patients (n = 103) with consecutive admissions to acomprehensive early psychosis program were included and followed for 2 years. Assessmentmeasures were the Positive and Negative Syndrome Scale, Global Assessment of Functioning,and the Clinician Rating Scale (for substance abuse).Results: Twenty-four per cent of patients abused either alcohol or drugs at baseline. The dropoutrate at 2 years was the same for substance abusers as for non-abusers. Substance use was not210

educed over the 2-year period. At 2-year follow-up, 72% of substance abusers and 31% of nonabusershad experienced at least one occasion of involuntary hospitalization. Patients withsubstance abuse had significantly higher risk for involuntary hospitalization during follow-up(OR 5.2).Conclusion: To adequately treat patients with FEP, clinicians must emphasize treatment of thesubstance abuse disorder, as well as the psychotic illness. Patients with defined comorbidsubstance use disorders and FEP are likely to have poorer treatment response than those withpsychosis alone.Perceived Humiliation in an Psychiatric Emergency Unit in NorwayMarit Svindseth, Aalesund University College & Aalesund Hospital (marit.svindseth@mac.com)(+47 70154163)Perceived humiliation in a psychiatric emergency unit in Norway. Patients (N=186) wereinterviewed and reported their level of perceived humiliation in different situations. We alsocompared differences and similarities between voluntary and involuntary patients.Psychiatric Ambulance – A New Feature in the Psychiatric Emergency CareKjetil Hustoft, Stavanger University Hospital, Stavanger, NorwayJan Olav Johannessen, University of Stavanger & Stavanger University Hospital, Stavanger,NorwayTor Ketil Larsen, Stavanger University Hospital, Stavanger, NorwayInge Joa, Stavanger University Hospital, Stavanger, NorwayFrode Bremseth, Stavanger University Hospital, Stavanger, NorwayRobert Jørgensen, Stavanger University Hospital, Stavanger, NorwayTrond Holbræk-Hanssen, Stavanger University Hospital, Stavanger, NorwayMaalfrid Frahm Jensen, Stavanger University Hospital, Stavanger, NorwayStavanger University Hospital started in 2010 a new pre-hospital service by creating apsychiatric ambulance vehicle in service during every day working hours from 8 AM until 22PM.Patient organizations and patient relative organizations through a joint letters from mayors in thecounties in the hospital catchment area asked for a better and more equal right for bothpsychiatric patients and somatic patient of emergency transportation to and from the hospital.211

The year 2011 was the first full year of psychiatric ambulance services. The service aims whereto reduce the stigma of being a psychiatric patient in an emergency situation, and avoidinguniformed police car and personnel transporting patient from the patient’s neighborhood.Method: All 838 psychiatric ambulance missions during 2011 in Stavanger, Norway.Results: The psychiatric ambulance mission started at the home of the patient in 26.6 percent ofall cases, 11 percent started at a shared county housing site, and 5.7 percent at an out-of -officeemergency clinic. The psychiatric ambulance started its mission in 39.1 percent of the caseswithin the hospital emergency unit or a district psychiatric center. In 42.7 percent of the cases thepatients were on a voluntary admission paragraph.In 83.4 percent of the missions there were no uses of the police during transportation to or fromthe psychiatric units.Conclusions: A psychiatric ambulance as a part of pre-hospital emergency service may reducethe use of police and coercive measures during admission voluntary or involuntary.87. Involuntary Outpatient TreatmentInvoluntary Outpatient Treatment around the WorldCarlos Cañete-Nicolás, Hospital Clínico Universitario, Valencia, Spain(carloscanetenicolas@hotmail.com)Involuntary outpatient treatment (IOT) for people with severe mental illness is common practicein countries like the USA, Canada, the UK, Australia, New Zealand and Israel. In general, theadministration of required medication is not included, except in Australia. Prolonged exitpermissions or supervised discharges are applied in countries like France (output test), Germany(23), Belgium, Luxembourg and Portugal. In England and Wales, with the new Mental HealthAct (Mental Health Act 2007), supervised discharges are replaced by supervised communitytreatment. This mode allows the patient to be discharged from hospital and continue treatment inthe community, with the possibility of returning to the hospital if the patient does not meet thecommunity treatment orders. In Spain there is no specific legislation on IOT but it is used locallyin some cities. Canadian and Australian studies on IOT indicate a prevalence of 5-15 per 100,000in the general population. In the USA, more than half the states have some form of compulsorycommunity treatment, used in about 3 of every 100,000 in the general population, 9.8% of newreleases and 7.1% of outpatients.Involuntary Outpatient Treatment for Persons with Severe Mental Illness:Results in the City of Valencia, SpainGuillem Lera-Calatayud, Hospital of Alzira, Valencia, Spain (guillemlera@comv.es)212

Involuntary outpatient treatment (IOT) is non-voluntary treatment applied in the community toensure therapeutic compliance by patients with severe mental illness and little insight, in whichnoncompliance involves a high risk of relapse, disruptive and violent behaviours, or frequenthospitalizations and emergency care. Although there is no specific legal regulation in Spain onIOT, some experiments have been launched in the last 15 years, in various Spanish cities, withthe aim of improving treatment adherence in individuals with severe mental illness and avoidingthe extremes of hospitalisation and civil incapacitation. This paper presents the results of twoobservational, retrospective studies of patients undergoing involuntary outpatient treatment in thecity of Valencia. We describe the psychiatric diagnosis, the persons seeking this treatment, andthe reasons for seeking it. We compare the number of emergencies and admissions and theaverage length of stay in the 6 and 12 months before and after the introduction of courtauthorization. Finally we analyze the events occurring during this period of time. Our impressionis that IOT is a measure that can be beneficial for some patients with severe mental illness and anadequate legal framework is required to explicitly govern its implementation.Involuntary Outpatient Treatment: The Views of the People InvolvedMiguel Hernández-Viadel, Hospital Clínico Universitario, Valencia, Spain (mhv4@comv.es)Involuntary outpatient treatment (IOT) aims to improve compliance with treatment, preventingthe deterioration of patients with severe mental illness and reducing the risk to themselves andother people. IOT is not free of controversy. Those who defend it regard it as a way of ensuringthat treatment is carried out, while opponents consider it a violation of the basic rights of theindividual, leading to an increase in coercion and stigmatisation of psychiatric patients. Thispaper presents a descriptive study, for which we have attempted to collect the opinions of peopleinvolved in IOT. The group studied was made up of all the patients in Involuntary OutpatientTreatment in the city of Valencia at the beginning of the project in October 2005, their relatives,and their outpatient unit psychiatrists. The results show that the great majority of psychiatristsand relatives think that IOT has been beneficial for patients’ treatment. There has even been anoverall clinical improvement since it was introduced. As for the opinion of the patients, over halfof them also feel that IOT has been a beneficial measure for their treatment.Social Influences and Challenges in Mandating Community Treatment OrdersNicole Snow, Faculty Centre for Nursing Studies & University of Alberta (nsnow@cns.nf.ca)Invoking Mental Health Acts and other legislation in mental health care is often controversial.While the law stipulates courses of action, occasionally these mandated processes arechallenging to follow, they are not amenable to the actualities in which they will be used, or they213

can be interpreted in a vast number of ways. Such is the case for Community Treatment Orders(CTOs). The purpose of this presentation is to present the findings of a study using InstitutionalEthnography (IE) that explored CTOs in Newfoundland and Labrador, Canada. Participants inthis study included clients, family members, and health professionals, administrators, and otherswho had experience with CTOs in mental health settings. Data collected through interviews andreview of institutional documents were examined for evidence of the social web of influence thatgoverns everyday actions. IE elucidated the everyday work/life experiences with CTOs andshowed how they were influenced by institutional social structures and discourses known asruling relations (Smith, 2005). It also uncovered disjunctures, points where what was actuallyoccurring did not match what was supposed to be occurring. In bringing these patterns anddisjunctures to light, hopefully the resulting awareness will foster a greater understanding ofCTOs, how issues may arise, and how best to deal with such concerns.88. Involuntary Treatment and HospitalizationFreedom Restrictions in Child and Adolescent Psychiatry: Future DutchLegislationVivianne Dorenberg, VU University – Medical Centre (v.dorenberg@vumc.nl)The legal position of young people with mental illness in the Netherlands is governed by a widerange of laws and regulations. None of these laws or regulations present a clear legal frameworkfor freedom restrictions when admitted to a psychiatric hospital, and mental health care providersstruggle with this issue. The term "freedom restrictions" refers to all kinds of measures, fromhouse rules to restraint and seclusion. Current law focuses strongly on keeping patients (or othersin their environment) from harm or danger, without realizing that the treatment of children andadolescents with mental illness entails so much more. Mental health care providers especiallystruggle with pedagogical measures, like sending a child to his or her room. Current law does notrecognize these measures, which means there are no clear legal guidelines for executing them.The Compulsory Mental Health Care Bill (sent to Parliament in 2010) will bring some clarity,but we have to realize that most children and adolescents with mental illness are treated on avoluntary basis. This presentation will discuss current and future Dutch legislation concerningfreedom restrictions in child and adolescent psychiatry (focusing on future legislation) and theneed for practical guidelines.Freedom Restrictions in Care for Youth and Young Adults with a MildIntellectual Disability: Future Dutch LegislationBrenda Frederiks, VU University – Medical Centre (b.frederiks@vumc.nl)214

The legal position of youth and young adults with a mild intellectual disability, when it concernsrestrictive measures, is regulated by the Dutch Psychiatric Hospitals Act. A main principle in thisAct is respect for self-determination. Freedom restrictions are only allowed if all other forms ofcare (alternatives) are not successful and if danger to a client or others can be prevented.However, in practice (too) many freedom restrictions are used for several reasons: to protectclients, to prevent risks or to study aspects of a client (pedagogical reasons). Many restrictions donot meet the legal criteria but are used in a sense of controlling clients (improperly). Thispresentation will discuss current and future Dutch legislation concerning freedom restrictions inthe care for youth and young adults with an intellectual disability and the need for practicalguidelines. Current law, and proposed future law, does not fully recognize the specialcharacteristics of these clients. In the (Dutch) Care and Coercion Bill many aspects are missingthat would improve the legal status of young people with an ID.Ethical Dilemmas for Statutory Tribunals/Committees in Determinations ofInvoluntary HospitalizationSamuel Wolfman, Zefat Academic College (s.wolfman@wolfman-law.com)Mentally ill patients, whose reality judgment is severely impaired and consequently present adanger to themselves and/or others, may be involuntarily admitted to a secure psychiatric ward,for the safety of both themselves and the public. The Israeli Statute for the Treatment ofMentally Ill Patients sets out rules and procedures for involuntary confinement, and grantsauthority to statutorily appointed psychiatrists to issue initial involuntary admission orders. Apatient may appeal such an order before a judicial statutory tribunal/committee, acting as amental health court. Such committees are also the statutory forum for determining whetherinvoluntary hospitalization should be extended. The committee may face ethical dilemmas evenwhen there is no question regarding the psychiatric condition of the patient, if legal requirementsare not met. The basic legal concept is that a psychiatric disease by itself, as severe as it may be,is not enough for involuntary admission and treatment. Still, leaving the patient untreated mayresult in harsh consequences. This paper discusses the legal aspects of involuntary admissionsvis-a-vis the ethical and moral dilemmas such Statutory Committees may face when deciding toextend hospitalization or to release the patient from committal.Predictors of Involuntary Hospitalizations in Acute PsychiatryKjetil Hustoft, Stavanger University Hospital (khu2@sus.no)Little is known about predictors of involuntary hospitalizations in acute psychiatric units.Method: The Multi-center study of Acute Psychiatry included all 3326 cases of acute consecutivepsychiatric admissions in twenty acute psychiatric units in health trusts in Norway, representingabout 75 percent of the acute psychiatric units in Norway during 2005-2006. The data were215

egistered during the admission process, including ratings on the Global Assessment ofFunctioning and Health of the Nation Outcome Scales. Results: Fifty-six percent of the patientswere referred for voluntary hospitalization and 44 percent were referred for involuntaryhospitalization. In a regression analysis we found that the strongest predictors for involuntaryhospitalization were contact with police, referral by physicians who did not know the patient,contact with health services within the last 48 hours, not living in one’s own apartment or house,high scores for aggression, levels of hallucinations and delusions, contact with an out-of officeclinic within the last 48 hours and low GAF symptom scores. Involuntary patients were older,more often male, non-Norwegian, unmarried and had lower levels of education. They more oftenhad disability pensions or received social benefits. They were also more often admitted duringevenings and nights, found to have more frequent substance abuse at time of admission, wereless often responsible for children and were less frequently motivated for admission. Involuntarypatients also had less contact with psychiatric services before admission. Most patients werereferred because of a deterioration of their psychiatric illness. Conclusion: The picture aroundreferral for involuntary hospitalization is complicated and manifold. Involuntary hospitalizationseems to be guided by the severity of psychiatric symptoms and factors “surrounding” thereferred patient. Important factors seem to be male gender, substance abuse, contact with ownGP, aggressive behavior, low level of social functioning and lack of motivation. There was aneed for assistance by the police in a significant number of cases. This complicated picture offerssome important challenges for the organization of primary and psychiatric health services and aneed to consider better pathways to care.The Anatomy of a Forced ECT Legal ProceedingDennis B. Feld, New York Special Litigation and Appeals State Court, USA(dbfeld@courts.state.ny.us)In the effort to secure a court order overriding a patient's objection to proposed psychiatrictreatment, any manner of resistance to the clinician's treatment recommendation is portrayed bythe clinician as driven by the underlying disease process. The recent case of Matter of G.K.,where a trial court authorized the involuntary administration of 120 shock treatments within aperiod of one year, illustrates this unfortunate approach. In G.K., a relatively eloquent objectionto ECT was clinically interpreted as a delusional statement, and a history fraught with theemotional toll familial conflicts exact on a vulnerable person was no longer utilized by thepsychiatrist to gain a more thorough understanding of the patient, but used as a source ofdamning facts to highlight the patient's pathology and alleged lack of credibility. The case furtherillustrates that a person's actions to physically resist the proposed treatment, such as grabbing andeating a piece of bread in violation of the ECT protocol thus forcing the cancellation of the shocktreatment for that day, will not be viewed as a measured resistance to a procedure that anindividual has previously experienced as extremely unpleasant, but instead will be characterizedas a self-destructive act justifying additional psychiatric measures including the employment ofphysical and chemical restraints. The judicial outcome in G.K. brings psychiatry back to the1930's when psychiatrists Cerletti and Bini saw how the application of electrodes to hogs in theslaughter house overcame their resistance to the butcher's knife, and were inspired to try this216

process on a human subject. Matter of G. K. is not an indictment of ECT. Instead it stands as adire warning against the type of narrow focus which fails to appreciate the humanity of theresisting patient.Confine is Fine: Have the Non-Dangerous Mentally Ill Lost their Right toLiberty? An Empirical Study to Unravel the Psychiatrist’s Crystal BallDonald Stone, University of Baltimore School of Law (dstone@ubalt.edu)This presentation will examine the reverse trend in civil commitment laws in the wake of recenttragedies and discuss the effect of broader civil commitment standards on the care and treatmentof the mentally ill. The 2007 Virginia Tech shooting and the 2011 shooting of CongresswomanGiffords have spurred fierce debates about the dangerousness of mentally ill and serve ascautionary tale about what happens when warning signs go unnoticed and opportunities for earlyintervention missed. This presentation will explore the misconception about the role medicationand inpatient civil commitments should play in prevention of dangerousness and undermine thebelief that we can medicate away the needs of the mentally ill. The adverse effect civilcommitments can have on individuals’ long-term recovery, future employment prospects andoverall mental, physical, emotional and economic stability can be far-reaching; so minimum dueprocess protections must be carefully guarded. This presentation contends that civil commitmentdecisions should be based on concrete evidence that the individual is an imminent danger to selfor others and not on a psychiatrists’ speculation about future deterioration absent coercedtreatment. Statistical data, collected from a survey of 100 psychiatrists, will be examined todetermine what is most significant to psychiatrists in commitment decisions and highlight theimpact state standards and types of hospital facilities have on psychiatrists’ testimony at civilcommitment proceedings. Finally, this presentation will outline how “need for treatment” and“grave disability” provisions in commitment standards have stripped away due processprotections for the mentally ill and discuss ways mental health advocates can fight back toreverse this troubling movement in commitment laws.89. Issues Arising from the Detention of Children with MentalDisorder in ScotlandDetaining Mentally Disordered Children and Young Persons in Scotland (Part1)Valerie Mays, Mental Health Tribunal for Scotland, Edinburgh, Scotland(valerie.mays@scotland.gsi.gov.uk)217

The Mental Health (Care and Treatment) (Scotland) Act 2003 ("the 2003 Act") came into forcein 2005 and established the Mental Health Tribunal for Scotland ("the Tribunal"), a specialist,independent judicial body responsible for granting, approving and reviewing compulsorymeasures for the detention, care and treatment of people with mental disorder. The Tribunaldetains approximately 50 children a year as a result of the child’s mental disorder. While this is arelatively small number of cases, these cases are particularly sensitive and require specialconsideration. This is recognized in the 2003 Act itself. The 2003 Act is a progressive, patientfocused piece of legislation and includes specific provision in relation to children. Mostimportantly, section 2 of the 2003 Act introduces the welfare principle which provides that thosedischarging functions under the 2003 Act must do so in the manner which best secures thewelfare of the child patient. The 2003 Act places a statutory duty on health boards to provideservices and accommodation that are sufficient for the particular needs of the child where a childis detained. This was a clear attempt by the Scottish Parliament to legislate in order to tackleconcerns about children being inappropriately detained in adult wards due to lack of specialistfacilities. Further provision is made in the 2003 Act imposing a duty on persons having functionsunder the 2003 Act to mitigate the adverse effect of any compulsory measures on parentalrelations where a child or person with parental responsibilities is subject to measures authorizedby the 2003 Act. Valerie Mays, the Tribunal’s Solicitor, will describe how the Scottish Tribunalworks in practice and how the provisions in the 2003 Act operate to ensure that in casesconcerning the detention of children with mental disorder, the child is placed at the centre ofproceedings and any decision taken is made in a manner which best secures the welfare of thechild.Detaining Mentally Disordered Children and Young Persons in Scotland (Part2)J.J. Morrow, Mental Health Tribunal for Scotland, Edinburgh, Scotland(mhtspresidentsoffice@Scotland.gsi.gov.uk)The Mental Health (Care and Treatment) (Scotland) Act 2003 ("the 2003 Act") came into forcein 2005 and established the Mental Health Tribunal for Scotland ("the Tribunal"), a specialist,independent judicial body responsible for granting, approving and reviewing compulsorymeasures for the detention, care and treatment of people with mental disorder. The Tribunaldetains approximately 50 children a year as a result of the child’s mental disorder. While this is arelatively small number of cases these cases are particularly sensitive and require specialconsideration. The Tribunal is an expert Tribunal and the 2003 Act contains provisions whichseek to ensure that the child is placed at the centre of the judicial proceedings (covered in moredetail in Part 1 of this Presentation) and which require the Tribunal to make decisions in themanner which best secures the welfare of the child. Dr Joe Morrow, the President of theTribunal, will discuss the approach of the Tribunal in considering applications for thecompulsory care and treatment of children with mental disorder. He will cover the types ofmental disorder which have led to children being the subject of proceedings before the Tribunalin Scotland; the particular issues that arise in relation to cases involving children with mentaldisorder; the culture and ethos within which the Tribunal operates; the way in which the Tribunal218

seeks to ensure the participation of the child in the Tribunal proceedings including the practicaloperation of the relevant statutory provisions and other tools which the Tribunal can utilize toincrease the participation of the child; the specialist training which has been delivered tomembers of the Tribunal to equip them to deal with cases involving children and adolescents;and the deployment of those members to sit on cases involving children.Non-Specialist Mental Health In-Patient Care For Young PeopleElizabeth Calder, Mental Welfare Commission for Scotland, Edinburgh, Scotland(elizabeth.calder@mwcscot.org.uk)The Mental Health (Care and Treatment) (Scotland) Act 2003 places a duty on Health Boards toprovide age-appropriate services and accommodation for persons under the age of 18 who areadmitted to hospital because of mental disorders. Ideally, admission should be in a specific childor adolescent mental health facility. This is not always the case. Some young people are admittedto adult mental health facilities or, less commonly, paediatric general hospital wards. PreviousScottish Government policy was to reduce the number of admissions to non-specialist facilitiesby half. The Mental Welfare Commission for Scotland asks for reports on all people under 18who are admitted to non-specialist facilities. There has been no consistent reduction in theseadmissions across Scotland, although some Boards have performed better than others. Mostyoung people admitted to adult wards receive specialist input to their care. Some do not and, inour view, receive inadequate and sometimes unlawful care. This presentation reports on theCommission’s work in this area, including case reports where we found significant deficienciesof care.Patterns and Trends in Detention of Young People in ScotlandDonald Lyons, Mental Welfare Commission for Scotland, Edinburgh, Scotland(donald.lyons@mwcscot.org.uk)The Mental Welfare Commission for Scotland provides reports on the operation of mental healthand incapacity legislation in Scotland. We publish statistical reports and conduct specialmonitoring of the detention of young people. We also visit people subject to detention,investigate improper detention, abuse, neglect or ill-treatment and we give advice and promotebest practice on applying best legal and ethical principles to individuals’ care and treatment. Thispresentation will focus on statistics on the use of mental health legislation in Scotland since theimplementation of the Mental Health (Care and Treatment) (Scotland) Act 2003. There has beensome variation in the use of the Act over the last few years. In particular, we have seen a rise inthe use of the Act for females under the age of 18. We will present our analysis of these casesand suggest reasons for this rise. We have found uncertainty among practitioners on when to usemental health legislation and when to rely on parental consent for treatment. We are often asked219

for advice in this situation. Our recommendation is usually to use mental health legislation. Wewill discuss the human rights basis for this recommendation.90. Jail and Mental Illness: Designing a Care System based onEmpirical Evidence and Program EvaluationTrends of Jail Recidivism and Mental Illness and Substance Abuse among thoseEntering JailChristina D. Kang-Yi, University of Pennsylvania (ckangyi@upenn.edu)Laura Murray, University of Pennsylvania (lamurray@gse.upenn.edu)Amy B. Wilson, Case Western Reserve University (abw38@case.edu)Trevor Hadley, University of Pennsylvania (thadley@upenn.edu)About 13 million people are admitted to jail in the U.S. each year (US Department of Justice,2011). Previous research has found that over 50% of those entering jail return within a year. Therecidivism rate was lowest among persons with serious mental illness, while the rate was highestamong those with dual diagnoses of serious mental illness and substance abuse disorder (Wilsonet al., 2011). These findings have increased the awareness of the importance of mental healthinterventions for persons with serious mental illness and substance abuse. Our study replicatesprevious studies using more recent jail and Medicaid claims data from Philadelphia County inthe U.S. to examine if there have been any changes in the trend of jail recidivism in relation tomental illness and substance abuse. The length of jail stay, risk factors for jail entry and jailrecidivism pattern of people with mental illness or substance use disorders compared with thosewithout the conditions are examined. Individuals who entered or left the Philadelphia PrisonSystem in the years 2007 through 2011 and individuals eligible for Medicaid or County FundedMental Health Services in Philadelphia County from 2007 through 2011 are included in thestudy.Impact of Mental Health Programs on Jail RecidivismTrevor Hadley, University of Pennsylvania (thadley@upenn.edu)Christina D. Kang-Yi, University of Pennsylvania (ckangyi@upenn.edu)Amy B. Wilson, Case Western Reserve University (abw38@case.edu)Laura Murray, University of Pennsylvania (lamurray@gse.upenn.edu)This study identifies mental health programs provided to persons with mental illness entering jailin Philadelphia County in the U.S. and examines the effect of mental health programs on jail220

ecidivism. Previous research (Wilson et al., 2011) that examined jail recidivism and mentalillness found that a lower proportion of persons with serious mental illness reentered jailcompared to those with no mental illness diagnosis. While this finding may indicate the positiveimpact of mental health programs on jail reentry, there is a lack of evidence on the effect ofmental health interventions on jail reentry. Our study identifies the mental health programsdesigned to decrease jail recidivism in the Philadelphia County of the U.S. and examines theeffect of the programs on jail recidivism. Individuals who have entered or left the PhiladelphiaPrison System in the years 2007 through 2011 and individuals eligible for Medicaid or CountyFunded Mental Health Services in Philadelphia County from 2007 through 2011 are included inthe study.Service Utilization Patterns of People with Mental Illness Leaving JailAmy B. Wilson, Case Western Reserve University (abw38@case.edu)Christina D. Kang-Yi, University of Pennsylvania (ckangyi@upenn.edu)Trevor Hadley, University of Pennsylvania (thadley@upenn.edu)Jeffrey Draine, Temple University (jeffdraine@temple.edu)Arthur Evans, Jr., City of Philadelphia Department of Behavioral Health, USA(arthur.c.evans@phila.gov)Over 9 million people are released from jails in the U.S. each year, a million of whom havemental illness (Kubiak et al. 2011). Prior research has found that receipt of community basedmental health services after release can reduce recidivism (Morrissey et al, 2007). Research onpeople with mental illness leaving prison has found low rates of service utilization that is marredby service disruptions and low levels of clinical intensity (Lovell et al., 2002). This paper willpresent findings from a study of the service utilization patterns among people with mental illnessleaving jail. It uses a cohort of people with serious mental illness admitted to jail in 2003(N=1,185). This analysis will present findings related to the length of time to receipt ofcommunity mental health services after release, the types of services received, intensity ofservices, and disruptions over a 3 year period after release. Discussion of how the utilizationpatterns described above vary based on the presence of co-occurring substance use disorders willbe included.Programs Designed for Diversion and Aftercare of Mentally Ill from JailArthur Evans, Jr., City of Philadelphia Department of Behavioral Health, USA(arthur.c.evans@phila.gov)Trevor Hadley, University of Pennsylvania (thadley@upenn.edu)221

Previous presentations in this session have provided empirically based background informationabout the real patterns of use and misuse of jail by people with serious mental illness andsubstance abuse. This presentation will focus on how that information has been used in a largecity’s behavioral health system to design and implement innovative and cost-effective programsto provide diversion and aftercare services to persons with serious mental illness and oftencomorbid substance abuse in the jail system. Over the past five years the City of PhiladelphiaDepartment of Behavioral Health has designed and implemented four new programs designed tobetter serve the needs of clients who are cared for in the system but enter or are about to enterjail. The four programs focus on creating connections to the care system and aggressivelyfollowing-up for a variety of clients. Descriptions of these four programs including the mentalhealth court, the diversion program, and follow-up aftercare programs will be provided. Theseprograms in many ways are designed to meet the needs of clients and reach out to them at themost appropriate time. Discussion will focus on how the design of these programs wasinfluenced by the previously described studies.91. Juveniles/YouthSelf-Esteem and Narcissism in Adolescence: Relations With Self-ReportedDelinquency in the Forensic and School ContextRui Manuel Xavier Vieira, University of Lisbon (ruivie2@gmail.com)The aim of the present study was to analyze the relative importance of self-esteem andnarcissism constructs and to assess the association between these constructs and self-reportedcriminal behavior. With a total of 760 youths of both sexes divided in a forensic sample (n =250) and a school sample (n = 510), comparisons was made with respect to the two constructsand a multiple regression model was employed, using self-reported delinquency as the dependentvariable. The results indicate that the forensic sample is characterized as having low self-esteemand high narcissism when compared to the school sample, that the correlation between the twoconstructs is almost non-existant, and that narcissism is the variable that contributes the most tothe prediction of self-reported delinquency.Do Gender and Traumatic Experiences Increase the Likelihood that JuvenileOffenders will Feel Angry or Irritable?Henrika McCoy, University of Illinois at Chicago (hmccoy@uic.edu)Traumatic experiences (TE) are common among juvenile offenders and are often comorbid withmental health disorders. Much of the research about TE highlights its relationship with PTSD butnot with other mental health disorders. This study explores whether gender and having at least222

one TE are associated with a greater likelihood of obtaining a “Caution” or “Warning” score onthe Angry/Irritability (AI) domain of the MAYSI-2, an international mental health screeningtool, which would indicate a level of disturbance warranting special attention. Methods: MAYSI-2 data (N=1,992) collected between 2006 and 2010 from a U.S Midwestern juvenile detentionfacility were analyzed using chi-squares and logistic regression. Results: 81% of males and 84%of females experienced at least one TE. The relationship between gender and TE was notsignificant, but the relationship between TE and the AI domain was significant (χ2=252.0807,df=5, p

items. Method: Data (N=1,992) were collected between 2006 and 2010 from a United StatesMidwestern juvenile detention facility. Results: Chi-square analyses revealed n=84 felt lonelyand had suicidal thoughts (χ2=150.41, p

Sofia T. Sepanyan, University of California at Los Angeles (sofia.stepanyan@yahoo.com)Much of the research on juvenile competency to stand trial (CST) has focused on age andintellectual functioning as consistent predictors of competency status. Clinical correlates of CSTstatus, such as psychopathology, diagnostic severity and presence of co-occurring disorders areless understood in young offenders. Only a limited number of studies have focused onpsychiatric disorders (Grisso, 2005) and diagnostic severity (Cowden and McKee, 1995; Vijoen,Roesch, & Zapf) as predictors of juvenile CST status. The current study aimed to investigate theextent to which diagnostic severity and psychiatric comorbidity predict CST status in a sample of324 juvenile participants in the Los Angeles County Juvenile Mental Health Court. Preliminaryanalyses identified that age, intellectual functioning, mental retardation, pervasive developmentaldisorders, mood disorders, substance use disorders and psychotic disorders are significantcorrelates of CST status in young offenders. Given that delinquent populations are at higher riskfor displaying mental and developmental disabilities, improved understanding of therelationships between CST status and mental health conditions is critical and may provideguidance on determining the types of services and rehabilitation programming young offendersmay need to proceed with their legal cases.92. Law and Emotions IEmotions in Lower Court Hearings: Some Sociological ReflectionsStina Bergman Blix, Stockholm University (stina.bergmanblix@sociology.su.se)Submission to the law requires a widely shared trust in the function of the judicial system touphold rational and impartial justice, supposedly presuming non-emotionality. This ideal ischallenged by research indicating that emotions are embedded in most everyday interactions ofbureaucratic and rational organizations. In fact, the conflicts solved in court often stem withemotions. For the participant laymen, the plaintiff and the defendant, the reasons for being incourt have emotional antecedents as well as consequences. For the defence lawyers, prosecutors,and judges the efforts to manage their own emotions as well as the emotions of the involvedlaymen in a way conducive to the dramaturgy of the hearing are essential aspects of the legalproceedings. Granted, it may be a problem that the role of emotional processes in the productionof justice is neither fully recognized nor sufficiently scrutinized. There is a need to know moreabout how this tacit professional competence is acquired and applied. The purpose of this paperis therefore to study the learning and mastery of emotions and emotion management using theexample of the Swedish lower courts. The focus is on the components comprising a process ofprofessionalization regarding emotion work in terms of how they are patterned, emphasized, andevolve over time. Put in more applied terms: which are the feeling and display rules inherent toeach of the role performances involved? How are they learned and sustained individually and asa collective achievement in courtroom interaction?225

The Emotional Performance of Neutrality in the CourtroomAsa Wettergren, University of Gothenberg (asa.wettergren@gu.se)In modern democracies justice is based on reason, presuming non-emotionality or, as Weber putit in his work on the rationality of bureaucracy: ‘without anger and fondness.’ Thus rationality isan ideal shared by all the bureaucratic agencies of democratic society, but it is especially crucialto the judicial system as seen in its main guiding principle: with impartiality and objectivity.Other associated mottos cherished by the Swedish legal professions are: ‘Justice must not onlybe done, but must also be seen to be done’, and ‘society shall be built by law’ (civitas legibusaedificetur — the motto of the Swedish king Karl XV 1859-1872). From this perspective, thelaw and the judicial system constitute the backbone of democratic society. Contrary to the idea ofnon-emotionality, submission to the law rests on emotional grounds, for it requires a widelyshared trust in the function of the judicial system. The moment it appears partial it will no longerserve to unite various social groups and collectives under the framework of one law. Banningemotions from the court is a way to contain the perceived partiality of group affiliations; to keeptheir consequentiality at bay. Meanwhile, the idea that an emotion necessarily gives rise to anaction is followed by the almost superstitious belief in ‘out of sight out of mind’. That is, anemotion not expressed does not exist, and hence, is not a problem. Research on the emotions oflaw has only begun to unpack the complexity of the emotion work performed in and by thecourts. This paper takes as point of departure existing research in this area, research on emotionsin organizations, and power/status theories of emotions, and contributes with an analysis of theneutral court as a collective performance, sometimes bitterly (but subtly) fought out in the courtroom. The legal professions – judge, prosecutor and lawyer – are here up against thesurreptitious emotional expressions of lay judges and the more obvious, at times indeeddramatic, emotional expressions of laymen appearing as defendants, plaintiffs, and witnesses.Based on observations of a number of court hearings in Swedish district courts, the analysis willfocus on how a-emotionality is staged, attained and sustained in court hearings. It will track thesubtle and disguised emotional expressions of triumph, resentment, disgust, disbelief, fear,competition, and so on, that can nevertheless be expected to be present. Unveiling the vividemotionality of ‘non-emotionality’, the analysis suggests that lack of emotional expressions doesnot mean that an emotion is contained. This widely shared but tacit assumption in the legalprofessions may in fact be a bigger threat to societal trust in the impartiality of the law, thanmore open and acknowledged emotional expressions would be.Identifying and Interrogating Judicial EmotionTerry Maroney, Vanderbilt University (Terry.Maroney@law.vanderbilt.edu)Judges invariably have emotional reactions to their work. Our legal culture, however, long hasinsisted that a “good judge” either feels no emotion or puts it firmly aside. Insistence onjudicial dispassion distorts judges’ efforts to manage the experience and expression of their226

emotions; further, it makes that emotional labor difficult to observe. The project I will describehas three goals. First, it seeks to dislodge the cultural commitment to judicial dispassion, bydemonstrating not just emotion’s inevitability but also its value. The affective sciencesconvincingly have shown that emotion reflects beliefs and values and motivates action; far frombeing inherently irrational, it contains its own rationality. Second, the project seeks to expandour ability to discern judicial emotion, including through empirical investigation. Judgessometimes self-report emotional reactions, and such reactions sometimes leak through in theirwords and actions. I gather together such evidence to suggest the range of judges’ emotionalexperiences, and outline the prospects for more systematic empiricism. Third, the project seeksto closely analyze the benefits and dangers of specific emotions in light of the judge’s role. Ituses judicial anger as the illustrative example, and shows how such anger can serve as either apositive or negative force in judging, depending on the beliefs and values it reflects, the mannerin which it is expressed, and the impact of such expression—both on others, such as litigants andcolleagues, but also on popular perceptions of justice.93. Law and Emotions IIGodly Jealousy, Righteous Anger and Loss of Self-ControlJohn Stannard, Queen’s University Belfast (j.stannard@qub.ac.uk)The focus of this paper is the perceived boundary between ‘good’ and ‘bad’ emotions, and theway in which it is reflected in the common law defence of loss of self-control in cases of murder.Jealousy and anger are now often seen in negative terms, but this contrasts with an older notionseen in the Bible and other literature, whereby such emotions can be both righteous and justified.Similarly, modern English law no longer allows the defendant in a murder case to rely on loss ofself-control triggered by sexual infidelity, in contrast to the traditional doctrine where the findingof a wife in adultery was one of the few factors, short of a physical attack, that would allow thedefence to be raised. The paper seeks to explore the parallels between these two developments,the aim being to cast light on the broader relationship between emotion and criminal culpability.Lay and Professional Conceptualizations of Emotions: In Search of CommonGroundTimothy Ritchie, University of Limerick (tim.ritchie@ul.ie)Eimar Spain, University of Limerick (eimear.spain@ul.ie)Research has shown that there are basic differences in how people think about and express theirown feelings. For example, Maio and Esses (2001) demonstrated that people have fundamentallydifferent ‘needs for affect’. Their research showed that, in general, some people prefer to227

approach emotion-inducing situations, whereas others prefer to avoid such situations. While thismay seem intuitive or common sense, there is still much to be learned about such basicindividual differences. The authors aimed to reveal the extent to which people'sconceptualizations of emotions overlap and differ, focusing on differences between the legal andmental health professions and whether individuals are influenced by sector specific display rules(Diefendorff, Erickson and Grandey, 2011). Further, there is an evident reluctance in law toengage explicitly with emotions (Kahan & Nussbaum, 1996), with emotions tending to beviewed in substantive law as highly irrational or ignored altogether (Reilly, 1997, 1998;Maroney, 2006). Hence, in the present study we examined if individuals working within the legalprofession adhere to this view about the nature of emotions. We attempted to illuminate adiscussion through comparison of conceptualizations with professionals in other disciplines. Forexample, at the other extreme, psychologists tend to be progressive in their theorizing andconceptualizations of emotions, so progressive in fact that oftentimes a long passage of time maytranspire before the scientific and applied fields wait to see which competing view 'wins'. Weaimed to elucidate both extremes, and at the same time assess lay persons' views and beliefsabout emotions, to assess, in part, which professional view(s) theirs overlaps with most, legal orscientific, if not a popular psychological notion of emotions. To achieve this we obtainedqualitative and quantitative data using a variety of research methods from individuals who workin the legal and mental health professions, as well as from the general public (i.e., from peoplewhose conceptualizations of emotion do not relate directly to their jobs, lay conceptions).Sibling Rivalry and the Emotions of Inheritance DisputesHeather Conway, Queen’s University Belfast (h.conway@qub.ac.uk)Succession law affects all families at an emotionally vulnerable time. As the family unitstruggles to adapt to the loss of a key figure, inheritance issues are a frequent source of conflict,especially between adult children. Sibling rivalry, underpinned by jealous struggles for parentalattention and affection, is one of the most common and destructive forces within families.Childhood resentments and feelings of anger or injustice based on perceptions of favouritism andpreferential treatment re-emerge on the death of a parent, as adults who can no longer fight forthe parental attention they craved as children compete for material possessions instead. Tensionsoften run high; yet in most instances, dividing family wealth is merely a catalyst for deep-seatedfeelings and old grudges which cannot be resolved because the parent is no longer there toarbitrate. Siblings involved in inheritance disputes will go to extraordinary lengths – not just tomake sure they are getting their fair share, but often simply to deny their brothers and sisters alarger part of the estate as jealousy and anger take hold. This paper looks at the emotionaldynamics which underpin family conflicts of this nature, and what drives adult children toembark on such ultimately destructive litigation. It also looks at the way in which judges haveresolved such disputes, and questions whether judges are importing their own subjective viewsand feelings on the nature and quality of parent-child relationships – for example, preconceivednotions of whether a particular applicant was a loving and dutiful child, or whether a deadparent’s greater love and affection for one child in life was rightly replicated through assetdistribution on death. In this sense, the paper questions whether judges are simply neutral228

observers (insofar as such emotional detachment is possible) in inheritance disputes, or whetherthey are straying beyond their legal remit in passing ‘judgement’ on the perceived rights andwrongs of the situation.The Impact of Neurodiversity and Emotionality on Clinical and LegalJudgements of Decision-Making CapacityRobin MacKenzie, University of Kent (r.mackenzie@kent.ac.uk)Medical decision-making by patients is respected as a lawful exercise of free will and agencyunless patients are found to lack “competence”. Yet, clinical measures of competence in medicaldecision-making typically assess only cognitive abilities. Emotionality is involved in decisionmakingand may affect how far patients’ decisions to accept or refuse medical treatment embodyfree will. Moreover, neurodivergence, or atypical neurological makeup, is often diagnosed asneurodegeneration, neurodysfunction, neural damage or neural difference and frequently leads todifficulties in considering the emotional aspects of decisions that standard tests do not measureor divulge. Neurodiversity activists assert that their neural differences are not pathologies to betreated or cured but are alternative ways of being which should be accepted as neuroequal.Nevertheless, who may claim to be neurodiverse is uncertain. I focus on atypical emotionality toconsider the limits of neurodiversity in relation to clinical and legal assessments of decisionmakingcapacity, particularly in relation to diagnoses of mental illness.94. Law and Representations of Social PathologiesTrauma in Kafka’s The Trial and Real Life Legal ExperiencesJoan I. Schwarz, University of Wisconsin at Whitewater (schwarzj@uww.edu)While the legal system in Kafka’s The Trial is often described as referring to no specific legalsystem, the system he portrays mirrors the inquisitorial system of law akin to German andAustrian criminal proceeding of the time. Kafka intentionally distorts anonymous bureaucratsinteracting with characters that lack a clear sense of direction; are unable to see beyondimmediate events; and do not discern any possibility of escape. His description of an inquisitorialsystem of law produces in the reader feelings of hopelessness, fear and trauma, and alienationand persecution, all with a sense of impending disaster. Kafka has written in his letters that “thebooks we need are the kind that act upon us as a misfortune, that make us suffer at the death ofsomeone we love more than ourselves, that make us feel like we are on the verge of suicide, orare lost in a forest remote from all human habitation – a book shall serve as an axe for the frozensea within us.” He further asserts that “we ought to read the books that wound and stab us. Weneed the books that affect us like a disaster, that grieve us deeply.” Hence, “Kafkaesque” is a229

term whose meaning has transcended his imaginative literature and applies to real-life situationsthat are incomprehensible, complex and traumatic to individuals unfamiliar with the law. Worksof trauma have a duty to tell and to direct us toward the future. Although Kafka’s The Trialrepresents an inquisitorial system of law, his tale can also be applied to those embroiled in theadversarial system. As an attorney, I will focus on the Kafkaesque in real-life legal experienceswhere individuals often are trapped inside an obtuse world of mirrors seemingly beyond theircontrol. Kafka’s fictionalization of trauma in The Trial foreshadows the trauma of realindividuals standing before the law, engulfed by the fear and hopelessness of being mired insidemyriad unknown and unrecognizable legal mazes, their lives forever changed with the trauma oftheir experiences living on in their psyches.Politics and Religion: Sources of Neurosis in a County’s National PsycheJohn O. Ifediora, University of Wisconsin at Platteville (ifedora@uwplatt.edu)In all nations, the quality and relevance of countervailing social institutions matter. That this isthe case is particularly of import since institutions are rules that govern individual and collectivebehavior in any society. In this regard reference is here made to primary and enabling rules andobservances that inform and guide conduct; specifically religious, political and economicinstitutions. In nations where these social institutions have evolved to the point where individualrights and freedom of choice are accorded universal cognizance with appropriate checks andprotection, the polity is reasonably well-adjusted. Under this state of affairs, malfunctions in anyof the constituent institutions are unlikely to have lasting effects, and minimal correctivemeasures are needed to restore normalcy; this sentiment enjoys durable currency. In advanceddemocracies such as the United Kingdom, France, Japan, and the United States, abnormalitiesare generally reflections of discontent, and may pose no serious danger to established norms,unless left unattended. It is thus presumed that advanced democracies have built-in mechanismsthat inexorably return them to long-run equilibrium in the event of temporary malfunctions inany of their institutions. Events within the last decade, however, have made this presumption lessserviceable. In this paper, I propound that malfunctions in religious and political institutions arealways and everywhere responsible for all forms of societal neurosis that inflict a nation’s psychein times of stress and uncertainty. That individuals, in extreme cases, are willing to kill theinnocent in order to advance religious and political goals attests to the potency of deranged andmalfunctioning institutions that guide and inform collective action. Suicide bombers readilycome to mind – but whether society acknowledges it or not, these suicide bombers, once wellfunctioningmembers of society, were mentally deranged. No well-adjusted and healthy personwants to die; only the neurotic chooses to die. And to a large extent, they are victims of distortedreligious and political institutions that cut across nations at various stages of socio-politicaldevelopment. My research highlights this growing epidemic in Nigeria, and grapples withsolutions.230

Attachment and TraumaGuy Lord, Medical College of Wisconsin (grlord@execpc.com)Researchers, beginning with John Bowlby, have studied attachment between an infant and aparental figure. Early studies of children in orphanages have evolved into a typology ofattachment that can describe relationship patterns well into adulthood. Similarly, post-traumaticstress was initially seen as a reaction to combat and other catastrophic events. It is now viewed asa disorder that can emanate from more complex, chronic experiences in childhood. Stress andtrauma are increasingly seen as interacting with genetic vulnerabilities to produce life-longdisabilities, perhaps involving changes to brain structure and DNA. Trauma and attachment mayinteract in yet-to-be understood ways. Increasingly, the developing or traumatized brain isconsidered in legal arguments in areas such as capital punishment, PTSD in veterans and in theculpability of those raised in impoverished, violent urban environments (the ghetto defense).Previously, in DSM- IV-TR, PTSD was classified as an Anxiety Disorder and ReactiveAttachment Disorder was under Other Disorders of Infancy, Childhood or Adolescence. Thecurrent thinking about disorders of attachment and their relationship to early childhood traumawill be reviewed in the context of diagnoses of Reactive Attachment Disorder and Post-Traumatic Stress Disorder in the Diagnostic and Statistical Manual (DSM) series. Growingrecognition of the relationship between these disorders is reflected in the placement of both inthe same category: Trauma- and Stressor-Related Disorders.Retelling the Holocaust: Popular Culture and the Evasion of the Message in theStoryRachel Brenner, University of Wisconsin at Madison (brenner@wisc.edu)This paper focuses on the cultural reception of the Holocaust in popular culture, mainly in filmand comics. The premise is that the preoccupation with the Holocaust originates in the repressionof the consciousness of Holocaust terror, so that its emotional impact as well as its ethicalmessage can be evaded. Appropriation and adaptation of the story enables evasion of the horror.Thus, for instance, Art Spiegelman appropriates his father’s story by presenting it through thegenre of his choice (comics) and by emphasizing the emotional problems that he tries to solvethrough becoming the sole heir of his father’s story. The adaptations of the story to literarythematic codes, such as the fairy tale in the movie Life Is Beautiful, sin and redemption inSchindler’s List, or biblical allusions of Exodus in Defiance represent strategies of evasion.These modes of representation reflect not only the need for emotional defenses; they also help toobfuscate responsibility to confront the moral rupture, which has not been mended. In this sense,the search for emotional relief from the horrifying past exempts the second-generation from theresponsibility of heeding the ethical message of the Holocaust event. This message expects therecipients of the Holocaust legacy to assume the responsibility of confronting the Holocaust as ahumanistic collapse and to engage in the task of repair. Thus, the popularization of the Holocaust231

communicates evasion of the responsibility to heed the victims, such as Primo Levy and JeanAméry, and accept duties as heirs to the ethical legacy in their story. This message requires revalidationof the humanistic values of empathy and compassion in the world that failed to live upto the humanistic tradition of the Enlightenment. The prolific production of Holocaustrepresentations and the enormous popularity of these productions evince insistent fear of theexperience that the story presents and of the message that it communicates. This evasionprecludes healing of the fearful trauma of the story and thus represses its ethical legacy.95. The Law and Vulnerable PopulationsPsychiatric Rehabilitation Reform: Lessons from the Israeli ExperienceUri Aviram, The Hebrew University of Jerusalem (msaviram@mscc.huji.ac.il)This presentation describes a case study on an innovative, government-sponsored, countrywidemental health reform enacted by Israel in 2000, analyzing implementation issues as the reformenters its second decade. This reform, focusing on the rehabilitation and integration in thecommunity of severely psychiatrically disabled persons, has been considered an important pieceof social legislation and a progressive one. This paper offers cautionary notes regarding thefuture direction of the reform, and highlights lessons learned that might be relevant to othercountries dealing with similar challenges. Methods: The study focused on the critical elements ofthe mental health service system, namely, clients, financial resources and personnel, and theprinciples governing their allocation and movement within the system. Findings: The decadeafter the psychiatric reform legislation was implemented saw an impressive increase inrehabilitation services, a significant reduction in the number of psychiatric beds, and majorchanges in government budget allocations. However, only about one fifth of the estimatedeligible population received rehabilitation services, ambulatory services suffered a set-back, nogovernment mental hospital was closed and efforts of the state to achieve the plannedcomprehensive reform, transferring mental health services to general health-care providingorganizations, have run into difficulties. Discussion and Conclusion: Factors that endanger theviability of the psychiatric rehabilitation reform and its role in bringing about a major mentalhealth services change in the country are examined in light of contextual factors and lessons tobe learned from the Israeli experience are discussed.Health Complaints and Regulatory Reform Flux: Implications for VulnerablePopulations?Terry Carney, University of Sydney (Terry.Carney@Sydney.edu.au)Fleur Beaupert, University of Western Sydney (fbeaupert@gmail.com)232

Complaints and disciplinary processes are one part of broader systems of health regulation.Many countries are transitioning from models of self-regulation to greater external oversightthrough systems – including meta regulation, responsive regulation, and “networkedgovernance” – harnessing in differing ways, public, private, professional and non-governmentalbodies to exert influence over the conduct of health professionals and services. Interestingliterature is emerging regarding complainants’ motivations and experiences, the impact ofcomplaints processes upon health professionals and features such as complainant and healthprofessional profiles, types of complaints and outcomes. This paper concentrates on studiesidentifying apparently vulnerable groups, including older complainants, women, and people fromlow socioeconomic or rural areas.Refugee Law and Mental Health Service Gap in the U.S.Hyojin Im, University of California, Berkeley (hyojinim@berkeley.edu)Mental health care for refugees in conflict-migration contexts – in spite of the high prevalence ofcommon mental disorders including PTSD in these populations – is often deprioritized due tolimited setting resources. Such neglect of mental health care, however, continues uponresettlement in developed host countries partially due to the dilatory response to refugee needs inlaw and policy. Overemphasis on rapid self-sufficiency in the Refugee Act of the U.S., forexample, has been criticized for the marginalization and isolation of refugees while failing toaddress mental health needs in traumatized communities. The current study will review U.S. andinternational refugee law with a focus on the relation between such policies, mental health needs,and issues in refugee resettlement. Based on in-depth interviews with marginalized refugees andcommunity stakeholders, the presenter will discuss policy implications for mental health servicesand refugee law.Lebanese Law/Policy and its Impact on Palestinian Mental HealthRachel Kaplan, University of California at Berkeley (rlkaplan@berkeley.edu)Despite the passing of four acts related to mental health in Lebanon between 1983 and 2004, thecountry has yet to achieve the capacity to implement protective laws for the mentally ill. InLebanon, mental health needs exceed the annual budget allocated to address mental illnesses; thesituation is further exacerbated by a shortage of mental health professionals. Despite evidence tosupport the integration of mental health services into primary care, mental health training formedical professionals in the country remains surprisingly low. A country that has suffereddecades of civil war and experiences a constant threat of political armed conflict, Lebanon hasyet to develop a national mental health policy. Within this context, Palestinian populations inLebanon navigate a wide variety of injustices that threaten mental health. This study will provideexamples from the field resulting from the legislative gaps with this vulnerable population.233

Civil Commitment Law, Mental Health Services, and US Homicide RatesSteven P. Segal, University of California at Berkeley (spsegal@berkeley.edu)Purpose: The study considers whether involuntary civil comment (ICC) statute provisions areassociated with homicide rates. Do statutes based solely upon dangerousness criteria vs. broaderICCcriteria – i.e. "need for treatment," "protection of health and safety," and family protection –have differential associations related to their goal of reducing the frequency of homicide?Method: State-level data were obtained from online data bases and key-informant surveys.Ordinary-Least-Squares and Poisson Regression were used to evaluate the association betweenstatute characteristics, mental health system characteristics and 2004 Homicide Rates aftercontrolling for firearm-control-law restrictiveness and social-economic-demographicgeographic-and-politicalindicators historically related to homicide rate variation.Results: Poisson and OLS models, respectively, were significant: Likelihood Ratio Chi Sq =108.47, df=10 p< 0.000 and Adj.R2=.72; df =10, 25; F= 10.21; p

The Crisis Intervention Team (CIT) is a collaboration between mental health and lawenforcement professionals to provide specialized training for police officers in mental healthissues and crisis intervention/de-escalation strategies. CIT was originally developed: a) inresponse to the demand for law enforcement training in the use of less lethal strategies fordealing with volatile situations involving mentally ill persons, and b) to reduce the likelihood ofinjuries and deaths in such encounters. Specific CIT training components include: signs andsymptoms of major mental illnesses (e.g., Schizophrenia, Bipolar Disorder), psychological andpharmacological interventions, crisis stabilization, and behavioral skills (e.g., active listening andproblem-solving). The purpose of this presentation is to provide: (1) an overview and critique ofcurrent CIT activities, (2) an examination of accrued data concerning program efficacy, and (3)findings from our research program on CIT applications in correctional settings, as well as one ofthe first controlled comparison studies of CIT with law enforcement samples. In addition,suggestions for directions that future work in this area might take are offered.Police and the Control of Marginalized Populations: Examining Resistance andUse of Force in Police Encounters with the Mentally IllPhilip Mulvey, Arizona State University (Philip.Mulvey@asu.edu)Michael White, Arizona State University (mdwhite1@asu.edu)Prior research has not sufficiently explored police encounters with marginalized populations, andparticularly the mentally ill. Gaps exist in understanding police encounters with the mentally illand specifically factors surrounding resistance to police, or the use of force by police in theseencounters. This study seeks to better understand resistance and the use of force through anexamination of 942 arrests made by officers in more than a dozen police departments in Phoenix,Arizona. Results indicate arrestees who had mental health problems were significantly morelikely to resist police. Suspect resistance was a consistent predictor of police use of force. Therelationship between mental illness and police use of force appears to be complex, however.Mental health problems were unrelated to police use of force generally, but findings indicate thatpolice were more likely to use higher levels of force against the mentally ill. This suggests athreshold effect whereby police have greater tolerance for low-level affronts committed bymentally ill offenders, but less tolerance for high-level affronts. The implications of thesefindings are considered in the context of ongoing discussions regarding the criminalization ofmental illness and the relationship between resistance to police and police use of force.Talking about Trauma without Being Traumatic: Using Simulation to Discussthe Impact of Psychological Trauma within a Police ForceBruce Ballon, SIM-one, the Ontario Simulation Network, Toronto, Canada (bballon@simone.ca)235

This presentation will highlight activities used to create a healthy learning climate to allowmembers of a police force to discuss the impact of trauma on that service. The Durham RegionalPolice Services had the author develop training to discuss Post Traumatic Stress Disorder in thecontext of policing. This grew into the creation of an interactive educational forum devoted to:policing culture regarding how to deal with trauma; experiential learning/simulation to bringforth attitudinal issues that created barriers for seeking help for trauma; reflective techniques onsimilarities between those the police try to help who have trauma issues (e.g. caused by domesticviolence) and themselves; and developing peer support and networking opportunities. This wastied into the concept of creating mental health champions across the force as “go-to” individualsas a first step for seeking information and help. Demonstrations of some of the techniques andthe key elements that came out of the training will be shared at this presentation.From Knowledge to Real World Practice: Are Online Simulations a Source ofAuthentic Learning for Police Officers?Wendy Stanyon, University of Ontario Institute of Technology (wendy.stanyon@uoit.ca)Phillip Lillie, Durham Regional Police Services, Canada (plillie@drps.ca)Marjory Whitehouse, Ontario Shores Centre for Mental Health Services(whitehousem@ontarioshores.ca)This presentation will highlight the findings from a research study designed to determinewhether police officers – after having completed a series of interactive, video-based simulations– are able to apply the knowledge they have gained in subsequent on-the-job interactions withmentally ill individuals within the community. This collaborative research effort between auniversity, a tertiary mental health facility and a regional police service builds on the findingsfrom a prior study undertaken by this unique partnership that examined the use of simulation toeducate police about mental illness and how to effectively interact with mentally ill persons. Theresearchers were able to conclude that simulation training is at least as effective as face-to-faceeducation; however, because the primary objective of the simulation training is long termtransfer of knowledge, further research was planned to evaluate whether police officers areapplying their acquired knowledge following the training program. This level of evaluation mayalso lead to the identification of factors that are inhibiting or conducive to knowledge transfer,which could help police services in creating environments that provide optimum conditions forthe sustained success of simulated training resources. A demonstration of the simulations willalso be included in this presentation.Moral Distress among Correctional PsychologistsMegan Fischer, Athabasca University (meganfischerpc@gmail.com)236

Rationale/Background: Ethical and moral issues in correctional mental health settings arecomplex and challenging. As evidenced in the literature, ethical conflict is intrinsic tocorrectional settings. Correctional settings, because of the competing demands of the legal andhealth care system, provide a particularly significant environment to explore the phenomenon ofmoral distress.Moral distress is a concept that captures a range of experiences that an individual mayexperience when morally constrained. Components of moral distress prevalent in the currentnursing literature are: (a) the embodied effects of moral distress, (b) awareness of a moralproblem, and (c) perception of correct moral action. The limited current research on moraldistress has not yet expanded to correctional psychologists.Research Question: The purpose of this study was to explore the lived experience of moraldistress among Canadian correctional psychologists..Methodology: Interpretative Phenomenological AnalysisResults/Findings: A preliminary finding as research is still in progress. Results will be completein March, 2013.Implications: Presentation of my findings will highlight common and challenging ethical issuesconfronting correctional psychologists, identify situations that support and constraint ethicalpractice, and outline rich, thick descriptions of the physiological, emotional, and socialexperiences of moral distress.97. Law’s Passions I: Is the Impartiality of the Law Threatened byRecognition of its Emotional Power?Pastoral Correctionalism: Care, Power and the StateChrysanthi Leon, University of Delaware (santhi@udel.edu)Specialized programs, including mental health courts and prostitution diversion programs,exhibit the pastoral form of state power identified by Foucault. Both the client/offenders and theprofessionals who operate the programs participate in what I call pastoral correctionalism: theuse of individualized care and empathy to shape behavior and restrict agency. These programsoperate in a space adjacent to the dominantly punitive forms of state control, and use therapeuticrhetoric to soften state power. But they are also in opposition to the client-centered approach thatcharacterizes the recovery model, as well as most contemporary treatments, since criminal justiceprofessionals will cede their expertise to treatment professionals, but not to the client/offenders.Ultimately, pastoral correctionalism provides a humanity missing from punitive regimes, whilemaintaining deeply invasive surveillance and reinforcing the assumption that by breaking thelaw, offenders have forfeited the capacity to set their own goals or pursue their own recovery.237

Against the Yuck FactorDaniel R. Kelly, Purdue University (drkelly@purdue.edu)The view I will defend here is that in virtue of its nature, disgust is not fit to do any moral orsocial work whatsoever, and that there are no defensible uses for disgust in legal or politicalinstitutions. I will first articulate my theory of the nature of disgust. Turning from descriptive tonormative issues, I will distinguish a number of separate roles that advocates of disgust haveargued the emotion can and should be used to fill. I will then consider the best arguments infavor of granting disgust the power to justify certain judgments, and to serve as a social tool,respectively. These are provided by Daniel Kahan, who advances a pair of theses that suggestdisgust is indispensible, and so has an important part to play in the functioning of a just, wellorderedsociety. After describing each thesis and showing where it fits with respect to thetaxonomy of possible roles disgust might be granted, I will examine the arguments in support ofthem and show where I think they fail.Evidence Law's Ambivalent Attitude towards Emotion: When is Too MuchEmotionally-Charged Evidence Unfair Prejudice? When is Too Little EmotionIncompetent Lawyering?Aviva Orenstein, Indiana University (aorenste@indiana.edu)Federal Rule 403 of the Rules of Evidence allows trial judges to exclude evidence where unfairprejudice substantially outweighs the probative values of a piece of evidence. The advisory notesto the rules explain that appeal to emotion rather than logic is a form of unfair prejudice. Yet, somuch of trial practice and good jury argument is emotionally based. The power of an emotionalnarrative not only organizes the evidence for the jury, but gives them a reason to care. A sterilestory without color risks boring or alienating the jury. Too much gory detail can be unfairlyprejudicial. This presentation will discuss the power of emotion in trial practice theory andtechnique and observe the deep ambivalence evidence law has in dealing with courtroomemotion.Visualizing the “Monstrous Brain”: The Rhetorical Implications of Brain Scansin Sex Offender TrialsPamela D. Schultz, Alfred University (fschultz@alfred.edu)Functional magnetic resonance imaging (fMRI), which detects regional increases in blood flowthat accompany neural activity, has become a powerful tool to investigate the brain’s cognitive238

functions. An increasing body of evidence shows that when accidents or disease have destroyeda potion of the prefrontal cortex, individuals may be left with drastically modified personalitiesand an inability to control impulsive, destructive behaviors. There is growing enthusiasm amongsome defense attorneys and neuroscientists for the use of magnetic resonance imaging in thecourtroom, as brain scans can demonstrate diminished culpability in cases where defendants areaccused of violent crimes such as sexual offenses. This paper looks at the rhetorical implicationsof using brain scans in sex offender trials, taking the standpoint that “brain imaging is more thana scientific research agenda – it is a persuasive visual rhetoric by which neuroscience isarticulated as relevant to the construction and maintenance of desirable selves” (Johnson, 2008,p. 148). A brain scan that shows damage to an accused sex offender’s prefrontal cortex canpotentially illustrate a physiological incapacity that contributed to the crime, and speak to thepotential of treatment. Yet just as probable, the image of a damaged brain can underscore theassumption that the offender is monstrous and beyond any hope of rehabilitation. The danger isthat, rather than leading to a new paradigm in which we value treatment as much as punishmentfor some sex offenders, the rhetorical charm of brain scans for lay audiences could instead evenmore powerfully perpetuate the myth of monstrousness.Taking the Heat Out? Prevention and Law’s Response to Sexual Offenders (ACriminologist’s Perspective)Bill Hebenton, Manchester University (Bill.Hebenton@manchester.ac.uk)Politicization and the dominant regulatory response to sexual crime have now givencontemporary conceptions of the sexual offender a durability that their predecessors lacked.Concisely captured by Eric Janus's term “the predator template”, commentators point to thepolitical “untouchability” of law’s response to such collective risk and argue that its variouseffects lie not simply in it being evidence-lite, but in the deeper expressive undertow. Yet, while“evidence-based” or “rationalist” approaches may appeal to technocrats and a number ofacademics, they often fail to compete successfully in the social context where affectiveapproaches to law and order policies resonate with the public and appear to meet deep-seatedpsychological needs. Many now reach for a model of public policymaking where emotions areneither privileged as desirable nor marginalized as basically irrational. However, less attentionhas been given to how these offenses might be prevented from occurring in the first place, andless still has been given to the design and organization of physical and social environments sothat the potential for these offenses to occur might be minimized. This paper examines the extentto which elision from offender to situation betokens a different congeries of the normative,emotional and practical in relation to expertise, public and governmental communication,deliberation and decision-making.98. Law’s Passions II: The Emotions and the Rules of Evidence239

Constructions of Deviance and Empirical Fallacies of Evidence Law: A CriticalLook at the Admission of Prior Sex Crimes by the Accused Under Federal Rules413-414 and their State AnalogsTamara Rice Lave, University of Miami (tlave@law.miami.edu)Aviva Orenstein, Indiana University (aorenste@indiana.edu)This paper looks critically at the sexual propensity rules. We begin by discussing the history andtraditional justifications for Rule 413 and 414, focusing on the assumption that prior sex crimesare particularly probative. We then examine whether the high probative value assigned to priorbad acts in sex cases is supported by the psychological and criminological research on sexoffenders. We focus in particular on recidivism, the effect of age on dangerousness, and the risksthat different offenders pose. We conclude that the overbroad propensity rules are not justifiedby the empirical data. We then discuss whether judges are effective at determining whether anaccused offender is likely to have reoffended. Although we disapprove of Rules 413-414 onmany grounds, only one of which is the overvaluing of such propensity, we are realistic thatthese rules and their state law analogs are here to stay. As such, we offer specific advice tojudges regarding how to use their broad discretion when admitting propensity evidence. Finally,again relying on the psychological evidence, we suggest that even when propensity evidence isrelevant, judges should seriously consider ruling it inadmissible on the grounds of unfairprejudice. Psychologists tell us that prospective jurors are so biased against sex offenders that theaccused will not be able to receive a fair trial as guaranteed by the Sixth Amendment.Disturbing, Distressing, Disgusting, Desired Gruesome Pictures, What’s the Lawto Do with Them?Christina Spiesel, Yale University (Christina.Spiesel@yale.edu)In four thousand years of history of trials in the West (Kadri 2006), I am struck by the elaborateand frequently bloody rituals historically employed by legal authority. Certainly, one intention ofthese devices is to use fear to promote obedience. In addition, however, it is safe to presume thattheir use also serves to satisfy needs – of participants, of leaders, and of followers as theyconstruct the social order by rule-governed display. Now in the twenty first century, Americanlaw has become, in large measure, invisible law. Most cases are now negotiated to settlement orplea bargained or resolved through alternative methodologies for dispute resolution, also takinglegal procedures behind closed doors and out of the public eye. Perhaps in compensation,television entertainment has risen to fill this void, offering crime and its resolution nightly withplenty of disturbing pictures; user generated video presents seemingly unlimited quantities ofdocumentary horribleness on-line as well. In this paper I look at this class of pictures: thedisturbing, disgusting, or gruesome that can come up in either criminal or civil litigation andform an experiential culture that people bring with them to the law. Why use them?240

Victim Impact Evidence and the Limits of Evidentiary Discourse: Reconsideringthe Probative, the Prejudicial, and the EmotionalSusan Bandes, University of Miami (sbandes@law.miami.edu)Legal discourse about whether various types of evidence are relevant or irrelevant, probative orprejudicial, too often relies on the simplistic assumption that evidence that evokes emotion mustbe prejudicial, irrelevant or both. This assumption is problematic for two reasons: it is at oddswith the growing consensus that emotion is an integral and often desirable part of the decisionmakingprocess, and it interferes with the legal system’s ability to distinguish between – orarticulate distinctions between – helpful and unhelpful types of evidence. This paper will usevarious types of victim impact statements, including documentary statements, statementsdelivered by live witnesses, and video montages with an audio component, as a lens throughwhich to consider the role of emotion in conveying legal information, and how legal discoursemight better evaluate and regulate that role.Visibly and Invisibly Offensive Offenders: Contrasting Timothy McVeigh andOsama bin LadenJody Lyneé Madeira, Indiana University (jmadeira@indiana.edu)Over the past 150 years, the practice of capital punishment has altered dramatically. The grislypublic spectacles favored for centuries have been moved inside prison walls, and painfulexecutions have been gradually replaced by ever more humane and discrete lethal technologies.This paper will consider how the visual dynamics inherent in execution, and thus the culture ofexecution, are in flux, dependent upon execution method, the medium of execution witnessing,and the identities of the condemned and the execution witnesses. Based on qualitative interviewswith victims of the Oklahoma City Bombing and 9-11, this presentation will focus on how thedeaths of two very visible terrorist defendants, Timothy McVeigh and Osama bin Laden,affected family members and survivors. Prior research shows that, from the moment ofMcVeigh’s perp walk, the Oklahoma City victims felt as if they were yoked with McVeigh in aninvoluntary relationship that terminated when McVeigh was silenced and rendered invisiblethrough lethal injection. Key questions to be answered are to what extent 9-11 victims felt yokedwith bin Laden in an involuntary relationship, how this relationship was experienced, how the“framing” of the terroristic act (domestic terrorism or mass murder versus an act of war) changedthis relationship, and whether this relationship changes when the offender is executed without acapital trial and when there is no opportunity to witness the offender’s death.241

Criminal Law: Protection from the Monsters Among Us, or Distraction from theMonster Within?John Douard, Rutgers University (douard@rci.rutgers.edu)Monsters and predators frighten, entertain, and disgust us. The idea of a creature that is a volatilemixture of human and animal parts (the monster) triggers our visual and visceral imaginationperhaps more than any other image. The fear of predation – literally, eating another’s flesh –disgusts and repels, but, like rubberneckers who slow down to witness accidents, our voyeurismseems unconstrained by shame. The monster and the predator threaten us by threatening to rendthe social fabric and bring about a state of nature in which, as Hobbes famously wrote, we areengaged in a war of all against all, and life is nasty, brutish and short. There is a direct narrativeline from the fascination with monstrous births that ordinary people experienced in the sixteenthand seventeenth centuries and our current fascination with monstrous crimes. That fascinationincorporated then, and incorporates now, in addition to emotions such as fear and loathing, akind of titillation, a powerful sexual interest in the unnatural. The physiognomy of the monsterhas changed from horrible, misshapen bodies to ordinary bodies – bodies that fascinate onlybecause they appear to harbor strange and disturbing desires.99. Legal Frameworks, Rights and Care for People Who LackDecision-Making CapacityDeprivation of Liberty Safeguards: Their Impact Upon Human Rights and CarePracticesJoan Langan, University of Bristol (J.Langan@bris.ac.uk)This presentation is based upon the findings of a mixed methods empirical study of theDeprivation of Liberty safeguards (DOLS) 2007. The safeguards aim to protect article 5 rightsunder the European Convention on Human Rights. Their remit is people in care homes orhospitals who lack capacity and are cared for in a way that deprives them of their liberty. DOLSare controversial and a particular challenge is determining what constitutes deprivation of liberty.This study has two sources of data: i) in-depth qualitative interviews with those involved in anumber of DOLS authorisations (the individual subject to a DOLS where possible, as well asprofessionals and family members) in 4 study sites in England and ii) an on-line survey ofprofessionals undertaking DOLS assessments in England. From i) the paper will present findingsin relation to professionals’ justification for invoking DOLS. It will also consider DOLS’ impacton human rights and care practices. From ii) it will consider the factors that professionalsconsidered to be indicative of deprivation of liberty.242

Restriction, Deprivation, and Detention: Limits to Freedom within EnglishMental Health and Mental Capacity LegislationIsabel Clare, University of Cambridge (ichc2@medschl.cam.ac.uk)In England and Wales, the freedom of men and women with a mental disorder or who lackcapacity to make decisions about their own care and treatment can, in certain circumstances, belimited lawfully through the use of appropriate legal frameworks. We use data from a mixedmethodsempirical research study to discuss how such frameworks are used in general and/orpsychiatric hospitals. We will illustrate the breadth of the relevant legislation, which includesboth unconscious patients who are receiving life-saving medical treatment and highly mobilepatients receiving predominantly nursing care. We will also illustrate the confusion relating tothe meaning of “care” and “treatment” and the emergence of new concepts, for example, that of“active” treatment, and rules of thumb differentiating those who are or are not expected tobenefit from treatment. We argue that clinicians struggle to apply these legal frameworks to therealities of patient care.Making Best Interest Decisions for Dementia Patients on Discharge fromGeneral Hospital: Do Family and Friends Fulfil an Effective SafeguardingFunction Under English Law?Charlotte Emmett, Northumbria Law School (charlotte.emmett@northumbria.ac.uk)In this paper we explore the role of family members and friends in the best interests decisionmakingprocess under the Mental Capacity Act 2005 in England and Wales. We ask whether, inthe absence of Independent Mental Capacity Advocates (IMCAs), close family and friends ofolder people with dementia are capable of fulfilling a safeguarding function when decisions arebeing made about where that person should live on discharge from general hospital. Our findingsare grounded in ethnographic ward-based observations and qualitative interviews conducted inthree hospital wards, in two hospitals (acute and rehabilitation), within two NHS healthcaretrusts in the North of England over a period of nine months from June 2008 to June 2009. Weask: Are family and friends there simply in an advisory/supportive capacity or are they oftenseen as the primary decision-makers by professionals? Does this role accord with the incapableperson’s (P’s) view or the family and friend’s own views and expectations of their role? Is thisperception promoted by professionals? Can relatives and friends really be expected to makeobjective assessments of P’s best interests in the context of decisions about where to live andfulfil an effective safeguarding function? Or are there simply too many competing tensions? Ourconclusions suggest that family and friends can only begin to act as an effective safeguard forthose they care about if communication with professionals is improved and they are involvedmore fully in the hospital discharge planning process.243

Making Best Interest Decisions: People and ProcessesMarcus Jepson, University of Bristol (marcus.jepson@bristol.ac.uk)The Mental Capacity Act (MCA) 2005 in England and Wales formalises the principle of bestinterests decision making. Hence, in circumstances where a person lacks capacity to make adecision, the “decision maker” has the responsibility for ensuring any decision made for thatperson must be done in their best interests. This presentation is based on the first nationalresearch study of best interests decision making under the MCA. The study used mixed methodscomprising an online practice survey and telephone interviews with decision makers,supplemented by face-to-face interviews with a range of people involved in best interestsdecisions. The face-to-face discussions provided multiple perspectives on 25 best interests’decision making processes. This paper will present some of the key findings from the face-tofaceinterview stage. Using anonymised case study examples, it will discuss the challenges ofimplementing important new legislation in health and social care, particularly including thetensions associated with being identified as a “decision maker”.Direct Payments for People who Lack Capacity to ConsentDan Robotham, Mental Health Foundation, London, UK (drobotham@mhf.org.uk)Direct payments have been the primary mechanism for achieving personalised social care inEngland. They are a mechanism by which people with social care needs can receive money topay for their own social care needs, rather than receiving a traditional service from the localauthority. Direct payments have been around for some time, but since November 2009 peoplewho may lack capacity to consent have been able to make use of them. They receive the directpayment through a third party chosen as a “suitable person” (often a family carer) to receivepayments on their behalf. This project investigated how direct payments have been administeredand managed in cases where people may lack the capacity to consent to them. Data was collectedfrom six regions across England from social care practitioners and people acting as suitablepersons. Semi-structured interviews were undertaken using predominantly qualitative methods toinvestigate different practice approaches across the country, and to highlight examples of goodpractice. The findings of this study will improve understanding of how to make personalised caremore appropriate for a greater proportion of people with social care needs.100. Legal Issues in Child AbuseChildren Taken into Care or Custody and the 'Troubled Families' Agenda inBritain244

Carol Hayden, University of Portsmouth (carol.hayden@port.ac.uk)This paper takes a critical look at how current policy initiatives in Britain characterise andrespond to 'troubled families'. The paper draws on current empirical research into the needs andissues in the lives of 196 children taken into care or custody in one city; and, the adults in theirfamilies. The research is being used to inform the development of a new service that will useMulti Systemic Therapy (MST) to work with 'troubled' families. The developing MST service ispart of a range of nationally promoted interventions and supports to troubled'families. The paperconsiders the evidence and value base for this type of intervention.A Case of Matrilinear Transgenerational Parental Alienation in Sweden -Lessons Learned and Recommendations for ChangeNils-Göran Areskoug, Strömstad Academy (nilsare@gmail.com)This case of parental alienation by a father toward his two children born in 1973 and 1975evolved across generations. An analysis of the case reveals a sequence of decisions by social andlegal authorities that brought about alienation over more than 30 years until the stage of"parentectomy". Major factors that cause such failure include (1) the level of competence amonginvestigators and judges, (2) the mode of communication and interaction between social andlegal agencies, and (3) the failure of prevention, including an inability to assess the probability oflong-term effects on children during development. It is concluded that authorities need to preventaggravation of parental alienation by (1) developing methods of coordinated efforts, (2) updatingthemselves on clinical research (and scientific progress) in the field, and (3) developing anepistemology for interdisciplinary interpretation that integrates insights from sociology,psychology, and psychiatry with the legal system. The system fails to protect children andparents from lifelong harm and victimization. Point by point recommendations focus on how toprovide an integrated "sociolegal" method for adequate handling of these cases as is required byinternational conventions of human rights, both those of the United Nations and of the EuropeanCourt of Human RightsParental Alienation Violates the Child's Legal and Human Right to Family Life:An American-Swedish Case StudyLena Hellblom Sjögren, Testimonia, Fagersta, Sweden (mail@testimonia.se)The child belongs to a family system, with roots on both parents’ sides, even if the parents do notstay together. The child has a legal and a human right to family life. The European Court ofHuman Rights (ECHR) has recognized how these rights are violated in complicated custodyconflicts when a child is alienated from one parent. In its decisions, the ECHR has supported the245

child’s legal and human right to family life and the child’s right to keep his or her identity. Acase study will be presented that illustrates the violation of these rights. The father was anAmerican and also a Swedish citizen, and the family had settled in the U.S. After the mother andthe couple’s three children, following a conflict, suddenly moved back to Sweden, a lower courtin Sweden awarded sole custody of the children to the father. However, the mother appealed herloss of custody and asked to have the court decision overruled, which was granted. The mothercontinued to influence the children to not want to see their father, or have any contact with himor any member of his family. In March 2009 the appeals court gave sole custody to this Swedishmother. Their address is now hidden.Compensating Uncertainty in Legal Decision Making in Child Sexual AbuseCasesKatarina Finnila, Abo Academy (katarina.finnila@elisanet.fi)This presentation will explore the effects of two pitfalls in legal decision making: compensatorypunishment (i.e. the uncertainty about guilt is compensated by a milder sentence) and theconviction paradox (i.e. the threshold for evidence is lower in aggravated crimes than simplecrimes), on child sexual abuse (CSA) sentences. The effect of experience and training ondecisions will also be examined. Four case materials in which the strength of the evidence wasmanipulated for simple and aggravated CSA were given to 64 judges, 82 law students and 99laymen. Participants were asked to decide on guilt or innocence and to report demographic data.Judges convicted more easily in simple than aggravated CSA cases when the evidence was weak.In the two other groups no support for the conviction paradox was found. Law students wouldhave given milder sentences for simple CSA with weak evidence than with strong evidence. Inthe other two groups, confirmation for the hypothesis of compensatory punishment was notfound. For aggravated child sexual abuse, no confirmation for the hypothesis of compensatorypunishment was found in any group. Training and experience affected sentences given, but didnot have an effect on the two decision making pitfalls.101. Legislation and the Effectiveness of Mental Health LawLegislative Style and Judicial Discretion: The Case of Guardianship LawLawrence Solan, Brooklyn Law School (larry.solan@brooklaw.edu) (718-780-0357)The criteria for appointment of a guardian, and the powers that the guardian will be given dependupon how a particular political entity balances respect for the individual’s right to autonomy onthe one hand, against society’s desire to protect those who cannot manage their own affairs, onthe other. In recent decades, the balance has tipped from concern about protection to concern246

about autonomy. This shift, in turn, has resulted in an evolution in the linguistic style of the lawsenacted. This project examines many different guardianship statutes from around the UnitedStates, demonstrating that subtle linguistic maneuvers in the style of drafting affects the degreeof discretion given to decision makers. Using advances in the psychology of concepts andcategories, the article demonstrates the descriptive inadequacy of the classical distinction of rulesversus standards in legislative drafting, and adds prototype-based laws and laws dependent uponenriched mental models to types of laws that legislators employ. The goal of the work is to builda self-conscious awareness of the tools available to policy-makers in their efforts to honelegislation in this important area of mental health law.When Mental Health is not Public Health: How Judicial Language and itsInterpretation Negatively Impacts Assisted Outpatient Treatment (AOT) in NewYork CitySusan J. Guercio, New York City Department of Health and Mental Hygiene, New York, USA(sjguercio@yahoo.com; sguercio@health.nyc.gov) (212-788-5270; 914-787-0401)In May 2011, the New York State Court of Appeals (the highest court in New York State) opinedthat the New York City Department of Health and Mental Hygiene was neither a public healthauthority nor a treatment provider as defined by the federal privacy statute called HIPAA (HealthInsurance Portability and Accountability Act). This decision was a blow to the localgovernment’s capacity to obtain psychiatric records to use in a court proceeding to compelmental health treatment without the patient’s permission or a court order with proper notice.Additionally, the last line of the Court’s decision called into question the legitimacy of all priorAOT court orders obtained since the beginning of the program with the language “We thereforehold that medical records obtained in violation of HIPAA or the Privacy Rule, and theinformation contained in those records, are not admissible in a proceeding to compel AOT.” Thispresentation will discuss what is believed to be the court’s good intentions in this ruling, andhow the language and intent is not only ambiguous, but could have the unintended consequencesof destroying the New York State Program which is considered a model for the entire country.The Tenacity of Mental Health Stereotypes of Women in Sexual and IntimateViolenceElizabeth M. Schneider, Brooklyn Law School, Brooklyn, USA (liz.schneider@brooklaw.edu)(718-780-7988)This presentation will examine the ways in which mental health stereotypes of women pervadecases of sexual and intimate violence in a number of different settings.247

102. Linguistics: Theories of Education and Inter-RelationshipDeception through Translation: Linguistic and Cultural IssuesRachel Taylor, University of Glamorgan (rtaylor@glam.ac.uk)Interviews with non-native speakers conducted through an interpreter are an increasing feature ofpolice practice. However from the perspective of assessing the credibility of such suspects,translated interviews present unique challenges. This paper outlines and critically discusses someof the main challenges for lie detectors when faced with a translated interview. Issues such ascognitive load, inter-cultural communication and the trade-off between accurate translation andgood quality communication are discussed. Further issues specific to police practice include theavailability of suitably qualified interpreters, wider cultural knowledge shared by the intervieweeand translator and the potential requirement for interpreters to work both in a police interviewand in a confidential conversation between a solicitor and a client. Finally this paper outlinessome strategies for researching this emerging area of credibility assessment.Modalities of Communication: Treatment, Education, and ResearchMonica Broome, University of Miami School of Medicine (mbroome@med.miami.edu)To improve the outcomes of communication, it is essential to understand important underlyingprincipals. New methods of technology in medicine have opened new areas and expanded otherareas of research of the brain to demonstrate why we do what we do when we communicate witheach other. There is now extensive evidence that nonverbal communication is a key factor inunderstanding what is really being said and increases the odds of getting to the heart of thematter. Communication is influenced by multiple factors, including but not limited to:nationality, culture, ethnicity, race, age, gender, and class. Understanding nonverbalcommunication gives an advantage because some basic core expressions and mannerismstranscend those factors and are universal. This research is used in many fields to detect whethersomeone is telling the truth for example. What we say with our words is only about 7% of ourcommunication, the majority is nonverbal communication. It is important that we understandwhat is really being said by understanding what is communicated to us on the nonverbal level,because nonverbal communication is a more reliable indicator of what the person is trulyexperiencing and expressing. When there is a discrepancy or incongruity in what a person saysand their nonverbal cues, nonverbal trumps verbal. This presentation will offer some basicneuroscience, basic concepts of nonverbal cues, and offer practical suggestions for picking upcues to what a person is really saying.248

103. Longitudinal Follow-Up Studies in Swedish ForensicPsychiatry: Perpetrators of Sexual Crimes and RecidivismSexual Child Abusers and Recidivism - A 10 to 15 Year Follow-Up Study of anEpidemiological Cohort and a Clinic-Referred Study GroupThomas Nilsson, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(thomas.nilsson@neuro.gu.se)T.B.E.*Sexual Offenders against Adults and Recidivism – A 10 to 15 Year Follow-UpStudy of a Clinic-Referred Study GroupChristian Baudin, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(felugah@gmail.com)T.B.E.*Sexual Crimes and Drives/Psychology of Sexual OffendersCecilia Fielding, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(cecilia.fielding@kriminalvarden.se)T.B.E.*104. Longitudinal Follow-Up Studies in Swedish ForensicPsychiatry: Risk Factors, Patterns of Recidivism and PredictionForensic Psychiatric Patients – A Basic Description of a Population-Based TotalCohort Including Follow-Up DataHedvig Vincent, Lunds University (hedvig.vincent@gmail.com)249

T.B.E.*Risk Assessment in Forensic Psychiatry – The Importance of Protective Factorsfor the Subjective Experience of Commitment and Self-ControlMarielle Nyman, Lunds University (marielle.mn.nyman@skane.se)T.B.E.*Negative Events during Forensic Psychiatric CareHelena Andreasson, Lunds University (helena.andreasson@skane.se)T.B.E.*The Outcome Implications of a New Law within Forensic Psychiatric Care:Compulsive Open Psychiatric CareJakob Jansson, Lunds University (jakob.jansson@skane.se)T.B.E.*Crime Patterns and Recidivism in Institutionalized AdolescentsOla Ståhlberg, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(ola.stahlberg@neuro.gu.se)T.B.E.*105. Management of Mentally Ill Offenders in the Community:Mental Health Courts and Beyond250

A Meta-Analytic Examination of Criminogenic and Clinical Risk Predictors forCommunity-Based Violence among Persons with Mental IllnessDonaldo Canales, University of New Brunswick (d.canales@unb.ca)Ainslie McDougall, University of New Brunswick (ainslie.mcdougall@unb.ca)Ran Wei, University of New Brunswick (Ran.w@unb.ca)Claire Goggin, St. Thomas University (cgoggin@stu.ca)Past research (e.g., Bonta, Law, & Hanson, 1998; Phillips et al., 2005) has concluded that mentalhealth variables have negligible associations with violence risk and should be viewed asperipheral to the well-established predictive validity of criminogenic risk factors. However, alimitation of previous studies is that mental health variables tend to be combined into oneheterogeneous category, which may mask the predictive validity of specific clinical variablesthat have been previously linked to violent outcomes (e.g., threat/control-override delusions,violent ideation). The current paper will discuss a meta-analytic examination of the predictiveutility of specific symptoms and behavioral features common across mental health clients,irrespective of diagnosis, for community-based violence. These clinical variables will becompared to the predictive validity of the Central 8 criminogenic risk factors as outlined in theRisk-Need-Responsivity model (Andrews & Bonta, 2010). Only prospective studies will beincluded to allow a true predictor-­‐outcome analysis, and data collection is presently underway. Itis expected that traditional criminogenic risk variables will have the strongest associations withcommunity-based violence, and that violence-specific clinical variables will add incrementalvalidity to violence prediction. The importance of assessing both criminogenic and relevantclinical risk factors to better inform risk prediction will be discussed.A Retrospective Analysis of the Case Management of Mentally Ill Offenders inthe Saint John Mental Health CourtJulie Wershler, University of New Brunswick (m066d@unb.ca)Mary Ann Campbell, University of New Brunswick (mcampbel@unb.ca)Donaldo Canales, University of New Brunswick (d.canales@unb.ca)Alex Macaulay, University of New Brunswick (alex.macaulay@unb.ca)Ran Wei, University of New Brunswick (Ran.w@unb.ca)The use of mental health courts is becoming more prevalent in North America, and research isgrowing supporting their ability to reduce recidivism (e.g., Hiday & Ray, 2010; McNeil &Binder, 2007). This type of program facilitates access to services that address mental health andsocial service needs through comprehensive case management plans. However, it is unclear to251

what degree these case plans actually directly target the criminogenic needs that are contributingto participants’ criminal behaviour. As such, case management plans for 102 mentally illoffenders who were processed through the Saint John Mental Health Court, Canada, wereretrospectively assessed to evaluate the degree of matching between criminogenic needs asidentified by the Level of Service/Case Management Inventory (LS/CMI) and interventiontargets in case plans. Offenders received a wide range of interventions, most commonly relatedto mental health issues. On average, only four of the seven dynamic criminogenic needs assessedby the LS/CMI were adequately matched with intervention services. Certain needs, such assubstance abuse, were more frequently addressed, whereas others were targeted less frequently(e.g., family and marital relationships). This is an important finding, given that the number ofcriminogenic needs present in a case predicted the number of re-offenses committed by thatindividual after statistically controlling for number of days free in the community. Thus, failureto address these needs in the case plan will limit opportunities for risk reduction. In addition,high-risk offenders posed specific case management concerns. Implications of these results andfuture research directions will be discussed.The Importance of the Case Manager/Offender Relationship in PredictingCompliance with Mandated Community-Based InterventionsAinslie McDougall, University of New Brunswick (ainslie.mcdougall@unb.ca)Mary Ann Campbell, University of New Brunswick (mcampbel@unb.ca)Skeem et al. (2003) found that a collaborative, fair, and respectful offender/case managerrelationship is essential for achieving compliance with mandated intervention in the community.Despite the importance of this relationship, it is unclear whether it influences the link betweenstatic predictors of current compliance with mandated community supervision and intervention.The current paper will discuss findings that speak to whether a strong offender/case managerrelationship mediates the link between static predictors of compliance (e.g., history ofcompliance, risk for recidivism, history of mental health concerns) and current compliance withcommunity case plans. The sample on which these findings are based consists of Canadian adultoffenders under community supervision for at least 6 months, who were classified into degreesof mental health status (none to severe). Case managers’ and offenders’ perceptions of theirprofessional relationship are expected to mediate the link between static predictors and currentcompliance behaviour. In addition, the effect of the professional relationship quality is expectedto increase with the strength of case plan adherence to the principles of the Risk-Need-Responsivity model of effective offender case management (Andrews & Bonta, 2010). Thisstudy will further solidify the importance of the case manager/offender relationship to maximizecompliance with mandated intervention in community-based offenders with and without mentalhealth problems.252

Real-Time Change in Mental Health Courts: A Dual-Site Evaluation ofCriminogenic and Mental Health Recovery Indicators of ProgressMary Ann Campbell, University of New Brunswick (mcampbel@unb.ca)Alex Macaulay, University of New Brunswick (alex.macaulay@unb.ca)The objective of this paper is to describe preliminary data from the prospective evaluation of twomental health courts in the Atlantic region of Canada: the Saint John Mental Health Court andthe Nova Scotia Mental Health Court. This research will reflect the degree of change inindividual factors associated with recidivism risk (i.e., criminogenic needs as measured by theLevel of Service/Risk-Need-Responsivity Inventory) and mental health recovery variables (e.g.,housing stability, quality of relationships, mental health status) during the first year of mentalhealth court involvement. These changes will be compared to a sample of mentally ill offendersnot admitted to the program who are matched on age, gender, mental health severity, andrecidivism risk. This matched sample will represent mentally ill offenders managed by thetraditional criminal justice system. The degree of change will be analyzed in relation to casemanagement and program characteristics, such as the type of intervention received and length ofinvolvement in the program. Collectively, this research will address a gap in the mental healthcourt research regarding the nature of changes that contribute to their positive outcomes andhighlight areas for improved case management.Contextualizing the Management of Mentally Ill Offenders in MHCs and OtherSettings: Beyond the Canadian PerspectiveVirginia Aldigé Hiday, North Carolina State University (vmaldige@ncsu.edu)Different strands of research on persons with mental illnesses who offend and/or who becomeviolent, and on methods of effectively addressing their offending and/or violence in thecommunity are brought together in this set of empirical papers. Three of the studies use datafrom two mental health courts in Canada to see whether recommended processes that showsuccess in other settings are operative in MHCs, and whether they bring about predictedtreatment compliance and subsequent change in criminogenic needs and mental health recovery.While these processes and their effects could apply to many treatment and diversion programs,this presentation will draw from research on other mental health courts and drug courts tocontextualize the findings from the studies in this session.106. Medical Errors and Safe Patient Management in Psychiatry253

Patient Safety in Psychiatry: Clinical Issues and Risk ManagementJacob C. Holzer, Pocasset Mental Health Center, Pocasset, USA(Jacob.holzer@dmh.state.ma.us)Medical errors and the potential for harm to patients exist in the fields of medicine andpsychiatry. As advances in the understanding and treatment of illnesses have been made,morbidity and mortality from disease has decreased. However, simultaneously, as treatmentshave become more varied and complex, morbidity and mortality from treatment has increased.The costs of errors include spending in the billions of dollars, increased lengths of stay in thehospital, and increased re-admissions, along with patient morbidity and mortality. There arenumerous causes of error, including human error, the complicated nature of medicine, andsystemic issues. As both direct care staff have more patients to care for, and non-direct care staffhave increased, so too have errors. This presentation will identify and review sources anddemographics of error, individual and system functions, communication, and areas ofimprovement in clinical psychiatric evaluation and management aimed at reducing error and risk,within the context of forensic psychiatry and risk management.Safe Patient Management in Geriatric Psychiatry: Issues inPsychopharmacological ManagementRobert Kohn, Brown University (robert_kohn@brown.edu)There are no FDA psychopharmacological agents approved for use in managing any behavioralproblem in Alzheimer’s disease. Antipsychotics are not FDA approved for treatment ofpsychosis or agitation in dementia. The black box warning for early mortality andcerebrovascular events places the clinician in a difficult situation in dealing with any geriatricpatient who may have behavioral issues that are not manageable with other alternatives. Thephysician treating an elderly patient with antipsychotic medications needs to weigh ethical andregulatory issues in prescribing, in the face of data questioning not only safety, but also efficacy,of antipsychotic medications. This presentation will review the controversy, the appropriate useof antipsychotic medications, and treatment alternatives to antipsychotics. In addition, the morerecent issues around SSRI safety, the use of cognitive enhancers, and other pharmacologicalagents will be discussed.Quality Control and Process Improvement Techniques for OutpatientPsychiatric PracticeRobert P Granacher, Jr, University of Kentucky (rgranacher@aol.com)254

Quality control is used to reduce variance in processes. Its purpose is to insure that scarceresources are employed in an efficient and effective way consistent with evidence based mentalhealth practices. Process improvement is a series of actions to identify, analyze and improveassessment and treatment processes within outpatient mental health treatment centers to meetgoals and objectives in order to improve performance, reduce costs, and create better outcomesfor patients. This lecture will demonstrate how to: 1. align mental health clinic policy for qualityimprovement; 2. write a quality standards document; 3. monitor quality mechanisms; 4. cyclequality improvement into existing clinic procedures; and 5. establish process review procedures.Also, this portion of the session will describe methods for standardization of outpatientpsychiatric treatment by use of templates for each component of psychiatric assessment andtreatment planning. The methods will be practical, and simple and can be incorporated into anelectronic medical record system or used in a traditional non-electronic written or dictatedformat, which is used in many countries. World Health Organization guidelines will beemphasized. Lastly, participants will learn that 30-50% of persons with major depressivedisorder are not diagnosed in primary care practices. For psychiatrically hospitalized patients,46% of suicidal ideation is undetected while 50% of psychosis may be missed duringassessment. With the elderly, as many as 48% do not see a physician within 30 days of dischargefrom a psychiatric unit.Client Safety in Public Sector PsychiatryAminadav Zakai, Pocasset Mental Health Center, Pocasset, USA(aminadav.zakai@dmh.state.ma.us)This presentation will review the experience of the patients in the public sector in Massachusettsunder the Department of Mental Health (DMH), it will focus on measures the department takesto ensure clients’ safety and focus on unstable chronically mentally ill as they move through thecontinuum of care offered by the department. The paper will present safety statistics and providea critical review around services available to manage patient safety as well as a review of thecrisis management system and acute care availability through the system. There will be a specialfocus on the management of forensic cases and the interface between the correction system andthe public health system and the management of violent patients within our system.107. Medico-Legal Implications of Social MediaInformed Consent and Social Media: How Not to Be an Ostrich, a Scaredy Cat,or a Bull in a China ShopRobert Hsiung, Dr. Bob LLC, Chicago, USA, (bob@dr-bob.org)255

Social media are exerting evolutionary pressure on doctors. Different subpopulations of doctorsare responding in different ways: (1) The ostrich ignores social media. He continues withbusiness as usual. He sees e-mail as analogous to and uses it like the telephone. He has heard ofFacebook and Twitter, but does not understand and is too busy to learn about them. (2) Thescaredy cat sees risks and runs the other way. She has learned a lot about social media. She hasread all the stories about the doctor who lost her job because of Facebook. She abstains fromsocial media and buys e-reputation insurance to protect herself from online libel. (3) The bullcharges ahead undeterred. He finished his residency US$ 229,132 in debt, started a privatepractice, and uses social media to try to gain a competitive edge. He Skypes with patients inother states and countries, blogs daily about his life as a young doctor, accepts all requests to be"Facebook friends", "follows back" anyone who "follows" him on Twitter, answers questionsfrom patents and others online, and has 54,986 followers and a Klout score of 63. (4) Thejudicious health professional responds the most adaptively, by learning about risks, safeguards,and potential benefits; discussing them with each patient; and introducing social media intothe doctor-patient relationship with, and only with, informed consent. Dr. Hsiung's presentationincludes his actual e-mail, Facebook, and Twitter informed consent forms.HIPAA Privacy Implications of Social MediaStacey Tovino, University of Nevada at Las Vegas (Stacey.Tovino@UNLV.edu)This presentation will examine federal and state statutes and regulations governing healthinformation confidentiality in the context of social media use by physicians, hospitals, and otherindividual and institutional health care providers. More specifically, this presentation will: (1)provide examples of the ways in which individual and institutional health care providers useFaceBook, Twitter, YouTube, and blogs to share information with friends and the general public;(2) provide an overview of federal and state rules governing health information confidentiality,including recent updates to the federal HIPAA Privacy Rule and more stringent state statutes andregulations governing health information confidentiality; (3) identify the ways in which healthcare providers’ use of social media implicates federal and state health information confidentialitystatutes and regulations; (4) address permissible and impermissible uses of social media withrespect to health care providers' online communications with patients and friends as well as theprovision of health care advice and information to the general public; and (5) provide examplesof recent federal and state enforcement actions to illustrate the types of civil, criminal, andadministrative penalties that can be imposed on covered entities and business associates who failto maintain the confidentiality of protected health information. The objectives of thispresentation include familiarizing conference attendees with the United States’ federal and staterules regarding health information confidentiality and the ways in which health care providers’social media use implicates such rules.256

Social Media in the Practice of Forensic Psychiatry Evaluation andManagementTracy D. Gunter, Indiana University – Purdue University Indianapolis (tdgunter@iupui.edu)By providing a self-documenting platform for the instantaneous exchange of user generatedcontent, social media encourages sharing of information and opinions in a relatively unregulatedspace without traditional geographic barriers. When used responsibly, social media outletsprovide opportunities for delivering health information and psychosocial support. However, thebroad scope and relative anonymity of virtual communities provide opportunities for nefariousand self-destructive activities such as bullying, harassment, fraud, collusion, and prosuicidecommunications. The forensic mental health practitioner is frequently involved in the evaluation,treatment and supervision of individuals who have exhibited problematic behavior. While themajority of this risky and disruptive behavior will be terrestrial in nature, Dr. Gunter will arguethat it is incumbent upon forensic mental health practitioners to consider the examination ofInternet and social media data as part of both evaluation and treatment. In the area of evaluation,daily time on line, content of online communications, and nature of online activities may provideimportant information. Access to these resources may be gained in collaboration with theevaluee, through an online search of the evaluee’s name or e-mail address, through an employer,or by warrant or subpoena (depending upon issue and jurisdiction). In the area of supervision,best practices are being developed and implemented worldwide. For example, the New SouthWales Chief Psychiatrist recently issued an opinion that improved supervision of Internetresources and regular auditing of Internet capable devices used by forensic patients should beimplemented after an insanity acquittee used these technologies to abscond from a facility. Thissession will review and propose best practices in this evolving area.Social Media and the Physician-Patient RelationshipNicolas Terry, Indiana University – Purdue University Indianapolis (npterry@iupui.edu)As people spend more time in social media, they will have more of their health-relatedexperiences there as they gather and disseminate information (and misinformation). And, aspatients turn towards social media, healthcare providers seem happy to provide an expandingnumber of destinations. In the US well over 1000 hospitals now have social networking sites,including Facebook pages and Twitter feeds. A complex and not always cohesive set of rulesregulates patient and provider behavior in the social media space; domain-specific privacyregulations are joined by computer crime and privacy statutes, labor law, ethics and professionalcodes and an increasing number of policies included in healthcare employment contracts. Thispresentation deals with the reality of medically relevant information about patients increasinglymoving online. It deals primarily with two practical questions. First, it asks whether there arecircumstances when physicians should explore the social media lives of their patients,particularly if therapeutically beneficial or even life-saving information is available online.257

Should the physician seek to access that information and could such an opportunity morph into alegal obligation imposed on the physician? Second, it explores how the patient-physician dialoghas increasingly spilled out of the consulting room and onto social media sites. Physiciansincreasingly are counseled about boundary issues when they interact with patients online becausethey might discuss and disagree about care issues in a public place. This part explores howphysicians should (and should not) react to online critical patient comments.Social Media in Medical EducationChristopher R. Thomas, University of Texas Medical Branch at Galveston (crthomas@utmb.edu)This presentation reviews the special problems of social media and medical education, thedevelopment of new policies to deal with them, and the creation of training for students andeducators on the professional standards regarding social media. Specific incidents of violation ofpatient privacy and unprofessional behaviour by students using social media serve as examplesof the risks involved. Creation of institutional policies is reviewed with attention to specificapplication of ethical and legal standards. A model training program educating students,residents and faculty members on social media is also reviewed.108. Mental Disorders in German Adolescents High at Risk forOffendingGerman Adolescents in Stationary Welfare Service: At Risk for MentalDisorders?Steffen Weirich, University of Rostock (steffen.weirich@med.uni-rostock.de)Claas Pätow, Gesellschaft für Gesundheit und Pädagogik, Rostock, Germany(claas.paetow@ggp-rostock.de)Frank Häßler, University of Rostock (frank.haessler@med.uni-rostock.de)Objective: Mental disorders in adolescence are known to increase the risk of offending in earlyadulthood. Juveniles living in stationary welfare settings are known to be at risk for offending aswell. This study asks if this risk might be an effect of increased rates of mental disorders injuveniles in welfare settings. The study compares prevalence of mental disorders in a sample ofyouths from stationary youth welfare service to prevalence in the general population andevaluates opportunities for psychiatric care in welfare.Method: A survey was conducted at all stationary welfare services in the rural area of BadDoberan, Germany with 42 adolescents answering to Achenbach´s Youth Self Report and theirteachers to the Teachers Report Form for mental problems.258

Results: In the self-reported data 57% of the adolescents showed clinically relevant symptomloads. Girls were significant more impaired in internal characteristics than boys. Ratings fromdifferent sources differed significantly.Conclusion: Higher prevalence of mental disorders was reported by juveniles from welfaresettings and their teachers. Compared to this need for treatment, chances for juveniles in welfaresettings are lowered by a number of structural risks. Results argue for a stronger integration ofchild and adolescent psychiatry and youth welfare systems. Altogether, adolescents fromstationary youth welfare services comprise a group high-at-risk, as do other groups reported onin this symposium.Psychiatric Disorders of German Adolescents in DetentionFrank Häßler, University of Rostock (frank.haessler@med.uni-rostock.de)Anne Wolter, Gesellschaft für Gesundheit und Pädagogik, Rostock, Germany(a.wolter@ymail.com)Claudia Engel, University of Rostock (claudia.engel@med.uni-rostock.de)Objective: According to police criminal records in Germany more than two million Germanswere suspected of having committed a crime in 2010. Among those were 10.75% juvenile and10.1% young adult suspects. German official statistics do not report prevalence of psychiatricdisorders, or mental retardation, or a combination of both, among offenders in Germany.Juvenile detainees however, are known to be at high risk for (untreated) psychiatric disorder.Method: The data gathered from incarcerated adolescents were analyzed in order to compare thesample with other populations at risk (see other papers at this symposium). 39 boys (aged from14 to 18 years) incarcerated in the juvenile detention center in Neustrelitz were interviewed andassessed by a battery of psychological tests (YSR, SDQ, BIS, PSSI, YPI, JTCI and others).Results: 71.8% of the juveniles in our sample displayed a conduct disorder (F 91 and 92), 30.8%were diagnosed with ADHD (F 90.0 and F 90.1), 15% suffered from a depression (F 32), and95% abused some kind of substance. Prevalence of these mental disorders is significant higherthan not only the normal population but also the population of stationary youth welfare service.Conclusions: Considering that juvenile prison inmates are burdened by high rates ofpsychopathology and mental disorders, it is essential to develop a structured diagnosticprocedure and adequate treatment strategies according to child and adolescent psychiatryguidelines in imprisoned conditions. Both are hard to find in German prisons. An effectivemultimodal treatment however, is known to prevent criminal relapse. The talk argues for anintegration of adolescent psychiatry into regular prison routines.Mental Health Problems in Adolescent Samples of Alcohol and Cannabis Abusers259

Olaf Reis, University of Rostock, (olaf.reis@med.uni-rostock.de)Christiane Baldus, University of Hamburg (c.baldus@uke.de)Rainer Thomasius, University of Hamburg (thomasius@uke.de)Objective: The abuse of legal and illegal drugs is known to already be associated withdiminished mental health during adolescence. Data from two recent German studies arepresented to analyze this association and suggestions are made to access juveniles at high risk.Method: In sample 1, 188 adolescents investigated during their stay at intense care units shortlyafter acute alcohol intoxication were rated on the distribution of F-diagnoses given by a trainedpsychiatrist. In sample 2, 266 adolescents taking part in a secondary prevention programme forcannabis users were investigated for self-rated (YSR, YASR) psychiatric problems after acutepsychoses were excluded.Results: Binge-drinking adolescents displayed significantly higher loads of psychiatric illnessescompared to the normal population as rated by a psychiatrist. Adolescents intoxicated afteralcohol abuse displayed higher rates of ADHD-related disorders (ratio 1:5), compared to thenormal population, and a higher rate of adaption disorders (F 43). A similar pattern of higherburdens of mental health problems occurred for adolescents consuming cannabis on a regularbasis.Conclusions: Binge-drinking as well as regular cannabis use may indicate higher loads of mentalproblems. At the same time, these adolescents are hard to access. A concept of “vulnerablemoments” for early detection and treatment of drug abuse and criminal offense prevention isdiscussed.Prevalences of Mental Disorders among Young Patients in a German Hospitalfor Forensic PsychiatryDetlef Schlaefke, University of Rostock (detlef.schlaefke@med.uni-rostock.de)Objective: Based on the German Criminal Code for both juveniles and young adults, theUniversity of Rostock’s hospitals for Forensic Psychiatry are responsible for compulsorytreatment of these offenders. To be admitted to a forensic hospital a causal association of mentaldisorder or addiction and criminal act is required. This study describes the ratio of co-morbidmental disorders found in patients in a north German hospital and their effects on treatment.Method: After a young offender is admitted to our Forensic Psychiatric Clinic, intensivediagnostics take place, covering personality, intelligence, and neuropsychological function. Staffmembers try to motivate patients and explain the course and rules of treatment. Individualtreatment plans are negotiated at the end of this period.Results: 126 patients have passed through inpatient treatment during the last decade with theirdata collected according to the Forensic Basis Documentation. 94% of all juvenile offenders (n =16) showed an additional mental disorder, out of which 65% suffered from a conduct disorder.260

91 addicted young adults (66%) displayed a co-morbid mental disorder, such as personalitydisorders (31.9%) and conduct disorders (19.8%). 18 patients were admitted because theysuffered from severe mental disorder during the time of offending. Out of these, 50-55 %suffered from a co-morbid disorder.Conclusions: Co-morbid mental disorders of various kinds put a challenge on the staff inhospitals for Forensic Psychiatry. Mechanisms limiting the benefits of therapeutic interventionsin forensic hospitals also include co-morbid mental disorders and should be studied in detail.109. Mental Health & Death RowCompetency and Capital Inmates Who Seek Execution by Opting to Waive theirAppealsLinda L. Griffis, Office of the Federal Public Defender, USA (linda_griffis@fd.org)It is not uncommon for death row inmates to "volunteer" to be executed by seeking to terminatetheir pending appeal or post-conviction proceeding. Not surprisingly, a high percentage of theseinmates struggle with chronic mental illness. Additionally, the literature makes clear thatconditions of incarceration can have an adverse impact on an inmate's psychological well-beingand, in turn, their competency to make rational, intelligent and voluntary decisions about theircase. The United States Supreme Court requires only that a death row inmate be competent towaive his appeals. The question of competency, as defined by the Supreme Court, asks whetherthe inmate has a rational and factual understanding of the consequences of his decision. If hedoes, and if the waiver is knowing, intelligent and voluntary, then he will be permitted to waivehis appeals. The question that arises, however, is whether the inmate's decision is attributable toa mental disorder — either chronic or as a result of his incarceration — or is instead truly theproduct of a rational choice. This presentation will address how some courts have dealt with thisrecurring issue and how any meaningful competence inquiry must focus not only on the inmate'sunderstanding of the consequences of the decision, but also on his or her reasons for wanting towaive pending litigation, and the rationality of the inmate's thinking and reasoning.“Moral Sufferings More Terrible than Death”: The Long wait on Death RowDenny LeBoeuf, ACLU Capital Punishment Project, Durham, USA (dleboeuf@aclu.org)Albert Camus wrote about the psychological pain the condemned experience in 1957. From theSoering case in 1989 through the Al-Saadoon case in 2010, the European Court of Human Rightshas found that the psychological suffering accompanying a prolonged wait on Death Row canamount to cruel, inhumane, and degrading treatment. The courts of states from India to Kenya toCanada have considered this mental pain in decisions regarding extradition, consular rights, or261

outright abolition of the death penalty, finding it to be a separate human rights concern from theimposition of death itself. These decisions have relied in part upon mental health experts, someof whom point out that the isolation, solitary confinement, and uncertainty about executionincrease the potential for profound mental illness: delusions, suicides, psychosis, and, in somecases, complete incompetence. Although the United States Supreme Court acknowledged thispotential more than 60 years ago, no modern Supreme Court case has followed the internationalpractice of examining the legal quandaries presented by a prolonged wait for execution.Prefrontal Cortex Regions and Rorschach DeterminantsMyla H. Young, Private Practice, El Dorado Hills, USA (mylayoung@sbcglobal.net)Jerald V. JusticeIn this research, 231 male prison offenders who had been referred for psychiatric evaluationwhile in prison participated in a study in which criminal and psychiatric records were reviewed,interviews were conducted, comprehensive neuropsychological testing was completed and theRorschach Test was administered. Using the Halstead-Reitan Neuropsychological BatteryImpairment Index, a group of participants who demonstrated brain dysfunction were comparedwith a group of participants who had normal brain function. The focus of this portion of theresearch study was to evaluate the usefulness of the Rorschach Test as a measure of brainfunctioning. Functioning of neuropsychological measures and Rorschach determinantsassociated with the prefrontal cortex (PFC) were identified. The dorsolateral, orbitofrontal,mesial, and motor regions within the PFC were independently evaluated and Rorschach Testdeterminants associated with each of these PFC regions were identified. Results demonstratedthat a pattern of Rorschach determinants significantly discriminated between prison offenderswith brain dysfunction and those with normal brain functioning. It was concluded that, as well asa measure of psychiatric disorder, the Rorschach Test should be considered a useful measure ofbrain functioning.The Role of Culture in Guantanamo’s Capital CasesScharlette Holdman, Center for Capital Assistance, New Orleans, USA(scharlette@mitigate.com)In the Guantanamo capital cases, culture is critical to the defense team’s understanding andinvestigation of detainees’ cultural and religious beliefs which will likely figure prominently inthe government’s case at all stages of the proceedings and require rebuttal and correction ifinaccurate or misleading.Culture is relevant to all phases of the Guantanamo proceedings, from building a relationshipwith the client to presenting claims arising from torture and cruel and inhumane treatment at the262

hands of the U.S. government. Culture affects pretrial investigation and litigation, resolution ofthe case, and guilt-innocence defenses as well as sentencing options. Finally, culture isinextricably linked to social history, and social history is the foundation of any competent,reliable assessment of an individual’s functioning and behavior, and is also a critical componentof assessing torture and its effects.Capital proceedings, by law and practice, require investigation, preparation, presentation, andconsideration of any fact that may shed light on the offender and the offense, the frailties ofhumankind, and the infinite array of human conditions that affect behavior and functioning.The consequences of torture and maltreatment affect each detainee differently and uniquely inaccordance with their own attribution of meaning, culture, and life history of experiences andperceptions. Defense counsel have a duty to investigate, learn, and appreciate the intimaterelationship between culture, torture, and culpability as a core organizing principle forrepresenting Guantanamo capital defendants. This paper presents the standard of care for bestpractices in investigating, developing, and presenting a culturally competent capital defense.Ethnopsychopharmacology and Culturally Competent Diagnosis: Applicationsin Criminal JusticeL. DiAnne Bradford, Morehouse School of Medicine (Dbradford@msm.edu;Dbradford@aol.com )With the advances in ethnopsychopharmacology (how people of different race/ethnicity mayrespond differently to drugs) and pharmacogenetics (determining the underlying genetic codingwhich may explain these differences), we have discovered that the benefits (efficacy) and safety(adverse events) ratio of drugs which were discovered and developed in Caucasians may differ inpeople of different race/ethnicity. Some of these differences in response to treatment ofpsychotropic drugs may be attributed to differences in genetic allele frequencies, or the samegenetic material impacted by further upstream genetic differences yet undiscovered. The clinicalimpact can be either an increase in adverse event burden or a decrease in the efficacy of certainpsychotropic drugs in people of Asian and African descent. These findings have a direct impacton court-ordered involuntary medication in order to restore competency, and should beconsidered in any treatment plan. An additional factor for consideration in the criminal justicesystem is the evidence that African Americans are being over-diagnosed as havingschizophrenia, while missing diagnoses of affective disorders such as bipolar disorder. This overdiagnosisof schizophrenia and under-diagnosis of bipolar disorders, among others, has beendocumented in out-patient clinics, inpatient hospitals and among prisoners incarcerated withinthe criminal justice system. Factors which play a role in this misdiagnosis include racial/ethnicdifferences in symptoms and clinician bias, i.e., using different decision rules in formingdiagnosis. Since a culturally competent diagnosis is the basis for treatment plans and mitigatingfactors, misdiagnosis of mental illnesses impacts criminal justice proceedings.263

110. Mental Health and Law in KoreaMental Health, Human Rights Legislation, and the UN Convention on theRights of Persons with DisabilitiesJung-jin Kim, Nazarene University (kimjj@kornu.ac.kr)We are facing a human rights emergency in mental health. In Korea, people with mentaldisabilities experience a wide range of human rights violations. Recent medical and socialstatistics have reported the shocking reality that one in four Korean people will suffer frommental illness at some point in their lives. People with mental disorders encounter prejudice anddiscrimination in almost all aspect of their social lives. A majority of people with chronicschizophrenic disorder are also kept in mental hospitals and asylums involuntarily due to themisuse of mental health law and the lack of government control systems. A recent incident inwhich 2 patients committed suicide and 1 patient was suspected to have been murdered bypersonnel at a local private mental hospital highlights the reality of living with mental illness anddisabilities. Generally, psychiatric institutions in Korea are associated with gross human rightsviolations including inhuman and degrading treatment and living conditions. Even outside thehealth care context, mentally ill people are excluded from community life and denied basic rightssuch as shelter, food and clothing, and are discriminated against in the fields of employment,education and housing due to their mental disability. Many are denied the right to marry andhave children. As a consequence, many people with mental disabilities live in extreme povertywhich, in turn, affects their ability to gain access to appropriate care, integrate into society andrecover from their illness. In 2008 the UN Convention on the Rights of Persons with Disabilities(CRPD) came into force. The Convention sets out a wide range of rights including, amongothers, civil and political rights, the right to live in the community, participation and inclusion,education, health, employment and social protection. It’s coming into force marks a majormilestone in efforts to promote, protect and ensure the full and equal enjoyment of all humanrights for persons with disabilities. The Korean government joined this convention in 2009. Ameeting of the United Nations Economic and Social Commission for Asia and the Pacific(ESCAP) will also be held in Incheon, Republic of Korea from 29 October to 2 November, 2012based upon the principles of the Convention on the Rights of Persons with Disabilities. But thatprocess will be too slow for Korea's mentally ill. Unjust discrimination against people on thegrounds of mental disorder must be stopped immediately, to improve mental health policy andadministration of admission and discharge procedures, and to strengthen community life. Severalsuggestions are offered, such as raising awareness and advocating change for the rights of peoplewith mental disabilities, collaborating with international organizations to disseminateinternational human rights standards, developing mental health policies and laws that promotehuman rights, and creating mechanisms to assess and improve human rights conditions based onthe WHO Quality Rights Project.The Addiction Policy, Law and Service Delivery System in Korea264

Myeong-Sook Yoon, Chonbuk National University (yoon64@jbnu.ac.kr)Sulki Chung, Chung-Ang University (chungs@cau.ac.kr)During the past 10 years, a growing number of Koreans have experienced addiction (either toalcohol and/or other drugs, gambling, or the internet). There is a high prevalence of addictionproblems in Korea. The lifetime prevalence of alcohol related disorders was 13.4% in 2011, andprevalence of gambling addiction and internet addiction was 6.1% and 7.7%, respectively.Addiction not only devastates individuals and families, but it also creates social and economiccrises. The aim of this study is to review addiction problems and service delivery systems inrelation to the management of addiction problems in Korea, with a specific focus on the role ofmental health professionals. Findings show a lack of systemic features in organizationalstructures, fiscal problems and a scarcity of experts. Despite increased awareness of the necessityfor addiction policy and services, each addiction system has developed independently, andpolicies, funding and service delivery models vary significantly. Developments in legislation andregulations in prevention and care are described. Directions for improvement have beensuggested in the form of integrated addiction services delivery systems. The government needs toconstantly evaluate its policy and develop its options within the area of legislation andregulations which should also include critical comparisons to the situation in other countries. Anintegrated addiction management system should develop to be more responsive to addiction andits symptoms.Introduction of New Laws and the Lack of Interface in the Mental Health Act inKoreaMoon-Geun Kim, Daegu University (ctstars@hanmail.net)The Korean Mental Health Act of 1995 provided grounds for the protection of the mentally illthrough provisions concerning involuntary admission and community mental health services.With the inclusion of disability from mental disorders into the definition of disability in therevised Disability Act in 1999, a new path was made for people with chronic mental disorders toreceive diverse disability benefits from governments. Recently the introduction of the ActivityAssistance Act (2011) and the introduction of adult guardianship by the revision of the Civil Act(2011) altogether enhanced the safety net for the mentally ill. But differences in definitions ofmental disability between these laws hinder seamless protection of human rights and welfare forthe mentally ill. For example, the Disability Act restricted the use of community rehabilitationservices for those disabled by chronic mental disorders on the grounds that they can use thoseservices under the Mental Health Act. But there are differences in definitions of mental disabilityand service paradigms between the two acts. Based on the principle of self-selection amongmultiple services in the Disability Act, the mentally disabled should have unlimited rights tocommunity services. We are also expecting adult guardianship services for the mentally disabledin July 2013, but the Mental Health Act does not have any provisions concerning mental capacityand adult guardianship services for the mentally disabled. Therefore a review of definitions of265

disability in different laws and revision of the Mental Health Act to make interface between theact and laws concerned is urgently needed in Korea. This study examines definitions of disabilityin laws concerning the mentally ill and suggests definitions of mental disability in the MentalHealth Act to provide seamless protection for the mentally ill.Exploring Roles of Social Workers to Prevent Suicide in KoreaMyungmin Choi, Baekseok University (mmchoi@hanmail.net)The suicide rate in Korea is currently the highest among OECD countries and is increasingrapidly. Suicide is one of the major causes of death in Korea and every sector of society isseeking solutions including the field of social work. Social workers provide services forvulnerable people in communities who are exposed to suicide risk relatively easily. But it isunknown how many social workers are facing suicide problems and how they deal with them intheir work. This study examines Korean social workers to find what kind of support is needed forthem to work more effectively.For this purpose, 615 social workers were surveyed and the datawere analyzed by SPSS 18. 108 respondents (17.6%) had lost a client to suicide in the last 3years. 180 respondents (29.3%) answered that their clients had attempted suicide and 330(53.7%) reported that clients had expressed suicidal thoughts in the last 3 years. During the sameperiod, 302 (49.1%) suspected clients of suicidal thoughts at least once, although clients did notsay so directly. However, among those cases, 108 social workers (17.6%) did not take any actionbecause they were too busy with other tasks, thought the probability of clients acting on suicidalthoughts was low, or didn’t know how to cope with it. respondents indicated that suicidal riskwas very relevant to their jobs, and that they needed the ability to cope with suicide problems(4.1 and 4.6 on a 5 point scale). They also very much wished (4.5 on a 5 point scale) to have theopportunity to train in suicide prevention (SP). The importance of SP training programs washighlighted by the fact that respondents trained in SP had significantly higher competency scoresin SP than those untrained. In conclusion, social workers are useful preventers of suicide asgatekeepers and professionals in Korean society. Appropriate training programs for SP should beprovided to social workers immediately in accordance with their needs.The Lived Experience of Koreans with Mental IllnessSun Kyung Kang, Sogang University (skshin2000@sogang.ac.kr)This qualitative phenomenological study explores the lived experience of individuals withmental illness in a clubhouse in Korea. Semi-structured interviews with nine participants wereconducted to examine the vicious circle of sorrow facing individuals with mental illness. Threemajor themes from the lived experience emerged: entering a haven, living in a haven, and havinga haven-like hometown. The results of the study indicated that participants had a broad range ofperspectives on mental rehabilitation, including recognition that rehabilitation was something266

more than holding a regular job; acceptance of their illness, situations, and limitations; and desirefor a meaningful and fulfilling life within the clubhouse. The results contributed to a betterunderstanding of the lived experience of individuals with mental illness in the context of aclubhouse and their extended rehabilitation and provided important implications for social workprofessionals.111. Mental Health Policy & Governance‘Nudging’ v Realist Governmentality Analytics: New Approaches for MoreEffective Social PolicyMaree Livermore, Australian National University (mliv@livermore.com.au)The currently-influential behavioural economics (‘nudging’) principles assert that some irrationalbehaviour is predictable and can be modified, through policy, by delimitation of citizen choice.This may involve the use of technologies designed to influence behaviour on a subconsciouslevel. Nudges are defended on the basis that they are ‘good’ – both for society and for theindividual, yet despite their potential power for both proper and improper purpose, no reflexivepractice attends. Furthermore, nudging principles apply totalised views of human behaviour withno consideration of idiosyncracy – including in relation to the (possibly deleterious) specificeffects of the nudging policies themselves, and to the conditions applying in the particular socialsystem in which nudges may be applied. This paper argues that, while nudges may be effectivelyapplied in appropriate conditions, the approach is blunt in its front-end analysis, particularly ofcomplex and unique social policy contexts like individual health sectors. By contrast, it isargued, the post-Foucauldian ‘realist governmentality’ approach may deliver more nuanced andultimately more reliable reporting on the landscape of influence, and processes of subjectformation and resistance, that actually prevail and determine outcomes in a particular socialcontext. ‘Realist governmentality’ empirical study has potential, then, to found cheaper andultimately more successful policy design (that may, or may not, include nudges).'Governance + Governmentality': Twinning Perspectives from the Air and on theStreet on Mental Health Sector RegulationMaree Livermore, Australian National University (mliv@livermore.com.au)As “fundamentally a social practice” (Burris, 2008), the agency of a law in a specific context willalways be contingent on and subject to an array of unstated, and largely untested, assumptions.Furthermore, the law is only one of an array of technologies of influence employed by an arrayof actors in a regulatory field in order to achieve an array of (sometimes-conflicting) objectives.In this pluralist complexity, characteristic of the mental health sector, it has been difficult to267

identify “what works”. This paper outlines an alternative mixed method analytic approach –governance+governmentality – that has the scope both to map the political complexity of amental health sector, and to characterise the actual effect of mental health law as a particularregulatory technology in a particular domain. The aim of the approach is to describe “what isreally going on”, and why, in a discrete section of a regulatory domain, thus to facilitate thedesign of regulatory interventions, for that particular set of conditions in time, that mayultimately (better) “work”. This paper outlines the policy development potential of thismethodological alliance between macro, meta-regulatory governance analysis, and microgovernmentality sub-analysis, presenting preliminary findings from an ongoing Australian studyon the effects of mental health law on the practice of clinicians in relation to the access to serviceobjective.The Future Role of the Nearest Relative in UK legislationPhilip O'Hare, University of Central Lancashire (po-hare@uclan.ac.uk)Gavin Davidson, Queens University, Belfast (g.davidson@qub.ac.uk)The Nearest Relative has been a legally defined role in UK mental health law since the 1950s,presented with a range of duties and powers to safeguard patient rights. It became a mandatorypart of mental health practice to consult with and work alongside the Nearest Relative during theassessment of a patient for compulsory detention in hospital. This task has become increasinglyburdensome, due in part to an inflexible definition, complex family dynamics and the prospect oflitigation awaiting any incorrect legal interpretation. The evolution of the Nearest Relative inScotland has taken a different route to resolving some of these difficulties with the introductionof the nominated person in the Mental Health (Care and Treatment) (Scotland) Act 2003.Northern Ireland plans to take a similar pathway by introducing a nominated person (BamfordReview of Mental Health and Learning Disability, 2007). England and Wales reviewed mentalhealth legislation in 2007 in light of challenges in the European Court of Human Rights andpreserved the role of the Nearest Relative. This paper will review the experience of changewithin each of these jurisdictions. It will identify some of the continuing legal challenges beforethe UK courts and reflect on the meaning of safeguarding patient's rights.Analytical Perspectives on the U.S. Affordable Care ActAlan G. Vaughan, Saybrook University (alanvaughan@sbcglobal.net)This presentation adopts Analytical psychology, as a critical theory, to interrogate the U.S.Affordable Health Care Act, 2010, the constitutionality of which is to be determined by the U.S.Supreme Court in the fall of 2012. A summary of the new health care reforms is offered, alongwith a statement of challenges to the constitutionality of the Act. Other factors highlighted in this268

presentation include: comparative global and U.S. health care costs; comparative global and U.S.mental health care services and costs; implications of the Act for U.S. mental health care servicesand delivery; and epidemiology of U.S. health and mental health disparities among Populationsof Color.U.S. Supreme Court Upholds Affordable Care Act – A Seminal Case – What ItPortends for the FutureRichard Kirschner, Kirschner & Gartrell, P.C., Bethesda, USA (leaglerk@aol.com)In 2012 the U.S. Supreme Court upheld the constitutionality of the Patient Protection andAffordable Care Act. By a 5-4 vote the Court approved the “penalty” imposed for failure to buymedical insurance, and upheld all of the Act’s components but one – that the federal governmentmight withhold all Medicaid funds from states which refuse new funds for Medicaid expansion.Claims of unconstitutionality included: (1) the mandated “penalty” was unconstitutional exerciseof Congress’s power to regulate interstate commerce; and (2) Medicaid (a joint federal-stateprogram providing health care to the poor/disabled) could not be imposed on states by threat towithdraw all Medicaid funds. The decision’s reasoning and the majority’s makeup weresurprising. Conservatives’ favorite Chief Justice Roberts led the majority, stating the “penalty” isa “tax” and “because the Constitution permits such a tax, it is not our role to forbid it. . .” And inruling that states cannot be coerced into expanding Medicaid the Court failed to acknowledgethat millions of the poorest would thus be denied the Act’s benefits! The Act’s provisions andpolitical efforts to frustrate and overturn it will be explored.112. Mental Health Research with Minors: The Ethical FrameworkRevisitedMental Health Research with Minors: The Ethical FrameworkInez de Beaufort, Erasmus Medical Center, Netherlands (i.debeaufort@erasmusmc.nl)Medical research with legal minors is regulated according to a variety of ethical guidelines andnormative requirements. To put it briefly, it is considered permissible only when it is eithertherapeutic and implies a potential direct benefit to the participating minor, or, if it is nontherapeuticand promises no such benefit, it must entail no more than low risk and minimalburden while it must be of specific relevance for minors considered as a group and as opposed toadults. This presentation provides an overview of the current normative framework regardingmedical research with children and adolescents. It applies this framework to the specificities ofmental health research and discusses the suitability of the ethical standards that currently reign269

ethical decision-making with regard to the set-up and implementation of relevant researchprojects.Psychobiological Studies on Risky Adolescent Substance Use: Ethical AspectsAnja C. Huizink, VU University (a.c.huizink@vu.nl)To gain insight into which psychobiological factors have an impact on the development of riskysubstance use among youth, including early onset of smoking, drinking and cannabis use, manyresearchers conduct longitudinal studies. In such a research design, it is possible to examine in atemporal manner if certain psychobiological factors (e.g. stress sensitivity) are associated withrisky substance use. However, direct effects of acute exposure to stress on increase in substanceuse, frequently found in adult populations, cannot be assessed in a younger population. This isdue to ethical guidelines, which imply that a researcher cannot actively expose an adolescent tosubstance use, by making, for instance, alcoholic beverages available to them when they areunder-aged. Nonetheless, several lines of research suggest that particularly adolescents may bevulnerable to stress effects. Adolescents’ brains are highly sensitive to reward, and thissensitivity may be further increased under stressful situations. With several examples ofimportant fundamental research questions, and their possible implications, I will describe theusefulness and limitations of ethical guidelines for research among youthWhat Researchers Want (and Medical-Ethical Committees Loathe):Dilemmas in Examining Gene-Environment Interactions in Children’sAntisocial BehaviorGeertjan Overbeek, University of Utrecht (g.overbeek@uu.nl)Suppose you are a psychologist who gets a grant to conduct an experiment on gene-environmentinteractions that underlie children’s antisocial behavior. Unfortunately, despite your new andrelevant research ideas it takes you a year and four resubmissions before you win acceptancefrom your medical-ethical committee. How is this possible? Building from my own experienceand gained insight, this presentation identifies some of the major ethical dilemmas in conductinga randomized trial that involves collecting data on children’s genetic make-up. The dilemmasconcern 1. the (un)desirability of giving participants information about their genetic make-up, 2.the (un)desirability of including a control group in an experiment of a known effectiveintervention, and 3. the fundamental necessity – or lack thereof – of collecting genetic data inboth children and their parents. Based on a critical review of medical-ethical review procedures,I conclude that several fundamental flaws now limit their efficiency and relevance. A moresystematic check of ethical difficulties in grant proposal reviews and the construction of an(inter)national database of previous ethical decisions and justifications can help to overcomethese current flaws.270

Title T.B.A.Don Linszen, University of Amsterdam (d.h.linszen@amc.uva.nl)Don Linszen will present his views and attitudes concerning the normative framework ofresearch ethics in mental health research with minors based on his experiences with research inthe area of early onset psychoses and schizophrenia.Mental Health Research with Minors: The Normative Framework RevisitedDorothee Horstkötter, Maastricht University (d.horstkoetter@maastrichtuniversity.nl)This presentation reflects on the current normative framework concerning the inclusion ofminors in mental health research. It embarks upon the assumptions that in addition to atheoretical ethical analysis, the views, perspectives and experiences of researchers in the fieldsshould be taken into account. The three preceding presentations concerning mental healthresearch with children and adolescents in the areas of substance use, antisocial behaviour andpsychosis, respectively, will provide important input in this regard. Combining a theoreticalethical analysis with information gained from practice reports, I will end with severalsuggestions concerning suitable amendments of current ethical standards in mental healthresearch with minors113. Mental Health, Rights, and the LawPlanning for Future Mental Health Crises in New ZealandKatey Thom, University of Auckland (k.thom@auckland.ac.nz)Allowing patients to make advance decisions regarding their future health care is an importantfeature of health service provision. Within mental health various models of advance careplanning (ACP) have been developed and many advocates believe such planning has thepotential to facilitate autonomous decision-making and increase patient perceptions of controlover treatment. The consideration of ACP in mental health care is also particularly relevant giventhe current policy climate following the ratification of the Convention for the Rights of Peoplewith Disabilities. The Convention promotes service users’ ability to claim their right to makeimportant decisions regarding their lives, rather than being viewed as ‘objects’ of medicaltreatment and social protection. ACP has been touted as one method of ensuring service usershave a stronger role in the decision-making about their health and social care needs. This271

presentation reports on a study that aimed to gain insights as to whether ACP could be clinicallytrialed in New Zealand mental health services. It will do this by briefly detailing a systematicreview of the different models of ACP in mental health internationally, followed by anexamination of clinicians’ attitudes to ACP and service users’ experiences of current planningprocedures.Mental Health Act Reforms during 30 Years of the Canadian Charter of Rightsand FreedomsJohn E Gray, Western University (jegray@shaw.ca)Thomas J Hastings, McMaster University (tom.hastingsmd@gmail.com)Steven Love, Government of Ontario, Toronto, Canada (steven_love@rogers.com)Richard L O'Reilly, Western University (O'Reilly@sjhc.london.on.ca)The Canadian Charter of Rights and Freedoms, introduced in 1982, requires that all 13 CanadianMental Health Acts conform with its provisions. Some people suggested that involuntaryhospital admission and treatment violate Section 7 of the Charter: "Everyone has the right to life,liberty and security of the person and the right not to be deprived thereof except in accordancewith the principles of fundamental justice." Notwithstanding Charter challenges over 30 years,Canadian courts have consistently deemed the rights restricted by involuntary admissions to be"in accordance with the principles of fundamental justice." Indeed, the majority of legislatureshave broadened their committal criteria beyond the concept of "danger to self or others" toinclude "likely to cause harm to the person or others or to suffer substantial mental or physicaldeterioration or serious physical impairment." The model for treatment authorization has notgenerally changed and treatment refusal by an involuntary patient is not allowed in somejurisdictions. Finally, in spite of opposition from groups citing the Charter, compulsorycommunity treatment has been introduced in a majority of provinces. What might happen tothese reforms in the next 30 years under the UN Convention on the Rights of Persons withDisabilities considering the Canadian declaration and reservation?114. MigrationWomen and Migration: The Mental Health NexusMaria Theresa Ujano Batangan, UP Department of Psychology and UP Center for Women'sStudies, University of the Philippines (mujanobatangan@yahoo.com)Given the significant number of women migrating as domestic workers, there is concernregarding their health and general well-being. The new transnational face of domestic workers272

generates important questions about the even greater vulnerability of this invisible community.Their daily interaction with the state, the host society, and their employers can be marked bydiscrimination on the intersecting basis of their ethnicity, nationality, class and gender. How dodevelopments concerning global migrant flows influence the health and well-being of thesedomestic workers? To answer the above mentioned question, a triangulation of methods wasemployed in conducting the study in four sites: La Union and National Capital Region (NCR) inLuzon, Davao City in Mindanao and Cebu City in the Visayas.). A total of 500 respondents wereinterviewed and 6 provided their life stories. FGDs were also conducted in the validation of thefindings. One of the sources of stress of migrant workers is the difficulty in balancingthedemands of work abroad and family life back home. Significantly, the number of physical andpsycho-emotional symptoms reported by the participants decreased while in the Philippinescompared to when they were abroad. Some respondents also narrated experiences of abuse invarious forms. The challenge of adjusting to the norms and mores of a different culture, coupledwith the identity of being a minority further exacerbates their problems. Recommendations aredrawn along three areas-policy, research and program development and intervention.Toward Safe Migration: Mental Health and Stress of Female Migrant DomesticWorkersA.J. van der Ham, VU University Amsterdam (a.j.vander.ham@vu.nl)In recent years, various international as well as regional development and human rightsorganizations have voiced their concern about the increase in documented cases of work-relatedmental health problems. Human rights of migrant workers have often been compromised due tothe inability of state parties and service providers to provide acceptable, affordable andappropriate measures to protect them from abuse and harm. Female migrant domestic workersform a particularly vulnerable population. In this study we aim to enrich our knowledge of thepsycho-social and mental health dimensions of overseas domestic work from a human rightsperspective. The study population included female migrant domestic workers from thePhilippines. Study methods combined quantitative (500 questionnaires) and qualitative researchtechniques (1 workshop, 2 focus groups, and 5 case studies). Results provide insight in thestressors of women migrant domestic workers, the manifestations of stress, ways of dealing withstressors and the impact of stressors on women’s personal, interpersonal, family and economiclife. We addressed these issues in different phases of migration: pre-departure, during migrationand upon return. Findings from this study indicate a need for measures to strengthen currentpolicy and program initiatives to address employment and related sources of stress of migrantworkers, both in sending and receiving countries. Simultaneously there is a need for an enablingenvironment for women to develop life skills and culturally sensitive self-empowermentstrategies to promote personal health and well-being.273

The Theory of New Normalising: Legal Implications and Mental HealthImplications for Migrant Health Care Professionals and their FamiliesJohn Collins, JCC Inc., Canada (jcollins@jcollinsconsulting.com)In 2011 there were 214 million migrants worldwide. In numerical terms, migration has beenincreasing steadily over recent years, even despite recent changes in world economic conditions.(IOM 2011) As a percentage of world population, migrants consistently represent around 3.1%(one in every thirty three persons). Further, there are around 16 million refugees who currentlylive outside their country of birth. (Kelley and Trebilcock 2010, IOM 2010) Part of thismigration story involves healthcare professionals, as healthcare systems around the worldrespond to shortages in their professional disciplines (OECD 2010b, Blythe et al. 2006, Bach2003, Joyce 2011, CIHI 2010b, Connell 2009). Doctors and Nurses are two professional groupswho were highly sought after in Canada and Ireland at the time of this study. In this groundedtheory study (Glaser and Strauss 1967, Glaser 1978, Glaser 1998) the transition experience ofthese migrant healthcare professionals is conceptualised as New Normalising, which occursthrough the stages of transplanting, regressing and adapting. It is through New Normalising thatparticipants resolve their main concerns of transition. This presentation will discuss the legalimplications of the theory as well as the implications for the mental health of migrant health careprofessionals and their families.115. The Need for Sustainability and Continuity in ForensicPsychiatryRecidivism Research at FPK InforsaIvo van Outheusden. FPK Inforsa, Amsterdam, Netherlands (ivo.van.outheusden@inforsa.nl)Background: Forensic treatment takes place in the context of different laws. Treatment in thecase of “TBS” has the longest duration (mean treatment duration is nine years). All otherforensic titles such as Article 37 (court order of unvoluntary admittence for one year) have amuch shorter term (the mean duration of treatment is usually less than one year). Little is knownabout recidivism after a short forensic treatment. Peek (2009) studied recidivism among patientswith psychotic vulnerability, treated in the context of Article 37 in an open forensic psychiatricclinic (FPA). The results of the study showed that vulnerable psychotic patients after treatment ina FPA quickly and often are sentenced for a new criminal act. No less than fifty percent of thedischarged patients committed a new offense within two years. In many cases, the offense ismore serious than the index offense for which the original Article 37 was imposed.274

Goal: The forensic psychiatric clinic Inforsa (FPK) wanted to get insight into the recidivism rate,the primary outcome measure for forensic treatment.Method: The Peek study is replicated as far as possible in order to be enable to compare thefindings.Conclusion: The results are discussed in the perspective of recent developments of new andshorter treatment in forensic psychiatry.Increased Severity of Offences in Clients after Article 37 CommitmentRon Dekens, FPK Inforsa, Amsterdam, Netherlands (ron.dekens@inforsa.nl)Background: The number of patients sentenced to a coerced TBS-treatment in the Netherlandshas steadily decreased during the last two decades. This is not only due to the fact that fewerTBS-equivalent offenses were committed but also to the fact that since the recommendations ofthe parliamentary inquiry commission-Visser, the treatment duration in the TBS clinics hasincreased significantly. Consequently the TBS treatment has become less attractive for clientsand their lawyers. Clients that are sentenced to TBS-treatment with coercion show an increase ofthe severity of the criminal acts. In particular, the offences had more often a violent component.The decrease in the number of TBS-treatments and the increase in the severity of offense leads tothe hypothesis that the offenses in the group "other forensic sentences” (including Article 37) aremore serious.Goal: To clarify the question of whether there is an increase in severity of the criminal offensesof patients in the FPK Inforsa, that were admitted in 2003/2004 in comparison with patientsadmitted in 2010/2011. It is expected that the offenses in the last group will be significantly moreserious.Method: For this purpose the offenses were classified in different ways: 1. based on themaximum sentence possible for the crime; 2. based on the national classification system (CBS)and 3. based on a seven-point scale designed by FPK Inforsa.Conclusion: The results and the implications for the clinic and the treatment are discussed.Regular Outcome Monitoring in a Forensic Psychiatric ClinicUdo Nabitz, FPK Inforsa, Amsterdam, Netherlands (udo.nabitz@inforsa.nl)Background: Routine Outcome Monitoring (ROM) is popular in psychiatric services over the lastfive years, in order to measure improvement and outcome of the treatment. Next to manyspecific questions the central research question is: What is the effect of the treatment in a275

forensic clinic measured in a routine way? There are additional hypothesis 1. most patients in thelong treatment program (TBS) internalized more visible effect than in the patients in the shorttreatment program. 2. patients with TBS-treatment and with an classified cluster B personalitydiagnosis (Pro Justice Reporting) at admission are not reclassified with cluster B diagnosis atdischarge.Goal: To demonstrate the utility of ROM for a forensic treatment and answer questions about thetreatment effect, the effect of duration of treatment and the change in diagnoses.Method: In the FPK Inforsa the Health of Nation Outcome Scale (HoNOS) is used since 2007 tomonitor the progress and the final result of the treatment. Results: The preliminary results showthat there are three client groups: a group that improves (35%), a group that stabilizes (32%) anda group that deteriorates (33%). The effect of the duration of treatment and the change of thecluster B diagnosis is analyzed.Conclusion: The Results of ROM are discussed in light of studying the possibilities to treatforensic clients effectively in short treatment programs. Methodological problems have to besolved in order to improve the validity of the findings.Client Satisfaction Studies in a Forensic Psychiatric Clinic in the NetherlandsPetra Schaftenaar, FPK Inforsa, Amsterdam, Netherlands (petra.schaftenaar@inforsa.nl)Background: Assessing client satisfaction is one of the standard quality measurements inhospitals. The concept of client satisfaction is also introduced in psychiatric care (Carlson, 2001;Aarssen, 2003) but in forensic psychiatric clinics client satisfaction studies are not yet a standardprocedure. The reason is mainly that the position of the clients in a confined treatment setting isfundamental different than in regular health care.Goal: To demonstrate that client satisfaction can be a meaningful concept for forensic psychiatryand that it can be carried out. To conduct in among forensic psychiatric patients two studies inorder to answer two research question: 1. What is the level of quality perceived by the clients? 2.Is there an improvement in quality over a period of 2 years?Method: In the forensic psychiatric clinic FPK Inforsa in Amsterdam two studies were carriedout in 2010 and in 2012. A satisfaction questionnaire with 23 items covering 5 dimensions(admission, housing, activities, professionals and seclusion). In 2010 the response rate was 69%the study of 2012 is still in progress.Results: The results of 2010 show that 70% of the clients were satisfied with the admissionprocedures, 65% values the activities and work positive, 70% is positive about the professionals,80% is satisfied with the housing. A diverse picture is seen concerning seclusion procedures. Theresults of the 2012 study are analyzed and will be presented in comparison to the findings of2012 and the target formulated.Conclusion: Patient satisfaction studies can be conducted in a forensic psychiatric clinic andprovides important insight in the view of the client about admission, treatment and setting.Methodological aspects of the study should be improved.276

A Better Working Alliance as a Result of Sustainability and Continuity inForensic PsychiatryIvo van Outheusden. FPK Inforsa, Amsterdam, Netherlands (ivo.van.outheusden@inforsa.nl)Background :The group of forensic patients with psychotic disorders in a relatively short-termtreatment is characterized by a high recidivism rate. The severity of their criminal acts aftertreatment seems to be more serious. One reason for the deterioration are the frequent transitionswithin the forensic treatment chain which leads to a fragmented treatment. Fragmentation isalready one of the characteristics of the prototypical psychiatric career of the forensic client. Thisfragmentation comes in handy for the distrusting patient, who’s goal it is to avoid contact. Inaddition, at each transfer information is lost. Harte (2010) has shown that the reduction ofrecidivism of TBS-treatment is related to an improved risk management and to longer treatmentdurations. Therefore it can be assumed that risk management and extend treatment can beeffective also for short-term treatment in a forensic clinic. In the short-term treatment in theNetherlands, there is an absence of a compelling legal framework, which exists in a longer-termTBS-treatment. Continuity of care could be achieved by coaching and building trust andconfidence. Through these means, sustainability and reduction of recidivism can be achieved.Goal: It is expected that sustainability and continuity after short-term treatment leads to areduced recidivism.Method: The FPK Inforsa designed a pilot project to evaluate the effects of working on the basisof this new paradigm of sustainability. Results: The initial experience with this way of workingwill be presented.Conclusion: By focusing in the short-term treatment on continuity and sustainability of care andon trust and confidence in the client the high recidivism rates are reduced. This proposition istested by a study and by a pilot project as a new way of working for clinical forensic practice.116. NeuroscienceBrain Imaging of Violent Juvenile OffendersMichael Caldwell, University of Wisconsin at Madison (mfcaldwell@wisc.edu)This study will examine the fMRI profiles of violent juvenile delinquents with elevated scores onthe PCL: YV as they progress through a specialized treatment program. The presentation willdescribe the characteristics of this unusual population and changes observed among those thatrespond to a specialized treatment program. This presentation is pending the results of our datacollection process.277

Notions of Psychiatric Disorder versus Disease in Psychiatric Classification andResearch: A Contribution to Historical/Philosophical Debate on the Very Natureof Psychiatry and its Future or Lack ThereofDenis Morrison, University of Calgary (denis.morrison@hotmail.ca)With the coming of DSM-V, still focused on disorders and more so on the dimensional criterion,Psychiatry could finally crumble under its own weight of “culturally derived abnormalbehaviours or harmful dysfunctions" (Jerome Wakefield). Research studies on disease entitiesare very few or non-existent (Shorter and Fink). Should Psychiatry become again a clinicalneuroscience like the old "Neuro-Psychiatry" of pre-Freudian days or something along the linesof Shatzberg and Kupfer's proposal? Should it continue to be a mix of the "psychological art ofhealing and understanding" adhering to both obligations of social contract and social control andstill be part of a physician's domain (medication prescription and diagnosis)? There is indeed areality not too far down the road of Psychiatry becoming simply irrelevant, not being a clinicalneuroscience, for Neurology will have taken over on one side of the fence and Psychology willhave taken over on the other. This paper discusses the implications of such and the more likelymajor changes ahead.Brain Interventions and the LawBjoern Schmitz-Luhn, University of Cologne (b.schmitz-luhn@uni-koeln.de)Deep Brain Stimulation has become an example of a most promising, reversible and versatilenew method of treatment for a variety of psychiatric conditions – only it involves entering thepatient’s brain. In clinical practice, the law is one of the major challenges to interventions in themost vital, personality-controlling, and sensitive organs of the human body. A whole frameworkof rules needs to be obeyed by physicians. While these legal norms differ internationally, theirfunction always includes safeguarding both the patient’s autonomy to decide whether to undergotreatment and to weigh risks and potential benefits of intervention, as well as adherence to thestandard of quality for medical treatment. But what are the rules that doctors have to almostuniversally obey? This presentation will give an overview of internationally fundamental aspectsof the law, categorizing requirements for good clinical practice regardless of the specificjurisdiction by their function, role and historical background, including the protection of patients’rights, the most difficult question of how to deal with impaired patient autonomy, enrolment inclinical trials vs. individual treatment attempts, ethical rules of conduct, the impact ofconstitutional law, and the avoidance of liability.278

117. Non-Pharmacological Treatments of AggressionPsychological Treatment Possibilities of AggressionAlessio degl ´Innocenti, CELAM, Center for Ethics, Law and Mental Health, GothenburgUniversity (alessio.deglinnocenti@vgregion.se)T.B.E.*Exercise, Physiotherapy and AggressionHenrik Bergman, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(Henrik.bergman@vgregion.se)T.B.E.*BMI and Child Aggressive BehavioursArmin Tajnia, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(tajniaarmin@gmail.com)T.B.E.*Physical Activity and ADHDTrevor Archer, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(trevor.archer@psy.gu.se)T.B.E.*118. Offender, Offender Behavior, and Collateral Consequences279

Reducing Gang Violence across Cultures: The Impact of Focused DeterrenceApproaches in Cincinnati, Ohio, U.S.A and Glasgow, ScotlandRobin S. Engel, University of Cincinnati (robin.engel@uc.edu)Youth and gang violence have become increasing concerns for politicians, police and the public.This research focuses on two cities with very different demographics and gang culture that haveimplemented focused deterrence strategies: Cincinnati, Ohio, USA and Glasgow, Scotland. Boththe Cincinnati Initiative to Reduce Violence (CIRV) and Glasgow’s Community Initiative toReduce Violence (CIRV) are multi-agency, community collaborations designed to reduce gunviolence perpetrated by violent groups/gangs. Specifically, the CIRV initiatives use a focuseddeterrence approach with specific coordinated strategies implemented by street advocates,community engagement specialists, law enforcement officials, and service providers designed to:1) change community norms regarding violence; 2) provide increased alternatives to at-riskpopulations; and 3) increase perceived risks of involvement in violence. Drawing uponethnographic research with police officers, young offenders, street workers and communityleaders, along with quantitative evaluations, this research examines the differing nature andcauses of youth violence and the perceived effect on youth and communities of focused deterrentapproaches to reduce violence. A 42-month evaluation demonstrated a 41% reduction in groupmemberinvolved homicides in Cincinnati since CIRV’s inception (Engel, Tillyer & Corsaro,2012), and a 50% reduction in the level of violent offending by gang members who haveengaged with the Glasgow version of CIRV (VRU, 2011). And yet, in terms of localdemographics, group dynamics and the sociological and criminological nature of gang culturethese two cities – Cincinnati and Glasgow – could not be more different. These differences ingang-related violence and the similarities of the effectiveness of the strategies implemented toreduce violence are discussed.A Unique Approach to Incentivizing the Implementation of Evidence-BasedPractices in the CommunityMyranda Schweitzer, University of Cincinnati (myrinda.schweitzer@ucmail.uc.edu)Paula Smith, University of Cincinnati (paula.smith@uc.edu)There is now clear and convincing evidence for “what works” in reducing recidivism (Andrewsand Bonta, 2006). In the past three decades, the principles of effective correctional interventionhave taken over as the leading paradigm for offender rehabilitation. However, in the most recenttwo decades, many states have found that both the state and local governments are facingresource and service delivery challenges that impact adherence to these principles. To combatthese challenges at both the state and local level, one Midwestern state established a program toimprove the conditions of confinement for youth in custody while also increasing and improvingthe quality of services in the local communities. As part of the program, counties in the state are280

incentivized for serving youth locally rather than sending them to a state institution. In a targetedeffort, the six largest counties in the state partnered with local universities to ensure propertraining, coaching, and implementation of evidence based programs. The purpose of this paper isto report on the six counties’ level of success with their implementation of community levelevidence based programs.Assessing the Impact of Collateral Consequences of Criminal Conviction onOffendersJames Frank, University of Cincinnati (james.frank@uc.edu)Angela K. Reitler, University of Cincinnati (reitleak@mail.uc.edu)Natalie Goulette, University of Cincinnati (nataliegoulette@yahoo.com)Convicted offenders often suffer a number of "collateral consequences" in addition to thesentence imposed for the crime. Collateral consequences are sanctions or restrictions imposed bystatutes, regulations, and rules that have the potential to affect offenders – personally, politically,and economically – for the rest of their lives. Both policy makers and academics are concernedabout the impact of collateral consequences of criminal convictions on offenders. Their claimstypically contain two assumptions. First, they assert that collateral consequences pose substantialbarriers to successful offender re-entry. Second, they implicitly assume that all collateralconsequences have the same detrimental effect on all offenders. While these two claims areconsistently offered in policy proposals to reduce collateral consequences, no empirical work todate has attempted to quantify the overall impact of these consequences on the lives of offenders.Nor has extant research explored the possibly differential impact of collateral sanctions on theoffenders. The present study examines the perceived impact of collateral consequences onconvicted offenders in Ohio. Using data collected through surveys of Ohio judges, prosecutingattorneys, defense attorneys, and probation and parole officers, we first examine respondents’perceptions of the proportion of offenders affected by a range of specified consequences.Second, we assess their perceptions about the magnitude of the impact such consequences haveon offenders. Third, we examine whether legal and social factors influence respondentperceptions. Finally, the study discusses policy responses to the problems posed by collateralconsequences of conviction.Genetic Markers and Behavioral Risk Measures as Predictors of Trajectories ofAdolescent Antisocial Behavior: Relative Utility and Potential for IntegrationChristopher Sullivan, University of Cincinnati (sullivc6@ucmail.uc.edu)Shaun Gann, University of Cincinnati (shaun.gann@ucmail.uc.edu)281

The increased use of biosocial explanations in criminology has extended the understanding of theetiology of the development of adolescent antisocial behavior. At the same time, their practicalutility for preventive and remedial intervention has not been examined to the same degree. Usinga large, nationally representative sample of U.S. youth and a series of latent growth curvemodels, this study examines the utility of genetic indicators and more traditional risk measures(including individual mental and behavior health) in predicting the onset and later developmentalpatterns of adolescent delinquency and substance use. The study considers the two approachescomparatively and also examines the likelihood that the knowledge they provide might beintegrated in ways that inform prevention and treatment of problem behaviors in adolescence.Ménage à Trois: The Braiding of Cognitive Behavioral Interventions,Implementation Science and Adult Learning Systematically Applied in aCorrectional System: An Analysis on a Multifaceted Approach of BridgingScience to ServiceEva Kishimoto, University of Cincinnati (kishimotoeva808@gmail.com)This paper will explore the strengths as well as the system challenges in undertaking a systemwide transformation to evidence based practices. Analysis will be done in the multiple domainsinvolved in bringing about the end result: delivery of high fidelity interventions. Furthermore,barriers to addressing these areas of challenge will be discussed. These qualitative findings willcontribute to the literature on knowledge transfer.119. Offenders and InmatesThe Concept Of Protective Factors Applied To Dangerous OffendersTiziana Costi, Institut Philippe Pinel de Montreal (tiziana.costi.ippm@ssss.gouv.qc.ca)The concept of protective factors helps to refine the assessment of risk. After years of practicingstructured professional judgment (SPJ) in the evaluation of risk, as clinicians in the forensic fieldwe have realized that we only aimed at risk factors. The factors that mitigate risk are calledprotective factors. The study of these factors has developed over the last few years. Takingpositive factors into account not only gives an improved and more comprehensive assessment ofrisk, it also helps to find more specific goals for treatment. In the past few years, instrumentshave been created to help assess these protective factors. Among them, the SAPROF (StructuredAssessment of PROtective Factors) is a very promising tool. It has already been translated intomany languages and is used in many countries. It includes seventeen factors, divided into threecategories: internal, motivational and external. After a brief presentation on this instrument, wewill discuss protective factors in relation to dangerous offenders (recidivists with high risk of282

violent and sexual re-offending). We will determine if the concept of protective factors is usefulwith those high risk offenders. The presentation will discuss the results of a pilot study using theSAPROF as part of the assessment of dangerous offenders. Interestingly, this study indicates thepresence of protective factors and the utility of the SAPROF with dangerous offenders. Thisinstrument made it possible to divide the sample into two clusters. New data concerning subtypesof dangerous offenders will also be discussed, as well as implications for assessment, treatmentand further legal recommendations.Older Mentally Ill Offenders: Profile and Treatment TrajectoriesStefaan De Smet, University College Ghent (stefaan.desmet@hogent.be)In parallel with the ageing of the general population in Western Europe and the U.S., policymakers, practitioners and academics gradually seem to be recognizing that ageing in offenderpopulations is an important treatment challenge. Because of specific age-related issues, theseclients seem to have special needs with regard to adapted forensic treatment. Like most Westerncountries, Belgium accepts the legal principle of providing psychiatric treatment to offendersjudged as irresponsible for their offences due to a mental illness. Research on the situation ofolder mentally ill offenders (60 +) is still scarce, although this seems to be a growing population.The objectives of this presentation are two-fold. First, the results of a retrospective case studythat was set up to investigate the characteristics of older mentally ill offenders in Flanders (theDutch-speaking region of Belgium) will be presented and discussed. Besides socio-demographicresults, the emphasis will be laid on distinguishing profiles with regard to their life coursetrajectories in mental health care and justice settings. A second part of the presentation will focuson the perceptions of older mentally ill offenders with regard to the treatment and support theyhave received. Implications for practice and research will be discussed.An Examination of the Pre-Offence Clinical Care of Known Psychotic PatientsWho Subsequently OffendGraham Mellsop, Waikato Clinical School, New Zealand(graham.mellsop@waikatodhb.health.nz)Patients/offenders admitted to the Forensic Psychiatric Services at three sites in Australia andNew Zealand (Auckland, Dr. Skipworth; Queensland, Dr. Hefferman; Waikoto, Dr. Tapsell), andwho have received treatment for a psychosis at some time in the preceeding 12 months, form thestudy cohort. The total catchment population for these forensic services is approximately 7million. This retrospective, observational study will examine the clinical care provided to thiscohort to seek an understanding of why that care did not prevent future offending. Particularemphasis will be placed on those aspects of clinical care (eg. pharmacolocial, medico-legal,283

psychological) which may lend themselves to improvement, and in particular those which maycontribute to reduced offending in this population.Solitary Confinement and Mentally Ill Inmates within State Prisons in theUnited States of America: Legal and Clinical ResponsesJeffrey Metzner, University of Colorado (jeffrey.metzner@ucdenver.edu)At year end 2009, US state and federal correctional authorities had jurisdiction over 1,613,656prisoners, an increase of 0.2% (3,897 prisoners) from yearend 2008. This was the smallest annualincrease in the current decade and continued the trend of slower growth observed in the prisonpopulation since 2006. Studies have consistently indicated that 8 to 19 % of prison inmates havepsychiatric disorders that result in significant functional disabilities. U.S. prison officials haveincreasingly embraced a variant of solitary confinement to punish and control difficult ordangerous prisoners. Whether in the so-called supermax prisons that have proliferated over thepast two decades or in segregation (i.e., locked-down housing) units within regular prisons, tensof thousands of prisoners spend years locked up 23 to 24 hours a day in small cells thatfrequently have solid steel doors. Mentally ill inmates are frequently overrepresented in suchlocked down units. The adverse effects of solitary confinement are especially significant forpersons with serious mental illness. Suicides occur disproportionately more often in segregationunits than elsewhere in prison. This presentation will summarize both legal and clinicalresponses to the use of locked down units for housing inmates with a serious mental illness on aprolonged basis.Changes in Mental Health Problems during ImprisonmentA. Dirkzwager, Netherlands Institute for the Study of Crime and Law Enforcement (NSCR)(adirkzwager@nscr.nl)Mental health problems are common in prison populations. However, little knowledge existsregarding changes in symptoms in custody over time. The aims of the current paper are: 1) toexamine the longitudinal course of mental health problems during the first 3 months in custodyand 2) to explore factors associated with changes in prisoners’ mental health problems. Data areused from the Dutch Prison Project, a longitudinal study on the effects of imprisonment on thefurther lives of prisoners. 848 male prisoners provided information on their mental health 3weeks and 3 months after their arrival in prison. The Brief Symptom Inventory was used toassess mental health problems. Compared to the general population, prisoners reported moremental health problems shortly after their arrival in prison. Most mental health problems seem todecline over time. However, after 3 months, prisoners still reported the same level of depressivesymptoms.284

Prevalence of Anxious and Depressive Symptoms among Women InmatesAdmitted to the Prison Hospital of Sao PauloQuirino Cordeiro Jr, Brotherhood of Santa Casa of Mercy of Sao Paulo, Brazil(qcordeiro@yahoo.com)Isis Marafanti, Brotherhood of Santa Casa of Mercy of Sao Paulo, Brazil(isis_marafanti@hotmail.com)Maria Carolina Pedalino Pinheiro, Brotherhood of Santa Casa of Mercy of Sao Paulo, Brazil(mariacaropinheiro@yahoo.com.br)Lilian Caldas Ribeiro Ratto, Brotherhood of Santa Casa of Mercy of Sao Paulo, Brazil(lilian.ratto@gmail.com)Rafael Ramisson Vicente Riva, Brotherhood of Santa Casa of Mercy of Sao Paulo, Brazil(rafaelrvriva@gmail.com)Higher prevalence of mental disorders and comorbidities have been described in the literature ondetainee populations. Statistics show that in the general population the prevalence of mentaldisorders is 15%, while in the prison population this number is around 42%, ranging from 37%to 89%. The main disorders reported among the female prison population are substancedependence disorder, posttraumatic stress disorder and major depression. The aim of this studywas to show the prevalence of anxious and depressive symptoms among women admitted to theHospital of the State Penitentiary in Sao Paulo. We used the Beck questionnaire to assess thepresence of anxiety symptoms and the Hamilton questionnaire to assess depressive symptoms,applied by the Mental Health team of the Prison Hospital, which is a general hospital. Among the77 inmates evaluated, there was a 33% prevalence of depressive symptoms and 39% prevalenceof anxiety symptoms. Knowledge of the prevalence of anxious and depressive symptoms amonghospitalized women is very important for the organization of Mental Health services in theprison system in order to expand and qualify such service, aiming to provide this portion of thepopulation with qualified treatment.120. Overarching Perspectives on Forensic Psychiatry in the Early2010’sTheories of Economic and Administrative Steering of Accountability-BasedEmpirics of pre-Emptive Work around Youth at Risk of Abuse and Criminality:Update of Previous Findings Developed in BerlinFredrik Dahlin, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(fredrik.dahlin@kriminalvarden.se)285

T.B.E.*Genetics behind the Development of Aggression and Violence in a LongitudinalTwin StudySebastian Lundström, CELAM, Center for Ethics, Law and Mental Health, GothenburgUniversity (sebastian.lundstrom@neuro.gu.se)T.B.E.*Substance-Related Disorders and AggressionAnn-Sophie Lindqvist, CELAM, Center for Ethics, Law and Mental Health, GothenburgUniversity (ann-sophie.lindqvist@vgregion.se)T.B.E.*Psychopathy and AggressionOlof Svensson, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(olof.svensson@rmv.se)T.B.E.*Hypermodern Forensic Psychiatry: An Overview of Epistemological Frames,Empirical Findings and Cultural Implications of Recent Trends in ForensicPsychiatry Using Gilles Lipovetsky’s Definition of the HypermodernHenrik Anckarsäter, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(henrik.anckarsater@neuro.gu.se)T.B.E.*286

121. Personality and AggressionValidating a Screening Instrument for Child Neurodevelopmental andDisruptive Behavior Disorders in a Population-Based CohortTomas Larson, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(tomas.larson@neuro.gu.se)T.B.E.*Instruments to Rate Aggression – Psychometric Evaluations and Content-of-Items AnalysesÖrjan Falk, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(ofalken@gmail.com)T.B.E.*Personality and Aggressive Behavior Disorders in Childhood in a Nation-WideChild- and Adolescent Twin StudyNóra Kerekes, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(nora.kerekes@neuro.gu.se)T.B.E.*Aggression by Different Phenotypical Assessments and Character Immaturity in18-Year-Old TwinCaroline Mårland, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(caroline_marland@hotmail.com)T.B.E.*287

The role of Character Maturity for Long-Term Outcome of Violence andAggression in a Prospective, Nation-Wide Child- and Adolescent Twin StudyDanilo Garcia, CELAM, Center for Ethics, Law and Mental Health, Gothenburg University(danilo.garcia@euromail.se)T.B.E.*122. Personality and Behavioral DisordersThe Association between Early Maladaptive Schemas and Personality Disorderin an Offender PopulationFlora Gilbert, Monash University (flora.gilbert@monash.edu)Schema-focussed therapy has become an increasingly popular treatment for offenders withpersonality disorder (PD), although to date, there have been few studies examining theassociation between Early Maladaptive Schema (EMS) and PD in forensic settings. Clarificationof the relationship between EMS and PD in offenders is therefore necessary for effectivetreatment delivery in this area. The present study extended previous EMS research byinvestigating the relationship between EMS and the DSM-IV PDs, in particular, Antisocial PD(ASPD) and Borderline PD (BPD), in an offender population. A sample of offenders (N = 87)undergoing pre-sentence evaluation were assessed on PD symptoms, EMS and depression, andcorrelation and regression analyses were conducted to examine the associations between theEMS and PD dimensional scores. The results showed that the majority of PDs were associatedwith individual EMS and that these relationships were idiosyncratic in nature. Relationshipsbetween ASPD symptoms and the Impaired Limits EMS domain and between BPD symptomsand the Disconnection/Rejection EMS domain were also identified. Overall, the resultssuggested that although Impaired Limits and Disconnection/Rejection EMS are common amongoffenders with ASPD and BPD, individually tailored assessment of the relationship betweenEMS and PD is critical.Findings of a Needs Assessment and Environmental Scan of MentallyDisordered Offenders Needs and Programs in Saskatchewan, CanadaArlene Kent-Wilkinson, University of Saskatchewan (arlene.kent@usask.ca)288

The intents of this research on the needs of offenders with compromised mental health were: toacquire a baseline of information of the current needs of mentally disordered offenders (MDOs)in the province of Saskatchewan to inform future research; and, to identify best practices andgaps in service delivery. This mixed methods province-wide study conducted in 2010-2011 wascommissioned by the Centre for Forensic Behavioural Sciences and Justice Studies, a recentlyapproved research centre at the University of Saskatchewan. The methodology of the study wastriangulated to include a literature review of government documents and peer reviewed literature,together with statistical and thematic analyses of the responses of family members of offendersand frontline personnel. Findings of the study showed that although national and provincialinitiatives are in place to address the needs of MDOs, Saskatchewan has unique demographicneeds. Indigenous peoples in our province represent 17% of the population compared to 3.8%nationwide. Indigenous populations in Saskatchewan are overrepresented in the criminal justicesystem at rates thirty-five times higher than the mainstream (CSC, 2009). Mental health andaddiction assessments and services were found not to be accessed by indigenous offenders at alevel consistent with their level of need.How Do Comorbid Psychiatric Disorders Influence the Appearance ofPedophilia?Frank Wendt, Institute for Forensic Psychiatry, Berlin, Germany (frank.wendt@charite.de)Nina Meyer-Blankenburg, Free University of Berlin (meyer.blankenburg@aol.com)Pedophilic sex offenders constitute a heterogeneous group for which all-inclusive solutions maynot be appropriate. Several typologies regarding different victim and offender characteristicshave been developed to address this problem. However, although it is widely known that the rateof comorbid psychiatric disorders is high in pedophiles, research about the impact ofcomorbidities on the appearance of pedophilia, starting from crime scene behavior through totherapeutic needs and the risk of recidivism, is scant. The aim of this study was to investigatetypes and frequencies of comorbid psychiatric disorders in pedophiles and to examine therelationship between comorbidity and crime scene characteristics. Files of 95 pedophilesconvicted for a sex offense between 1999 and 2010 in Germany were examined through casuisticanalysis. Results indicate that differences in crime scene behavior exist not only between groupsof pedophiles with and without comorbid psychiatric disorders but also between subgroups ofpedophiles with different types of comorbid disorders. Thus, the detailed analysis ofcomorbidities provides the potential to affect decisions concerning legal as well as therapeuticand prognostic questions.Paramedics under Mental Health Legislation in AustraliaVaughan Parsons, University of Newcastle (vaughanparsons@hotmail.com)289

Louise O’BrienColin JamesMental health emergencies in the community setting can present unique challenges forparamedics. With the recent introduction of emergency powers for paramedics under someAustralian based mental health legislation, paramedics are now being called upon to manage andtreat an increasing number of behaviourally disturbed patients; a domain traditionally confined tothe role of police. The purpose of this descriptive qualitative study was to examine clinicaldecision-making in relation to paramedics exercising their legislative responsibilities underAustralian-based mental health legislation. The key research questions identified in this studywere: 1. Can traditional clinical decision making approaches be applied to the phenomenon ofclinical decision making in relation to paramedics fulfilling their mental health legislativeresponsibilities? 2. To what extent does the Ambulance mental health training enhance theclinical skills and competencies of paramedics and does it prepare them clinically to fulfill theirlegislative responsibilities? 3. To what extent do existing Ambulance decision tools assistparamedics in making clinically appropriate decisions in relation to mental health care? 4. Howdo paramedics negotiate the complex interplay between their professional experience of dealingwith behaviourally disturbed patients, their individual beliefs and attitudes regardingbehaviourally disturbed patients, and their legal responsibilities? Hermeneutic phenomenologywas chosen as a suitable research methodology for this research. Data analysis revealed fourthemes, which described the phenomena of how paramedics engage in clinical decision makingwhen fulfilling their legislative responsibilities under the mental health legislation. The fourmain themes relate to: ‘Managing a scene with a person thought to have a mental illness’;‘Having inadequate clinical knowledge and working with the Mental Health Act andorganizational protocols’; ‘Decision making at the interface’; and ‘Being stuck between a rockand a hard place: Facing ethical dilemmas and stigmatization’.123. Perspectives on Assessing Risk for Sex Offender Recidivism:The Debate ContinuesWill They Do It Again? Assessing Sexual Offender Recidivism RiskJoseph J. Plaud, Applied Behavioral Consultants, LLC, Whitinsville, USA(plaud@fdrheritage.org)Sexual offender assessments typically occur in response to a court's concern about the safety ofthe community when someone convicted of a sexual offense is about to be released fromincarceration. Given the proliferation of sexual offender civil commitment laws, it is imperativethat courts understand the statistical principles involved in making judgments about future sexual290

offender recidivism. Sexual offender risk assessments need to be conducted with up-to-datetechniques, based on solid statistical underpinnings, and have relevance to the questions posedby a given court. This presentation will provide both an overview of the fundamental principlesof sexual offender risk prediction, and a tie-in to the integration of statistical principles to otherforms of sexual offender assessment which bear upon an analysis of the offender's presentvolitional control. Program objectives: 1) participants will understand both the recent history ofsexual offender assessment, and the diverse legal/political/cultural emphases that affect sexualoffender litigation; 2) participants will gain knowledge about effective sexual offenderassessment, focusing on statistical principles; and 3) participants will become knowledgeableabout recidivism rates, and how differing interpretations of the rates affect assessmentconclusions (as well as prosecutorial opinion).Getting the Balance Right: Structuring Structured Professional Judgment inSexual Reoffense Risk and AssessmentJeffrey C. Singer, Morris Psychological Group, P.A., Parsippany, USA(drsinger@morrispsych.com)There are three general methods to assess sexual reoffense risk. For the past 40 years,unstructured, or unguided, clinical judgment (UCJ) has been shown to be an inaccurate methodto make diagnoses or judgments and typically creates false positive results (Janus & Meehl,1997). A false positive is concluding that a condition exists when it does not. UCJ has beenreferred to as “subjective and impressionistic” (Grove & Meehl, 1996) as well as “unrestrained”(Wollert, 2007). Such approaches have poor inter-rater reliability and are vulnerable to varioussources of error including the Fundamental Attribution Error as well as various forms ofcognitive heuristics, i.e., thinking short cuts when faced with complex tasks.Another method to accomplish this kind of evaluation is the actuarial approach. True actuarialassessment eliminates the potential error and bias of human judgment. This approach considers asmall number of variables with the application of explicit statistical rules for combining andweighing a few variables into a total risk tally. Actuarial assessment can be used for riskassessment with caution given its apparent limitations in being able to apply such tallies to aparticular individual as opposed to groups. (Cooke, 2010, Cooke & Michie, 2009; Hart, Michie,Cooke, 2007; Vrieze & Grove, 2007; but see also Mossman, 2007 & 2008).A variant of the actuarial is the adjusted-actuarial approach, which uses an actuarial startingpoint and risk is adjusted up or down based on other risk factors. Research (Hanson & Morton-Bourgon, 2009) has borne out that this is not an acceptable method as it creates error from themixing of two completely different approaches of assessment. The effects of the cognitiveheuristic of anchoring further compounds the error rate with an adjusted-actuarial approach.A third approach to assess sexual recidivism risk is the empirically guided, clinical method,which has also been called structured professional judgment (SPJ; Douglas & Skeem, 2005) orguided professional judgment (GPJ; Lieberman et. al., 2007). The SPJ method relies on assessingrisk factors and symptom variables that have been found repeatedly in the empirical literature291

extant to be associated with sexual reoffense risk. SPJ allows the examiner to integrate andsynthesize a multitude of variables in a structured manner with the goal of deciphering theempirically supported relevant risk factors.The SVR-20 and RSVP are structured clinical checklists designed for the risk assessment ofsexual violence in sex offenders and risk management. The SVR-20 authors refer to it as amemory aid. These tools reflect the application of an empirically guided approach, or SPJ, asitems are based on sexual offense recidivism risk factors gathered from reviews of the empiricalliterature extent. The final risk judgment can be indicated in terms of low, moderate, or high. Asecond edition of the SVR-20 is under development (Boer, 2009).Among the strengths of SPJ risk assessment is that the risk items have an empirical basis forconsideration, and that “case- specific” factors can be considered, which in such evaluations,seems prudent. The SVR-20 and RSVP helps organize the myriad of variables in suchevaluations. While this approach allows for the consideration of either higher, or lower, sexualrecidivism risk than fixed actuarial scoring rules allows, to merely tally the factors to adjust anactuarial score is not acceptable practice, as this leads to unacceptable error rates.Limitations to using the SVR-20, or RSVP, in the service of SPJ, is that there is the absence ofempirically derived norms, presumption that more risk factors present automatically meansgreater risk, assumption that the list is exhaustive, and that this type of risk assessment approachleaves the weighting of each risk factor to each individual examiner. It is also worth noting thatseeing a large number of risk factors can unduly bias the perception of risk just as easily asseeing a small number of risk factors as an artifact of heuristics and biases.Due to the previously noted substantial limitations, professionals are left literally left to theirown devices on how to compensate for these deficiencies. This workshop will provide a SPJassessment rubric focusing on how to think of risk factors along the continuums of frequency,intensity, duration, likelihood, imminence and salience. Protective risk factors will also beconsidered with suggestions on how to integrate such variables into an evaluation. This SPJassessment rubric allows the evaluator to make an integrated, systematic, professional opinionabout an examinees relative sexual recidivism risk that ultimately informs the management ofthat risk.2. Two learning objectives or goals:A-Workshop participants learn how to conceptualize sexual reoffense risk assessment from threedifferent approaches (unguided clinical judgment, actuarial assessment, and structuredprofessional judgment) and recognize each methods strengths and weakness.B- Workshop participants will learn a Structured Professional Judgment assessment rubricfocusing on how to think along the risk factor continuums of frequency, intensity, duration,likelihood, imminence and salience to help an evaluator make an integrated, systematic,professional opinion about an examinees relative sexual recidivism risk that informs themanagement of that risk.292

Neuropsychology, Neuroscience, Volitional Impairment and Sexually ViolentPredators: A Review of the Literature and the Law and their Application to CivilCommitment ProceedingsJohn Matthew Fabian, Consulting Psychologist, Columbus, USA(john@johnmatthewfabian.com)The U.S. Supreme Court held in Kansas v. Crane, that a person’s mental abnormality orpersonality disorder must cause the individual to have "serious difficulty in controlling his sexualbehavior," rather than "total or complete lack of control." While most state civil commitmentstatutes do not mandate this volitional impairment language relevant to loss of control, theyinstead incorporate the requirement of findings of "likely" or "likelihood" to reoffend. Yet insome of these state Sexually Violent Predator (SVP) hearings, the forensic mental health expertwitnesses testify as to the offender’s ability to control his sex offending behaviors. Occasionally,some of these experts are neuropsychologists and neurologists who testify about a sex offender’sneurological and cognitive impairment resulting in sexually deviant behavior, volitionalimpairment, and likelihood of reoffending. This paper’s focus is to assess deviant sexualoffending behaviors and volitional impairment through a neuropsychological and neurologicallens. The author will provide an analysis of the literature as to the structural and functionalneurocognitive processes of sex offending pertaining to neuropathology, neuropsychology, andneuroimaging data. The author will attempt to apply these findings to the legal requirementsoutlined in Crane necessitating commitment of sex offenders who experience some volitionalimpairment in their behaviors that lead them to be likely to sexually reoffend. The author willreview state case law addressing neuroscience in SVP proceedings.Polygraph and Sex Offender Assessment: The Polygraph is not a RiskAssessment Tool, so How Can It Help?Kenneth Blackstone, Consulting Psychologist, Atlanta, USA (kenblackstone@gmail.com)Polygraph examination is a catch-all term used to describe the use of the polygraph instrument ina variety of applications associated with the risk assessment and treatment of sex offenders. Thispresentation will focus on the use and misuse of the polygraph during the assessment ofconvicted and/or civilly committed sex offenders. This presentation will include a history of theused of polygraphs in conviction sex offender proceedings, descriptions of the types ofexaminations that can be administered and how each might play a role in risk assessments forcivil commitment proceedings, suggestions on how mental health professionals can effectivelyincorporate polygraph examinations results into evaluations and recommendations, and adiscussion of the limitations of the polygraph examination and how it might be misused incommitment courts.293

Evaluating Sex Offender Recidivism – An Attorney’s PerspectiveJoan Van Pelt, Attorney-at-Law, Plainfield, USA (jdvanpelt@gmail.com)Over the past 2 decades, the number of jurisdictions which impose post-incarceration restrictionson convicted sex offenders has burgeoned across the United States and in other countries.Registration is the norm. It is often accompanied by restrictions on where the offender can live,work or spend his time. In the more extreme cases, 20 states and the federal government havestatutes which permit civil detention as sexually predators. This detention may be in essence alife sentence. With these statutes there has been created growing areas of practice in both mentalhealth and law. The number of clinicians – both psychiatrists and psychologists – who specializein sex offender evaluations has increased dramatically during this time. These mental healthprofessionals evaluate, testify and write for publication relating to the best or most accurate wayof assessing which convicted sex offenders are likely to reoffend. At the same time, law schoolsnow offer courses to train young lawyers in representing sex offenders facing registration or civilcommitment proceedings. As advocates, rather than neutral evaluators, lawyers have asignificantly different perspective regarding the efficacy of sex offender assessments. This paperevaluates the strengths and weaknesses of the various methods of sex offender risk assessmentfrom the perspective of a lawyer representing clients before both judges and juries in sexoffender civil commitment proceedings.124. Post Traumatic Stress Disorder (PTSD)Review of the Current State of Knowledge of Comorbid mTBI and PTSD inNATO Military Personnel who Served in Iraq and AfghanistanAlexander E. Obolsky, Northwestern University (a-obolsky@northwestern.edu)Comorbid mTBI and PTSD has affected significant numbers of the NATO soldiers who haveserved in Operations Iraqi Freedom and Enduring Freedom. The comorbidity of mTBI and PTSDhave confounded physicians and researchers since well before the current military conflicts, butit is not until now that a large population of affected individuals that require proper assessmentand treatment, has made the scientific and clinical understanding of this elusive phenomenon anurgent necessity. This confluence of factors is bringing forth concerted and well-funded effort tostudy the phenomenon. This presentation will provide an overview of the current understandingof the prevalence, incidence, phenomenology, assessment, differential diagnosis, treatments, andprognosis of the comorbid mTBI and PTSD. The probable etiologies of this comorbidity will bereviewed. Finally the implications for clinical practice and forensic import of the new insightsinto the mTBI/PTSD comorbidity in civil litigation will be identified.294

Malingering in Psychological/ Psychiatric Injury: Detection Strategies andCautionsGerald Young, York University (gyoung@glendon.yorku.ca)Problematic presentations and performances in psychological/psychiatric injury evaluations arecommon, but there are many reasons for them, including varying response biases other thanmalingering. Psychological injury concerns PTSD, mTBI, and chronic pain, in particular, afterevents at claim. This presentation will focus on PTSD. First, controversies related to PTSD arepresented. Second, the issue of malingered PTSD is discussed, in civilian populations.Malingering can be detected, but incontrovertible evidence is needed. The literature is repletewith conceptual and empirical difficulties. Even the definition used varies, with some sourcesincluding even mild exaggeration as part of malingering. Prevalence or base rate estimates varywidely because of this inconsistency and others. Recommended detection strategies consideredmost effective in the literature range from the clinical interview to psychometric testing.Moreover, which tests to use vary between different sources. This presentation concludes withresearch recommendations, including on the definition of malingering (DSM-IV based) and howto survey it to get an appropriate base rate estimate; it presents a “diagnostic” model ofmalingering that includes inconsistencies/discrepancies and psychometric test data. At thepractice level, the presentation examines assessment strategies, appropriate tests to use, and howto integrate the data gathered.The Impact of PTSD on Performance and Decision-Making in EmergencyService Workers: Implications for Forensic AssessmentCheryl Regehr, University of Toronto (cheryl.regehr@utoronto.ca)Research has identified alarming levels of traumatic stress symptoms in individuals working inemergency services. Yet the impact of these symptoms on performance and hence public safetyremains uncertain. This presentation discusses a program of research that has examined theeffects of prior critical incident exposure and current post-traumatic symptoms on theperformance and decision-making during an acutely stressful event among police officers,emergency communicators, paramedics and child welfare workers. Four studies using simulationmethods involving video simulators, human-patient simulators, and/or standardized patients,examined the performance of emergency workers in typical workplace situations related to theirindividual profession. Exposure to critical incidents in the workplace and current level oftraumatic stress symptoms were assessed prior to participation in the scenarios. Subjectivepsychological stress and physiological stress responses were measured before, during and afterparticipation in the scenarios. Results regarding performance and decision making varied bysituation. PTSD symptom levels did not affect performance in emergency situations requiringfrequently practiced skills, while complex clinical judgment was correlated with PTSD. Thus,295

the relationship between PTSD, performance and decision-making in emergency serviceprofessions is complex and varies by the nature of the emergency situation. Implications forforensic assessment will be discussed.Sexual Harassment and PTSD: A Model of Harm and RecoveryLouise F. Fitzgerald, University of Illinois at Urbana (lff1353@gmail.com)Sadie Larsen, VA Hospital, Milwaukee, USA (sadieelarsen@gmail.com)C. Vaile Wright, St. Elizabeth’s Hospital, Washington D.C., USA (vaile.wright@gmail.com)Linda L. Collinsworth, Millikin University (llc2402@gmail.com)Angela Lawson, Northwestern Memorial Hospital, Chicago, USA (angela.lawson@hotmail.com)Workplace sexual harassment continues to be a widespread problem. Although evidenceconfirms its impact on mental health, little is known concerning pathways that lead to injury andvirtually nothing about those facilitating recovery. This paper presents a set of theoretical modelsframing these issues, as well as data tracking the progress of several hundred class-actionplaintiffs who developed Post-Traumatic Stress Disorder in response to workplace harassment.Based on these models, we undertook a 5-year longitudinal study of over 1200 U.S. professionalwomen, each a member of a class-action lawsuit against their employer. Psychological Harm:Initial examination revealed that 33% of these women met DSM-IV-TR symptom criteria forPost-Traumatic Stress Disorder at Time 1. Multiple hierarchical linear regressions wereconducted in a randomly chosen half sample (A) and results cross-validated in Sample B. Crossvalidatedresults confirmed that frequency and severity of harassment, as well as the power of theperpetrator, were the most potent predictors of harm, whereas the plaintiff’s individualvulnerability contributed an additional 4.6% of variance, and attributions of self-blameaccounted for 1.7%. Recovery: With respect to recovery, we predicted that harassment wouldaffect symptoms at Time 2 through its effect on the original symptoms, its damage to schema oftrust, safety and intimacy, and attributions of blame. We also predicted that social support wouldpredict recovery. Finally, we included previous victimization as a control for other widespreadtraumatic events. This cross-validated model provided an acceptable fit to the data, and waslargely consistent with theoretical predictions.Let them Satisfy Their Lust on Thee: The Stage as a Reflection of HistoricalViews on RapeKaitlyn Regehr, King's College London (kaitlyn.regehr@kcl.ac.uk)Titus Andronicus, in which the young Lavinia is raped and then brutally mutilated, is arguablyShakespeare’s most explicit and complex play involving rape. A range of theatrical, feminist,296

and performance literature examines the character of Lavinia and the representation of herassault. Yet, the representation of rape, like rape itself, is socially and historically constructed.Using Titus Andronicus as a forum for analysis, this presentation will argue that the extent towhich advances in modern science and medicine have been accepted into the societal lexicon isreflected in art. This paper reviews societal, legal and medical views of rape from Shakespeare’slate 16th century London to the present. By applying a temporal lens to productions of TitusAndronicus, performance can be seen to illustrate stages in the understanding of rape victims andtheir subsequent trauma. By this means, the theatre offers insight in both of how rape ispresented to and perceived by the public consciousness. Thus, Titus Andronicus, a 400 year oldplay, continues to reflect modern lived reality by depicting a contemporary awareness of rapeand trauma, shaped by social mores, legal structures, and scientific knowledge.125. Post Traumatic Stress Disorder and the Law: Civil andCriminal Aspects from a North American PerspectiveDiagnostic ConsiderationsPratap Narayan, University of California, San Francisco (prat65@hotmail.com)PTSD was first accepted as a diagnosis in the DSM-III (1980), though this condition had beendescribed by different names earlier. This is the only diagnosis that is etiologically linked totrauma. The definition of a traumatic event has been broadened from catastrophic trauma witheach successive revision of the DSM. DSM-IV TR (2000), which is in current use, specifies thatthe subject's response must include intense fear, helplessness or horror. PTSD is often used incivil as well as criminal arenas from workplace harassment to cases involving rape and murder.Forensic assessments have some innate problems. The diagnosis is mainly based on symptomsthat can be easily malingered. Symptoms such as flashbacks and blackouts often invoked as alegal defense do not lend themselves easily to assessment of the mental status at the time of thecrime. The contributory effect of associated substance or alcohol use may be hard to tease out.Additionally, the effects of trauma and PTSD symptoms may be on a continuum. The legalsystem however only recognizes the presence or absence of criteria, not symptoms on acontinuum. Civil as well as criminal case examples will be presented involving PTSD from theUnited States and Canada. Audience participation will be encouraged to stimulate discussion ofappropriate steps in forensic evaluations.Issues Involving US Military MembersAntony Fernandez, Virginia Commonwealth University (antony.Fernandez@va.gov)297

The wars in Iraq and Afghanistan have renewed emphasis on PTSD as a basis for a criminaldefense. In a recent case a Veteran being treated for service-connected PTSD argued that hiskilling of an unarmed man occurred while he was having a flashback. A Grant County, Oregonjury found him guilty but insane due to PTSD. In addition to the use of PTSD as the basis of aninsanity defense, recent cases have seen the stress associated with combat exposure considered asa mitigating factor in sentencing: Porter v. McCollum, 130 S. Ct. 447 (2009), United States v.John Brownfield, No. 08-cr-00452-JLK (D. Colo. 2009). Since 2008 the Veterans TreatmentCourts (VTC) a new treatment court model, has addressed Veteran defendants’ mental health andsubstance use issues (http://www.nadcp.org/JusticeForVets). The perceived prevalence of PTSDamong justice-involved Veterans is often cited as the impetus for these courts’ formation(Russell, 2009; Clark et al., 2010). State legislatures have been active in proposing legislationthat directs their court systems to address mental illness of Veterans in their courts' shifting fromthe traditional focus on victims’ interests (retributive justice), toward defendants’ interests(therapeutic justice).Issues Involving US Civil LawBabu Rankupalli, University of Florida (babu.rankupalli@va.gov)PTSD is context dependant both in its formation as a condition and in recovery. The prevalenceof PTSD has increased dramatically. The presentation of PTSD in relation to legal contexts andforensic settings is not uncommon. The purpose of this presentation is to identify Nomothetic(Transcultural) variables and Idiographic (Life event) variables as applicable to PTSD. Legalbarriers to the concept of “mental harm”, worker’s compensation and civil litigation will beupdated. The role of U.S. Supreme Court decisions in PTSD as a construct for compensation anddefense will be addressed. The impact of intervention within the confines of the forensic settingwill also be reviewed.Issues Involving US Correctional SettingsAbdi Tinwalla, Wexford Health Sources, Inc., Pittsburgh, USA (atinwalla@wexfordhealth.com)Despite the steady frequency of media reports of law enforcement response to people with PTSDin crisis, the frequency of PTSD occurrence and the extent of training content for PTSDidentification and management have not yet been identified. Epidemiological surveys by the U.S.Department of Justice Bureau of Justice Statistics, while estimating that 64% of jail inmates havea mental health problem (James & Glaze, 2006), have not reported specifically on the prevalenceof PTSD. The National Co-Morbidity Survey of community populations, estimate a 6-monthprevalence of PTSD among jail inmates of 4-8%. Lengths of incarceration are generally short,usually less than 1 year, and PTSD intervention in jails have not received attention in the clinicalliterature. The National Commission on Correctional Health Care reported an estimated lifetime298

prevalence of PTSD in prison inmates of 5-12% in state and federal prisons. Inmates servelonger sentences which allow opportunitties for comprehensive mental health evaluation andtreatment (Patterson & Greifinger, 2007). We will discuss the importance of assessing andtreating PTSD and substance abuse co-morbidities. Much remains unknown about PTSD inforensic settings and research needs to be conducted to answer specific prevalence and outcomequestions relevant to PTSD in correctional settings.Issues Involving Cases in CanadaJulian Gojer, University of Toronto (juliangojer@hotmail.com)PTSD is well recognized in Canadian law. The case of R v Borsch [2007] MJ No 343, isexamined from a criminal perspective in the role that PTSD had in war veterans. R v Lavallee[1990] 1 SCR 852, the “Battered Woman Syndrome”, and exculpation of criminal responsibilityare re-examined and the understanding of the trauma of living with an abusive partner iscompared with other similar situations e.g. prisons, bullying etc. In the civil realm, a growingnumber of cases have awarded trauma victims with settlements, as in Gauthier v Brome Lake(Town) [1998]SCJ No 55. On a national level, the overseas torture of Canadian Maher Arar, atthe hands of national security officials, placed trauma at the forefront of the intersection of lawand medicine. It is not surprising that Canadian Senator Romeo Dallaire, the humanitarian andformer head of the United Nations peacekeeping mission in Rwanda, has become an advocate forindividuals suffering from PTSD. The presenter will discuss PTSD and how it has impacted theCanadian medical and legal landscape.126. Practicalities of a Best Practice Use of Force Model whenWorking with People in Psychiatric CrisisWhy the Traditional ‘Alpha Bravo’ Approach to De-Escalation Does Not Workin Police Encounters with People in Psychiatric CrisisStuart Thomas, Monash University (stuart.thomas@monash.edu)Concerns have long been expressed that police may be using excessive force to resolveencounters with people in psychiatric crisis. While a number of reasons have been proposed forthis, these have generally focussed on assessments of increased risk based either on reportsprovided to police en route to the scene or on observable behaviours witnessed by police duringthe encounter itself. As such, issues around perceived dangerousness, aggression and impulsivityhave dominated the popular literature. More recently, however, some scholars and oversightbodies have started to consider the impact of the standard approach and engagement style ofpolice and questioned whether these traditional methods could actually be aggravating the299

situation when the suspect is in a state of psychiatric crisis. This presentation will critique themore traditionalist approaches of limit setting and de-escalation in aggression management andconsider the possible additional influence of interpersonal style as a mediating factor inachieving a peaceful resolution.Effective Police Strategies when Resolving Incidents of Psychiatric Crisis:Averting Attempted Police-Provoked ShootingsDragana Kesic, Monash University (dragana.kesic@monash.edu)Police-provoked shootings, more commonly known as suicide by police, occur when a suicidalindividual provokes police into shooting him or her. Existing research suggests that thisphenomenon occurs in anywhere up to half of police shootings. A number of common features inthese incidents have been proposed, among which is the presence of mental disorder. Less focusto date has been levelled at elucidating strategies which are successful in averting these fataloutcomes. The aim of the present study was to identify practical and tactical strategies thatoperational police from Victoria, Australia identified as being successful in averting fataloutcomes in incidents where the individual appeared suicidal and behaved as though they wantedthe police to shoot them. Findings that will be presented suggest important practical implicationsfor future research and for the prevention of police-provoked suicide.Use of Force in Australia: Policy Guidelines for Vulnerable PopulationsLouise Porter, Griffith University Mt Gravatt (l.porter@griffith.edu.au)This presentation discusses an analysis of police Use of Force guidelines and policies that pertainto Australia’s eight police jurisdictions. Jurisdiction-specific policies, and national guidelines arecompared and analysed from the perspective of the needs of potentially vulnerable populationsthat can frequently come into contact with Police. It is argued that such populations, particularlythose experiencing psychiatric crisis, may necessitate distinct guidance for police to assess andrespond to situations safely and effectively. The content of current policies is assessed anddiscussed, particularly regarding guidance on selection of force options and assessment of riskand threat. Aspects of policies that are particularly relevant to vulnerable populations arehighlighted, as are areas that may warrant consideration for change in order to improve policingprocesses and outcomes.Policing Mental Disorders: Rethinking Use of Force Models in AustraliaSimon Bronitt, Griffith University Mt Gravatt (s.bronitt@griffith.edu.au)300

Duncan Chappell, Griffith University Mt Gravatt (chappell@bigpond.net.au)In Australia, there has been more than two decades of policy and law reform aimed at improvingpolicing responses on the streets for individuals experiencing mental health crises. In this paper,the author evaluates the shifts in the law, policy and practice governing police use of forceagainst this vulnerable class of persons. The prevailing “offender-centric” models governing theuse of force prioritize police assessment of the threats, risks and the safety (of the officer,“suspect” and community). In this paper, the author outlines an alternative model of intervention,based on a “human rights-centric” perspective, which addresses these limitations and wouldenable the police officers to tailor their responses to the specific needs of those experiencingmental health crises.Practical Tools for Taking Mental Health Training for Police ForwardMichael Williams, Victoria Police, Melbourne, Australia (michael.williams@police.vic.gov.au)Across the different States and Territories in Australia there are a number of different approachestaken to providing mental health training to operational police. This presentation will outline thekey elements of a novel e-learning package that is currently being rolled out as a portion of thebi-annual Operational Tactics and Safety Training qualification in Victoria. The “CriticalIncidents Involving the Mentally Ill” package is an interactive program covering a range ofmental health topics. Key information about different disorders is provided to the reader,followed by an interactive element (e.g., a short video). Individuals are then required to completeand pass a short quiz on the topic with a 100% pass mark required to proceed. After outliningthis framework, this paper will go on to discuss early evaluations of this package and set anagenda for taking mental health training for police forward.127. Pre-Trial Forensic Mental Health Evaluations in theNetherlandsViolence Risk Assessment in Forensic Mental Health Evaluations of Youth:Clinical and Predictive AspectsIris Berends, Netherlands Institute of Forensic Psychiatry and Psychology(I.Berends@dji.minjus.nl)Nils Duits, Netherlands Institute of Forensic Psychiatry and Psychology(N.Duits@dji.minjus.nl)Martin Wiznitzer, Netherlands Institute for Forensic Psychology and Psychiatry(m.wiznitzer@diji.minjus.nl)301

Violence risk assessment instruments have been developed and tested in treatment settings, butnot in pre-trial report settings. Risk assessment in the pre-trial report setting differs fromassessment in the treatment setting: it is focused on (recent) index offences and possiblepsychiatric disorders, there is no conviction or sentence yet, the relation with the examinee iscomplex (poor cooperation, denial), and clinical judgment is based on less information.Discussion exists about the predictive validity of risk assessment instruments. An instrument, theRAP (Risk-Assessment Adolescents Pre-Trial mental health evaluation), has been specificallydeveloped for the pre-trial report setting. It relies on structured professional judgment. Theresults of two studies are presented. The first prospective clinical study examines the predictivevalidity of the RAP. 56 forensic experts were trained in using the instrument in combination withthe SAVRY in their pre-trial mental health evaluations of adolescents suspected of havingcommitted a violent crime. Violent recidivism was measured with a follow-up of two years. Inthe second retrospective study the predictive validity of the SAVRY is measured and comparedto the PCL:YV and clinical judgment with a ten year follow-up.Personality Disorders, Psychopathy, and Criminal ResponsibilityMarleen Spaans, Netherlands Institute of Forensic Psychiatry and Psychology(M.Spaans@dji.minjus.nl)Marko Barendregt, KZN Benchmarking, Bilthoven, Netherlands (info@sbggz.nl)Bernadette Haan, Forensic Psychiatric Outpatient Clinic Het Dok, Rotterdam, Netherlands(rotterdam@hetdok.nl)Henk Nijman, Radboud University Nijmegen, Netherlands (h.nijman@acsw.ru.nl)Edwin de Beurs, KZN Benchmarking, Bilthoven, Netherlands (info@sbggz.nl)The present study empirically investigates whether personality disorders and psychopathic traitsin criminal suspects are reasons for diminished criminal responsibility or enforced treatment inhigh security hospitals. Recently, the tenability of the claim that individuals with personalitydisorders and psychopathy can be held fully responsible for crimes has been questioned ontheoretical bases. According to some interpretations, these disorders are due to cognitive,biological and developmental deficits that diminish the individual's accountability. Two studiesare presented among suspects of serious crimes under forensic evaluation in a Dutch forensicpsychiatric observation clinic. The first study examined how experts weigh personality disordersin their conclusions as far as the degree of criminal responsibility and the need for enforcedforensic psychiatric treatment are concerned (n = 843). The second study investigatedassociations between PCL-R scores and experts' responsibility and treatment advisements(n=108). The results suggest that in Dutch forensic practice, the presence of a personalitydisorder decreases responsibility and leads to advices for enforced forensic treatment. Expertsalso take characteristics of psychopathy concerning impulsivity and (ir)responsibility intoconsideration when judging criminal accountability. Furthermore, they deem affective302

deficiencies sufficiently important to indicate suspects' threat to society or dangerousness andwarrant a need for forensic treatment.Predicting the Need for Forensic Psychiatric and Psychological Mental HealthEvaluationJosé Buisman, Netherlands Institute of Forensic Psychiatry and Psychology(J.Buisman@dji.minjus.nl)Stefan Bogaerts, Tilburg University (s.ogaerts@uvt.nl)Wim van Kordelaar, Netherlands Institute of Forensic Psychiatry and Psychology(w.van.kordelaar@dji.minjus.nl)Thomas Rinne, Netherlands Institute of Forensic Psychiatry and Psychology(t.rinne@dji.minjus.nl)In 2005 a decision support model (BooG) was developed for predicting the need for a forensicpsychiatric and psychological assessment. In this longitudinal study we investigate the predictivevalidity of the decision support model. The prediction-model contains 12 indicators whichconcern the characteristics of the committed crime: severity, repetition, and behaviour of theaccused but also the juridical weighing of the crime – for instance, is enforced treatment apossibility? The independent variable in the development of this model is the decision of whethera prosecutor would order a forensic psychiatric and/or psychological mental health evaluation.Now – in a prospective view – we can investigate how good the prediction was. Therefore weapply the model, validated in 2009, to the 2004 sample with 4000 unique cases. In this samplewe collected data which shows whether a accused had a forensic psychiatric/psychological orclinical mental health evaluation in the years from 2004 until 2011. We then show the predictivevalidity by presenting the receiver operating characteristics (ROC). We also investigate if abetter prediction is possible by collecting data about recidivism, mental or personality disordersand verdicts.Pre-Trial Forensic Mental Health Evaluations among Juveniles: Quality andRecent DevelopmentsMaaike ten Berge, Netherlands Institute of Forensic Psychiatry and Psychology(M.ten.Berge@dji.minjus.nl)Nils Duits, Netherlands Institute of Forensic Psychiatry and Psychology(N.Duits@dji.minjus.nl)In the Netherlands, pre-trial forensic mental health evaluations (“pro Justitia” reports) play animportant role in the juvenile justice system. For example, the custodial measure “institutional303

placement order” (Plaatsing in een Inrichting voor Jeugdigen; PIJ measure), which comprisesmandatory treatment for juveniles, can only be imposed after the court has obtained advice fromat least two forensic experts (psychiatrist and psychologist) who have made such a pre-trialmental health evaluation. The quality and usefulness of the reports have been studied, withrespect to the development of instruments to improve quality (e.g., STER), as well as to itsusefulness for judges and therapists, and concordance rates between pro Justitia advices and thecourts’ sentences. Recent developments and results will be presented and discussed.Quality of Pre-Trial Forensic Mental Health Evaluations among AdultsTryntsje S. van der Veer, Netherlands Institute of Forensic Psychiatry and Psychology(t.van.der.veer@dji.minjus.nl)Wim J. Canton, Private Practice, Den Bosch, NetherlandsNils Duits, Netherlands Institute of Forensic Psychiatry and Psychology(N.Duits@dji.minjus.nl)Maaike Kempes, Netherlands Institute of Forensic Psychiatry and PsychologyWim van den Brink, University of Amsterdam (w.vandenbrink@amc.uva.nl)Maarten Koeter, University of Amsterdam (m.w.koeter@amc.uva.nl)In the Netherlands, pre-trial forensic mental health evaluations (“pro Justitia” reports) play animportant role in the Dutch justice system. The hospital care order (TBS) can only be imposedafter the court has obtained advice from forensic experts (psychiatrist and psychologist) whohave made such a pre-trial mental health evaluation. Due to the impact on decisions of the courtthe quality of pre-trial forensic mental health evaluations should be of a high quality standard.The development of a structure in which feedback on quality is provided fits with today’s qualityawareness. In the present research, quality of reports of mandatory forensic health evaluationsamong adult suspects have been studied. Results will be presented and discussed.128. Prevention of Antisocial Behavior in Children and Adolescents:Ethical, Social, and Philosophical AspectsThe Return of Lombroso? Ethical and Philosophical Aspects of ForensicScreening, Risk Assessment and PreventionChristian Munthe, University of Gothenburg (christian.munthe@phil.gu.se)Italian 19th century criminologist Cesare Lombroso is notorious for his seminal ideas aboutcriminality and anti-social behaviour resulting from physiological anomalies that should be304

detected by society and used for forensic preventive purposes. After an extended period ofdisrepute following World War 2, similar ideas have been resurrected in psychiatry, genetics,neurology and criminology in the past decade or two. In particular, there is a growing focus onearly detection and application of preventive measures. This development actualizes a complexweb of ethics and policy issues having to do with the well-known fact that screening andprevention in the health area are far from ethically clear-cut activities and actualize vividprospects of doing extensive harm to individuals as well as society. Also, taken to its extreme, itactualizes the idea of using prenatal or preimplantation testing to preselect against children witha predisposition for criminal or antisocial behaviour. In the forensic case, such screeningpreventionstrategies will connect further to a complicated issue about the proper use of riskassessmentmodels for societal decision making for precautionary purposes. Based on formerwork in all of these areas, this paper will outline and analyze the basic issue of the defensibilityof activities of this sort, with the perspective of forestalling unintentional harm to individuals andsociety.‘Budding Psychopaths’: Options for Appropriate and Ethical EarlyIdentification and InterventionIlina Singh, London School of Economics and Political Sciences (i.a.singh@lse.ac.uk)What reasons do we have for wanting to identify children at risk of psychopathy at a young age?If there are good reasons for early identification, does this mean we should also intervene early?How early? And what technologies of intervention are appropriate and ethical? This talkintegrates an historical look at bio-prediction strategies with an analysis of potentially plausible,and ethical, management of ‘budding psychopaths.’ The talk draws on literature fromdevelopmental psychobiology as well as bioethics and the social sciences to construct a set ofcases around which social and ethical concerns in this area can be illustrated and discussed. Aprimary focus of the analysis is to ask how we should balance public health concerns aboutpotentially dangerous criminals and individual rights in the context of developing children.Answers to this question are hindered by the fact that bioethics lacks a substantive ethicalframework to guide analysis of bio-technical interventions in children. In biomedical contexts,interventions in children have been guided by a combination of the Geneva conventions on therights of the child and by parental rights. One aim of this talk is to demonstrate the need for amore specific, child-centred ethical framework, and to suggest some key values that that could beincorporated therein.Early Prevention of Antisocial Behavior: The Role of Parents, Families and theParent-Child RelationshipDorothee Horstkötter, Maastricht University (d.horstkoetter@maastrichtuniversity.nl)305

Recent biomedical research on the risk-factors and development of antisocial behaviour pointstowards potential clinical applications that target not only the treatment of children with actualbehavioural problems, but also, and in particular, the early detection of children at-risk and theearly prevention of such troubles. The lives of young children, however, are particularly contextbound,that is, they are closely connected with parents and embedded in families. Consequently,screening and prevention measures that intend to affect young children are highly likely toconcern parents and families at the same time. The goal of this presentation is to discuss the roleand position of parents and families in this regard from an ethical point of view. Is theassumption that screening and prevention mainly provide support and help to families indifficulty warranted and if so under which conditions? Instead, could the interests of children,parents and families conflict with those of society and what would it entail to balance the variousperspectives involved proportionately? What about conflicts of interests between children andparents? Questions concerning parental autonomy and ethical reasons for as well as against itsdiminishment for the sake of antisocial behaviour prevention complete the discussion.Young Offenders, Direct Brain Interventions, and Personal IdentityNicole Vincent, Macquarie University (nicole.vincent@mq.edu.au)Hank Greely has recently argued that with advances in knowledge of the neurobiological causesof human behaviour, we may eventually develop direct brain intervention (DBIs) basedtechniques for changing people's behaviour. Candidate DBIs include (though are not limited to)psychopharmaceuticals like SSRIs which seem to diminish propensity towards reactiveaggression and Oxytocin which is linked with pro-sociality. When people's (mis)behaviors arecaused by conditions that are perceived as disorders of the brain – as illnesses or diseases – theuse of DBIs will probably tend to be more readily accepted. But "what about direct braininterventions that treat [the] brain-based causes of socially disfavored behaviors that are notgenerally viewed as [caused by or as manifestations of] diseases" (Greely 2012:163)? Forinstance, if we discovered the neurobiological causes of paedophilia, should it be permissible to"treat" (maybe even involuntarily) "afflicted" individuals? Elsewhere I have argued that DBIspose a special problem for personal identity (Vincent 2012). However, in this paper I will arguethat whatever other reasons there might be to be wary of using DBIs for this purpose, from theperspective of personal identity there would be fewer concerns about using DBIs on youngerthan older individuals.129. Prevention of SuicidePrevention of Suicide in a Forensic Psychiatric ClinicFrank Goldbeck, Klinik Nette-Gut für Forensische Psychiatrie, Weißenthurm, Germany,(F.Goldbeck@kng.landeskrankenhaus.de)306

Patients of a forensic psychiatric clinic are at high risk of becoming suicidal because they arementally ill, in an exceptional situation, not knowing when or if they will leave the clinic. Manytimes they have drug problems or have already attempted to commit suicide. In the forensicpsychiatric clinic in Andernach four patients out of 390 committed suicide within 16 months.Until last year the clinic did not have structural management for suicide prevention, therefore itwas decided to start a project. The aim was to develop a structural program of suicide preventionin order to recognize suicidal patients, to talk about this subject and also to get the staff to feelsafe. The recommendations include: A quality standard with criteria regarding structure, processand outcome to identify suicidal patients in order to handle the crisis; giving a flyer to allpatients; and offering patients the possibility to talk in a group about "suicide" including tailormadeteaching lessons. The aim is now to implement the standard, to create a flyer and todevelop special teaching lessons. The staff needs further training regarding suicidality and clinicprevention of suicide, all this well-planned and computer-based.Suicide in German and Austrian Prisons: A Chance to Change?Katharina Bennefeld-Kersten, Höhbeck, Germany (suizidforschung@gmx.de)Stefan Fuchs, Austrian Directorate for Prison Administration, Austria (stefan.fuchs@justiz.gv.at)Between 2000 and 2011, nearly 85 prisoners committed suicide in Germany each year. Thisnumber is the result of a study conducted by the Criminological Services Unit of the Lower Stateof Saxony. In Austria, the average number of suicides in prisons for that period was a little morethan 10. There was a reduction in these figures from 2000 to 2005, and in the last couple of yearsthe number of suicides has been increasing again.Are there differences between suicides inAustrian and German prisons? What causes this high number of people to think they have noalternative to suicide? What are the most important characteristics of people with suicidaltendencies and what can we do in order to help them? This presentation addresses the followingtopics: (1) The background and main facts about prison suicides and (2) explanations and basicknowledge about safety measures that play a decisive role in these settings.Crisis Line for Prisoners – An Attempt to Establish Alternatives: Talking Insteadof Taking Away!Katharina Bennefeld-Kersten, Höhbeck, Germany (suizidforschung@gmx.de)The high number of suicides in German prisons gives us cause to concern. Are we taking enoughcare of prisoners, especially in the first instance of imprisonment? The normal method ofhandling people with suicidal thoughts is safety measures. This means separating the inmate307

from others and accommodating him in a special safety cell. But is this the safest way? Or doesisolation even heighten suicidal tendency? Out of this idea two projects emerged in prisons ofLower Saxony and Bavaria. In one of them remand prisoners are given the opportunity to speakanonymously with a pastor over a “crisis line” during the night. In the other project “listeners” inBavaria give recent offenders with suicidal tendencies the possibility of spending the first nightunder arrest with a selected cell inmate. Both projects intend to test whether having this optionhelps to alleviate some of the emotional trouble typically experienced after initial offender intaketo prison. The next presentation will provide information about listeners. In this presentation thecrisis line will be discussed, including the background of safety measures as well as theconceptualization and realization of the project. This presentation also addresses thedevelopment of the projects and furthermore results of its evaluation.The Listener Scheme and Social Therapy for Violent Offenders: Helping “BothSides”Willi Pecher, Munich Prison, Germany (wilhelm.pecher@jva-m.bayern.de)Johannes Lohner, University of Applied Sciences Landshut (johannes.lohner@fh-landshut.de)Suicide prevention is a common need among penal institutions around the world, and Bavarianprison authorities currently focus upon this issue extensively. Traditional approaches involvingonly correctional staff in suicide prevention efforts have proven to have their limitations,especially since recent studies have shown that prisoners would rather appeal to other prisonerswith their concerns. The involvement of inmates in peer prevention efforts seems to be areasonable alternative approach. In Munich Prison, volunteer prisoners, who are participants ofthe Social Therapeutic Institution for Violent Offenders, are in service as listeners for newlyincarcerated prisoners. In this presentation we show results from a study about the effects onnewly incarcerated prisoners, discuss framework requirements of the project and a trainingprogram for later listeners. Moreover, possible therapeutic effects for the listeners, which couldbe utilized within the therapeutic process, are presented.Suicide in German and Austrian Prisons: A Chance to Change?Stefan Fuchs, Kirchberggasse, Innsbruck, Austria (stefan.fuchs@justiz.gv.at)Katharina Bennefeld-Kersten, Höhbeck, Germany (suizidforschung@gmx.de)Between 2000 and 2011 nearly 85 prisoners committed suicide in Germany each year. Thisnumber is the result of a study that is being conducted by the Criminological Services Unit of theLower State of Saxony. In Austria the average number of suicides in prisons for that period islittle more than 10. There was a reduction in these figures from 2000 to 2005, in the last coupleof years the number of suicides is increasing again.308

Are there differences between suicides in austrian and german prisons? What causes this highnumber of people who think they have no alternative than suicide? What are the most importantcharacteristics of people with suicidal tendencies and what can we do in order to help them?The presentation addresses the following topics: (1) The background and main facts about theprison suicides and (2) explanations and basic knowledge about safety measures that play adecisive role in these settings.130. Prison Mental Health and Forensic Care in a Changing SocietyChanges in Dutch Forensic and Penitentiary Psychiatric Care: Where We HaveCome From and Where We Are HeadingErik Sikkens, NIFP Amsterdam (e.sikkens@dji.minjus.nl)The Dutch forensic and penitentiairy care system has gone through major changes the last tenyears. The major goal was to organize better care and make society safer. There has been achange in the financial system from 2007 when all the costs has been transferred from theMinistry of Health to the Ministry of Justice. This has brought new possibilities, but also newproblems, which have to be tackled. These changes and what is has meant for the forensic caresystem will be discussed.Diversion from the Prison Mental Health System into Forensic Psychiatric Care:Is It Better and Safer?M. van Berkel, NIFP Amsterdam, Netherlands (m.van.berkel@dji.minjus.nl)In prisons a large group of inmates have psychiatric disorders. In The Netherlands it is possibleto give basic psychiatric care if needed by a prison psychologist and/or a psychiatrist. Whenspecialized care or more intensive care is needed, an inmate can be transfered to a forensicpsychiatric clinic or to a special unit in the prison system, a penintentiairy psychiatric centre.This presentation will give an overview of all the possibilities of psychiatric care for inmates andwill address the question of why certain choices are made.Does ISD Work? How to Keep the Streets Clean from Habitual Offenders withAddiction and Psychiatric DisordersTwan van Bakel, NIFP Den Bosch, Netherlands309

ISD is a measure for active habitual offenders, which became law in 2004. Big problems withaddicted patients who committed petty crimes and were responsible for the majority of nuisancein neighbourhoods had led to an earlier law, SOV (Detention and Care for Addicts). In anevaluation of the SOV law, the measure proved succesful, but was only meant for alcohol- anddrug-addicts. Other groups were also responsible for a large number of petty crimes like stealing.Therefore a new law, ISD, was introduced in 2004, which made it possible for all kinds of peopleto be subject to this measure. The measure made it possible to put someone in a special prisonfor two years. For motivated people all kinds of psychiatric and social care was available. Recentfindings show a diminished criminal recidivism among people who underwent an ISD measure.Routine Outcome Monitoring in Dutch Prison Mental Health: A Pilot forMeasuring Feasibility in Four PrisonsHenrik Keijer, NIFP Utrecht, Netherlands (h.keijer@dji.minjus.nl)In 2011 the NIFP started a pilot with routine outcome monitoring (ROM) in four prisons in thecity of Utrecht and Amsterdam. ROM has become standard practice in regular psychiatric care.The reason for this pilot was to establish whether it was feasible to do ROM in a prison setting.Results of this pilot will be presented.Indications for Forensic Psychiatric Care: Facts and FiguresAnnet Slijkhuis, NIFP Centraal, Utrecht, Netherlands (a.slijkhuis@dji.minjus.nl)With a new funding system for forensic psychiatric care in 2008 also a system of formulatingindications for the different levels of care was established, to determine both intensity oftreatment/care as well as the intensity of safety measures. Every person with a judicial measurewho needs forensic psychiatric care, whether imposed upon him by court or when diverted fromthe prison system, needs such an indication. Facts and figures will be presented for the periodfrom 2008 to 2012.131. Prison Psychiatry IAre Antisocial Personality Traits Less Frequent in Individuals Raised inSocialist Systems?Annette Opitz-Welke, JVKB, Berlin, Germany (opitz-welke@web.de)310

Introduction: In Germany there is a vivid discussion about whether personality is influenced bythe fact that a person was born and brought up in the former German Democratic Republic(GDR) or the former Federal Republic of Germany (FRG). Of special interest is the question ofwhether antisocial personality traits are fostered or suppressed by a system that supportsindividuality. In the psychiatric department of the Berlin prison hospital the birthplace of allprisoners is documented, which offers the opportunity to compare prisoners who are born andraised in the former GDR to those from the former FRG.Methods: The psychiatric department of Berlin Prison Hospital offers inpatient treatment for allmentally disturbed prisoners who need hospital care. All patients born in the former GDR arecompared to an age-matched random sample of patients born in the Federal Republic ofGermany. The PCL-R score, criminal records and sociodemographic variables of those 2 groupswill be compared. A regression analysis will be performed to identify determinates of a highPCL-R score.Results: Characteristics of both groups will be described. A multivariate model to explainvariations in PCL-R scores will be presented. Further need for research will be discussed.Suicide amongst Prison Populations in Germany: An Overview of Risk Factors,Protective Factors, and High-Risk GroupsDanielle Goodwin, JVKB, Berlin, Germany (dgoodwin@live.fr)This report is based on a nationwide monitoring of suicide-tendencies amongst prisonpopulations throughout Germany, initiated by the German Society for Suicide Prevention. In thebeginning of 2005, a specific work-group focusing on suicide in custody was created. Theprincipal objective was to monitor suicidal behaviour of incarcerated individuals in order to gaina better understanding of the phenomenon as a whole, and thus, to improve suicide-preventionstrategies on a primary, secondary and tertiary level, and ultimately, to contribute to a decrease insuicide rates in prison. Socio-demographic, individual, criminological, custodial, and psychiatricdata of each suicide victim were systematically compiled and analysed using the SPSS system.External and internal suicide risk factors leading to specific risk-constellations were identified.Age, sex, health condition, nationality, marital and familial situation, financial situation, type ofcustody, type of crime, number of previous imprisonments, type of accommodation within thefacility, time at which suicide occurred, month in which suicide occurred, life-events, psychiatricrecord and previous suicidal behaviour were all taken into account. The data analysis reveals thatyoung male inmates, incarcerated primarily in remand custody, in a single-cell accommodationrepresent the highest risk-group, especially during night time. The month with the highest suiciderate was January, the month with the lowest, December. The days with the highest suicide rateswere Sundays and public holidays, as on these days, staff presence is lower. Protective factorswere also analysed, such as being in a relationship, having access to conversations with a doctor,a psychologist or a priest, and, as in correctional facilities in the federal state of Lower Saxony,access to a 24/7 crisis hotline. Data were collected by means of a specific questionnaire that was311

systematically filled out by the prison guard discovering the suicide victim. The aim was toidentify specific suicide-profiles in order to identify future behavioural patterns before theincarcerated individual attempts to commit suicide, to minimise risk factors and to enhanceprotective factors.A Randomized Controlled Study on the Effects of PsychoeducationalInterventions on Schizophrenic Patients in Prison PsychiatryIlona Kogan, JVKB, Berlin, Germany (Ilona.Kogan@jvkb.berlin.de)Background: The efficiency of psychoeducational intervention in psychiatric inpatient treatmenthas been established over the past 20 years. Early psychoeducational intervention has beenlinked to increased medicinal compliance and less recurrence of schizophrenic episodes, and theinpatient treatment duration has been proven to decrease. However, there have been no studies inGermany that investigate the effectiveness of these interventions in prison psychiatry onschizophrenic inmates.Objective: This study will examine the effects of psychoeducational interventions in prisonpsychiatry.Methods: All male inmates who meet the criteria for an ICD-10 diagnosis F20.X will berandomly assigned to 1 of 2 treatment conditions. In the psychoeducational interventioncondition, patients will be able to obtain knowledge and insight into their disease. Patients in theother treatment condition will receive TAU (treatment as usual) and psychoeducationalintervention 6 months later. All participating patients will be tested with the following battery oftests: PANSS, SKID I and II, ESI, IRAOS and PCL Factor 2 at three different times in the study(pre-intervention, post-intervention and 6 months after intervention).Results/Conclusion: It is expected that similar efficiency results will be achieved in prisonpsychiatry as those in inpatient treatment facilities in public hospitals. In addition, it isanticipated that due to the early intervention, the acquired knowledge and the increasedmedicinal compliance a subsequent incarceration could be avoided. This would counteractfurther stigmatization and social descent.Relationships and Sexuality of Imprisoned Men in the German Penal SystemThomas Barth, JVKB, Berlin, Germany (Thomas.Barth@jvkb.berlin.de)Sexuality among prisoners is one of the few taboo topics in the modern penal system and theperception in society is blurred by clichés and ignorance. The lack of concrete scientific data onthe sexual behavior of inmates in German prisons is surprising, especially given the extantinternational scholarship on prison culture and sexual violence. The first German study aboutrelationships and sexuality of imprisoned men was conducted in an adult correctional facility for312

long-term prisoners in Berlin-Tegel, and data of one cohort-study unveiled for the first time in2011. The survey, which is based on results of a questionnaire by voluntary study participants,has a special focus on the occurrence of consensual homoerotic contacts between heterosexualinmates. The emphasis is on the potential impact of such contacts on role behaviour duringconfinement and sexual identity after release. Different forms of homosexual contact betweeninmates include prostitution and “protective pairing“, both characterized as “dark” issues –nonconsensual sexual acts – which still have not been scientifically researched. Furthermore thesurvey reveals first data on the incidence and prevalence of sexual violence and coercion withina German correctional facility. The complete data of both cohort-studies of the survey will bepresented for the first time.132. Prison Psychiatry IISexual Offending in Schizophrenia: Discussion and Implications in ComparingPrevious and Recent FindingsSonja Pitum, Bundeswehrkrankenhaus, Berlin, Germany (sonja_pitum@web.de)Studies suggest a complex relationship between schizophrenia and sexually offensive behaviour.Partly conforming to previous findings, we found in this study similarities in demographic andpsychosexual variables as well as in sex offence features and behaviours in schizophrenic andnon schizophrenic sex offenders. Furthermore, differences in offending variables becameapparent within the heterogenous schizophrenic offender group. We compared illness relatedvariables, comorbidity, psychosexual, demographic and offense related variables from our studywith recent findings. Recent studies have found a relationship between psychosis and violentsexual offending, the direction of which remains unclear. Specific psychotic symptoms inschizophrenic offenders are an area for further research. According to our data, psychotic sexualoffenders tended to have a history of sexual and non sexual offending, a psychiatric history,comorbidity with dissocial personality and substance abuse disorders impaired psychosexualvariables and adverse childhood experiences. The presence of a personality or substance usedisorder seemed to increase the risk for violent and non-violent sexual offending. Focusedstudies are needed to elaborate on effective strategies of treatment and risk assessment.Developing Trends in the European Prison SystemKlaus Rabe, LVR-Klinik Dueren, Germany (walther-raBE@gmx.de)In Europe approximately 524,000 people are in prison, approximately 0.1% of the generalpopulation in the European Union. Per country there are, on average, 137.8 people incarceratedper 100,000 inhabitants. This study will describe the development of the prison population in 24313

European countries from 1997 to 2008 by analyzing the data from the Council of Europe AnnualPenal Statistics (Statistiques Penales Annuelles du Conseil du L’Europe). To characterizeunderlining developing trends, changes in sentencing and pretrial detention praxis as well ascharged offenses are studied. During this time period many European countries increased theirprison populations by increasing charges for drug offenses and property crimes as well aslengthening sentences. Because of the increasing number of prisoners, the development of prisonmortality and prison suicides as specific risks are additionally studied on the level of time-seriesper country.Therapy of Sex Offenders: The Risk of Negative Countertransference ReactionsJoachim Zeiler, Vivantes Klinikum, Berlin, Germany (joachim.zeiler@vivantes.de)The burden involved in being mentally ill includes stigma. The degree of stigmatization appearsto be linked to the fear elicited by bizarre, dangerous and morally offensive behaviour. Thesocial exclusion of the mentally ill is legitimized by a broad set of prejudices which comprisesstereotypes and negative emotions. Schizophrenic psychoses and paraphilias associated with sexoffending exemplify the quintessential danger of otherness. On a moral scale, sex offenders areascribed the lowest position because everyday reasoning tends to treat them as subjects withunimpaired accountability. They seem to consciously violate the idealized romantic lovestereotypeshaped by cultural tradition. This stereotype still functions as a guiding norm althoughsocial reality has generated a broad array of mating patterns. New paradigms of sexualbehaviour, formerly considered as deviant, are increasingly shaping mainstream attitudes.Against the backdrop of public rejection psychotherapy of sex offenders has to achieve aworking relationship. Therapists have to be aware of the risk of negative countertransference andto overcome their own cultural biases. They must reflect their personal biography, sexual historyand value orientation to facilitate therapeutic change. Therapeutic personnel working in prisonsor forensic commitment institutions may be at special risk to unconsciously maintain a culturalbias and take part in rejecting the patient’s search for acceptance, thereby confirming their ownmental health and sexual integrity.Legal and Psychosocial Risk Factors of Forensic Psychiatric PatientsWithdrawn from Conditional ReleaseThomas Ross, University of Ulm, Germany (thomas.ross@uni-ulm.de)Klaus Hoffmann, Reichenau Forensic Psychiatric Centre, Germany (Thomas.ross@uni-ulm.de)Background: There are small but considerable numbers of forensic psychiatric patients who donot manage to comply with the legal requirements of conditional release from forensicpsychiatric hospitals. These patients are usually referred back to inpatient treatment, with little314

chance of another timely release, especially if they have re-offended. As a matter of fact, allpatients discharged from forensic psychiatric hospitals had, at the time, been considered fit forconditional release. From a risk assessment point of view, those who did not do well may beconsidered false negatives.Objectives: 1. To investigate two sub-groups of patients released from German forensicpsychiatric hospitals: 1.a) patients who have done well under the legal requirements ofconditional release and 1.b) those who did not, i.e. the patients whose conditional release waslegally withdrawn within a relatively short time at risk. 2. To investigate the reasons forwithdrawal of conditional release in group 1b). 3. To identify a set of legal and psychosocialperson-related variables associated with the odds of withdrawal of conditional release fromGerman forensic psychiatric hospitals.Method: Several German forensic psychiatric hospitals were asked to provide data on legal andpsychosocial person-related variables that might distinguish between the subgroups describedabove. The cut-off for group assignment was the legal status at thirty months at risk, i.e. thepatients whose conditional releases were not withdrawn within thirty months from dischargewere considered “to do well”. Assessments of over 800 patients discharged from 2009 to 2011are analysed and compared with respect to their legal background, type of offence, psychiatricdiagnoses, prior psychiatric treatments, and variables tapping psychosocial adaptation prior toadmission.Results and Discussion: Preliminary results will be presented and implications discussed.133. Problem-Solving CourtsImproving the Criminal Justice Response to Offenders with Mental Illness inRemote Northern CommunitiesPriscilla Ferrazzi, Queen’s University (priscilla.ferrazzi@queensu.ca)Tery Krupa, Queen’s University (terry.krupa@queensu.ca)In remote communities in the Far North, the capacity of criminal justice systems to deal withoffenders with mental illness is taxed by limited available resources and the absence ofspecialized "mental health courts" and related "diversion programs" used in the south. Thisresearch explores the ability to incorporate principles of problem-solving courts that guidemental health courts and diversion programs into the criminal court structure and practice ofremote communities. The application of problem-solving principles results in people with mentalillness accessing community treatment rather than facing prosecution or incarceration whenmental illness is seen as the main cause of criminal behaviour and the approach is appropriate tothe nature and circumstances of the offence and the background of the offender. Exploration ofthe viability of this approach in northern communities is undertaken through a) an exploration ofthe essential principles of problem-solving courts and b) mental health support systems thatinclude a community-based rehabilitation model and/or the use of remote technologies. This315

esearch addresses a significant health need in isolated northern communities and provides analternative approach to making criminal justice systems more responsive to mentally ill offendersin small, under-resourced and isolated jurisdictions.Utility of Risk-Need-Responsivity Driven Case Management Strategy within aMHC Context: Criminogenic Needs Relative to Diagnostic CategoryW. Alex C. Macaulay, University of New Brunswick (alex.macaulay@unb.ca)The Saint John Mental Health Court (MHC) is a court in New Brunswick, Canada that offersspecialty legal processing for mentally ill offenders. A significant body of research has shown astrong link between dynamic factors and recidivism, known as criminogenic needs (Andrews &Bonta, 2010). The purpose of the current paper is to discuss research findings that address howthese criminogenic needs (e.g., companions, education/employment, etc.) relate to generaldiagnostic categories (e.g., schizophrenic, bi-polar disorder, etc.) and severity ofpsychopathology among MHC clients. Criminogenic needs were identified by using the Level ofService/Case Management Inventory (LS-CMI) at the time of intake to the MHC program,whereas mental health diagnosis will be assessed by file review and the Symptom Checklist-90-Revised (SCL-90-R). It is expected that criminogenic needs related to psychosocial functioning(e.g., education/employment, the quality of intimate and family relationships, etc.) will be moststrongly associated with severe mental health issues, whereas criminogenic needs related topersonality and distorted thinking (e.g., antisocial personality, attitudes, etc.) will show weakerassociations with severe mental health issues. Results will inform case management planning ofMHC teams and speak to the value of targeting criminogenic needs within comprehensive caseplans for MHCs.The Interplay between Mental Health Courts and Veterans Courts in the UnitedStatesMichael Finkle, King County District Court, Seattle, USA (michael.finkle@kingcounty.gov)Mental Health Court (MHC) is a specialized criminal court designed to bring treatment andhousing services to people whose interaction with the criminal justice system is caused insignificant part by a major mental illness. This is carried out by assembling a multi-disciplinaryteam of professionals, including judge, prosecutor and defense counsel. That team is familiarwith both the criminal justice and social services systems. In the past 20 years the United States’criminal justice system has experienced a dramatic growth in MHCs. In 1995, only one MHCexisted in the United States; in March of 1999, there were four; currently, there are more than250. Recently, a new form specialized court, referred to as a “Veterans Court,” has emerged inthe United States. Veterans Courts bring treatment and housing services to veterans whoseinteraction with the criminal justice system is caused in significant part by Posttraumatic Stress316

Disorder, or PTSD. Though they serve two different populations, these two specialty courts sharemany common characteristics. That leads one to ask why a jurisdiction would want or need bothan MHC and a Veterans Court. In this presentation, participants will answer that question byexamining the interplay between the two Courts.The Working Relationship and Mental Health Court ParticipationKelli E. Canada, University of Missouri (kecanada@uchicago.edu)MHCs are growing rapidly across the nation. Research is beginning to shed light on outcomeslike reduced criminal recidivism and increased access to services. However, little is known aboutthe factors facilitating change. This presentation focuses on one possible factor, relationships, byexploring the role relationships with MHC caseworkers play in promoting change. Participantswere recruited from two mid-western, urban MHCs (N = 80) and took part in a 60-minutestructured interview involving a battery of empirically tested measures. Descriptive statistics,bivariate analyses, and multiple regression were used to analyze the data. The alliance with MHCcaseworkers is significantly associated with service use. Specifically, the conflict subscale, ratherthan the bond, is significant such that as conflict decreases, service use increases, B = -0.12 ± -0.23, -0.01, p = 0.05, f 2 = 0.40. Similarly, conflict with MHC caseworkers was significantly loweramong participants who remained in or graduated from the MHC than individuals who quit orwere terminated, OR = 0.91, p = 0.01. The alliance was not associated with recidivism. AmongMHC participants, perceptions of conflict within relationships with caseworkers are one factorfacilitating service use and engagement.Gender Assignment and Construction in Australian CourtsBrenda McGivern, University of Western Australia (brenda.mcgivern@uwa.edu.au)The High Court of Australia, in the landmark judgment in “Marion's case”, limited the power ofparents to make certain treatment decisions for their children. By contrast, the power of courtsexercising their welfare jurisdiction to made orders in the best interests of those lacking legalcapacity has been described as “almost limitless”. This paper explores the exercise, and potentialexercise, of the welfare power under Australia's Family Law Act in the context of applications toauthorise treatment for so-called intersex children (those born with ambiguous gender ordisorders of sex development) and children having gender identity dysphoria. It considerswhether the approach to “special medical procedures” developed in Marion's case is well adaptedto respond to such cases.134. The Prognosis of Psychiatric Diseases317

Specific Alcohol Dependence Treatment according to the Lesch Typology: AProspective 2 Year Outcome StudyOtto M. Lesch, Psychiatric Medical University Vienna (otto.lesch@meduniwien.ac.at)Introduction: In guidelines from the European Medicine Agency (EMEA, 18. 02. 2010) andfrom the FDA it is clearly stressed that we need more homogenous phenotypes for clinical trialsin alcohol dependent patients defined by ICD-10 and DSM IV. They should be definedmultidimensionally and it is accepted internationally that four different subgroups are the bestsolution (e.g. typologies by Windle and Scheit, Del Boca and Hesselbrock, or Lesch). The Leschtypology has been investigated in many international basic and clinical trials and nowadays isused in daily practice in different countries (Portugal, Bulgaria, Poland, Germany, Switzerland,and so on).Objectives: Using specific treatment approaches we hypothesize that we can significantly reducerelapse rates and durations. The aim of the present study was to assess the outcome of 2 years ofLesch-typology based treatment of alcohol dependent patients.Methods: 321 alcohol dependent patients treated and classified during in- or outpatient treatmentin our department were contacted two years later by a structured telephone interview. 101(31.46%) persons could be reached and were included in the study. A profile of daily alcoholconsumption was assessed with the “Timeline Follow back” method and categorized asabstinent, slips, episodic or steady. Furthermore the CCAD and a prognosis for each Lesch Typewere calculated.Results: 37% of patients had an abstinent course of alcohol consumption, 31% had slips, 12%had an episodic and 20% a steady course. The rate of abstinence in patients treated according tothe Lesch typology was significantly higher than in patients who received treatment as usual.Using this intent to treatment method it is obvious that the results have serious limitationsbecause we could only reach one third of our patients. These methodological problems should bediscussed.How to use Lesch-Typology in Forensic Questions?Werner E. Platz, Vivantes Forensic Psychiatry, Berlin, Germany (werner.platz@vivantes.de)Following a decision of the Federal Constitutional Court, prior to hospitalization of an addictedoffender in a detention center withdrawal unit, the prospects for success of withdrawal treatmentare to be tested. In the Guidelines of the Federal Constitutional Court (BVerfG), a successfulprognosis for "cure" or at least abstinence for "a certain period of time" is required by thetherapy. So far, only limited meaningful forecasting tools have been available, so therapy andprognosis based on Lesch-Typology in forensic psychiatric evaluations and follow-ups havebeen used in detention centers. It has been determined that dependent patients according to318

Lesch-Type II have significantly better chances for successful therapy within forensic psychiatry.A computer-aided diagnosis facilitates the assignment to Lesch-Typology and "break-points"have been found suitable for a quick diagnosis in daily practice for definition of drinking patternsof alcohol addicts. These will be presented in relation to Lesch-Typology (I-IV).Predictors of Bipolar Disorders: Relevance for Forensic ExaminationAndreas Erfurth, Krankenanstaltenverbund Vienna, Austria (Andreas.erfurth@wienkav.at)Bipolar disorders and disorders of the bipolar spectrum are of great epidemiological importance.Evidence has been provided for a prevalence of at least 5% (Akiskal HS et al. 2000)). In the lastcentury different approaches have been evaluated to find predictors for affective disorders(Nurnberger JI Jr et al. 2011, Howes OD et al. 2011, Angst J, Clayton P. 1986). The concept oftemperament and its linkage to full-blown pathology has been shown to be of central importance(von Zerssen D. 1996, 1998). Recently, the concept of the temperamental basis of bipolaraffective disorders and of other psychiatric disorders including somatoform disorders andalcoholism has been extensively re-examined (Amann B et al. 2009, Vyssoki B et al. 2011, SkalaK et al. 2012, Unseld M et al.). The literature will be reviewed and the implications for forensicpsychiatry will be discussed.The Diagnosis of "Burn Out" Used for Forensic QuestionsHenriette Walter, Psychiatric Medical University Vienna (henriette.walter@meduniwien.ac.at)The diagnosis of “Burn out“ is increasingly used in psychiatric praxis. In 1974 Freudenberger, apsychoanalyst, introduced the term “Burn out“ in the medical praxis. In 1976 Christina Maslachdeveloped scientific instruments to assess this diagnosis and its severity. Burn out relatedpsychiatric and somatic diseases seem to depend on the severity of the course of Burn outassessed by MBI. The course of Burn out will be presented and the diagnosis of Burn out(problems to cope with life events ICD-10: Z 73.0) in relation to different psychiatric andsomatic diseases will be shown. Chronic fatigue syndrome, depressive syndromes and addictionare the main psychiatric consequences. In forensic examinations the long term course ofdepression or alcohol dependence often has to be discussed. The assessment of the course ofBurn out could be very helpful in answering these questions.135. Prostitution and Human Trafficking319

Men Who Buy Sexual Services – Findings FROM A Swedish Population BasedStudy about ProstitutionGisela Priebe, Department for Child & Adolescent Psychiatry, IKVL, Lund University(Gisela.Priebe@med.lu.se)In 1999, Sweden became the first country in the world to introduce legislation that prohibited thepurchase, but not the sale, of sexual services. An evaluation of the effects of this legislation wasconducted in 2010 on behalf of the Swedish government and concluded that the criminalizationof the purchase of sexual services has helped to combat prostitution (SOU 2010:49). Thispresentation is based on data from a population-based study conducted in 2011 with 5,071participants (49.2 % males) aged 18 – 65 years about experiences of and attitudes towardsbuying and selling sexual services. Among male participants, 253 (10.2 %) reported that theyhad bought sexual services at least once in their life. The prevalence rate is compared with ratesfrom previous Swedish studies and possible trends over time are discussed. Frequency andcircumstances of the purchase of sexual services are presented. Buyers and non-buyers of sexualservices are compared with regard to socio-demographic variables, psychic symptoms (SCL-25),self-esteem (Rosenberg), sexual behaviour in general and problematic sexual behaviour (SexualAddiction Screening Test).Challenges in Assisting Victims of Human Trafficking WorldwideJane Nady Sigmon, US Department of State, Washington D.C., USA (sigmonjn@state.gov)Trafficking in persons, the umbrella term for activities involved when someone obtains or holdsanother person in compelled service, is increasingly recognized as a global crime requiring aconcerted response by governments and civil society. Although much progress has been made inthe last decade, as nearly all countries have enacted new laws to address this crime, the victimprotection and enforcement envisioned by advocates and international instruments are not areality. The International Labor Organization estimates that 21 million people are victims offorced labor. Of these, 22 percent are victims of forced sexual exploitation and 78 percent arevictims of forced labor. Recent research has described the extreme forms of physical and sexualabuse suffered by many victims of trafficking for sexual exploitation and forced labor and newinformation about the health and mental health impacts on victims is emerging. However, fewmodels for victim assistance have been evaluated and many programs struggle to develop andprovide services to meet the needs of diverse populations of trafficking victims. Thispresentation will discuss the current literature related to the impact of trafficking on victims,identify challenges in assisting victims, and describe promising approaches in victim assistanceworldwide.320

Evaluation of Therapeutic Interventions Given by Specialized Service Providersin Sweden for Females and Males who have Sold SexCecilia Kjellgren, Linnaeus University (Cecilia.kjellgren@lnu.se)The aim of the study was to evaluate the effects of therapeutic interventions delivered by threespecialized service providers in Sweden to women and men with experiences of prostitution.Method. Thirty-four clients who agreed to participate in the study were interviewed andcompleted questionnaires pre treatment and post treatment, on average one year later.Results. The respondents (31 females and three males) were on average 29.1 years by thebaseline interview. The majority turned to the specialized unite to get help to deal with negativeexperiences of prostitution. They were on average 21.3 years (sd=7.2) at their first experience inprostitution. They reported having sold sex on average seven years. The majority reported drugmisuse and mental health problems. The respondents reported more extensive symptoms thancertain other clinical groups. Further respondents reported a number of potential traumaticexperiences during childhood.Twenty-six respondents participated in a follow-up interview. For the majority the treatment wascompleted by follow-up. Participants reported significant positive changes in relationships withothers. The majority (80%) reported that they did not sell sex any longer. Significant changeswere also reported on questionnaires as decreased mental health problems and increased selfesteem.Further the participants reported high treatment satisfaction.Conclusions. The three unites use different therapeutic techniques but the outcome was equallygood for clients at various units. The units have in common a strong focus on prostitution andopenness to talks on various aspects of it. That component seems to have significant impact onthe outcome.136. Psychiatric and Psychological Autopsy, the Alphen SpreeShooterPsychiatric and Psychological Autopsy: Reasons and PrinciplesNils Duits, Netherlands Institute of Forensic Psychiatry and Psychology(N.Duits@dji.minjus.nl)On April 30th, 2009 a suicide attack on the Dutch queen resulted in eight deaths and multiplepeople wounded. On April 9th, 2011 a spree shooter killed six and wounded seventeen people inthe shopping mall of Alphen. Both persons killed themselves. The Netherlands Institute ofForensic Psychiatry and Psychology developed psychiatric and psychological autopsies of theoffenders. These autopsies were to clarify eventual psychiatric conditions and behaviour in321

elation to the events. In a press conference answers were given to questions that arose in societyand the media about the offenders. Clarification to the family of the offenders and the victims ledto understanding and psychological coping. The final reason was to obtain, expand and exchangethe expertise and knowledge on these (possible) offenders, not in the least for preventativemeans. Scientific research and a group of national and international experts are in development.In this presentation the development of the psychiatric and psychological autopsies is explained.Arguments are given why and how forensic psychiatry and psychology and public prosecutionhas to incorporate this post mortem knowledge on a national and international level.Evidence in Multiple Homicide and Homicide and SuicideErik Sikkens, Netherlands Institute of Forensic Psychiatry and Psychology(E.Sikkens@dji.minjus.nl)In this presentation the scientific literature on multiple homicide and homicide and suicide issummarized. Definitions and terminology are explained, and the existing literature and profilingissues with these offenders are presented.Psychiatric and Psychological Autopsy: Benefits and NecessitiesIngrid Degeling, Public Prosecution Service, Den Haag, Netherlands (i.j.e.h.c.degeling@om.nl)The juridical context of homicide-suicide offenders is explained. The Public Prosecution Serviceis responsible for investigating criminal offences, prosecuting offenders and making sure thatsentences are carried out properly. Preventing crime and protecting the interests of people whohave suffered as the result of a crime are also tasks of the Public Prosecution Service. After theautopsy of the Alphen spree shooter a public discussion developed on weaponry allowances andprofessional secrecy due to a report of the Health Care Inspectorate on the psychiatric treatmentof the offender. The public prosecutor had contact with the family and victims. The autopsyreport played an important role in this contact and led to understanding and contact between thefamily and the victims.Psychiatric and Psychological Autopsy: Methods and Practical ExperienceBarend van Giessen, Netherlands Institute of Forensic Psychiatry and Psychology(B.van.Giessen@dji.minjus.nl)322

In this presentation the practical and personal aspects of a psychiatric and psychological autopsyare illustrated and explained.137. Psychopathology behind Razor Wire: Mental Illness in JuvenileJusticeYouth Behind Bars: Prevalence of Psychiatric Disorders in State CorrectionsOhiana Torrealday, The University of Texas (ohtorrea@utmb.edu)It is commonly understood that many youth who enter the Juvenile Justice System come fromchaotic home environments, have experienced multiple traumas, and present with complexmental health needs. The majority of published studies examining the extent of psychiatricdisorders among juvenile justice-involved youth in the United States have been based on small,predominantly male, youth samples held in pre-adjudication detention settings. Prevalence rateshave ranged from 65-70% of detained youth meeting DMS-IV-TR criteria for at least onepsychiatric disorder. How would this compare with adjudicated and sentenced male and femaleoffenders with more extensive delinquent histories? With 116,698 arrests in 2010 alone, Texashas one of the largest incarcerated Juvenile Justice populations in the U.S. and its six securecorrectional institutions serve as the last opportunity for rehabilitation before entering the adultDepartment of Corrections. Youth placed in these facilities have committed more frequent oregregious acts and have exhausted less restrictive graduated sanctions. We set out to investigatethe prevalence of psychiatric disorders among 11,600 youth committed to a state-wide juvenilecorrectional system. This presentation will address the prevalence rates found when comparingyouth across age, sex and race variables, as well as how these patterns compare to other juvenilejustice samples.Psychiatric Comorbidity in Secure Juvenile Settings: How Complex an Issue is itReally?Joseph V. Penn, The University of Texas (jopenn@utmb.edu)One characteristic commonly shared by youth involved in the U.S. Juvenile Justice System is ahistory of experimentation with or use of illicit substances. The prevalence rate for a substanceuse disorder among youth in the community has ranged from 6-10% while the rate for youth indetention centers was found to be substantially higher (47-81%). It is also known that substanceabusingyouth are likely to have contact with the mental health system, with many meetingcriteria for at least one other psychiatric disorder. The existing literature primarily focuses on theextent of comorbid psychiatric and substance use disorders among juveniles in pre-adjudicationdetention settings, with only one study examining prevalence rates in a small adjudicated323

population. No published prevalence estimates exist to date of the co-occurrence of a substanceuse disorder with other psychiatric disorders from a large sample of youth committed to juvenilecorrectional facilities. This presentation will outline the recent study carried out in the TexasJuvenile Correctional System to more closely examine the extent to which youth met criteria fora substance use disorder in addition to a major psychiatric disorder, ADHD or another disruptivebehavior disorder. How this information may be used to guide programmatic decision-makingand juvenile justice policy will also be discussed.DOC in a Box: Telepsychiatry the wave of the future?Christopher R. Thomas, The University of Texas (crthomas@utmb.edu)How can a statewide correctional health care system that spans 268,581 square miles ensureproper and reliable treatment by child-specialist psychiatrists when juvenile justice-involvedyouth are housed in remote locations several hundred miles away? Simply stating that theservices aren’t available or do not exist is not an acceptable answer. Fortunately, technologicaladvancements, specifically Telepsychiatry, has made this issue a thing of the past. Can apsychiatrist evaluate psychiatric symptoms just as effectively without interacting with a patientdirectly? How does the process actually work? Who needs to be involved? What are the pros andcons and challenges in providing care this way? And lastly, what must be considered whendesigning a training program for providers new to Telepsychiatry? This presentation will addressone large system’s design and implementation of a state-wide process to ensure psychiatricservices are accessible to incarcerated youth regardless of location.Juvenile Delinquency And Psychopathic Traits: An Empirical Study WithPortuguese AdolescentsRui Manuel Xavier Vieira, University of Lisbon (ruivie2@gmail.com)The objective of the present study was to analyze the role of psychopathic traits in juveniledelinquency. Using a sample of 543 young males from the Juvenile Detention Centers of thePortuguese Ministry of Justice and from schools in the Lisbon region, a group of highpsychopathic traits (n = 281; M = 15.97 years; SD = 1.5 years; range = 13-20) and a group oflow psychopathic traits (n = 262; M = 15.94 years; SD = 1.5 years; range= 12-20) were formedbased on the Portuguese version of Antisocial Process Screening Device (APSD-SR). Resultsshowed that youths with high psychopathic traits start engaging in criminal activities earlier inlife, come into contact with the justice system earlier in life, have higher levels of conductdisorder, behavior problems and delinquent behaviors, as well as lower levels of self-esteem.324

Psychopathy and Behavior Problems in Incarcerated Male and Female JuvenileDelinquentsPedro Pechorro, University of Lisbon (ppechorro@gmail.com)The objective of this study was to compare incarcerated male and female juvenile offendersregarding psychopathic traits, behavior problems, psychopathy taxon, conduct disorder, selfreporteddelinquent behavior, and crime seriousness. Within a total forensic sample of 261detainee participants, subdivided in a male group (n = 217) and a female group (n = 44),statistically significant differences were found. Female juvenile offenders show less callousunemotionaltraits, more emotional symptoms, more prosocial behaviors, less self-reporteddelinquent behavior, and lower crime seriousness. Conduct disorder prevalence was very high,but no statistically significant gender differences were found. The predictive importance ofpsychopathic traits, behavior problems, psychopathy taxon, and conduct disorder for theprediction of group membership (female versus male) was established by binary logisticregression.138. Psychopaths: How They Think, Act and Benefit fromTreatment, a Neurobiological PerspectivePsychopaths Know Right From Wrong, They Just Don’t CareMaaike Cima, Tilburg University (M.J.Cima@uvt.nl)The behavior of psychopaths is, without doubt, morally inappropriate, including murder, sexualmolestation, fraud, and arson. Further, clinical analyses show that they present abnormalemotional profiles, as well as problems with inhibitory control, often leading to both reactive andinstrumental aggression. What is unclear is the extent to which psychopaths suffer from damageto morally-specific knowledge that, in healthy individuals, guides intuitive judgments of rightand wrong independently of their moral actions. On the one hand, studies indicate thatpsychopaths, both adults and juveniles, show a diminished capacity to distinguish betweenconventional and moral transgressions. Psychopaths also show diminished inhibitory control, adeficit that may contribute to their impulsive behavior, especially in the context of violence. Thisresearch has led to the view that because of their emotional deficits, psychopaths havecorresponding deficits in moral knowledge, which, coupled with poor inhibitory control, leads tomorally inappropriate behavior. Two studies will be presented here. The first study examineswhether psychopaths know right from wrong. In this study psychopathic offenders werepresented with moral dilemmas, contrasting their judgments with age- and sex-matched 1)healthy subjects and 2) non-psychopathic delinquents. The second study investigates whetherpsychopaths understand and feel pain, by asking offenders (psychopaths and non-psychpopaths)to make decisions regarding the severity of pictures that depict moral or non-moral situations and325

make decisions regarding the perception of pain with pictures that depict pain and non-pain.Furthermore, in order to measure their own pain threshold, participants were asked to place theirhand in a tub of cold water (test often used in pain research). Results of these two studies will bepresented at the conference.The Role of Antisocial Personality Disorder and Psychopathy in PredictingInstitutional Violence: What’s the Difference?Farid Chakhssi, Forensic Psychiatric Centre ‘de Rooyse Wissel’, Venray, Netherlands(fchakhssi@derooysewissel.nl)Psychopathy has been shown to be related to violent recidivism in the community, and toinstitutional violence in forensic settings. Furthermore, in Dutch forensic psychiatry psychopathyplays a major role in risk management decisions, such as granting leave privileges andresocialization in the community. However, it remains unclear if psychopathy predicts futureviolence much better than a past history of criminal behaviour or antisocial personality traits. Inthis paper we aim to examine the differences between antisocial personality disordered offenders(ASPD) with and without psychopathy in acts of institutional violence. In a Dutch male forensicpsychiatric sample, ASPD was assessed using a structured interview for personality disorders.Psychopathy was assessed using the PCL-R, and defined using the Dutch cut-off score of 26 todistinguish between offenders with ASPD with psychopathy, and offenders with ASPD withoutpsychopathy. The results will be presented together with the possible implications for riskmanagement decisions.The Treatment of (Psychopathic) Offenders: The Effectiveness of SchemaTherapyMarije Keulen-de Vos, Forensic Psychiatric Centre ‘de Rooyse Wissel’, Venray, Netherlands(MKeulen-deVos@derooysewissel.nl)Schema Therapy (ST; Young, et al., 2003) is rapidly becoming more popular as a treatment forpersonality disorders (PDs). ST is an integrative psychotherapy that combines cognitive,behavioural, psychodynamic, and experiential components. This therapy was originallydeveloped for non-forensic patients with PDs or other longstanding problems, but has recentlyalso been adapted for forensic patients (Bernstein, et al., 2007). Core elements of ST are earlymaladaptive schemas, schema modes, and (dysfunctional) coping styles. There is good evidencefor the effectiveness of ST in (non-forensic) outpatients with borderline PD (Giesen-Bloo et al.,2006). To test this treatment in forensic PD patients, a randomized clinical trial (RCT) of ST istaking place at 8 forensic institutions in The Netherlands. In this study, male offenders withcluster B PDs are randomized to receive 3 years of either ST or treatment as usual (TAU). Theyare assessed every 6 months on multiple outcome measures. In this presentation, preliminary326

RCT results will be presented. Our findings suggest that ST is outperforming TAU with respectto drop-outs, supervised leave approval, and possibly recidivism. These differences are greatestin psychopathic patients. These preliminary findings suggest that ST is more effective than usualforensic treatment in psychopathic offenders, and that these patients may be more amenable tochange than believed possible.The Neurocognitive Correlates of Reactive Aggression: What Does the BrainTell Us?Franca Tonnaer, Forensic Psychiatric Centre ‘de Rooyse Wissel’, Venray, Netherlands(FTonnaer@derooysewissel.nl)In the forensic field, reactive aggression is associated with violent behavior and is an importantaspect of risk assessment in daily clinical practice. Neuropsychiatric abnormalities in the frontallobe in persons displaying reactive aggression and criminal behavior suggest an associationbetween frontal brain abnormalities and increased reactive aggression. However, brain imagingstudies have focused on different forms of frontal lobe abnormalities in aggressive individuals,such as differences in mechanisms and volume. Up to now, no study has examined groupdifferences between violent offenders and healthy controls triggering the actual emotion ofinterest: reactive aggression. Recent literature reviews of functional and structural neuroimagingstudies imply that a combination of decreased medial prefrontal activity along with increasedsubcortical activity is related to reactive aggression. We think it is important to investigate theintegrated neural networks using independent component analysis (ICA) between groups insteadof conventional fMRI analysis identifying specific brain activity. The current study thereforeexamines the relationship between medial prefrontal functioning and subcortical inhibitoryactivation after inducing aggression in offenders with a history of violent behavior and healthycontrols using fMRI. Results of the study will be presented, along with possible clinicalimplications.Clinical ImplicationsSanne Verwaaijen, Forensic Psychiatric Centre ‘de Rooyse Wissel’, Venray, Netherlands(sverwaaijen@derooysewissel.nl)During the last decades, evidence has accumulated showing that neurobiological factors have animpact on behavior, including criminal behavior. Recent results regarding such neurobiologicalfactors should be more integrated with current treatment protocols. The individual differencesand neurobiological factors should be taken into account to choose the most effective treatmentand to decide which interventions might have contrary effects. New methods of diagnosis basedon the executive factors should be used to fine-tune specific treatment program and to select themost effective interventions. In order to examine a person’s treatment readiness, not only327

motivation should be taken into account, but neurobiological factors might also be veryimportant. Especially in this relatively new field of brain research and neurobiology, treatmentand research should progress in close cooperation. Furthermore, findings might be used inexperimental treatment conditions to help integrate and adapt research findings to clinicalpractice. The “what works” principles (Andrews et al. 1990) to determine the best treatment forcriminal behavior are based on social and psychological factors. Adding genetic andneurobiological factors, which will especially have an impact on the Responsivity Principle,would enrich this model.139. PsychopathyPsyochopathy, Between the Neurosciences and the Law: An Observational StudyF. Carabellese, University of Bari (felicefrancesco.carabellese@uniba.it)(f.carabellese.@criminologia.uniba.it)C. Benazzi, Psychiatric Hospital of Castiglione delle Stiviere, Italy (cristina.benazzi@aopoma.it)A. Calogero, Psychiatric Hospital of Castiglione delle Stiviere, Italy(antonino.calogero@aopoma.it)C. Candelli, University of Bari (chiaracandelli@gmail.com)L. Castelletti, Psychiatric Hospital of Castiglione delle Stiviere, Italy(luca.castelletti@aopoma.it)R. Catanesi, University of Bari (roberto.catanesi@uniba.it)F. Franconi, Psychiatric Hospital of Castiglione delle Stiviere, Italy(filippo.franconi@aopoma.it))I. Rossetto, Psychiatric Hospital of Castiglione delle Stiviere, Italy (ilaria.rossetto@aopoma.it)T. Sartori, Psychiatric Hospital of Castiglione delle Stiviere, Italy (tiziana.sartori@aopoma.it)In recent publications it has been hypothesized that persistent immoral behavior may be due todeficits in some zones of the so-called “moral circuit” (Glenn et al., 2009). We conducted anobservational descriptive study of a population interned in the “Ospedale Psichiatrico Giudiziariodi Castiglione delle Stiviere” (an Italian psychiatric hospital under the aegis of the ItalianMinistry of Justice established in the 1970s) in order to: a) individuate psychopathic subjects;and b) examine which legal and clinical variables are correlated with a psychopathic condition.All patients (65 subjects) diagnosed at the forensic psychiatry assessment as affected by aPersonality Disorder were examined, applying the Psychopathy Checklist-Revised (Hare, 1991).A diagnosis of psychopathy was made in 30.7% of the sample. In 85% of the psychopathic malesthe expert witness diagnosis had been that of an Antisocial personality, while in females aBorderline disorder was prevalent (78%). These data seem to be in agreement with the literature(Sprague et al., 2012), that stresses a widespread underestimation, in the risk assessment field, ofthe potential for violence and female psychopathy rates. Analysis of the legal variables328

demonstrated a positive correlation between the PCL-R score and the type of crime committed(Mann-Whitney p=0.004).Validation of the Portuguese Version of the Antisocial Process Screening Device– Self-Report (APSD-SR)Pedro Pechorro, University of Lisbon (ppechorro@gmail.com)The main objectives of the present study were to validate a Portuguese version of the AntisocialProcess Screening Device–Self-Report and to evaluate the predictive importance of someconstructs in discriminating between inmate delinquent youth and community youth. With a totalof 760 participants, male (n = 543) and female (n = 217), divided in an inmate forensic sample (n= 250) and a community sample (n = 510), the authors were able to demonstrate psychometricproperties that justify the ASPD-SR’s use with the Portuguese juvenile population, in terms offactor structure, internal consistency, temporal stability, convergent validity, divergent validity,concurrent validity, and cutoff score. The predictive importance of psychopathic traits, selfreporteddelinquent behavior, and behavior problems on the prediction of sample membership(forensic vs. community) was established by binary logistic regression.The Prognostic Value of the PCL-R in the Assessment of Successful Completionof TreatmentPeter Rotermund, Hildburghausen Hospital for Psychiatry and Neurology, Germany(peter.rotermund@fachkrankenhaus-hildburghausen.de)Psychometrical instruments to assist in the assessment of the likelihood of future criminaloffense like the Psychopathy-Checklist-Revised (PCL-R) by Robert Hare have assertedthemselves in forensic psychiatry in recent years. Furthermore, several authors suppose that thePCL-R might assist in the assessment of which patients would complete and benefit fromtreatment. There are different findings about the prognostic value of the PCL-R Total score andthe division of the Total score in two separate factors, as proposed by Hare. Factor 1 reflects theaffective and interpersonal psychological traits and Factor 2 the socially deviant conduct. Thepresent study investigates the prognostic values of the PCL-R Total score and the two separateFactor scores concerning a successful conclusion to therapy. We assessed 91 patients using thePCL-R during their treatment in the forensic professional clinic at the hospital for Psychiatry andNeurology Hildburghausen. The results show significantly lower scores in the PCL-R Totalscore and Factor 1 by patients who completed treatment. Factor 2 showed no differencesbetween patients who completed and those who aborted treatment. The results suggest thatFactor 1 has a higher prediction strength for successful conclusion to therapy than Factor 2329

Aggression Profiles in Male PsychopathsHoria Fabini, JVA - Tegel, Berlin SothA, Germany (hfabini@me.com)In this study we are conducting an assesment of social, selfharming and physical aggression in asample of male inmates suffering from Axis II disorders and / or Alexithymia. The main questionasked is: Are Axis-II comorbidities and / or Alexithymia correlated with typical patterns ofaggression in male Psychopaths? Secondly, we attempt to verify whether specific Axis-IIdisorders are correlated with a higher incidence of aggressive behaviour then others. To date, thesample consists of a total of 45 participants. After exclusion of Axis-I disorders, the test subjectshave been examined by conducting a SKID-II interview. Subsequently the TAS-20, theAggression-Questionary, the FAF, and the BVAQ - followed by the PCL-R. We found acorrelation between increased aggression as measured by the FAF and high Scores in the PCL-Ras well as with social aggressive behaviour. We also found that alexithymia occurs more often insubjects with high values in the PCL-R., and that Psychopaths diagnosed with Alexithymia showsignificant higher scores in social aggression than non-alexthymic Psychopaths. Due to the smallnumber of cases, we have to interpret these results with extreme caution and more research isrequired to investigate the implications of our findings.140. The Quality Circle of Forensic Science: Creating Awareness forthe Forensic Science Area 2020The 2010 Dutch Law on Court Experts, Experiences, and Current Affairs of theDutch RegisterEsther M. van Ruth, Netherlands Register of Court Experts, Utrecht, Netherlands(e.m.van.ruth@nrgd.nl)The Dutch Expert in Criminal Cases Act took effect on 1 January 2010. It states that there is aregister for court experts that guarantees and improves a consistent high quality of individualcourt experts working within criminal law. The NRGD is the first European register for courtexperts on a legal basis, with an independent position and structural funding. Registration ofcourt experts provides lawyers, judges or public prosecutors with evidence of the individual highquality of the registered experts they wish to appoint. With its focus on the knowledge, skills andprofessional attitude of the individual expert, the NRGD forms one part of the quality circle forforensic science, which is based on training and education, standards, certification andaccreditation and continued professional development. The register develops objective,substantive and clear quality standards for forensic expertise in conjunction with experts and isopen for applications from Dutch as well as foreign candidates. One of the fields of expertiseopen for application is Forensic Psychiatry and Psychology (FPP). For this field of expertise,around 500 experts will have been assessed by the summer of 2013 and re-registration330

equirements will have been set for 2014-2018, providing for a continuous system of qualityassurance and improvement. This presentation will discuss the experiences of the register,procedures, the (re)registration standards for forensic psychiatry and psychology and the addedvalue of the register for court expert quality assurance and improvement within the quality circle.Dutch Standards for and Assessment of Forensic Psychiatrists and PsychologistsJack Oudejans, Netherlands Institute of Psychiatry and Psychology (j.oudejans@dji.minjus.nl)One of the fields open for registration in the Netherlands Register of Court Experts is ForensicPsychiatry and Psychology. The standards for this field of expertise were set in 2010 inconjunction with the field. Around 500 forensic psychiatrists and psychologists will have beenassessed by the summer of 2013 and re-registration will start in 2014. The assessments of theNRGD have shed light, sometimes painfully, on the quality of forensic experts working withinthis field of expertise. Around 20% of experts do not (yet) meet the registration criteria and aredenied registration. In the past three years, the assessors have come across a number of issuesconcerning the quality of psychiatrists and psychologists working within the context of thecriminal law. On those bases quality improvement initiatives have been made. Assessors, expertsand institutions are working together to pinpoint elements for improvement and take actionwhere needed. This presentation will describe the standards and re-registration requirements forthis field of expertise thereby providing the international public with a concrete example ofstandardization and the experiences with the assessment of experts. In addition, a number ofpoints for improvement for the field that arose from the assessments will be discussed, as well asthe effects of the register on forensic practice within this field of expertise.Training and Continued Professional Development for Psychiatrists andPsychologistsWim F.J.M. van Kordelaar, Netherlands Institute of Psychiatry and Psychology(w.van.kordelaar@dji.minjus.nl)Maarten Beukers, Netherlands Institute of Psychiatry and Psychology (m.beukers@dji.minjus.nl)The Netherlands Institute of Forensic Psychiatry and Psychology (NIFP) is the centre ofexpertise for forensic psychiatry and psychology in the Netherlands. It is a national service of theMinistry of Justice, incorporated in the National Agency of Correctional Institutions. The NIFPprovides independent psychiatric and psychological expertise (diagnosis, care and advice) tojudicial and social chain partners. It provides feedback to sole practitioners who are appointedvia the NIFP, making use also of generalized input from the NRGD assessments. It has a trainingscheme for new forensic psychiatry and psychology court experts which the NIFP aspires to haveofficially acknowledged, forming an additional method of promoting and assuring the high331

quality of court experts. In this way it contributes to the due course of justice, effectiveimplementation of custodial psychiatric care and treatment as part of the quality circle of forensicscience. In this presentation the quality stimulating initiatives taken by the NIFP for practitionersin the field will be discussed, as well as the role of the NIFP in the assurance of court expertquality for forensic psychiatry and psychology.Round Table Discussions on the International Perspective of ForensicPsychiatry and PsychologyMichel M.A. Smithuis, Netherlands Register of Court Experts, Utrecht, Netherlands(m.m.a.smithuis@nrgd.nl)Over the last years, awareness of the importance of establishing quality standards for forensicexpertise has increased significantly. Interest has come not only from forensic institutions andthe science community, but also from the judiciary and politicians. With increased globalisationcomes the call for international standards for court expertise, for instance through the EUCouncil initiative towards a European Forensic Science Area by 2020 (will be distributed at thesession). But are there common grounds for international forensic psychiatry and psychologystandards? Is the work done by forensic psychiatrists and psychologists defined in the same wayin different countries? Are educational paths to forensic expertise comparable? Can there be aninternational register for forensic psychiatrists and psychologists? What is needed if aninternational system for quality assurance and improvement should be established? In roundtable discussions, the previous presentations will be put in an international light by the discussionleaders, each table focussing on one or two statements derived from the quality circle of forensicscience, for instance, training and education, quality assurance through certification andaccreditation and common grounds for standardization. In these discussions, participants canactively give their views on the need for and possible ways to come to an international systemfor quality assurance and improvement for the field of expertise of forensic psychiatry andpsychology.Plenary Discussion on the Possibilities and Limitations for International QualityStandards and Quality Assurance for Forensic Psychiatry and PsychologyMichel M.A. Smithuis, Netherlands Register of Court Experts, Utrecht, Netherlands(m.m.a.smithuis@nrgd.nl)In this plenary discussion, the possibilities and limitations for international qualitystandardization and quality assurance for forensic psychiatry and psychology will be discussed.Round table discussion leaders will voice the views of the participants on the statements given,making clear what views are shared internationally and where differences of opinion or working332

methods exist. A report will be made of the input provided in this session and will be distributedto participants upon request some weeks after the congress.Closing remarks (5 minutes) by John Coster van Voorhout, Dutch Board of Court Experts(j.a.costervanvoorhout@nrgd.nl).141. Quality of Life in Forensic Mental Health (Medium SecureUnits)Quality of Life Research in Secure Settings: An Overview of the ResearchLiteratureDouglas MacInnes, Canterbury Christ Church University (douglas.macinnes@canterbury.ac.uk)This presentation will help link the topic underpinning all of the other presentations. The termquality of life (Qo|L) is seen as significant as it is an important element in integrating patients'subjective experience of their life during illness into clinical care. In adult mental health services,a better quality of life has been associated with increased recovery, higher levels of engagementwith services and increased satisfaction with services. However, the role of quality of life forservice users in secure mental health settings has not been examined. Aims: 1. To examine thebest current evidence regarding quality of life in secure mental health settings; 2. To identify theclinical role QoL plays in secure mental health settings. Methods: A systematic literature searchwas undertaken examining the research literature from 1995-2012 undertaken in secure mentalhealth settings where Quality of Life was an identified outcome. Qualitative and quantitative datawill be collected and analysed separately. Findings: The presentation will identify the number ofstudents and types of design used; the tools used to assess quality of life in these studies; thedifferent settings where QoL research has been undertaken; the main variables are examined inconjunction associated with QoL; and the main results obtainedParenthood in Medium Secure Psychiatric Care: Forensic Service UserExperiences of Being a ParentFiona Parrott, University of Amsterdam (Fiona.Parrott@lshtm.ac.uk)Little research exists on the subjective experiences of mothers and fathers with severe mentalillness. Parents in specialist forensic services may be a marginalised group in relation to attentionpaid to their parenting needs. Responding to this knowledge gap, an exploratory qualitative studywas developed using a forensic medium secure unit (MSU) in south London as a case study, withmale and female in-patients. Aims: 1. To quantify the prevalence of parenthood and level of333

child contact at the research site, a specialist forensic service for men and women; 2. Tounderstand the experiences of parents on short and long-term medium secure and forensicrehabilitation wards. Methods: 1. Analysis of patient records to establish the number andcharacteristics of parents in medium security and extent of contact, frequency analyses to exploredistribution of cases, univariate analyses using chi-square or rank sum tests; 2. Individualinterviews with a purposively sampled group of 18 parents (10 men, 8 women) from short andlong-term medium secure and rehabilitative wards. Findings: The number of recorded parentsand child contacts were noted as well as differences in the level of contact between differentfamily members. The qualitative data noted five themes: impact of mental illness, positiveexperiences, support from staff, parent talk, and perceptions of detention. These will be detailedin the presentation. Conclusions will then be drawn on the quality of life experienced by parentsin secure settings.Carers' Quality of Life in Forensic Mental Health ContextCatherine Kinane, Kent and Medway NHS and Social Care Partnership Trust, Maidstone, UK(catherine.kinane@kmpt.nhs.uk)Douglas MacInnes, Canterbury Christ Church University (douglas.macinnes@canterbury.ac.uk)Janet Parrott, NHS Oxleas Foundation Trust, Dartford, UK (janet.parrott@oxleas.nhs.uk)Families are the main caring resource for service users with severe mental health problems.Although carers of people using forensic mental health services have higher levels of stress,there is only a limited amount of work on the needs of this group of carers. It is crucial torecognise the impact an admission to a forensic mental health unit has on the carer’s quality oflife. This study examined the carers’ views of services aiming toward an understanding of theexperiences of carers of patients in a forensic mental health inpatient setting. A mixed methodsapproach was used with 63 carers interviewed by telephone using a semi-structured interviewschedule to gain information from the respondents. The data was analysed by separate membersof the team qualitatively and quantitatively. The results suggest most carers were pleased withthe service provided although some negative views were expressed. The most important needidentified by this group of carers was to provide regular and appropriate information. Theimplications of the findings will be discussed.A Research Approach in a Pilot Trial to Assess the Effect of a StructuredCommunication Approach on Quality of Life in Secure Mental Health SettingsJoanna Krotofil, Canterbury Christ Church University (Joanna.krotofil@kmpt.nhs.uk)Catherine Kinane, NHS Kent Forensic Mental Health Service, Maidstone, UK(catherine.kinane@kmpt.nhs.uk)Tom Craig, King's College London (thomas.craig@kcl.ac.uk)334

Sandra Eldridge, Queen Mary, University of London (s.eldridge@qmul.ac.uk)Douglas MacInnes, Canterbury Christ Church University (douglas.macinnes@canterbury.ac.uk)Ian Marsh, Canterbury Christ Church University (ian.marsh@canterury.ac.uk)Janet Parrott, NHS Oxleas Foundation Trust, Dartford, UK (janet.parrott@oxleas.nhs.uk)Stefan Priebe, Queen Mary, University of London (s.priebe@gmul.ac.uk)Forensic mental health services have largely ignored examining users' views on the nature of theservice offered to them. An intervention using a structured communication approach placingservice users’ perspective of their care at the heart of discussions between service users andclinicians has been developed with a view of changing this situation. The intervention consists oftwo elements: a computer mediated discussion on patients' quality of life and their satisfactionwith treatment (DIALOG) and non-directive counseling based on Solution Focused Therapy. Inprevious research in community based psychiatric services this has been found to be an effectivemethod of developing users’ involvement in their treatment. This presentation will outline thedesign of the randomized control trial to assess the effect of the intervention based on thestructured communication approach in forensic mental health settings. The research approachproposed for this study embraces the concept of ‘patient involvement’ in two different ways: theinvolvement of the patient is seen as an important factor influencing the patient’s quality of life,and as an important aspect of all research procedures.Preliminary Findings from a Study Assessing the Effect of StructuredCommunication Approach on Quality of Life in Secure Mental Health Settingsin EnglandJanet Parrott, NHS Oxleas Foundation Trust, Dartford, UK (janet.parrott@oxleas.nhs.uk)Joanna Krotofil, Canterbury Christ Church University (Joanna.krotofil@kmpt.nhs.uk)Tom Craig, King's College London (thomas.craig@kcl.ac.uk)Sandra Eldridge, Queen Mary, University of London (s.eldridge@qmul.ac.uk)Catherine Kinane, NHS Kent Forensic Mental Health Service, Maidstone, UK(catherine.kinane@kmpt.nhs.uk)Douglas MacInnes, Canterbury Christ Church University (douglas.macinnes@canterbury.ac.uk)Ian Marsh, Canterbury Christ Church University (ian.marsh@canterury.ac.uk)Stefan Priebe, Queen Mary, University of London (s.priebe@gmul.ac.uk)The effectiveness of a psychosocial intervention based on the structured communicationapproach in forensic mental health settings has been tested in a multisite randomized controlledtrial in 6 medium secure units in England. The intervention combines a computerized toolguiding communication between patients and key workers (DIALOG) with brief counseling335

sessions based on Solution Focused Therapy. In the first two sites taking part in the trial 32patients and their key workers were allocated to DIALOG or to treatment as usual. Every monthfor a period of 6 months, service users met with their key workers to rate their satisfaction withquality of life and treatment and to identify the areas where they needed additional help. Theirresponses were displayed on the screen, compared with previous ratings and discussed. Theprimary outcome measure was quality of life. In this presentation preliminary findings from thefirst two sites participating in the study will be examined. The implications of presented resultsin relation to use of quality of life as an outcome measure will be discussed.142. Reduction of Coercive Measures in PsychiatryDevelopment of a Nationwide Benchmark: Findings from Five Years ofResearchE.O. Noorthoorn (E.noorthoorn@ggnet.nl)W.A. Janssen,G.A.M Widdershoven,H.L.I. Nijman,A. Smit enC.L. MulderBackground: From 2006 onwards the Dutch Government provided funding for Dutch MentalHealth institutions to reduce seclusion by 10% a year. To evaluate the effects of severalinitiatives, the Dutch case register on coercive measures was developed. This register currentlycontains information on the use of coercion from all closed psychiatric wards in the Netherlands.Goal: To develop a Nationwide Benchmark on the use of coercion, allowing corrections onseveral confounders and factors influencing outcome. Methods and Materials: Data on the use ofcoercive measures were collected by nurses at the wards and were compared to the number ofbeds. Patient, team and ward characteristics were taken into account. Multilevel analyses wereperformed to determine the associations between these factors and the use of coercive measures.Results: Results were obtained from 33 large mental health trusts and 8 psychiatric wards locatedwithin a general hospital. The sample contained more than 450 wards covering 95% of all bedsfor involuntarily admitted patients. We found that some hospitals met the goals of a 10%reduction in seclusion rates, while others did not. Between hospitals and wards a tenfoldvariation in the chance of being secluded was observed. Multilevel analyses showed that only asmall part of the variance could be explained by the factors mentioned above. Conclusion: Bygathering coercion data in a central nationwide database, it is possible to compare mental healthtrusts with respect to the use of coercion. Patient, team, and ward characteristics only partlyexplain differences in the use of coercion.336

Coercion Reduction: More than InterventionsY. Voskes (Y.voskes@vumc.nl)J. TheunissenG.A.M. WiddershovenBackground: Over the past 5 years many Dutch Mental Health trusts have developed initiativesto reduce coercive measures. Which initiatives show effect and which do not? What contributesto the effect? These questions were the main topics in an inventory of best practices in coercionreduction in the Netherlands. Goal: The aim of the study was to get an overview of seclusionreduction activities and understand which preconditions served successful implementation.Methods and Materials: 26 Mental Health Trusts which had organized seclusion reductionprograms for more than a year were visited. Interviews were held with key stakeholders and 2wards were visited. Team members were interviewed and team collaboration at the ward wasobserved. Before the visits documentation of the hospitals’ interventions, such as projectdescriptions and evaluation reports were studied. Results: We found 12 clusters of interventionsin the participating institutions: personal approach, prevention, de-escalation, incidentevaluation, reflection, collaboration, client participation, participation of next of kin, registration,intensive care, and collaboration with ambulatory care. Apart from these interventions structuralpreconditions (such as changes in physical environment and structural supportive activities) aswell as culture changes in team attitude and organisation were mentioned as relevant by theinterviewees. Conclusions: This study shows that implementing interventions alone is notsufficient in reducing coercion. Effective coercion reduction needs changes in work organisationas well as in the attitudes of teams. A change in working routines is only effective whenaccompanied by change in organisational structure and culture.Effects of Nursing Staff on Time in SeclusionW.A. Janssen, (Wim.Janssen@ggnet.nl)E.O. Noorthoorn,H.L.I. Nijman,A. Smit,C.L. MulderG.A.M. WiddershovenBackground: Recently in the Dutch Mental Health organisation, policy makers discussed flexibleplanning of personnel. This would allow more one to one or one to two patient supportpreventing the possibility of leaving a severely ill patient alone. Previous studies into personnelshow conflicting findings. Some show an increase in personnel leads to more seclusion, while337

others argue staff shortage leads to more seclusion. Studies show flexible personnel, unfamiliarto the ward and team, may induce aggression in wards. Personnel planning depends primarily onthe distribution of financial means. It remains unclear to what extent personnel planning isrelated to the severity of the patient population at the ward. Methods and materials: In anationwide benchmark study into coercion, information into personnel planning was gathered.Of all admitted patients data on diagnosis, global assessment of functioning, age, sex and ethnicbackground were gathered. Diagnosis was transformed into a severity index. These data wereincluded in a single database and univariate and multi level analyses were performed. Results:Seclusion rates at ward level varied from less than 1 up to 157 hours per bed hour. Wards withlower rates contained more patients with anxiety and mood disorders, and as well as a higherGAF (mean=47). Wards with higher seclusion rates contained more patients with bipolardisorders and schizophrenia and a lower GAF (mean=40). The number of nurses varied littlebetween wards with high and low rates despite a clear difference in patient severity. Personnelplanning seemed not related to patient severity. Conclusions: This study showed that structuraladjustment of personnel deployment to patient severity may possibly prevent seclusion. Thisimplies that organisations need to develop instruments for monitoring patient severity as well ascare intensity allowing the adjustment of personnel deployment. Criteria have to be set,warranting one to one or one to two nursing support.Associations between Short Term Structured Risk Assessment Outcomes andSeclusionR. van de Sande, (Roland.vandesande@hu.nl)E.O. NoorthoornA.I. Wierdsma,E.M. Hellendoorn,C. van der Staak,C.L. Mulder.H.L.I. NijmanBackground: Seclusion as a routine intervention to manage dangerous behavior is still in use atmany acute psychiatric wards around the world. Apart from the therapeutic value of thisintervention, the objectivity of clinical decisions on whether to seclude or not, may bequestioned. Research findings indicate that symptoms and behavior of acutely admitted patientsfluctuate drastically within hours and that structured daily risk assessment canreduce the risk of aggressive incidents and duration of seclusion. Goal: The aim was to study theassociations between scores on two, daily administered structured observation tools (BrøsetViolence Checklist and the Kennedy Axis V) and seclusion. Methods: Patient characteristicswere gathered from hospitals databases. Nurses daily scored two scales on self-control andglobal patient functioning, using the Brøset Violence Checklist and the Kennedy Axis V. Datawere analysed using multi-level techniques. Results: In this study, 7403 risk assessments (BVC's338

and Kennedy Axis V) were gathered, over 10725 admission days (72% of the maximum numberof structured assessments) in 301 patients. Dysfunctional scores on the item confusion of theBrøset Violence Checklist and level of psychological and social skills impairment on theKennedy Axis V were associated with seclusion. We also found that patientcharacteristics showed associations with seclusion: non-western descent, male gender, age under35, unmarried, bipolar or personality disorder and to a lesser extent psychosis or drug abuse.Conclusions: We concluded that the BVC and the Kennedy Axis V may be helpful in identifyinghigh risks for seclusion. Even though these findings need validation in larger samples, theysupport the clinical validity of daily risk assessment in standard practice.The Results of a National Dutch Effort on Reducing SeclusionC.L. Mulder (c.l.mulder@erasmusmc.nl)F. Vruwink,H. NijmanE. NoorthornBackground: The coercive intervention of first choice in most European countries is involuntarymedication. In the Netherlands, it is seclusion. This partly explains why the use of seclusion ismuch higher in the Netherlands than in surrounding countries. To fund a nationwide program toreduce seclusion by 10% per year, the Dutch government provided annual grants from 2006 to2009. Methods: Grants were awarded to 42 Dutch psychiatric hospitals, covering approximately90% of all beds at closed wards. The total national investment was €40m. The projects variedwith respect to the interventions used for reducing seclusion. Results: The number of seclusionshad increased 3.2% annually from 1998 to 2005 (logit slope=1.032), followed by a decreasebetween 2006 and 2009 of 2.0% (logit slope=0.980, difference 1,2%: z=-8.58, p

Richard Brown, Agency for Community Treatment Services, Inc., Tampa, USA(rbrown@actsfl.org)The behavioural health care delivery industry in the United States is presently engaged in a rapidchange cycle to incorporate the best of science informed care while simultaneously adjustingbusiness models to respond to policy changes in the financing of services. To effectivelyresponds to these changes, service providers are incorporating perpetual review and alignmentprocesses to evaluate clinical, technological, and administrative practices against consumerneeds, payer preference and stakeholder satisfaction. To remain market responsive, providersmust continually evaluate, and where appropriate, incorporate science informed interventions;medical and technological advancements; and business practices that support efficiency andpromote productivity. This session utilizes experience gained in an applied behavioural healthsetting to frame the issues and demonstrate the benefits of employing a perpetual alignmentprocess business model. Particular emphasis is targeted to practice alignments that focus onpayer and consumer needs and preferences; workforce composition and the development ofprofessionals and specialists; product branding and marketing; strategic alliances and affiliations;research to practice initiatives; outcomes and performance measurement; integrated care; andhealth information exchange.Legislative and Regulatory Reform Initiatives in Five U.S. States: Experiences ofa Mutual Assistance Program for States (MAPS)A. Thomas McLellan, The Treatment Research Institute, Philadelphia, USA(TMcLellan@tresearch.org)Mady Chalk, The Treatment Research Institute, Philadelphia, USA (mchalk@tresearch.org)Jack Kemp, The Treatment Research Institute, Philadelphia, USA (jkemp@tresearch.org)Even robust research evidence on effective substance abuse interventions has rarely made itsway into broad utilization to reduce the educational, health and criminal/civil justice problemsproduced by alcohol and other substance use. Recent legislation such as the ACA, the ParityAct, the Second Chance Act; and changes in financing by Centers for Medicaid/Medicare havecreated new opportunities for states to reduce substance-related problems and save costs bybringing more effective research-based interventions into broad use. But the Departmentsecretaries most affected by substance use problems in each state rarely know about the relevantresearch or about how to take advantage about new federal opportunities to reduce substancerelated problems. To assist states in learning about these new opportunities and about the newand relevant substance abuse research, the Treatment Research Institute created the MutualAssistance Program for States (MAPS) where for a two-year period, policy makers (stateSubstance Abuse Directors, Attorneys General, Sec of Health, Sec of Welfare) from five keystates are invited to work with each other and with TRI (and other) research investigators toidentify their most pressing policy needs in this area, to acquire research evidence on those topicsand to collectively craft state policies that are politically, fiscally and scientifically sensible. The340

esearch rationale for and procedures to adapt and implement three low cost, evidence-basedpolicy initiatives will be reviewed: Efficient, safe integration of treatment and communitysupervision in drug related offenders; performance contracting to increase value from substanceabuse treatment; accessing new prevention funding to create effective school-basedprevention/intervention clinics.Advocacy Organizations’ Role in Better Linking Science and Public PolicyDavid Shern, Mental Health America, Alexandria, USA (DLSTampa@aol.com)Despite important advances in behavioural sciences during the last three decades, the translationof knowledge into policy and practice remains abysmally slow. Advocacy organizations holdpromise for helping to accelerate translation since they are interstitial between the researchcommunity and key implementation audiences. In this presentation we will explore the potentialfor better integrating advocacy and knowledge generation using examples drawn from the U.S.’oldest mental health advocacy organization, Mental Health America (MHA). The integration ofscience and practice to improve care was an essential part of the founding rationale of theorganization and this legacy continues. Advocacy organizations, like MHA, are well suited forthis integrative task. Many advocacy organizations have national presence as well as state andlocal chapters located throughout the nation that can facilitate dissemination and fostersuccessful implementation. Advocacy organizations are a communication hub that connects thegeneral public, primary consumers, services providers, and policy staff with the scientificcommunity. When effective linkages with the academic community facilitate actionabletranslation of science into practice, these channels can be used to build public support, consumerdemand, provider skills and policy/funding mechanisms to support improved populationbehavioural health. Funding these activities, however, remains a challenge. A greater emphasison dissemination/implementation on the part of the scientific community as well as creative,revenue producing partnerships may provide solutions to these infrastructure problems.Examples from recent MHA policy initiatives related to insurance parity and prevention sciencewill be used to illustrate the potential of improved linkages.What Gets Measured Is What Gets Done: How Data Drives Better Outcomes atthe Florida Department of Juvenile JusticeWansley Walters, Florida Department of Juvenile Justice, Tallahassee, Florida(wansley.walters@djj.state.fl.us)Under the leadership of Secretary Wansley Walters, the Florida Department of Juvenile Justice(DJJ) has placed data-driven measurement and outcomes at the forefront of juvenile justicepolicy making. Florida is well known for its robust data gathering and analysis. DJJ collects,analyzes and publishes a multitude of variables and statistics for the public. The success rate for341

youth released, defined as adjudications, adjudications withheld or convictions for offenses thatoccurred within 12 months of their release from commitment programs (or within six months ofrelease from prevention programs) are just a few of the trends analyzed using empirical data.Data from almost 1,000 different programs and case management units of Prevention and VictimServices, Probation and Community Intervention, Detention Services, and ResidentialCommitment Services branches of DJJ are also collected and analyzed. Delinquency programsare designed to provide supervision and services to reduce a youth’s further involvement with thejuvenile justice system. Annual evaluation of these programs is critical to the implementation ofeffective services. A key outcome of interest to all stakeholders is recidivism following programservices or program release. For more than a decade, DJJ has maintained accountability inservices through its comprehensive statewide assessment of recidivism rates. DJJ has receivednational recognition for these outcome evaluations and continues its strong record of serviceassessment. DJJ is working to use data for better decision making in its health-care deliverysystem, and especially mental health, for youth in the agency’s supervision.The Dangerous Nexus between Research and Policy: Notes from a Thirty YearCareerEric D. Wish, University of Maryland (ewish@umd.edu)I have been fortunate to have been involved in a number of research projects designed to informpublic policy. These projects have included Lee Robin’s classic follow-up study of VietnamVeterans returning to the United States in the early 1970’s commissioned by the President’sSpecial Action Office for Drug Abuse Prevention (SAODAP), the design and supervision of thelaunching of the national Drug Use Forecasting Program (DUF) by the U.S. Department ofJustice, National Institute of Justice, and the pilot testing of the Adult Offender Population UrineScreening program (OPUS) in Maryland. Each of these projects involved politically sensitivetopics fraught with potential pitfalls. I will describe these projects, some reactions to them, andhow the researchers dealt with the politically motivated reactions to the results. Of special notewill be my recent research involving the emerging epidemic of buprenorphine mis-use in theU.S. and the unexpected resistance received from affected constituencies. The talk willincorporate a discussion of the CESAR FAX as a means to rapidly alert the public and researchcommunity to important policy-relevant research findings.144. Restorative Justice and Elder Abuse“Access to Justice” for Victims of Elder Abuse in WalesAlan Clarke, Aberystwyth University (ahc@aber.ac.uk)342

The Access to Justice Project is a Welsh Government initiative to facilitate criminal and civiljustice remedies for older vulnerable people who are victims of domestic abuse. It seeks toaddress some of the difficulties encountered by older people who have been the subject ofdomestic abuse, in particular the need for agencies to work together to ensure that older victimsdo not feel that they have been denied justice. This presentation will report the findings from anevaluation of the project based on quantitative and qualitative data drawn from 200 victim casefiles and interviews with both professionals and lay people. Topics addressed will include thedefinition of elder abuse, different perpetrator typologies, the need for policies and practices tobe sensitive to the complexities of the issue and the importance of an integrated, multi-agencyresponse.“Cultural Iatrogenesis” in Health and Social Care Decision-Making in Cases ofElder AbuseSarah Wydall, Aberystwyth University (sww@aber.ac.uk)Older people experiencing abuse in the home are often transformed by welfareist and justiceinterventions into “cases” processed through bureaucratic systems that can lead to outcomes inwhich their safety, choice and wellbeing are compromised in the best interests of maintainingfamily life. This presentation draws on findings from two empirical studies: the first is acollaborative pilot project that critically examines the feasibility of employing restorative justicetechniques to address elder abuse, and the second is an evaluation of the “Access to Justice”initiative for older people in Wales. The presentation will use case studies to explore howcultural norms and practices across different professional domains may inadvertently lead to aform of iatrogenesis in which older people’s views are not always sought and their best wishesare overlooked. In light of these findings, the research team at Aberystwyth University areworking collaboratively with policy-makers, practitioners and lay people to critically assess howRestorative Justice approaches could be used in this context. In particular, attention will be givento how victims might play a more active role in safety planning and decisions taken to promotetheir health and wellbeing.The Failure of Traditional Justice Mechanisms for Victims of Elder AbuseJohn Williams, Aberystwyth University (jow@aber.ac.uk)Elder abuse is an international phenomenon. Reliable data are very scarce, as is often the case inrelation to matters concerning older people. However, NGOs, practitioners and human rightsactivists report that older people are abused in their own homes and institutional settings.Perpetrators may be family, caregivers, friends, or practitioners. Very often abuse is also acriminal offense. Assault, attempted murder, sexual offenses, property and financial abuse andharassment are universally proscribed by the criminal law; however, such evidence that exists343

suggests that criminal prosecution is rarely contemplated and convictions rare. This can leaveolder people still vulnerable to abuse and also feeling that they have not received justice. Apurely welfare response to elder abuse may in some cases be appropriate, but it cannot be rightthat we have effectively decriminalized elder abuse. What are the reasons for the lack ofprosecutions? Is this failure a result of ageist assumptions about the physical and/or mentalcapacity of older people? If so, how can such ageism be effectively challenged by practitionersand others? Is it because of the often complex dynamics of elder abuse? Family and caringrelationships create strong mixed feelings if the abuser is a relative or neighbor. Thispresentation will address the reasons behind what appears to have been a denial of justice forvictims of elder abuse.Research Opportunities in Restorative Justice and Elder AbuseRebecca Boaler, Department of Law and Criminology, Aberystwyth University(rrb8@aber.ac.uk)Research opportunities in Restorative Justice and Elder Abuse are increasingly identifiableacross the spectrum of academic and professional disciplines, including law, psychiatry,psychology, criminology, nursing, and social work. The methodologies and associatedprinciples of Restorative Justice continue to pervade standardized approaches to social scientificdata gathering, analysis, and policy recommendations, while inquiries into the phenomenon ofElder Abuse have graduated from mere reviews of institutionally tended arrest and incidencestatistics to fully evolved investigations with a complex, stepwise blend of psychologicalassessment, interview, treatment, and intervention components. This presentation addressesoptimal approaches to multidisciplinary team building, grant application, institutional reviewboard communications, community relations, and ethical and safety considerations wheninteracting with a unique subject population that functions under a variety of socioeconomic,legal, and health-related stressors. A timeline for developing and executing Restorative Justiceand Elder Abuse research will be reviewed within the context of a currently ongoing study,identifying and explicating distinct stages that progress from conceptualizing the originalresearch question to popularizing research findings via academic publication and professionalpresentations.Contrasting British and American Approaches to Restorative Justice and ElderAbuseEric Y. Drogin, Harvard Medical School (edrogin@bidmc.harvard.edu)Although the American legal system owes far more to traditions of British jurisprudence than toany other historically identifiable source, these two societies have adopted approaches toRestorative Justice and elder abuse that differ in several critical aspects. One might be tempted to344

assume that these differences were determined, at least in part, by key distinctions between earlyCeltic and Native American models, but in fact, modern British and American approaches reflectin both instances a deliberately eclectic blending of strategies and techniques unlimited bygeographical or cultural boundaries. In each case, the true source of discernible methods fordealing with elder abuse from a Restorative Justice perspective can be found in relatively recentlegislative and policy developments that reflect, for example, the influence of codified Americansentencing guidelines and the comparative independence of the British judiciary when it comesto fixing penalties for criminal transgressions. This presentation will underscore salientdifferences with reference to case law, statutes, regulations, ethical codes, and sociolegalresearch. Participants will be encouraged to consider how the most humane, effective, andheuristic innovations can be adopted and applied from one system to another in enhancingRestorative Justice approaches to elder abuse.145. Rights, Risk of Harm, & Decision Making Capacity:International Responses to Involuntary Psychiatric Treatmentin Light of the CPRDRising to the Human Rights Challenge: Capacity-Based Treatment Arrives inAustralian LawSascha Callaghan, University of New South Wales (sascha.callaghan@sydney.edu.au)Christopher Ryan, University of Sydney (christopher.ryan@sydney.edu.au)Australian mental health law is on the verge of a major change. Legislative reviews in severalstates under the influence of the Convention on the Rights of Persons with Disabilities have seenthe introduction of some important human rights based innovations. For example Mental HealthBills in Tasmania and Victoria will only permit treatment without consent where patients lackcapacity to make their own treatment decisions. However, problems still remain in the retentionof risk-of-harm criteria which may unfairly restrict access to health services for people withmental illness. This session will give an overview of key rights based developments in Australianmental health law and discuss the remaining challenges in ensuring true equal treatment forperson with mental illness in line with the requirements of the CPRD.Compulsion in Mental Health Treatment: Is Capacity Really the Way Forward?Peter Bartlett, University of Nottingham (peter.bartlett@nottingham.ac.uk)The tendency among progressive mental health policy advocates in the last years has been tomove towards a system where capacity serves as the gateway of compulsion. This paper345

considers the limitations of a capacity-based approach, with particular attention to the followingissues: The international experience appears to be that patients will rarely be found to have madea capable refusal in the face of medical views that treatment is necessary. To what degree does“capacity” reduce to “doctor knows best”? This is a particularly difficult problem in psychiatricsettings. These issues are particularly problematic when law is invoked: courts do not deal withthese situations well. The Convention on the Rights of Persons with Disabilities raises issues asto whether capacity can be used in decisions regarding compulsory treatment. What options areleft for us by way of compulsory treatment in serious situations?Clarifying Capacity: International Human Rights Norms and InvoluntaryMental Health TreatmentLance Gable, Wayne State (lancegable@wayne.edu)Notions of an individual’s mental capacity have a central and longstanding place in the lives ofpersons with mental disabilities. Judgments about an individual’s capacity have been used inmany ways: to target treatment regimens and provide appropriate assistance, to justifyinvoluntary detention and treatment, to limit an individual’s rights to participate or makedecisions in many areas of life, and to trigger legal powers and protections. International humanrights systems have greatly influenced the legal and ethical norms applicable to capacity. Indeed,as rights-based approaches to involuntary treatment have proliferated around the world over thepast few decades, a finding that an individual lacks capacity has increasingly become aprecondition for involuntary mental health treatment. This presentation considers the influence ofinternational norms regarding capacity and human rights on national-level law and practice.While international human rights law often establishes consensus norms, the development ofthese norms takes time and may generate considerable disagreement. The presentation willexamine and assess the relationship between the normative development of human rights at theinternational level and the adoption of various approaches to evaluating capacity. Theimplementation of the Convention on the Rights of Persons with Disabilities (CRPD) will haveimportant ramifications for how capacity is used for mental health treatment decisions. Inparticular, the impact of the legal capacity norms articulated in Article 12 of the CRPD will raisechallenging legal and ethical issues surrounding how capacity determinations are used.The State’s Duty to Protect the Suicidal PatientNeil Allen, University of Manchester (neil.allen@manchester.ac.uk)A duty to take reasonable precautions to avoid real and immediate risks to life may seemuncontroversial at first. Indeed, it is now well-established in English law that a failure to preventa psychiatric patient’s suicide may violate their right to life. But such human rights developmentsfly in the face of traditional common law thinking which has done little to encourage the Good346

Samaritan. This session will outline recent case law and consider how much further the duty tosave life might extend before considering the potential implications.Risk Assessment: Trouble with Numbers; Why we Need to Move on from “Risk”and “Dangerousness” Criteria in Mental Health LawMatthew Large, University of New South Wales (mmbl@bigpond.com)In the last 50 years the concept of ‘risk’ has become increasingly used as the basis forinvoluntary psychiatric treatment. In addition, risk is often central to civil claims against healthproviders after suicides. However, there is a strong statistical argument based on the lowprevalence of severe harms associated with mental illness and the modest strength of theassociation between high-risk categorisations and later suicide that indicate that risk assessmentcan never distinguish between high and low-risk patients in a way that is clinically meaningful.Despite the widespread acceptance of risk assessment as a method for reducing harm, Dr. Largewill present research showing that risk assessment is fundamentally flawed approach, and willargue that it should not be used as a rationale for coercive psychiatric treatment.Moderated Round Table Discussion with Presenters: “Capacity and Risk ofHarm: Themes, Tensions, Questions”Audience questions and answers.146. Risk AssessmentReforming Mental Health Policy In Sweden − Risk, Control and Patient RightsStefan Sjostrom, Umea University (stefan.sjostrom@socw.umu.se)In 2012, The Mental Health Law Committee submitted its report to the Swedish parliamentconcerning compulsory psychiatric care. The report covers both forensic and civil commitmentand contains components that expand the possibilities for care providers to commit patients.However, the committee also claims that it imposes stricter control on care providers. The reportrepresents a shift in ideology concerning criminal perpetrators suffering from mental illness andforensic care. The committee proposal will be the foundation for further discussions and mostlikely a governmental bill in the coming year. This paper will analyse the policy debatestemming from the committee proposal. The debate will be analysed in terms of social control,risk and human rights theories. Data will consist of committee proposals and any furtherproposals stemming from it, parliamentary debates and documents as well as debates inprofessional journals and the mass media.347

Risk Assessment in Offenders with Intellectual Disability: A Validation Study ofthe Dutch Version of the Violence Risk Appraisal Guide in Predicting AggressiveIncidentsClaudia Pouls, Knowledge Centre Forensic Psychiatric Care, Lanaken, Belgium(claudia.pouls@opzcrekem.be)In the past years, risk assessment research has been extended to offenders with intellectualdisability (ID). Existing risk assessment tools are now validated and new instruments –specifically for offenders with ID – are being developed. However, most of this research focusesprimarily on the prediction of (long term) recidivism, and relatively little attention has beengiven to the prediction of institutional aggression. The few studies that have been done, showconflicting results. In this presentation, the results of a validation study in a Belgian sample ofoffenders with ID will be presented in the prediction of aggressive incidents. An approved Dutchtranslation of the Violence Risk Appraisal Guide (VRAG), one of the most widely used riskassessment instruments, was scored in 60 forensic ID patients. This sample was then followed upfor a period of 6 months regarding institutional aggression. Although the psychometrics weregood, the VRAG failed to predict aggressive incidents in the clinic. In conclusion, while theVRAG has proven its value to predict aggressive recidivism, the instrument could not reliablypredict aggressive incidents in the current forensic ID sample.The Psychometric Characteristics of the HKT-EX Risk Assessment Tool in aSample of 342 Forensic Psychiatric Patients in the NetherlandsMichelle Willems, Tilburg University (M.Willems@uvt.nl)Stefan Bogaerts, Tilburg University (s.bogaerts@uvt.nl)Marinus Spreen, Dr. S. van Mesdag Forensic Psychiatry Centre, Netherlands(m.spreen@fpcvanmesdag.nl)In the Netherlands, the Dutch risk assessment tool HKT-30 (Historical-Clinical-Future-30) isincreasingly used in forensic psychiatric practice. Currently, the HKT-30 is being revised in alarge research project, for the purpose of which an experimental version of the HKT-30 has beencreated, containing more and other items: the HKT-EX. This study investigated somepsychometric properties of the HKT-EX, namely the factorial structure, the internal consistencyand inter-rater reliability. The study sample consisted of 342 forensic psychiatric patients, whohad been discharged from any of the Dutch maximum-security forensic psychiatric hospitalsbetween 2004 and 2008. The HKT-EX was rated by trained Masters level Psychology studentson the basis of criminal file information. To determine the inter-rater reliability, for 60 patientsthe HKT-EX was rated twice by two different raters. To determine the factorial structure, factor348

analyses were performed. The internal consistency was computed using Chronbach’s alpha. Theintra-class correlation was used to assess the inter-rater reliability. Implications of thesepsychometric characteristics for the use of the HKT-EX risk assessment tool in forensic practicewill be discussed.Quantitative Analysis of the Quality of HCR-20 Risk Assessment ReportsNilanjan Chatterjee , EoE Deanery,UK (nilv15@doctors.org.uk)Piyal Sen, St Andrew's Healthcare Essex, UK (psen@standrew.co.uk)Simone Lindsey, St Andrew's Healthcare Essex, UK (slindsey@standrew.co.uk)Marco Picchioni, St Andrew's Healthcare & St Andrew’s Academic Centre IOP, UK(mpicchioni@standrew.co.uk)Background and Aims: The HCR-20 (Webster et al 1997) is a widely used guide for assessingthe risk of violence in a variety of secure and community settings. There are however few, if any,quality control standards. In the absence of any existing HCR-20 standards, the authors sought todevelop and pilot a quality assessment framework that could be used in the secure inpatientsetting. Methods: The McNeil et al (2011) Competency Assessment Instrument for ViolenceRisk (CAI-V) was modified for use in a low secure in-patient population. 51 recently completedHCR-20 reports were evaluated using this tool. HCR-20 reports were given an overall rating onan eight point scale ranging from 1(Unacceptable) to 8 (Advanced), with a score of 6 achievingthe Competent rating. Inter-rater reliability was checked both at the beginning and end of thestudy. Results and Clinical Implications: Overall, 80% of the HCR-20 reports were rated as'Competent’. 90% of the reports achieved ‘Advanced’ ratings for ‘Evaluating Present and FutureRisk Factors for Violence’, ‘Communicates the Estimate for Violence clearly’ and ‘Risk Factorsfor Violence are Addressed’. Two main areas were identified that needed improvement,‘Considered Duty to Protect’, was not completed in 92% of reports, while ‘Obtained CollateralInformation from Family or Significant Others’, was not completed in 90% of reports. Thesepreliminary findings will be disseminated across the hospital and practice development pointsdiscussed with clinical teams before re-auditing in 3-6 months time.The Introduction of the START Risk Assessment Tool and its Impact on theManagement of Risk within a Medium Secure Assessment Ward in NorthLondonNicole Eady, Barnet, Enfield, and Haringey Mental Health Trust, UK (n.eady@hotmail.co.uk)Tim Rogers, North London Forensic Services, UK (tim.rogers@beh-mht.nhs.uk)349

Aim: To improve the knowledge and documentation of risk on a medium secure ward byintroducing the Short-Term Assessment of Risk and Treatability (START) Risk assessment tool.Methods: An audit was completed of the multidisciplinary team’s (MDT) knowledge anddocumentation of risk on a medium secure ward. Members of the MDT completed ananonymous questionnaire to establish their knowledge base of the patient’s risk assessments. TheSTART risk assessment tool was introduced into pre-admission assessments and wardhandovers. The audit was repeated 6 months later. A review of the correlation between riskassessments and care plans was conducted including a review of the risk incident forms. Results:Following the implementation of the START risk assessment tool the knowledge scores of staffimproved by an average of 6%. The most significant improvement was in the scores forawareness of relapse signatures which increased from 37% to 67%. A comparison of thepatient’s care plan with their risk assessment showed an increased correlation between identifiedrisks and care plan items. Conclusions: The START tool has improved the staff’s knowledge andawareness of risk. We continue to assess if START will enable the ward to better forecast riskincidents in the long term.147. Risk and Protective Factors Influencing Criminality forOffenders with Mental Disorders: Implications for InterventionsFactors Associated with Negative and Positive Outcomes for Higher RiskOffenders with Mental DisordersLynn A. Stewart, Correctional Service of Canada, Ottawa, Canada (StewartLA@csc-scc.gc.ca)Geoff Wilton, Correctional Service of Canada, Ottawa, Canada (WiltonGE@csc-scc.gc.ca)Offenders with major mental disorders (OMD) constitute a significant percentage of prisonpopulations, representing a group that poses a challenge to correctional administrators who aremandated to provide the specialized services many require. This research confirmed that adiagnosis for a mental disorder was a factor affecting correctional outcomes even when other riskfactors were controlled. Most importantly, offenders with co-occurring substance abuse andmental disorder had the worst outcomes suggesting that substance abuse is a primary enginedriving poor outcomes among this population. This presentation also examines protective factorsassociated with high risk and high need mentally disordered offenders who remained offencefreeafter one year of release.Preliminary Investigation of Pattern of Offending among Offenders with MentalDisordersBrian Grant, Correctional Service Canada, Ottawa, Canada (GrantBA@csc-scc.gc.ca)Kirsten Marko, Carleton University (kmarko@connect.carleton.ca)350

Alissa Schlote, Carleton University (aschlote@me.com)There is ambiguous research on the role of mental disorder in increasing risk for offending andfailure after release to the community. This may be due to mental disorder being related tospecific offence patterns and not to offending in general. In this study two groups of mentallydisordered offenders, those newly admitted to prison and those being returned to custody afterrelease to the community, were compared to groups of non-disordered offenders in terms of theiroffence history, crime types and offence characteristics. The results from the research revealedthat mentally disordered offenders and non-disordered offenders differ significantly on an arrayof factors that suggest at least some of their criminal behaviour is linked to their mental healthproblemsMale Depression and Domestic Homicides: Recognizing Risk Factors fromDomestic Violence Death ReviewsAnna-Lee Straatman, University of Western Ontario (astraat2@uwo.ca)Peter Jaffe, University of Western Ontario (pjaffe@uwo.ca)Marcie Campbell, Domestic Violence Death Review Committee, Toronto, Canada(mhcampbe@yahoo.com)This paper reviews the role of depression in male perpetrators of domestic violence and domestichomicide. The authors summarized the findings and recommendations from 25 DomesticViolence Death Review Committees (DVDRCs) from across the U.S. and Canada regardingdepression and its link to domestic violence and homicide. The findings suggest that maledepression is often overlooked as a warning sign for homicide. Although mental healthprofessionals often screen for suicidal ideation, homicidal thoughts and rumination over murdersuicideare rarely addressed. The implications and recommendations are grouped into six majorthemes: 1) education and awareness; 2) training; 3) screening and assessment; 4) interventions;5) firearms; and 6) research and investigations of domestic homicide/suicides.Criminogenic Needs in Sex Offenders: What Have Years of ActuarialAssessment Research Taught us about the Critical Targets of EffectiveCorrectional Treatment?Howard Barbaree, Waypoint Centre for Mental Health Care, Penetanguishene, ON, Canada(howardbarbaree@bellnet.ca)Over the last 25 years, the development of actuarial instruments to assess sex offender risk forrecidivism has been accomplished through empirical studies of the relation between actuarial351

items and recidivism outcome. While this important development has been accomplished withoutany process of theoretically driven hypothesis testing, principal components analysis of actuarialitems reveals putative latent risk factors. In the present study, the effects of aging were partialledfrom the data set using semi-partial correlation. Then, principal components analysis (PCA) wasconducted on the residuals. The analysis revealed 13 factors that reflect easily recognizable andcommonly understood risk factors. In this presentation, these factors will be grouped into superordinatefactors that reflect Antisocial Behavior, Sexual Deviance, and Sexual Impulsivity.Implications for risk assessment methodology, the relationship between static and dynamic riskassessment, and the treatment of criminogenic needs in sex offenders will be discussedProtective Factors that Mitigate Risk among Justice Involved Clients withMental Health Problems: Best Practice Guidelines for Promoting FavourableOutcomesMarilyn Van Dieten, Orbis Partners Inc., Ottawa, Canada (mvandieten@orbispartners.com)Dave Robinson, Orbis Partners Inc, Ottawa, Canada (drobinson@orbispartners.com)While there is evidence of a number of risk factors associated with criminal justice involvementand re-involvement, only recently has an interest emerged in factors associated with resilience.Research has facilitated the identification of protective factors that can buffer or mitigate theimpact of risk. In this presentation we will focus on criminal justice involved clients who havemental health problems to explore specific factors or combinations of factors that appear tocontribute to favorable outcomes. Drawing from existing research and data from a largecommunity sample, guidelines will be presented to support the delivery of effective supervisionand interventions in community settings.148. Risk Assessments of Domestic Violence: Perspectives of theCourt, Forensic Science, and JurisprudenceDomestic Violence: View from the BenchAnne Rowles, Court of Appeal of British Columbia, Vancouver, Canada(anne.rowles@courts.gov.bc.ca)Does risk assessment evidence in family law proceedings enhance the protection of children,spouses and vulnerable adults who may be part of the household? This paper will discuss thejudicial view of risk assessment evidence in both criminal and civil proceedings. In criminal lawproceedings in Canada, the risk of future harm an offender poses is relevant in determining thesentence to be imposed following conviction for a violent offence. Under Canada’s Criminal352

Code, expert opinion evidence assessing risk is required in cases in which a dangerous offenderor long term offender designation is sought by the prosecution. In civil proceedings, the use ofexpert opinion evidence to assess risk is not required by statute although submissions may bemade by counsel on the risk of future harm, based on past misconduct. In civil cases, questionsabout the validity of risk assessment evaluations may limit the admissibility of opinion evidencebased on such evaluations. Mental health professionals who are assessing the risk of harm bothto adults and children in family law cases need to understand the relevant rules on theadmissibility of expert opinion evidence and be aware of the limits on admissibility whenpreparing reports for use in Court.Domestic Violence: Post MortemMary Ellen Turpel-Lafond, British Columbia’s Representative for Children and Youth, Victoria,Canada (maryellen.turpellafond@rcybc.ca)Judge Mary Ellen Turpel-Lafond is the Representative for Children and Youth for the Provinceof British Columbia, and an independent Officer of the Legislative Assembly. She is a judge ofthe Provincial Court of Saskatchewan, on leave during her assignment to oversee the childwelfare system and improvement for children and families. Judge Turpel-Lafond will describeher work conducting inquiries into domestic violence homicides with child victims, and theopportunity to build collaborate systems of support for children and families to protect themfrom violence. In particular, she will discuss the development of tools and approaches in thechild welfare, family law, criminal justice, health and education systems to support victims,especially children, exposed to domestic violence.Domestic Violence: Intimate Partner Violence (IPV)Jocelyn Coupal, Crown Counsel, Vancouver, Canada (jocelyn@spotthesigns.ca)This paper will discuss systemic concerns surrounding risk assessment of IPV between Criminaland Civil Courts in Canada. In contrast to Criminal Law proceedings, in Family Lawproceedings there is no requirement that there be any case screening for the presence of riskfactors prior to determining the course a case will take through the Courts. And often, theCriminal Justice System has never been involved with the family so there is no formal record ofa prior history of violence or formal risk assessments. Without a thorough and fully informedability to assess the risk of harm and lethality in a given case, the reality is that Justice Systemparticipants (lawyers, mental health professionals, family court counsellors, etc.) cannot respondeffectively to the needs of families who have experienced violence. The proper administration ofjustice ought to require that all those involved in these cases, (within the context of their roles)ensure that Judges are provided with the information they need so that informed decisions can bemade and the safety of families is the paramount consideration in the decision making process.353

Intimate partner homicides are the most predictable and preventable of all murders. They share apattern of risk factors that can be detected if we know what to look for and the questions to ask.There is no special expertise required; just a basic knowledge of the dynamics of domesticviolence and the risk factors commonly present in domestic homicides. Internationally, domesticviolence death review committees have been identifying the presence of common risk factors inIPV cases they have reviewed since the early 1990s. No matter what part of the world, thepatterns detected by these fatality review committees are the same: among them separation froman abusive, controlling, jealous partner who has a prior history of violence, post-separationcriminal harassment or stalking, mental health issues, unemployment, alcohol and drugaddiction, child custody and access issues to name a few of the more prevalent risk factors.Ongoing assessment of risk should (but does not always) continue to inform decisions as the casemakes its way through the Justice System up to the imposition and completion of any sentenceimposed. Unfortunately the reality is that intimate partner violence is largely unreported.Risk Assessments of Domestic Violence: Psychological Research and PracticeAllan Posthuma, Consulting Psychologist, Vancouver, Canada (drposthuma@shaw.ca)In spite of the plethora of research addressing Monahan’s (1981, 1984, 1998) harsh criticism ofrisk assessments three decades ago, risk assessments remain problematic, both from a researchstandpoint as well as from their application in Court. The introduction of robust psychologicalprocedures for predicting the risk of violence has made considerable progress within theCriminal Court but not in Civil Court proceedings. Domestic violence usually occurs incircumstances where there is no history of mental health problems or prior criminal convictions.Unlike the random violence that occurs with violent offenders in the criminal system, domesticviolence is usually behind closed doors in the family residence and often goes unreported. Thispaper will discuss the evidence based psychological procedures for assessment of violence inboth criminal and civil proceedings. Particular focus will be directed at the systemic problems inforensic evidence. The” battle of experts” exists in both criminal and civil proceedings in spite ofresearch evidence indicating that aggressive cross examination of experts seldom results in theCourt’s correct understanding of the research applicable to the litigant or accused. Often lost inthe focus on the risk of violence in the accused is the research that demonstrates the detrimentaleffects on children’s future adjustment and welfare from witnessing domestic violence.149. Risk Assessment, Social Network Approach, Single CaseStatistics and Music Therapy Related to Forensic PsychiatricPatientsSocial Network Changes in the Personal Social Networks of ForensicPsychiatric Patients354

Lydia Pomp, Stenden University and INTERVICT, Tilburg Law School, Tilburg University(lydia.pomp@stenden.com)Little is known about the social network dynamics of forensic psychiatric patients. Suchinformation is of great importance for risk assessment and management. A change in socialcircumstances may cause behavioural changes that affect the risk of recidivism. Thispresentation compares the social networks of forensic psychiatric patients at the time of theiroffenses with these networks during treatment. Thirty-six inpatients were interviewed using aForensic Social Network Analysis (FSNA) questionnaire. The FSNA is an instrument tosystematically chart the relationships and personal networks of forensic psychiatric patients inthe context of their individual risk behaviour. During the two time frames, various social networkcharacteristics were analyzed. We found significant differences between the two time points;after a period of incarceration, there was a decrease in network size and a decrease in the numberof social supporters, stressful relationships and network members with potential risk factors.These findings are important to assess the influence of social resources on a successfullyreintegration of forensic psychiatric patients into the community. Because of the dynamic natureof social networks and their influence on rehabilitation, forensic psychiatric professionals need tocheck frequently if there are significant changes in the patient’s network.Music Therapy within Forensic PsychiatryLaurien Hakvoort, Tilburg University & ArtEZ Conservatorium, the Netherlands(L.Hakvoort@ArtEZ.nl)A cognitive understanding of factors contributing to an offence alone is not enough to preventrelapse. There are a number of contextual factors that contribute to violence. A patient has toexperience his lack of specific skills, experience that he overestimates his ability to handlesituations, or acts differently under factors like stress (Bouman, De Ruiter & Schene, 2003).Subsequently, the patient has to practice and train newly acquired skills in order to master theseskills and apply them in real-life situations. During multidisciplinary treatment, including musictherapy, many contextual factors receive attention in different contexts. Just like the majority ofthe treatment programs within international forensic psychiatry, music therapy focuses on overtbehavior and is assumed to affect a patient’s (re)actions in a well-defined and structured situation(Codding, 2002; Smeijsters & Cleven, 2004). Due to its nature of evoking basic emotional,cognitive, behavioral and neurological reactions in people, music therapy can be an appropriatetool to evoke emotional, cognitive, neurological and behavioral reactions (Gabrielson, 2010;Juslin, Liljeström, Västfjäll & Lundqvist, 2010; Peretz, 2010; Sloboda & Juslin, 2010; Thaut,2005). To explore whether it is possible to put some clinical evidence on these theoretical claimsof music therapy effectivity within forensic psychiatry, a number of explorative studies wereexecuted within four different forensic psychiatric clinics in the Netherlands with a total of fivecredentialed music therapists. This presentation focuses on a couple of these studies to explorewhether and what kind of behavioural change of forensic psychiatric patients can be influenced355

through music therapy treatment. The focus is on three need factors of forensic psychiatricpatients: anger management, impulse regulation and coping skills (Bonta & Andrew, 2007).Predictive Validity of the HKT-EX Risk Assessment Tool for Reoffending AfterDischarge in 342 Forensic Psychiatric Patients in the NetherlandsMichelle Willems, Tilburg University (M.Willems@uvt.nl)In the Netherlands, the Dutch risk assessment tool HKT-30 (Historical-Clinical-Future-30) isincreasingly used in forensic psychiatric practice. Currently, the HKT-30 is being revised in alarge research project, and for this purpose an experimental version of the HKT-30 has beencreated containing more items: the HKT-EX. This retrospective study investigated the predictivevalidity of the HKT-EX for different recidivism end points. The study sample consisted of 342forensic psychiatric patients, who had been discharged from any of the Dutch maximum-securityforensic psychiatric hospitals between 2004 and 2008. The HKT-EX was rated by trainedMasters level Psychology students on the basis of criminal file information. In 2011, officialreconviction data were retrieved from the Ministry of Security and Justice. Receiver OperatingCharacteristic-analyses were performed to compute the predictive value of the different aspectsof the HKT-EX for reoffending after discharge. A distinction is drawn between general, violent,and sexual reoffending within 2 and 5 years after release into the community. Implications ofthese findings for the use of the HKT-EX risk assessment tool in forensic practice will bediscussed.Treatment Evaluation Using Routine Outcome Monitoring and Single CaseStatistics in a Dutch Forensic Hospital Using the IFTE (Instrument forFrequent Treatment Evaluations)Erwin Schuringa, Tilburg University (E.Schuringa@fpcvanmesdag.nl)Individual treatment evaluation in this forensic hospital is aided by a method which combinesRoutine Outcome Monitoring (ROM) with Single Case Statistics. A behaviour observation formwhich consists of dynamic risk factors was especially constructed for this purpose: TheInstrument for Frequent Treatment Evaluation (IFTE). The IFTE is independently filled out byall professionals involved around the treatment of a patient. This way all available information iscombined to produce the most accurate picture of the current status of the patient. By doing thison a regular basis, progress (or the lack of it) can be monitored. Data of numerous patients can becombined in different ways to evaluate treatment of specific groups or to evaluate specifictreatment modules. In this presentation examples of the above mentioned possibilities will bediscussed.356

150. Sane Enough (for What)? Mental Capacity in CriminalResponsibility and CompetenceShould an Incapacity Defense Replace the Insanity Defense?Gerben Meynen, Tilburg University (g.meynen@uvt.nl)Defendants can be excused for their criminal actions because of legal insanity. Differentjurisdictions may have quite different standards for criminal responsibility. For instance, awidespread legal rule is the M’Naghten Rule, which focuses on specific kinds of knowledgeconcerning the criminal act. Other legal standards for the insanity defense, like the AmericanLaw Institute’s Model Penal Code, include the defendant’s ability to control his or her actions. Inthis presentation I will explore to what extent the insanity defense can be understood in terms ofcertain mental capacities that the defendant is lacking at the moment of the crime. In otherwords, is it possible – and perhaps desirable – to phrase criminal responsibility in terms that areusually applied to ‘competence’? Rather than answering the question of whether a defendant wassane enough to secure a conviction, the law should, then, be interested in whether a defendantwas sufficiently competent during the commission of the crime.Insight and Action Control in Forensic Psychiatric ReportsSusanna Radovic, University of Gothenburg (susanna@filosofi.gu.se)Swedish penal law does not allow acquittal due to diminished accountability. If a court of lawdecides that a criminal offender has acted under the influence of a severe mental disorder s/hecannot be sentenced to prison, but may instead be sentenced to forensic psychiatric care, which isone criminal penalty among others. A recent addendum to the legislation (from 2008) allowsprison sentences for offenders with severe mental disorders in some special circumstances.However, for offenders who due to a severe mental disorder “lack... the capacity to appreciatethe nature of their actions or the ability to adjust their actions according to such knowledge”, aprison sentence is still ruled out. All such forensic psychiatric assessments are issued by a stateauthority — the National Board of Forensic Medicine — which is a branch of the Ministry ofJustice. The present study surveyed all forensic psychiatric evaluations conducted in 2010 inStockholm and Göteborg (121) where the questions of insight and action control were evaluatedwith the aim of representing what psychiatric symptoms and psychological impairments areconnected to the assessment of diminished capacity for insight and control and how thoseconclusions are argued for.Blameworthiness, Fitness to Plead, and the Diachronic Nature of Responsibility357

Filippo Santoni de Sio, Delft University of Technology (f.santonidesio@tudelft.nl)In this paper I challenge the view that there is a clear-cut conceptual distinction between aninsanity defence and a plea of unfitness to plead, a view based on the distinction betweeninsanity as a doctrine of substantive law affecting the agent’s responsibility, and unfitness toplead as a doctrine of procedure affecting the legitimacy of trial. What this picture tends toconceal is the fact that responsibility has a diachronic nature, as far as it depends on the abilityon the part of the agent not only to act according to reason, but also to engage in a reflection onhis actions and the reasons for them. If so, a lack of the relevant capacities at the time of the trialmay impinge on the responsibility of the offender, not only on the right to proceed with the trialagainst him. To highlight this point some cases of serious dissociation of personality are takeninto account. These cases are particularly interesting, insofar as they concern agents who didn’tmanifest any serious mental defect at the time of their wrongful action, nor at the time of trial.Still, doubts about these agents’ responsibility arise because of their apparent inability torecognize, at the time of trial, their actions as something that they did, for which they should nowanswer.Sane Enough for Execution (and Other Punishments)Nicole A Vincent, Macquarie University (nicole.vincent@mq.edu.au)What mental capacities should people have to be "sane enough" for punishment, and wouldmental capacities instilled, for example through forced medical treatment with anti-psychoticdrugs, suffice? I will argue that to answer these questions we must consider at least four factors.Firstly, whether we take the aim of punishment to be retribution, deterrence (specific or general),reform, rehabilitation, therapy, incapacitation, communication (to/with the public, to/withcriminals), expression of solidarity (with victims and their families), restoration of the law'sauthority, revenge, etc. Secondly, supposing that we settle on retribution, whether ourinterpretation of what retribution requires is merely that the party should suffer, or that theyshould also understand the state’s reasons for making them suffer, etc. Thirdly, what mode ofpunishment is proposed – e.g. execution, imprisonment, flogging, community service, fines, etc.And fourthly, a range of normative considerations might also come into play – for instance, ifretribution requires understanding of the state’s reasons for infliction of suffering, then whatdegree of understanding is required and why; if plural aims are being pursued (e.g. retributionand deterrence) then what is the relative importance of each aim; and why that particular mode(and degree) of punishment is seen as appropriate.151. Seeking ReformTitle T.B.A.358

Cheryl E. Amana-Burris, North Carolina Central University (camana@nccu.edu)This presentation is on children who have been raised by same sex couples. I presented severalyears ago on sexual orientation as a consideration in custody and adoption actions. At the timethere was not a lot of data on the development of children who had been raised by same sexcouples. Since then, there have been a number of studies following such children and comparingtheir development to children raised in heterosexual unions. The presentation will discuss thesestudies and present data on the development of children raised in same sex unions. This data iseven more relevant as states and countries consider whether same sex marriages will berecognized. Many opponents of such marriages have argued that children fare better if they areraised in a heterosexual union, yet studies have consistently shown that this is not the case.Mandatory Reporting Laws for Domestic Violence and Abuse Lacking…Why?Alexis Meshi, Superior Psychiatric Services, Newport Beach, USA(info@superiorpsychiatric.com)Awareness, perception, definition and documentation of domestic violence and intimate partnerviolence differ greatly from culture to culture and era to era. What is domestic violence andabuse? The emotional toll on victims of domestic violence and their families is great. Victimstend to experience higher levels of stress, fear and anxiety. Some sixty percent of victims meetdiagnostic criteria for depression either during or after termination of their relationship. Manystruggle with long term anxiety and are often diagnosed with Generalized Anxiety Disorder,Panic Disorder or PTSD. Medical professionals can make a difference in the lives of those thatexperience abuse. Many cases of abuse are handled by physicians and do not necessarily involvethe police or other legal authority. Medical professionals are in a position to empower people,give advice, document and refer people to appropriate services. Often, however, the helpprovided by providers is often lacking. On average women experience 35 incidents of domesticviolence before seeking treatment. Mandatory reporting for providers is an area of greatimportance and also, interestingly enough, is an area of substantial controversy. Currentlyapproximately five US states including California have mandatory reporting laws for physicaldomestic violence and sexual assault. The remainder do not, and no state has reporting laws forother types of domestic abuse including emotional, verbal, financial or spiritual. It seems thatboth the medical community and the law may be lacking in helping to reduce and eliminateviolence and abuse…Why? This paper will review the literature and attempt to find an answerfor the..."Why"?How Medication Reform Can Have an Impact on Our Clients Now and in theFuture359

Tammy Harris, Arkansas Public Defender Commission, Little Rock, USA(tharris@co.pulaski.ar.us)The cornerstone for any defendant facing capital punishment is the necessity of a thorough socialhistory investigation beginning before birth and concluding at trial. This scorched earth approachto gathering mitigation evidence helps ensure that the death penalty is reserved for individualswho are the “worst of the worst”. When we begin to really know our clients’ stories and theirbackground, common themes emerge and those often involve medications used to treat mentalhealth indications in children, adolescents and those often in state custody. With mandated healthcare reform and ever increasing federal and state budget shortfalls, where will this leave ourclients now and in the future?Dopamine NationRichard Juman, New York State Psychological Association, Albany, USA(dr.richard.juman@gmail.com)We’re an addicted nation. Would you care to dispute it? Recent numbers confirm an alarmingreality. Our national mindset relies on the external fix when it comes to addressing our problems.Whether we’re speaking of the routine disruptions we face in our work lives, the crises that hitevery family at one time or another, or our children who absorb conflicting messages –Americans no longer turn to internal or interpersonal resources to establish personal equilibrium.Our first thought is to seek a quick and external source – as both the cause, and the solution.Most Americans have perfected reliable techniques for feeling better, or, as I like to say, forgiving themselves a little “dopamine spike.” Dopamine, as you probably know, is the brainneurotransmitter that is triggered by “rewarding events.” I recently signed up with a new primarycare physician. When she found out that I’m a psychologist, she asked me “why is every kid inNew York on Ritalin, and every adult taking Ambien?” It’s an excellent question. Here’s onereason – these external fixes are readily available. There are billion dollar industries dependenton our continuing – alcohol, tobacco, gambling, online shopping, pornography, prostitution, andeven compulsive texting. Each of these fuels the American economy. Turn on the TV, and theprevailing wisdom says there’s no reason to suffer discomfort. We’re being instructed thatcontinuous synthetic bio psychosocial regulation is the norm – there’s a pill for whatever ails you– ADHD, shyness, erectile dysfunction, fibromyalgia – you name it. We’re all human, and welike to feel good. Dopamine is naturally generated from any number of physical and emotionalsources. The accumulation of externally generated dopamine, however, creates a vicious cycle ofrelief seeking that ultimately spirals out of control. For those who are lucky – or smart – it landspatients in our offices where we can finally begin to “lift up the hood” — and actively addressthe real problems.360

152. Self and Other: Conceptual and Empirical Aspects of Identityand DifferenceOtto Rank, the Brothers Grimm, and Snow White’s Queen: PsychologicalDistortions in Seeing Ourselves and OthersOlivette R. Burton, University of Pennsylvania (burtoethics@yahoo.com)‘“Mirror, mirror, on the wall, who in this land is fairest of all?” And the mirror always said:“You, my queen, are fairest of all”’. And thus the Queen in Snow White begins her day by beingreassured, by some hazy figure, that she is somehow different, better and more special thanothers. Discrimination begins with self-delusion. This can and has been quickly followed bycognitive dissonance and the inability to tolerate difference. This chain contributes significantlyto produce the “isms” with which our society continues to struggle. This presentation is about theothers; those that society perceives as being different and possibly threatening and the reasonswhy. People who look different, act different and possibly think differently irrespective ofwhether that difference is religious, cultural, or racial. Is the inability to tolerate the other’sdifference a product of personality? Does it emanate from personal defects of egodevelopment, or from issues of paranoia or lack of object constancy? Or rather is it trainingproduced by the environment, lack of resources, or biochemical factors? This presentation willdiscuss how narcissistic distortion on both the societal and individual level consciously andunconsciously creates significant psychic pain and suffering.Patient Responsibilities in a Psychotherapeutic AllianceDuff R. Waring, York University (dwaring@yorku.ca)Patients in a psychotherapeutic alliance should act responsibly in their progression towardrestoration of self. I will concentrate on the ethical virtues that patients should cultivate in thisprogression. The patient in this alliance is a “normative project” for both the therapist and him orherself. I focus on self-regarding ethical responsibilities. I elucidate them as virtue ethicalaspirations to develop and strengthen one’s capacity for better responding to the demands of theworld, i.e. commitments to aspire to self-improvement. This requires cultivation of a contextspecificprofile virtue of self-regarding care. This idea was foreshadowed by Hellenistic ethicsand invites a reformulated contemporary expression. To that end, I will show how this virtuediffers from Kantian duties to the self (Kant 1985) and from Foucault’s notion of “care of theself” (Foucault 1994, 2001). I relate it to Swanton’s profile virtues of self-respect and self-love(Swanton 2003). It subsumes more specific patient virtues, e.g., persistence, courage, honesty,hopefulness, and flexibility (Radden and Sadler 2010, 137). Psychotherapy can enable patients torespond to the ethical challenge of leading a critically good life. Meeting this challenge connectswith moral respect for others (cf. Dworkin 2011).361

Do We Really Know Where Sex Offenders Reside: A Syntonic Analysis ofIdentity ManipulationDonald Rebovich, Utica College (debovi@utiica.edu)This presentation will analyze identity manipulation by registered sex offenders in the U.S. Dataare explained using Clinical Psychologist Joan Pastor’s “Syntonic Syndrome” decision-makingparadigm of temperament, temptation, and opportunity, and Sociologist Donald Cressey’s“Rational Choice” paradigm of perceived pressure, opportunity and rationalization. Thecollective importance of offenders’ expressed perceptions of personal impact of their financialsetbacks, diminished sense of empathy for victims, increased personal dependencies, andmeticulous calculation of the hypothetical probabilities of detection avoidance are demonstrated.The unique situation of registered sex offenders and their relationship to two decision makingparadigms are covered. In this case, emphasis is placed on the role of psychological disordersand the rationalization of seeking “invented identities” to avoid registration/tracking systems andto regain societal status and attain emotional “rebirth” through these invented identities. I providerecommendations on how research results can apply to psychological screening of applicants forsensitive information access positions and enhanced monitoring of “high risk” employees withpotential access to such information. These are presented in the context of their utilization ineducational curricula for economic crime investigation programs and employer public awarenessprograms. I conclude with a discussion of the industries (e.g., retail, health care) most susceptibleto insider victimization in the future.153. Sex Fiends, Perverts, Pedophiles, Monstrous Crimes: HowShall We Understand Policy in the Light of Disgust and MoralFailure?Authors meet their critics: This session will explore three new books that can help frame theproblems caused by our responses to people on the edges of our social order. Attendees will betreated to short synopses of the books and discussion of the issues.Sex Fiends, Perverts and Pedophiles: Understanding Sex Crime Policy inAmericaChrysanthi LeonT.B.E.362

Yuck!: The Nature and Moral Significance of DisgustDaniel KellyT.B.E.Monstrous Crimes, Framing, and the Preventive State: The Moral Failure ofForensic PsychiatryJohn DouardPamela SchultzT.B.E.154. Sex Offenders and Public Policy: Bridging Research, Policy,and PracticeBehind the Numbers: Understanding the Scope and Characteristics ofRegistered Sex Offenders in the United StatesJill Levenson, Lynn University (jlevenson@lynn.edu)Andrew J. Harris, University of Massachusetts Lowell (andrew_harris@uml.edu)This presentation will discuss the scope and characteristics of the United States registered sexoffender population and discuss the related implications for policy and practice. The datapresented, drawn from the first nationwide sample of sex offenders collected directly from statepublic registry websites (n = 445,000), will include demographic characteristics of offenders,offense characteristics, registry status, and risk related variables. We will then apply thesefindings to the current state of the research regarding sex offense recidivism and sex offendermanagement practice, and in the context of federal sex offender registration standards in the U.S.as reflected in the Adam Walsh Child Protection and Safety Act. Finally, the presentation willprovide an overview of sex offender management considerations in the context of U.S.registration policies, including risk, needs, and community reintegration.363

Breaking the Impasse: Toward a New Generation of Sex Offender PolicyResearchAndrew Harris, University of Massachusetts Lowell (andrew_harris@uml.edu)Recent years have produced a growing body of research evaluating the impacts of public policiesdesigned to control known sex offenders within the community. In the United States, findingsfrom these studies have frequently challenged the public safety efficacy of prevailing policies,pitting the research establishment against those advocating stronger and more extensive socialcontrols over sex offenders. For those in the research community, the problem has often beenframed as a battle between empiricism and ideology — the triumph of "moral panic" overreasoned policy development. From the vantage of those advocating tougher policies, researchdata are often viewed with skepticism, particularly when such data are contravened by individualcases with tragic outcomes. This presentation will explore the dynamics of this impasse, arguingthat much of the problem resides in a failure of researchers to frame their analyses in a way thatresonates within the policy domain. Presenting the results of a comprehensive study analyzingthe methods, measures, and outcomes from recent sex offender policy studies, we will present aframework for a new generation of sex offender policy research – one that relies on buildingeffective researcher-practitioner collaboration and that places greater emphasis on mixed-methodapproaches.Understanding Sex Offender Disclosure, Restorative Justice and Reintegrationin the UK: Practitioner, Policymaker and Academic PerspectivesKieran McCartan, University of the West of England (kieran.mccartan@uwe.ac.uk)Hazel Kemshall, DeMontfort UniversityKirsty Hudson, Cardiff UniversitThis paper will discuss the realities of sex offender reintegration in the UK, focusing on how thesharing of sex offender information with the public and how community members’ awareness ofthe identity of sex offenders in their communities helps sex offender reintegration as well asrehabilitation. The paper will focus on the current public disclosure of sex offender informationin the UK and on the role of restorative justice organisations (Stop it Now! & Circles of Supportand Accountability). The paper will discuss the starting point and policy evolution of sexoffender public disclosure in the UK; the research that has helped shape it; its impact upon sexoffender management in the community and how it ties in with restorative justice schemes; andsome of the barriers to the current schemes (i.e., assessing impact and access to the scheme bycommunities). In doing this, the paper will discuss regional variations in the public disclosure ofsex offenders in the UK and how they impact the national UK strategy. The presentation willalso draw on practitioner, policymaker and academic perspectives derived from across the UKbased upon a knowledge exchange network.364

Prosecuting Sexual Assault: The Pre-Arrest Screening Process and itsImplicationCassia Spohn, Arizona State University (cassia.spohn@asu.edu)Research on prosecutorial decisions in sexual assault cases focuses on the post-arrest chargingdecision. This reflects an assumption on the part of researchers that law enforcement will arrest asuspect if they have probable cause to do so and that they then will present the case to theprosecutor for a formal charging decision. Research on sexual assault case processing decisionsin Los Angeles revealed that prosecutors play a role in screening cases prior to the arrest of thesuspect. In this jurisdiction, law enforcement officials who have probable cause to make an arrestoften present the case to the district attorney and, if the district attorney determines that the casedoes not meet the standard of proof beyond a reasonable doubt, they then clear the case byexceptional means. In this paper, I present data on the prevalence of pre-arrest screening and Idiscuss the explanations given by detectives and district attorneys for this practice. I also identifythe predictors of prosecutors’ pre- and post-arrest filing decisions and discuss the implications ofthe pre-arrest screening process and the overuse of the exceptional clearance.155. Sexual Assault and ViolenceSex, Power, and Sexism in Sexual AggressionEmily Blake, University of Kent (eab28@kent.ac.uk)Several studies have found an automatic power-sex association in sexually aggressive men (e.g.,Bargh, Raymond, Pryor & Strack, 1995). This lends support to theorists who propose that a needfor dominance and power are motivating factors for harmful sexual behaviour. Furthermore,evidence of such an automatic link provides evidence that non-concious processes may play arole in the offence process. However, in a study designed to assess the strength of an automaticlink between power and sex in rape prone men, we instead found a relationship in the oppositedirection. This link was related to high levels of endorsement of rape supportive beliefs andsexual dominance. This indicates that men who report sexual dominance, and who endorse highlevels of rape supportive beliefs tend to associate weakness with sex, rather than power with sex.We propose that this unusual finding may represent an interaction between sexism, rapesupportive beliefs, and sexual dominance. We hypothesise that the stimuli in our study designedto represent weakness as a concept may be interpreted by some males as a representation oftraditional gender roles, or attributes sexually dominant men look for in a partner. Thesehypotheses are explored in terms of feminist theories of rape and more contemporary sociocognitivetheories. Finally, results are discussed with references to further research as well astreatment implications.365

Impulsive Violent Sexual Behaviour: Antilibidinal Hormonal TreatmentConsiderations in Mentally Disabled PerpetratorsRob C. Brouwers, University of Tilburg (brour@xs4all.nl; rbrouwers@trajectum.info)J.A. Troelstra, Van der Hoeven Kliniek, Netherlands (J.A.Troelstra@xmsnet.nl)Antilibidinal hormonal treatments, such as steroidal antiandrogens and gonadotrophin-releasinghormone (GnRH) analogues, seem to be effective in paraphilic disorders. This presentationdiscusses when to consider antilibinal hormonal treatment in mentally disabled perpetrators withrecurrent impulsive violent sexual behaviour. There is some evidence that antilibidinal hormonaltreatment can be helpful in diminishing recidivism of impulsive violent sexual offences inmentally disabled perpetrators through delay of arousal and improvement of impulse control. Ifwe apply the bimodal model of violence then antilibidinal hormonal treatment can be used in anearlier phase of treatment. Lowering of testosterone will diminish sexual arousal, decreaseamount of violence, enhance control and perhaps decrease anger responses (inhibitingdominance and risk taking) in the impulsively violent mentally disabled perpetrator.Unfortunately it seems that the majority of offences by mentally disabled perpetrators are notimpulsive in nature. Because it is difficult to understand all the considerations for the mentallydisabled perpetrator and this kind of treatment is an ethical minefield, we recommend a specialmultidisciplinary committee that is not involved in the treatment and able to give independentadvice. In the two years’ experience we have with this kind of expert advice we have noticed thatan antilibidinal hormonal treatment is not always necessary, especially in those cases whentwenty four hour supervision is demanded.Student Sex Work Research in Wales: Enhancing Student Well-BeingTracey Sagar, Swansea University (t.sagar@swansea.ac.uk)Debbie Jones, Swansea University (deborah.a.jones@swansea.ac.uk)This paper provides an overview of the All Wales cross sector research project ‘InteractiveHealth: Student Sex Work Wales’, which aims to uncover the motivations and needs of studentsex workers and to provide a new innovative e-health service for this relatively invisible cohortof sex workers. It also reports on the findings from student sex worker focus groups carried outin July 2011 in the city of Cardiff. In particular, the paper raises questions regarding the potentialimpact of sex work in terms of safety, sexual health and mental wellbeing, and the need toreduce stigma and victimisation towards young sex workers. It is argued that reducing stigmaamongst the general public and professional service providers could facilitate the disclosure ofsex work as an occupation and that this would go some way to ensuring that young people areable to access appropriate services.366

The Relevance of Interpersonal Style to Aggression in Psychiatric UnitsMichael Daffern, Monash University (michael.daffern@monash.edu)Recent research on aggressive behaviour in psychiatric hospitals has emphasised the importanceof the interaction between characteristics of patients and aspects of the hospital environment.Interpersonal style, a key component of personality and personality disorder that characterisesthe way individuals relate to others, influences how patients respond to the demands ofpsychiatric hospitalisation. The aim of this presentation is to explore the value of interpersonaltheory as a parsimonious and unifying theory to understand the reactions of psychiatric patientsto involuntary hospitalisation. A program of research describing the relationship betweeninterpersonal style and aggression in patients admitted to civil and forensic psychiatric hospitalswill be presented. The results of these studies reveal a consistent relationship between a hostiledominantinterpersonal style and aggression. Finally, results of recent research into the treatmentof problematic interpersonal styles will be presented. The implications of research based oninterpersonal theory that has been drawn upon to enhance patient satisfaction and compliancewill be presented, and opportunities for preventing aggression will be introducedThe Past is Not Necessarily Prologue: The Contribution of PreviousVictimization to MMPI Profiles of Sexual Harassment PlaintiffsLinda L. Collinsworth, Millikin University (llc2402@gmail.com)Louise F. Fitzgerald, University of Illinois at Urbana (lff1353@gmail.com)Sadie Larsen, VA Hospital, Milwaukee, USA (sadieelarsen@gmail.com)Although research indicates that sexual harassment can have significant impact on its victims’psychological well-being, some legal commentators have argued that such distress is oftenrelated, not to the harassment experience itself, but rather to previous victimization, mostspecifically, childhood sexual abuse. Although previous research on childhood sexual abuse hassuggested that abusive experiences are typically associated with a number of psychologicalsymptoms, the psychological status of such survivors varies greatly and there appear to beimportant individual differences among them. We argue that any determination of causation(specifically for legal purposes) must always be made on an individual basis, and demonstrateempirically that legal arguments for an “assumed” alternative cause of damages are not justified.Employing complete-link cluster analysis, a classification technique developed to summarizecommonalties in a dataset thus facilitating identification of distinct subgroups within a sample,we examined MMPI-2 profiles of 123 individual plaintiffs involved in contested sexualharassment litigation. Each plaintiff underwent a comprehensive psychological assessment, thatincluded a battery of standardized measures and an extensive structured interview (which367

included questions regarding previous victimization) and provided a reliable SCID-derivedDSM-IV-TR diagnosis. The cluster analysis of MMPI2 produced three distinct clusters, differingprimarily in the severity (i.e., profile elevation) of distress reported. Importantly, these groupingswere not related to a history of childhood sexual abuse or previous trauma more generally in anysimple way. Contrary to suggestions in the psycho-legal literature, abuse victims do not appear tobe a homogeneous group and the mere presence or absence of a history of sexual or physicalabuse does not appear to account for the severity or type of psychological distress found amongplaintiffs in sexual harassment litigation.156. Sexual OffenseTracks To Change, Multi-Track Model in Therapy For Sexual OffendersNils Verbeeck, Forensic Institute Deviant Sexuality (FIDES), Beernem, Belgium(nils.verbeeck@fracarita.org)Ellen Gunst, Forensic Institute Deviant Sexuality (FIDES), Beernem, Belgium(ellen.gunst@fracarita.org )In the FIDES (Forensic Institute DEviant Sexuality) treatment centre it was decided 12 years agoto offer treatment by way of a multi-track model which starts from a global view of a person. Inthis model, and as such also in our treatment programme, we have the cognitive track, theemotional track and the social contextual track. Firstly, the cognitive track is the cognitiveprogramme for relapse prevention (the risk-need model) which is well known in the forensicfield. Secondly, by offering experiential and interactional group psychotherapy, drama-therapyand expressive therapy we acknowledge the importance of emotions in our therapy. For instance,in the experiential group psychotherapy we use Emotional Focusing Therapy (EFT) which is anexcellent model to add a positive approach to the treatment of sex offenders in order to improvetheir (emotional) functioning, their well-being and their relationships. The person-centered,process-guiding stance and the therapist exploratory response style makes clients more aware oftheir emotions and allows them to accept and express their feelings which in turn leads to a moreflexible management of their emotions. Thirdly, the social contextual track runs through thewhole therapy and promotes resocialisation from the beginning.Sexual Offending and Paraphilias: A Meta-Analytic Evaluation of TreatmentJohn Reece, RMIT University (john.reece@rmit.edu.au)A meta-analysis was conducted to evaluate treatment and methodological effects on adult malesexual offender recidivism from a sample of 54 treatment outcomes. In particular, therelationships between sexual offender type (e.g. paraphilic, violent, generic), treatment type,368

study design, and recidivism were investigated. Inclusion criteria required studies to haveevaluated a treatment of any type using a single sample or controlled design. Each study had toreport adequate recidivism data as a measure of treatment outcome. Cognitive and behaviouralmeasures were included for descriptive purposes, but only recidivism data were included in thestatistical analyses (k = 47). Offender type and treatment type were found to significantly predictrecidivism, but this became non-significant once odds ratio data from controlled designs wereincluded. Recidivism data from single sample designs were predicted by more methodologicalvariables compared with recidivism data from controlled designs. Implications for sexualoffender policy, treatment, and research are discussed.An Evaluation of the Implementation and Impact of the Central District ofCalifornia's Suicide Prevention Program for Federal Sex Crime DefendantsDonald Rebovich, Utica College (debovi@utiica.edu)The study examines individuals charged with federal sex crimes that have been placed on pretrialsupervision and appear to be at significantly higher risk of suicide than members of the generalpopulation. While there are no national incidence studies that can be cited to support this view,several suicides of sex crime defendants awaiting trial or sentencing did occur in this part ofCalifornia prior to the development of the program studied. To address the problem of suicideamong sex crime defendants, a new approach to their pretrial supervision was developed in theCentral district of California, based on a unique partnership of key criminal justice actors(pretrial, public defenders, prosecutors) and a private sector treatment provider, Sharper Future.This presentation is a report of the results of an evaluative review of the implementation andimpact of this program, based on data provided by the vendor, Sharper Future, on-siteobservational research, interviews with key staff, and a review of court processing data providedby the Federal pretrial office. In the final section of the presentation, we offer an agenda for bothresearch and program development in this emerging area of federal pretrial correctional practice,and consider the implications of changes in the profile of sex crime defendants for the Federalpretrial system, particularly in the area of risk assessment and evidence-based practice.Do We Really Know Where Sex Offenders Reside: A Syntonic Analysis ofIdentity ManipulationDonald Rebovich, Utica College (debovi@utiica.edu)This presentation entails an analysis of identity manipulation by registered sex offenders in theU.S. Data are explained using Clinical Psychologist Joan Pastor’s “Syntonic Syndrome”decision-making paradigm of temperament, temptation, and opportunity and Sociologist DonaldCressey’s “Rational Choice” paradigm of perceived pressure, opportunity and rationalization.The collective importance of offenders’ expressed perceptions of personal impact of their369

financial setbacks, diminished sense of empathy for victims, increased personal dependencies,and meticulous calculation of the hypothetical probabilities of detection avoidance aredemonstrated. The unique situation of registered sex offenders and their relationship to twodecision making paradigms are covered. In this case, emphasis is placed on the role ofpsychological disorders and the rationalization of seeking “invented identities” to avoidregistration/tracking systems and to regain societal status and emotional “rebirth” through theseinvented identities. The paper provides recommendations on how research results can apply topsychological screening of applicants for sensitive information access positions and enhancedmonitoring of “high risk” employees with potential access to this information. The import ofthese recommendations is presented in the context of utilization in educational curricula foreconomic crime investigation programs as well as in employer public awareness programs. Thepresentation concludes with a discussion of industries (e.g., retail, health care) most susceptibleto “insider” victimization in the future.Sex Offender Commitment Laws in the U.S.A and their Inevitable FailureJohn Q. La Fond, University of Missouri at Kansas City (lafondj@comcast.net)This paper analyzes the inevitable failure of sex offender commitment laws in the USA enactedsince 1990 to prevent sexual recidivism. These laws allow the indefinite civil commitment of sexoffenders to secure mental health facilities after they have served their prison terms. Prosecutorsmust prove the targeted offender suffers from a mental abnormality or personality disorder thatmakes him or her likely to commit another sex crime. However, these laws do not providemedically meaningful definitions of mental illness or resulting behavioral impairments.Consequently, mental health professionals cannot apply the statutory criteria objectively andconsistently to the large number of sex offenders who qualify for civil commitment. More sexoffenders are being committed and fewer released than anticipated. In addition, courts have ruledthat sex offenders have a constitutional and statutory right to treatment, including placement inhumane, therapeutic facilities staffed by qualified professionals and the opportunity for lessrestrictive community placement. Thus, states must maintain secure and therapeutic facilities. Asa result, costs to implement these laws have soared at the same time as economic resourcesavailable to the states have declined precipitously. Another strategy, risk-management, wouldcost much less, allow supervision of many more sex offenders, match the degree of social controlto the level of danger posed by each offender, and prevent more sex crimes, thereby maximizingpublic safety.157. Shifts in the Provision of Mental Health Care & ManagementInternationallyDistance Therapy Conundrums370

Terry R. Bard, Harvard Medical School (Terry_Bard@hms.harvard.edu)Distance therapy is an increasing practice globally, and models for such practice are emerging.Both benefits and limitations characterize such practice. However, nettlesome issues remainpertaining to privacy, confidentiality; treatment models, licensure, and professional responsibilityhave yet to be addressed formally. Several recent court cases have highlighted such concerns.These issues will be discussed, and a number of possible stratagems to rectify these concerns willbe identified to facilitate workshop discussion about how to approach and protect thisburgeoning model of health care.Special Problems in Forensic TelepsychiatryThomas G. Gutheil, Harvard Medical School (gutheiltg@cs.com)Current literature stresses the benefits of forensic telepsychiatry in terms of cost savings, dealingwith distance and remote settings (especially internationally), and the relative improvement overtelephonic interviewing and testimony. However, a number of problems still exist with thisotherwise useful method. These include lack of person-to-person physical interaction; alterationof the subjective response experience of in-room forensic evaluative interviewing; and the effectof the very common split-second delay experienced with a number of platforms for suchinterviewing. This presentation will address these problems and suggest solutionsIssues of Interpretation in Global Mental Health CareTyler Carpenter, Disability Rehabilitation Commission, Boston, USA(jtcarpenter30@hotmail.com)Clear and mutually shared and understood communication is fundamental to all humanundertakings. From the adaptation and evolution of human personalities through the dyadic andpassionate semiotics of a mother-child relationship, to the clinical forensic dialectic of multilingualinternational courts and treatment settings, shared and comprehensible meaning throughtranslation is the foundation upon which all tasks are undertaken and successfully accomplished.This paper lays out and discusses the process, challenges, and some possible solutions to theglobal complexities of sharing reliable and valid meaning-making in global multi-lingual, multipersonsystems; it is designed to encourage a discussion of this process and identify strategies.The Role of Virtual Technologies in the Mental Health World371

M. Myra S. White, Harvard Medical School (mswhite@fas.harvard.edu)The explosion of new virtual technologies in the past ten years has changed the way we live andwork. For mental health professionals these technologies provide new ways to deliver care buttheir use also poses special challenges to a profession that has traditionally delivered carethrough the establishment of live human connections with patients. This paper will consider thelimitations and benefits of different virtual technologies in delivering care and coordinatingmental health treatment teams. As part of this analysis it will also address legal and ethicalconstraints that should temper the adoption of virtual technologies.Provision of Mental Health Care for Persons Incarcerated InternationallyRobindra Paul, Consulting Psychiatrist, San Diego, USA (robindra3@yahoo.com)To provide informed consent a patient must have the capacity to make a decision. In the UnitedStates, the process of informed consent involves healthcare providers providing patients withmaterial information such that the patient can weigh the benefits, risks, and alternatives totreatment including no treatment at all. The process of informed consent, where it does exist,varies internationally. This presentation will initially focus on the development of informedconsent from the Greek philosophy to American landmark case of Schloendorff v. Society of NewYork Hospital, 211 N.Y. 125, 105 N.E. 92 (1914). There will then be a presentation on thedeparture of from the principles of informed consent during the Shoah and the lessons learned inthe aftermath of the Shoah. Finally, there will be a presentation about the process of informedconsent in selected countries.158. Specialized Interventions for Persons with Serious MentalIllnesses in the Criminal Justice System: Moving the Field ForwardCIT – Moving ForwardAmy C. Watson, University of Illinois at Chicago (acwatson@gmail.com)The Crisis Intervention Team (CIT) model is now considered a “Best Practice” model for policeresponse to mental health crisis. The model generally includes 40 hours of specialized mentalhealth training for a select group of officers, community partnerships and changes in policepolicy and procedures. Key elements of the model have been identified and there are now over1,500 jurisdictions in the United States and elsewhere implementing some version of CIT. Theprimary goals of CIT programs are to increase safety in these encounters and divert individualswith mental illnesses away from the criminal justice system to appropriate psychiatric treatment.372

Some jurisdictions are implementing modifications and/or enhancements to the CIT model,while others are expanding the training portion of the program beyond law enforcement to otherfirst responders and correctional officers. The research on CIT is limited, but suggests it may behaving some positive impacts on immediate outcomes of police encounters. However, we havelittle information on the longer term effect on outcomes for persons with mental illnesses, thecriminal justice and mental health systems, and communities. Additionally, research is needed onfactors influencing successful implementation of CIT, modifications to the model that mayfacilitate success in varied contexts, and program maintenance over time. The presentation willfirst summarize the CIT model, variations in the model, and the research to date on CITeffectiveness. Then, next steps for the evolution of the CIT model and CIT research will beexplored.Moving Beyond Current Research on Mental Health CourtsVirginia Aldige Hiday, North Carolina State University (Ginnie_aldige@ncsu.edu)Those who established and wrote about the early mental health courts (MHCs) envisioned themto replace punishment with mental health treatment so as to address the presumed underlyingproblem causing offending and reoffending, mental illness or severe mental illness. The MHCwas to marshal treatment and monitor mentally ill offenders to assure, with support andsanctions, that they complied with treatment long enough to become set on a course of nonoffending.This paper explicates how successful MHCs did much more than offer and assurecompliance with treatment, describes the ten essential structural elements of MHCs, and presentshypothesized procedural elements that influence success. It then summarizes and critiquesempirical research on the major intended outcome, criminal recidivism, and suggests directionsfor future empirical research.Critical Time Intervention for Men with Mental Illness Leaving PrisonJeffrey Draine, Temple University (jeffdraine@temple.edu)Dan Herman, Hunter College (Daniel.herman@hunter.cuny.edu)Liat Kriegel, University of Southern California (liat.kriegel@gmail.com)The period following prison release is associated with a high risk of morbidity, mortality andadverse social outcomes. However, few theory-driven evidence-based models exist to supportpopulations during this period. Critical Time Intervention (CTI) is an established EBP that hasbeen shown to enhance continuity of support for persons with severe mental illnesses followingdischarge from hospitals and shelters. We posit that the focused transitional nature of CTI couldbe effective with men with mental illnesses leaving prison. Using a conceptual framework builtaround social capital, we hypothesize that CTI will be more effective than enhanced release373

planning in achieving engagement with mental health services. This, in turn, would lead toimproved mental health and community stability outcomes, including reduced risk of reincarcerationAn NIMH-funded field-based RCT is currently underway, in which 216 men withmental illness recruited from the mental health services of a state prison system were randomizedto either CTI or a comparison condition, Enhanced Reentry Planning (ERP). Participants werefollowed for up to 18 months after release. CTI was associated with stronger engagement withcommunity care practitioners 90 days after release. The accessibility and capacity of services inthe community settings are a key challenge of this work. Further analysis will test the completemeditational outcome model towards varied outcomes relating to health, social integration, andcriminal justice involvement. It appears that social isolation and limited network resources aremore essential elements of the challenge than access to psychiatric care alone.Inside the “Black Box” of Forensic Assertive Community TreatmentBeth Angell, Rutgers University (angell@ssw.rutgers.edu)Concern about the overrepresentation of people with mental illness in the criminal justice systemhas led to the development and/or adaptation of interventions to divert offenders to mental healthtreatment in lieu of incarceration or during the reentry period. Forensic Assertive CommunityTreatment (FACT) represents the adaptation of an evidence based treatment program for mentalillness to the context of justice involvement. Although preliminary evidence of FACTeffectiveness is promising, its specific program elements continue to be debated and refined.According to a recent study, the most controversial area concerns the role of leverage forpromoting adherence to treatment and behavioral expectations; some existing FACT programsinsist that leverage is necessary to engage a high risk population, whereas others maintain thatleverage is overly coercive and undermines trust and self determination. This presentation willpresent an overview of the current evidence base for FACT, trace major issues of controversyand, drawing upon an ethnographic study of a FACT program designed for prison reentry inChicago, discuss how practitioners use and strategize to find alternatives to leverage in thecontext of FACT. Specifically, the use of relational strategies of adherence management will bedelineated and illustrated through specific cases.Envisioning the Next Generation of Behavioral Health and Criminal JusticeInterventionsMatthew W. Epperson, University of Chicago (mepperson@uchicago.edu)Nancy Wolff, Rutgers University (nwolff@cbhs.rutgers.edu)Robert Morgan, Texas Tech University (robert.morgan@ttu.edu)William Fisher, University of Massachusetts Lowell (Bill.Fisher@umassmed.edu)B. Christopher Frueh, University of Hawaii (frueh@hawaii.edu)374

Jessica Huening, Rutgers University (jhuening@cbhs.rutgers.edu)Over the past two decades in the U.S., there has been a systematic effort to develop interventionsto address the needs of persons with serious mental illnesses (SMI) who are involved in thecriminal justice system. Despite the proliferation of these interventions, the prevalence of peoplewith SMI in the criminal justice system has not been meaningfully reduced. We refer to theseinterventions collectively as “first generation” for two reasons: 1. To acknowledge that they areunited by a common philosophy – the criminal justice involvement of people with SMI isreduced primarily by providing mental health treatment; and 2. To draw attention to the need fora more nuanced and evidence-based foundation for the next generation of interventions. Thepurpose of this paper is to cast a vision for the next generation of behavioural health and criminaljustice interventions by presenting a complex set of individual and environmental factors thatdirectly and indirectly contribute to criminal justice involvement for individuals with SMI andare, therefore, critical targets for intervention. This framework acknowledges that persons withSMI, in general, display many of the same risk factors for criminal involvement as the broaderoffender population. We conclude by presenting structural and content recommendations fordeveloping the next generation of interventions and suggest a research agenda for the future.159. The Social Construction of Risk in Mental Health and JusticeSystemsAn Exploration of the Discursive Construction of Risk in Forensic MentalHealth PracticeRichard Whittington, University of Liverpool (whitting@liverpool.ac.uk)Within UK mental health services, “risk” has become a dominant discourse guiding discussionsabout service-users and broader service objectives. This trend has generated extensive attemptsto specify, and quantify, risk of violence, or self-harm, at individual and population levels,accompanied by systematic, standardised, approaches to risk through local and nationalguidelines (DoH 2009, Logan et al 2011). Despite institutional pressures to mechanise riskmanagement processes, the persistence of concepts like “relational security” remind us that theseare dynamic activities involving human interaction and co-constructed professional-patientperspectives mediated by language. A core objective of mental health policy dictates thatsecurity is proportionate to perceived levels of risk, and that movement between high, mediumand low-secure settings be guided by the principle of proportionality. It is vital that practitionersfrom different professional disciplines have a shared understanding of the meaning of “risk”; anuncritical assumption in much of the literature. This paper reports findings from an ongoingqualitative study, based on discourse analytic principles, which critically engages with multiprofessionalaccounts of risk, and decision-making, across levels of forensic provision. Data wascollected from a series of discipline specific focus groups with psychiatrists, mental healthnurses, clinical psychologists, and social workers.375

Pathologising Growing Up: The Re-Construction of Risky Behaviour as MentalIllness?Alina Haines, University of Liverpool (a.haines@liverpool.ac.uk)Liz Perkins, University of Liverpool (e.perkins@liverpool.ac.uk)Richard Whittington, University of Liverpool (whitting@liverpool.ac.uk)In 2008 the Department of Health [DoH] funded six pilot schemes in England for young people,with multiple social and health needs, in early stages of contact with the youth justice system.Reports highlighted unmet complex needs, levels of educational attainment and mental healthneeds of children and young people at various points in the UK youth justice system. Mentalhealth problems and learning disabilities among this population are roughly double those ofchildren in the general population. Lord Bradley (2009) defined “diversion” in a way that aimedto balance offender rights with those of the victim, and public protection. The YJLD initiativewas developed to ensure health problems and vulnerabilities were addressed at the earliestopportunity. This paper explores the extent to which these diversion schemes achieved intendedoutcomes, and questions whether they redefined normal risky adolescent behaviour as a mentalhealth risk. Data is derived from a DoH funded evaluation which examined aspects of servicedelivery and short-term outcomes over the period 2008-11 using standard quantitative andqualitative research methodologies. The paper is based on analysis of qualitative data whichincluded in-depth interviews with children and young people, key stakeholders, representativesfrom the Department of Health and Centre for Mental Health.“Seeing Like Them” and “Being Like Them”: Masculinist Risk Discourses in aHigh-Security HospitalDave Mercer, University of Liverpool (dmercer@liverpool.ac.uk)Liz Perkins, University of Liverpool (e.perkins@liverpool.ac.uk)The management of commercial pornography in secure treatment services for sexual offenders,detained under mental health legislation, has emerged as a clinical, ethical and professionalconcern in the UK (Fallon 1999). There is an abundance of behavioural science and feministliterature attesting to relations between sexually violent media and sexually abusive malebehaviour. Little of this, though, has direct relevance to the working lives of practitioners whoengage therapeutically with offenders in forensic settings; where estimating risk is a function of“individual” rather than “public health”. This paper draws from a larger discursive project(Mercer 2012) into the way mental health nurses, and incarcerated sex offenders with a diagnosisof personality disorder, talked about sexual crime and pornography. Findings revealed an overtlymasculine discourse that dominated the institutional culture, framed wards as male space and376

promoted gendered inequality. In this presentation, attention is given to the specific issue of riskdiscourses that focused, largely, on “fantasy” and “offending”, with pornography as theembodiment of men’s sexuality. A discourse analytic design illustrated performative aspects oflanguage that socially, and sexually, positioned male speakers in relation to each other and tofemale staff on the unit, and discursive repertoires that constructed women as ‘other’ anddelineated the normal man from the deviant individual.“Sex without a Story”: Female Nurse Discourse about Pornography and Risk ina Masculine CultureLiz Perkins, University of Liverpool (e.perkins@liverpool.ac.uk)Dave Mercer, University of Liverpool (dmercer@liverpool.ac.uk)Since its inception in the mid-nineteenth century, the English ‘special hospital’ system has beendesigned to contain, and rehabilitate, men deemed to be disordered and dangerous. Until recentlythese institutions contained a small number of female patients, but political pressure andhealthcare reforms eventually led to acknowledgement that this was an inappropriate treatmentenvironment for vulnerable women. Though small in number, there is documentary evidence oftheir lives within an isolated, discriminatory and rigidly gendered world (WISH 1999). Incontrast, hardly anything is known, or written, about the experiences of female nurses working inthe male dominated culture of high-secure services, often looking after men who have committedsexually violent crimes against women. This paper reports the findings from a discourse analysisof in-depth interviews undertaken as part of a larger study into the constructive nature andtextual variations of language used to construct accounts of pornography and offending in oneforensic hospital. Five female nurses, based on a Personality Disorder Unit, talked aboutstrategies to maintain relational safety in an environment that prized masculine physicality.Female respondents spoke about being prevented from engaging with sexual offenders, survivingin a ‘dangerous’ environment, coping with the sexism of male colleagues, and struggling tomaintain a professional persona. ‘Risk management’ in this culture, both defined their role andconstructed their identity.Dangerous Men, Unproblematic Masculinities? A Critical Reflection on thePlace of Risk Assessment in Strategies to Reduce Sexual HarmMalcolm Cowburn, Sheffield Hallam University (m.cowburn@shu.ac.uk)This paper makes the link between risk assessment of individual sex offenders and wider policyinitiatives to develop safer communities. It is suggested that whilst it is important to consider theindividual circumstances of men convicted of sexual crime, throughout the time they are understatutory supervision, risk assessment on its own can make only a small contribution to public377

safety. It is argued that wider approaches to sexual threat and sexual harm are needed, and thatwhilst there are ongoing efforts to enhance the accuracy of risk prediction measures they canonly ever focus on a part of the problem. The paper draws on evidence which indicates that awide group of men are, at different times, involved in committing sexually abusive acts withvarying degrees of social and sexual harm. It is proposed that an additional dimension isincorporated into Laws' (2008) tripartite approach to public health in relation to sexual violence.This is to consider how harmful ways of being a man can be challenged, and positive ways ofbeing male can be nurtured. This will involve a multi-agency pro-active initiative similar topublic health campaigns that have changed other entrenched behaviours in the UK such as drinkdriving, and smoking in public space.160. StalkingStalking: An Analysis of the Phenomenon in the South of Italy after Passage ofthe Italian Law, “d.d.l. n°11/2009”Fabio Delicato, Centro Studi & Ricerche in Psicologia clinica e Criminologia, Italy(webmaster@criminiseriali.it)Before “d.d.l. n°11 of 23 February 2009”, in the Italian system of Law there was no specific rulefor the phenomenon of stalking. This document introduced a crime called “Atti Persecutori” byinserting Article 612-Bis of the Codice Penale. Only since then has it been possible to examineofficial data on this phenomenon. Examination is also complicated by the fact that many victimsof stalking don’t report the offence. We assume that the “dark number” on this phenomenon isvery high. Our analysis is limited in the South of Italy, in particular the regions of Basilicata,Campania, Calabria, Puglia and Sicilia. The goal of this research was firstly to monitor theprogress of the phenomenon of stalking by analyzing the official data of the Italian “Ministerodell’Interno” on complaints in the South of Italy since 2009. Our research also aimed to bring outthe “dark number” of stalking in the South of Italy through a specific and anonymousquestionnaire administered to representative samples in selected cities which investigate whetherthe subject has been victim of stalking, whether or not he or she reported it to the police, whetherhe or she knew the offender and how long the stalking persisted.T.B.E.*161. Suicide and Assisted SuicideA Long Way for Suicide Prevention in JapanIsao Takayanagi, Arisawabashi Psychiatric Hopital, Toyama, Japan (yagiisao@aqua.ocn.ne.jp)378

The number of suicides in Japan has been more than 30,000 per year since 1998. Japan's suiciderate per 100,000 people was 24.9 in 2010, which was one of the highest in the world. The mainfactor for such a high suicide rate relates to an increase in the population of the so-called"working poor", which was accelerated by the amendment of the Worker Dispatch Law in 1999.The author outlined this situation, and Japanese government countermeasures, at the 32ndIALMH Congress. The Japanese government issued the Foundamental Priciples forComprehensive Suicide Countermeasure in 2007. However, the Japanese suicide rate has not yetsignificantly improved. The objectives of the government's countermeasures are mainly mentaldisorders such as mood disorders, alcoholism, schizophrenia, etc. But the basic changes inJapanese society such as the employment system are more important to lowering the suicide rate.The government, led by the Democratic Party in 2009, has been trying to reform the socialsystem. The reform has not proved successful due to lack of experience. Further details will bediscussed by means of case presentations.Ideation and Attempted Suicide among Women Inmates of the PenitentiaryHospital of Sao PauloLilian Caldas Ribeiro Ratto, Centro de Atencao Integrada a Saude Mental, Centro Hospitalar doSistema Penitenciario Irmandade da Santa Casa de Misericordia de Sao Paulo, Brazil(lilian.ratto@gmail.com)Quirino Cordeiro Jr, Centro de Atencao Integrada a Saude Mental, Irmandade da Santa Casa deMisericordia de Sao Paulo, Brazil (qcordeiro@yahoo.com)Isis Marafanti, Centro de Atencao Integrada a Saude Mental, Irmandade da Santa Casa deMisericordia de Sao Paulo, Brazil (isis_marafanti@hotmail.com)Maria Carolina Pedalino Pinheiro, Centro de Atencao Integrada a Saude Mental, Irmandade daSanta Casa de Misericordia de Sao Paulo, Brazil (mariacaropinheiro@yahoo.com.br)Rafael Ramisson Vicente Riva, Centro de Atencao Integrada a Saude Mental, Irmandade daSanta Casa de Misericordia de Sao Paulo, Brazil (rafaelrvriva@gmail.com)Introduction: High prevalence of mental disorders and suicide risk among detainee populationshas been described in the literature. Over the past four years the female prison population ofBrazil has increased 37.47%, representing an annual growth of 11.99%. Several studies suggestthat the prison population has higher rates of mental health problems than the general population,and there is a profile of women particularly at risk, which is characterized by being young, singleand involved in drug abuse or addiction.Objective: To show the prevalence of suicidal ideation and previous suicide attempts amongwomen admitted to the Hospital of the State Penitentiary in Sao Paulo.Method: Questionnaires by the Prison Mental Health Hospital (General Hospital) team.Assessing the presence of suicidal ideation and previous suicide attempts among inmateshospitalized.379

Results: 31% prevalence of suicidal thoughts, 9% of women possessed a history of suicideattempts in a sample of 77 women, and 75% were aged between 21 and 30 years.Conclusion: Knowing the prevalence of suicidal thoughts among hospitalized women is veryimportant for the organization of mental health services in prisons in order to prevent furthersuicide attempts through intervention in preciptant symptoms.Does Suicide Have to Be Intended?Dennis Cooley, North Dakota State University (dennis.cooley@ndsu.edu)Michael Cholbi recognizes that the standard definition of suicide relied too heavily on a mistakennotion of intention and how intention works in suicides. As Cholbi shows in various examples, aperson does not have to intend his own death primarily for an action of self-killing to be asuicide. Intentionality is sufficient to make the act one of suicide. The result of Cholbi’s work isa fuller understanding of what suicide is, which allows us to evaluate better its morality, andpossibly, devise improved treatments for those who are suicidal. However, I contend thatCholbi's definition should be broadened even further to include other mental states. Instead ofusing the actor's intention or intentionality to determine if an action is suicide or not, I argue thatthe actor's acquiescence in his self-killing is sufficient to do all the work we want done in regardto identifying suicides, talking about their morality, and devising ways to help those who aresuicidal.Physician Assisted Suicide/Death: A Mental Health PerspectiveVolker Hocke, Western University (Volker.Hocke@lhsc.on.ca)Gertrud HockePhysician assisted suicide/death is a controversial topic with multiple dimensions. A discussionof pros and cons requires an in-depth discussion of each dimension. A first dimension focuses onthe person who requests an assisted suicide/death, specifically his relationships, personal history,suffering and motivation to seek this solution. A second dimension is the sphere of the physicianwith his/her personal and professional values. A third dimension explores the interactionbetween society and person on one hand and society and physician on the other hand. A fourthdimension looks at the mental health status of the person requesting the assistance. A thoroughliterature review found that up to 98% of suicide victims suffered from depression prior to thefinal step and that independent of depression, feelings of hopelessness, a sense of loss ofmeaning in life, a perceived lack of social support and a loss of dignity strongly contribute to thedecision to actively end one’s life. Therefore, the question arises as to why changes in the lawshould support the wish to end one’s life rather than fostering suicide prevention by providing380

help living a meaningful life and dying in dignity? This presentation will focus on the availabledata to support action to circumvent assisted suicide.First Do No Harm: Euthanasia and Terminal Sedation in BelgiumRaphael Cohen-Almagor, The University of Hull (R.Cohen-Almagor@hull.ac.uk)The aim of this paper is to provide a critical review of euthanasia policy and practice in Belgium.Euthanasia is defined as practice undertaken by a physician, which intentionally ends the life of aperson at her explicit request. Physician-assisted suicide is different than euthanasia in that thelast act is performed by the patient, not by the physician. The physician provides the lethal drugsto the patient who takes them by herself. The methodology of this research is based on criticalreview of the literature supplemented by interviews and exchanges with leading scholars andpractitioners during 2003-2011. First, background information is provided; then majordevelopments that have taken place since the enactment of the Belgian Euthanasia Act areanalysed. Concerns are raised about (1) euthanizing patients without explicit request – endingpatients’ lives without request is a lingering problem; (2) euthanizing demented patients andpeople who are tired of life, and (3) terminal sedation. Terminal sedation, a procedure that doesnot require the patient’s consent, is practiced. Finally, some suggestions designed to improve thesituation are offered. Belgian legislators and medical establishment are invited to reflect andponder so as to prevent potential abuse.162. Tales of the Unmet Needs: Mental Health in Juvenile JusticeJuvenile Court Records in Belgium (Flanders): What is Included for Minorswith a Mental Disorder?Freya Vander Laenen, Ghent University (freya.vanderlaenen@ugent.be)Sofie Merlevede, Ghent University (sofie.merlevede@ugent.be)Purpose: This study examined (1) which information could be found in the juvenile court recordsin Belgium and (2) if specific information was included in the records for minors with a mentaldisorder.Method: The sample consisted of 107 juvenile court records. SPSS version 20 was used toanalyse the information.Results: Within the juvenile court records, information could be found on juvenile courtcharacteristics (applied measures, reason for referral), child demographics (age, gender,ethnicity), school-related factors (education level, suspension, truancy, repeating grades andregularly attending school), functioning of the minor (running away, aggression, discipline,381

destructive behaviour, mental health, bad peers) and family characteristics (family structure,employment status of the parents, mental health of the parents, destructive behaviour, criminalantecedents, domestic violence). When focusing on the juvenile court records of minors withmental disorders, significantly more information was found on school problems (suspension,truancy), functioning of the minor (aggression, running away from the institution, destructivebehaviour) and the received mental health care than in the records of minors without a mentaldisorder.Conclusion: The information in the court records varies. More specifically, the information in thecourt records of minors with and without a mental disorder differs on several factors. This affectsthe decision making of the juvenile judge, which is partly based on court records. Based uponour findings, we recommend minimum standards of what ought to be included in a record tooptimize the court files.The Decision-Making Process of Belgian Juvenile Judges Concerning Minorswith Mental DisordersLeen Cappon, Ghent University (leen.cappon@ugent.be)Purpose: Over the years, numerous studies have examined the factors that influence thedecisions of juvenile judges. These factors can be organized in an analytical frameworkconsisting of four categories (legal factors, characteristics of the minors, structural context andsocial context). Despite high prevalence rates of mental disorders in minors in juvenile court,decision-making research has rarely focused on this subgroup of the juvenile court population.Therefore, this paper aims to gain insight into the decisions of juvenile judges concerning minorswith mental disorders.Method: The judgments of 104 juvenile court records of minors with mental disorders (n=792),from two juvenile courts in Belgium, were analyzed based on the four categories of the analyticalframework. The analysis was executed in Nvivo 9.Results: The majority of juvenile judges in their judgments concerning minors with mentaldisorders referred to legal factors and to the information present in the juvenile court record(structural context). Remarkably, almost no references to the mental health problems of theminors were found in their judgments.Conclusion: This paper concludes that the judgments more frequently referred to so-called legalfactors than to factors related to the minor with mental disorders. These results urge furtherresearch on the decision of the juvenile judge concerning this subgroup.Placement Moves in the Care of Minors with and without Mental Disorders inJuvenile CourtSofie Merlevede, Ghent University (sofie.merlevede@ugent.be)382

Purpose: This study (1) examines the placement moves in the care of minors in juvenile courtand (2) makes a comparison between the placement moves of minors with and without mentaldisorders in juvenile court.Method: Data were collected through a file study of records present at the juvenile court for atleast 24 months (107 files). This study replicated James et al.’s (2004) inductive methodology toidentify common patterns of movement for both groups.Results: Within the juvenile court records, the number of placement moves varied between oneand nine. This variation was attributable to two main reasons. First, a small number of minorsaccounted for a disproportionate high number of placement changes. Second, stepping down incare also resulted in placement moves. Four main patterns of movement were found: a stablepattern, stepping down in care, an unstable pattern, and a variable pattern. Within these patterns,the movement profiles of minors with a mental disorder will be studied in depth.Conclusion: In the presentation, the number of patterns, the main patterns of movement, and thespecific profile of the patterns for minors with mental disorders are discussed.Mental Disorders in Detained AdolescentsLore Vandamme, Ghent University (lore.vandamme@ugent.be)Purpose: To provide insight into the prevalence of mental disorders among detained adolescents,with a particular focus on gender differences.Method: The past-year prevalence of mental disorders was measured in a sample of detainedboys (N=245) and girls (N=196), using the DISC-IV youth version.Results: In boys, the past-year prevalence of any disorder was 83.5%. Pure externalizingdisorders were most frequently found (58.8%), followed by comorbid ex- and internalizingdisorders (18.8%) and pure internalizing disorders (1.6%). In girls, the past-year prevalence ofany disorder was 94.9%. Comorbid ex- and internalizing disorders were most frequentlyobserved (48.7%). Criteria for pure externalizing disorders were met for 37.4% of the sample.The prevalence of pure internalizing disorders was 8.3%. Prevalence rates will be presented indetail during the presentation.Conclusion: Both detained boys and girls bear substantial mental health needs, indicating theneed for effective mental health services for this population. Rates of many disorders are higheramong girls, urging further research on gender-specific prevalence rates and protective and riskfactors.“Once I leave care, I will feel fine again”: Experiences of Young People LeavingCare with Regard to Health Care383

Sharon Van Audenhove, Ghent University (sharon.vanaudenhove@ugent.be)Context: For most people, young adulthood is a period in which they start taking definite steps toachieve independence. Most young people succeed in making this transition to adulthoodsmoothly. However, young people who have been cared for in residential facilities experienceconsiderable difficulties during their transition to adulthood. Purpose: The purpose of thisqualitative study is to understand the experiences and needs of young people in youth care withregard to mental health at the eve of their transition to adulthood.Method: To obtain an elaborate picture of the transition period, a follow-up study will be used.The young people will be interviewed twice: once before they leave youth care and once 18months after the first interview. The research data will be derived from in-depth qualitativeinterviews with 80 youths (ages 17-20). The research data from the first phase of the follow-upwill be presented. This presentation will focus on the voices of the youths themselves and whatthey need to manage the transition to adulthood successfully, with specific focus on the lifedomain of “mental health”.Results: The interviews reveal that the experience of residing in youth care is negative overall.Young people experience a series of significant losses and they perceive their time in care asleaving negative emotional scars. Few respondents develop strategies for coping and resilienceduring these experiences. They expect that the mere fact of “leaving care” will help them inestablishing balanced mental health. They feel they do not need the support of mental healthservices to achieve this balance.Conclusion: Attachment, grief, traumatic stress, and resilience can help to inform best practicefor youth care practitioners and caregivers involved in youth care.163. TBS: Ethics and TreatmentPsychiatric Detention and Long-Term Imprisonment as “Belt-And-Braces”MeasuresKarel Oei, Tilburg University (t.i.oei@tilburguniversity.edu)In the Netherlands we often see that in the case of serious crimes, such as rape followed bymurder, the judge will impose a sentence combining extended imprisonment with compulsorytreatment in a clinic. For a long time, the practice was that the compulsory treatment wouldalready start once a third of the prison sentence had been served. This practice has now beendiscarded. We also see that for many offences maximum prison terms have been increased. Thismeans that an offender often has to spend many years in prison before any treatment in a cliniccan commence. In these cases, the judge uses the compulsory treatment as a “belt-and braces”measure to make doubly sure the offender is not released. We often see this combination (of along prison sentence followed by compulsory treatment) in cases where the experts fear that theoffender in question is only marginally susceptible to treatment (for example Robert M. in the384

significant vice case in Amsterdam). The possibility of a perpetrator ever returning to society –after all, one of the aims of compulsory treatment – in this kind of case is small, which showsthat the current system no longer operates as it should.Moral Deliberation in Forensic PsychiatrySwanny Kremer, Groningen (s.kremer@fpcvanmesdag.nl)Staff in forensic psychiatry often have to make decisions in difficult dilemmas. They wonderwhat to do when they want to achieve “the good” or “the just”. These difficult choices are oftenrelated to moral issues. Questions that appeal to “the good” or “the just” raise issues about whatexactly “the good” and “the just” are in a specific situation. One could argue that TBS-patientsare ultimately dependent on staff. Not only are they separated from society for treatment, it isalso unclear how long this separation will last. Therefore it is important to make a wellconsideredbalanced decision that does justice to the patient, to society and to other personsconcerned. Several methods have been developed for moral deliberation. Usually, a distinction ismade between “problem”-orientated and “attitude”-orientated methods. Problem-orientatedmethods are often used to formulate a solution, or at least a decision regarding a dilemma.Attitude-orientated methods examine what moves people, what they find important. It iscustomary to decide which method to use after deciding what the aim of the dialogue is. Inforensic psychiatry both aims are important. Is it possible to develop a method of moraldeliberation that combines problem- and attitude-orientated methods?The Use of Diverse Intelligence Assessment Instruments in Offenders: A Reasonfor Concern?Inge Jeandarme, KeFor OPZC Rekem, Belgium (inge.jeandarme@opzcrekem.be)Kasia Uzieblo, Lessius, Antwerp, Belgium (Kasia.Uzieblo@lessius.eu)A wide range of assessment instruments are applied to detect intellectual impairments in bothforensic research and practice. The question is whether all these assessment instruments measurethe same underlying construct. In addition, Uzieblo and colleagues (2012) have recently arguedthat the assessment of intellectual capacities in forensic psychiatry appears to be informed bypractical aspects rather than grounded in a solid theoretical model. Hence it is often ignored thatthe different intelligence measures represent fundamentally different latent intelligence factors.In this study we will explore which intelligence assessment instruments are being used on aregular basis in a medium security forensic population in Belgium. Discrepancies in IQ total andindex scores will be analyzed. Implications of the usage of different assessment instruments willbe discussed in light of the Cattell-Horn-Carroll theory, a prominent psychometric theoreticalmodel of cognitive abilities.385

Working to Results in the TBSAart Goosensen, Tilburg University (aartgoosensen@kpnmail.nl)Karel Oei, Tilburg University (t.i.oei@tilburguniversity.edu)The number of psychiatric detention TBS has decreased from 226 to 99 since 2004. The mostimportant reason is that the duration of the treatment has exploded (4 years in 2000 to 9 years in2012). In court this dilemma has often been solved in a resourceful way. At the moment half ofthe (un)conditional termination patients are still in the clinic. And after one year conditionaltermination subsequently results in an unconditional termination. A qualified interaction betweentreatment and risk assessment for release is hardly known. To arrive at a recognizable treatmentmethod for all actors in the TBS-sector, treatment is aimed at the dynamic risk factors of theHKT-30. The physical journey and release plan are fixed within four months, as is the exit target(also in terms of HKT-30). Competences per discipline or module are balanced out against riskfactors to support the decision of how to treat tension between the actual score and target score.Therefore the treatment plan can be explained in less words; the professional understands thesense of “his” risk factor. This and more has been developed in the route card, valued by the Ist(inspection) as best-practice.Side effects of Androgen Deprivation Therapy in the TBSJelle A. Troelstra, Van der Hoevenkliniek, Utrecht, Netherlands (jtroelstra@hoevenkliniek.nl)Karel Oei, Tilburg University (t.i.oei@tilburguniversity.edu)The goal of Androgen Deprivation Treatment in sex offenders is to reduce the availability oftestosterone. If the testosterone level declines, a man produces less estrogen. The resulting dropin estrogen production leads to mental and physical complaints. These are complaints thatresemble climacteric complaints: mood swings with depressive complaints, sweat attacks (hotflushes) and osteoporosis. The decline in testosterone can reduce muscle mass and may causecomplaints of fatigue. Using progestagene substances such as cyproterone acetate or MPA cancause weight gain and breast enlargement (gynecomastia) as adverse side effects. To preventosteoporosis, patients use calcium tablets, vitamin D and a bisphosphonate. Bone densitymeasurement by DEXA scan takes place at regular intervals. The psychiatrist supervising thetreatment will constantly make comparative assessments of the desired effects and the burdens ofadverse reactions that may occur. When a patient has a desire to have sex with an approvingadult partner, there will not be much resistance from the team that treats the patient. For a patientwith hypersexuality or a patient with a non-exclusive paraphilic sexual preference, such a sexualdesire can fit within a positive life plan. When such a patient starts a relationship with an adultpartner one can consider a milder form of antilibidinal medication.386

164. TerrorismThe Nexus between Terrorism and Latin American Drug-Trafficking NetworksSilvia Leo, Universita La Sapienza - Rome (slsawuk@milnet.org)The nexus between crime and terrorism has received much attention after 9/11 and since thenseveral narco-terrorism links and terrorist financing sources, ranging from Colombia toAfghanistan, from Morocco to the Bekka Valley, from Europe to Southeast Asia and to otherparts of the world, have been brought to light. During the last ten years, drug trafficking,transnational gangs and other criminal organizations have grown in size and strength and,according to Drug Enforcement Administration sources, Al Qaeda groups in West Africa werecharging protection fees from cocaine drug-trafficking groups affiliated with the RevolutionaryArmed Forces of Colombia (FARC). Terrorist group operatives would also be linked to Mexicandrug cartels, providing the terrorists easy access to the U.S. and would receiving support,training, weapons and cash by Latin America. Through the analysis of facts we will try tounderstand the strength and complicity of criminal networks with terrorist organizations andwhat trends are predictable.The Norwegian Terrorist Case (Breivik)Aslak Syse, University of Oslo (aslak.syse@jus.uio.no)The Norwegian terrorist case (Breivik) Aslak Syse Anders Behring Breivik (1979) is aNorwegian terrorist. On 22 July 2011, Breivik bombed the government buildings in Oslo, whichresulted in eight deaths. He then carried out a mass shooting at a camp of the Workers' YouthLeague (AUF) of the Labour Party on the island of Utøya where he killed 69 people, mostlyteenagers. Breivik was diagnosed with paranoid schizophrenia by the court-appointedpsychiatrists, acting compulsively based on a delusional thought universe. Among other things,he alluded to himself as a future regent of Norway pending a takeover by a Templar-likeorganization. Breivik's far-right militant ideology is described in a compendium of texts, titled2083 – A European Declaration of Independence and distributed electronically by Breivik on theday of the attacks. His worldview includes cultural conservatism, right-wing populism,Islamophobia, Zionism, anti-feminism, and white nationalism. In Norway, the outcome ofBreivik's competency evaluation was fiercely debated by mental health experts. Counselrepresenting victims filed requests that the court order a 2nd opinion. In February 2012 a newperiod of psychiatric observation, this time more encompassing, started. The report will besubmitted to the court on 10 April. The court case will start April 16. In the presentation thepsychiatric evaluations will be reviewed and the outcome of the court case will be discussed.387

Efficacy of Combined Interviewing Techniques in Detecting Deception Relatedto Bio-ThreatCharles A. Morgan III, Yale University (charles.a.morgan@yale.edu)In the absence of objective evidence, forensic psychiatrists working in conjunction with securityand law enforcement professionals must rely on subjective judgments in order to determinewhether a person being questioned is being genuine or deceptive. This research assessed theefficacy of two well-validated ‘detecting deception’ methods (aIAT and Cognitive Interviewing)when applied to a group of interest (i.e. scientists) with expertise in an issue of interest (i.e.production of biological materials) under conditions of interest (i.e. low base rate deception). Inaddition, we compared the efficacy of these methods to professional judgments. The resultssuggest that cognitive interviewing yields data that is superior to professional judgmentsregarding truthfulness or deception; aIAT was not significantly better than professional judgmentdata.165. Theory and Research in Criminal Psychology IFunctional Diagnostics in Forensic PsychiatryStefan Bogaerts, Tilburg University (s.bogaerts@uvt.nl)Studies on personality disorders and the relationship between clinical factors such as insight intoproblem behavior, (lack of) empathy and the quality of coping skills is often done in the past.However, most studies are primarily focused on the question of whether individuals with aspecific personality disorder differ on these clinical factors compared to individuals withoutpersonality disorder. Unfortunately, within forensic psychology and psychiatry, the severity ofthe personality disorder, more particularly the presence of multiple personality disorders inindividuals as they relate to clinical factors is very rarely examined while scientific researchpoints out that relevant factors in the past, such as conduct disorders and experiences of neglectand abuse in youth, are strong predictors for the development of a problematic personalitystructure. This gap in forensic scientific research has obvious implications for treatment, socialreintegration of forensic psychiatric patients and the likelihood of recidivism. In this lecture, wewill talk about the relationships between the severity of personality disorders, empathy andcoping skills in adulthood, and negative childhood experiences and conduct disorder.Sexually Violent Predators and State Appellate Courts’ Use of Actuarial Tests inCivil Commitments388

Frances P. Bernat, Texas A & M University (frances.bernat@tamiu.edu)Jacqueline B. Helfgott, Seattle University (jhelfgott@seattleu.edu)Nicholas Godlove, Attorney at Law, USA (ngodlove@gmail.com)The transfer of the use of the term “predator” from pop culture to law coincided with theexponential accumulation of research in the area of psychopathy, sexual deviancy, and violentcrime. In recent years, psychopathy has emerged as one of the more robust indicators of chronicoffending and violent recidivism. In the United States, some laws have been enacted that focusattention on violent offenders who are diagnosed to be sexual predators. The state laws providefor the civil commitment of those deemed to be a sexual predator either prior to or after theircriminal sentence has been completed. In order to understand how civil commitment of sexualpredator determinations are handled on appeals, this paper examines 107 state appellate courtcases whose central legal issue was whether a defendant was a sexually violent predator in needof civil commitment. These state court appellate cases, rendered between 1990 and June, 2011,utilized a variety of psychological forensic assessments to make sexually violent predatordeterminations. We focus on expert testimony provided to state courts and the degree to whichcourts utilized forensic tools in their findings of psychopathy, sexual violence, and predatoryaggression. Implications for the use of the actuarial predictors of dangerousness in sexuallyviolent predator civil commitments are discussed.Profiling Psychopathic Traits in Serial Sexual Homicide: A Case Study of thePersonality and Personal History of the Green River Killer, Gary Leon RidgwayLoren T. Atherley, Seattle University (lorentatherley@gmail.com)Psychopathy is believed to be a defining personality trait in violent sexual offenders – researchconducted on serial sexual homicide offenders reveals psychopathy to be a contributory,functional aspect of the offender’s personality. Commonly accepted modes of aggression (i.e.predatory and catathymic) suggest an exclusivity; this study suggests the comorbidity andcollusion of these factors to enable a series of sexually motivated homicides. This paper isadapted from thesis research conducted on the offense behavior and personality of the GreenRiver Killer, Gary L. Ridgway. The conclusions of this study suggest that Ridgway operated asboth predator and catathymic actor when he killed seventy-eight prostitutes in and around KingCounty, Washington. Allowing for this duality challenges concepts of the role of aggression.Implications for investigations and criminal profiling are discussed.Actuarial Prediction in Determinate-Plus Sex Offender Release DecisionsBeck Strah, Snohomish County Sheriff's Office, USA (strahb@seattleu.edu)389

Jacqueline B. Helfgott, Seattle University (jhelfgott@seattleu.edu)In 2001 the Washington State Legislature enacted Determinate-Plus Sentencing for sex offendersconvicted of certain sex offenses who are subjected to an indeterminate life sentence withdiscretionary release by the Indeterminate Sentencing Review Board. Little is known about thefactors that influence Indeterminate Sentencing Review Board decisions in Determinate-Plus Sexoffender release decisions. The purpose of this study is to determine the factors that influenceIndeterminate Sentencing Review Board decisions to release determinate sentencing-plus sexoffenders with a focus on the role of actuarial tools in these release decisions. The studyexamines 688 Determinate Sentencing-Plus cases reviewed by the Washington StateIndeterminate Sentencing Review Board from 2003-2010. Research questions include: What isthe profile of a determinate-sentencing plus case that results in release? What role do clinicaljudgment versus actuarial scores play in release decisions? What role does offender expressionof remorse play in release decisions? Does completion of sex offender treatment influencerelease decisions? Factors including nature of crime, victim type, actuarial risk scores,expression of empathy and remorse, completion of treatment, offender accountability, and victimimpact are examined. Implications for parole decision-making, sentencing policy, and offenderreentry are discussed.The Popular Conception of the Psychopath: Implications for Criminal JusticePolicyJacqueline B. Helfgott, Seattle University (jhelfgott@seattleu.edu)The scientific conception of psychopathy has become clear in recent years as researchers havereached a consensus regarding the definition and understanding of psychopathy with thedevelopment and widespread use of the Psychopathy Checklist-Revised. The popular conceptionof the psychopath is not so clear. The term is widely used in culture – in films, television shows,true-crime novels, the news media, the Internet, and everyday conversation. The meaning of theword “psychopath” among the general public and how the popular conception of the psychopathinfluences criminal justice policy has not been empirically studied. The purpose of this paper isto present results of a general public survey on the popular conception of the psychopathconducted during an era of legislative change in Washington State to determine what the termpsychopath means to people and the ways in which the popular conception of the psychopathshapes decisions about criminal justice policy. Three-hundred fifty-three respondents wererandomly selected from the Seattle-area telephone directory for participation in a telephonesurvey. Results suggest that the popular conception of psychopathy is inconsistent with thescientific conception and impacts citizen beliefs about criminal justice practice. Implications forcriminal justice policy are discussed.166. Theory and Research in Criminal Psychology II390

Emotional Correlates of Radicalization and TerrorismStephen K. Rice, Seattle University (ricest@seattleu.edu)Robert Agnew, Emory University (bagnew@emory.edu)Limited attention has been paid to the intersection of emotions and the etiology of terrorism.Instead, research priorities have tended to focus on the structural (e.g., poverty; weak and failingstates), sociopolitical (e.g., U.S. foreign policy), or dialectical. The aim of this study is to outlinean agenda which transitions discourse related to the “body” of the terrorist (i.e., his/her historicaland social positioning) to one focused on intrapsychic and interpersonal emotional processes. Inour view, criminology is well suited to assess the expressive byproducts of humiliated fury,contempt, moral outrage, and disgust and how such emotions may distillate as impulses that forma basis for terror. One compelling theoretical lens is provided by strain-based explanations ofterrorism, whereby collective strains increase the likelihood of terrorism under select conditions.Female Desistance from Criminal Offending: Exploring Gender Similarities andDifferencesElaine Gunnison, Seattle University (gunnisone@seattleu.edu)Over the past several decades, researchers have more fervently examined female offending. Thecriminal career research paradigm put forth by Blumstein and colleagues in 1986 offers anopportunity for researchers to examine offending, including female offending, from multipleperspectives including onset, persistence, and desistance from a multitude of theoreticaltraditions (e.g., psychological & sociological). The purpose of this presentation is to provide abrief overview of theoretical perspectives on female offending as they relate to desistance as wellas presenting research results from an investigation into female desistance using data from wave6 of the National Youth Survey. The results from the examination of the similarities and/ordifferences between female and male discrete offender groups (desisters, persisters, late onseters,and conformers) and theoretical predictors of desistance from general delinquency will beprovided. The research and policy implications will be discussed.Beyond RNR: Risk Limits ResponsivityFaye Taxman, George Mason University (ftaxman@gmu.edu)James Byrne, University of Massachusetts (profbyrne@hotmail.com)391

A thorough review of the empirical evidence supporting the Risk-Need-Responsivity Modelsuggests that the formula needs to be revised to incorporate new empirical evidence and theconcept of desistance. This paper will review a third generation of RNR models with a focus ondesistance. The paper reviews the empirical literature on offender change which notes thatoffender outcomes may be a product of stabilizers in a person's life which serve to preventcriminal offending. Stabilizers are factors that promote stabilization and include family relations,employment, housing, mental health status, and other factors that are supportive of a positivebehaviors. Destabilizers such as substance abuse, mental health illnessness, periods ofunemployment, residence in a crime "hot spot", and other factors should be used to identifyhigher structured interventions. The new model advances a focus on responsivity by focusing ontemporal factors that can be altered to promote a prosocial lifestyle. Empirical models will beprovided to demonstrate the new models.The Phenomenology of Addiction and the Artifact of Criminal BehaviorDavid Polizzi, Indiana State University (david.polizzi@indstate.edu)The relationship between drug use and criminality has become a well established fact over thelast four decades in American society. The “war on drugs” sought to eradicate the illegal sale anduse of drugs through the enactment of stiffer penalties for drug-related offenses in the belief thatsuch governmental action would effectively deter subsequent involvement in the “drug lifestyle.”Perhaps the most glaring omission of this response is the lack of recognition that the adjudicationand criminalization of addiction will have little to no deterrent effect on the continued use ofillegal substances given the complexity and psychological specificity of the phenomenology ofthe addictive process. This paper explores the complex nuances that are present within thephenomenology of addiction. Implications for law enforcement strategies in responding to thephenomenology of addiction and fundamental structure of the addictive process are discussed.The Media Construction of Mental Illness in Offenders Perpetrating Extremist& Terroristic Violence in AmericaWilliam Parkin, Seattle University (parkinws@gmail.com)Jeffrey Gruenewald, University of Arkansas (jgruenew@uark.edu)Through the utilization of content and theme analyses, this study examines the media andjournalistic accounts of terroristic and extremist violence in the United States, specificallyfocusing on the discussion and presentation, if any, of an offender’s mental state prior to and atthe time of the act. Data from the Extremist Crime Database is used to examine open-sourcedocumentation related to violent, ideologically motivated extremist incidents that occurred in theUnited States between 1990 and 2010 by the far-right, Jihadists, and environmental and animal392

ights extremists. The vast majority of American society has no direct experience withideological violence and therefore the frames through which they understand and discuss theevents and the mitigating and aggravating factors specific to offender motivation, such as theirmental health, are developed primarily through the media. The analysis of these frames isimportant as they can inadvertently, or otherwise, impact policy depending on whether the publicand policymakers view extremists as rational or irrational actors.167. Title T.B.A.An Ultra Short Admission Unit to Provide Flexibility in the Admission Capacityin AmsterdamHans Nusselder, Arkin, Amsterdam, Netherlands (hans.nusselder@mentrum.nl)Astrid Vellinga, Arkin, Amsterdam, NetherlandsWorking in acute psychiatry is often put under pressure by a shortage in admission capacity,especially in large cities. This shortage has increased considerably in the last few years becauseof the greatly increased amount of involuntarily committed patients, the cutting back onadmission capacity and the altered norm for the maximum duration of a psychiatric patient’s stayin a police cell. In this context a Short Transitional Admission Unit (STAU) (“TijdelijkeOverbruggingsAfdeling – TOA”) in Amsterdam functions as a gateway to admission into allclinics. In this session we will evaluate the role of a STAU as a component of acute psychiatry.The STAU must have the capacity for at least one admission at all times. This is realized bymeans of a “worst in, best out” system. This results in shorter stays in police cells and drasticallydecreased out-of-area placements. Patient characteristics and applied forced interventions arebeing reviewed in a sample of 5000 patients admitted to the STAU in the last 10 years. Theestablishment of an ultra short transitional admission unit as a gateway for admission to a clinicis effective as a buffer during a shortage in admission capacity.Involvement of the Patient’s Family in Psychiatric Treatment: The Necessity, aModel and the Juridical ProblemsJurgen Cornelis, Arkin, Amsterdam, Netherlands (jurgen.cornelis@arkin.nl)The notion that it is important to involve patient’s families in psychiatric treatment is now widelyaccepted. Research has shown that systemic therapeutic interventions are effective in differenttypes of psychiatric illnesses. Experience shows that involving the family, for example in crisissituations, can lead to a breakthrough in treatment. Furthermore, family can give a wealth of newinformation about the problem and working with the patient and his family together helpstreatment succeed in the long run. But in which way we can work together with the patient and393

his family? Different models are described in family therapeutic handbooks but most of them aredifficult to apply, for example on psychiatric wards or in emergency rooms. In this presentation amodel for working with families will be presented, which is very easy to learn, which can beproblem- or solution-driven and in which the social worker or doctor can be in the role of expertor process manager. By means of case material, the tension between privacy of the patient andaccurate care when the family is involved will also be discussed."No More Psychiatric Patients in Police Cells!" Ten Years of Experience withthe Psychiatric Emergency Unit in Amsterdam, the NetherlandsJeroen Zoeteman, Arkin, Amsterdam, Netherlands (jeroen.zoeteman@spa.nl)After the turn of the century, disturbances in the cooperation between police and mental healthinstitutes in Amsterdam escalated to scandals in the newspapers, legal conflicts and formalquestions in the Dutch parliament. Psychiatric patients had to be held for a long time in policestations after they were brought in by police because of dangerous behavior or public nuisance. Ittook many hours before they could be assessed and treated by psychiatric services. All thisturmoil resulted in a unique alliance between police, the municipal health service and the mentalhealth institutes. In 2003 the mental health institutes formed one Psychiatric Emergency ServiceAmsterdam (PESA) and a Psychiatric Emergency Unit (SPOR). The PESA offers immediatehelp to young people and adults in severe and acute mental distress in the community, the causevarying from psychosocial crises to severe mental illness, 24 hours a day, 7 days a week. Everyyear approximately 6000 consultations take place, one third leading to admissions in psychiatrichospitals and half of which involve coercive measures. By concentrating this specific populationto one location, the staff have gained more experienced. It has been possible to cause a strongdecline in the use of coercion (14% to 1%) and to improve the quality of care and the responsetime of the service.Compulsory Admission of Severely Mental Ill Patients in Mental Health Care?Jack Dekker, Arkin, Amsterdam, Netherlands (jack.dekker@arkin.nl)To our best knowledge, severely mentally ill patients can get optimal treatment from a medicinalperspective. However, the efficacy of medication is moderate and the use of it can result inmultiple side effects that can possibly lead to polypharmacy and a shorter life expectancy;frequently they are compulsorily admitted and often transferred to a different ward or institution;they are subject to discrimination and victimization by society rather than being the aggressorsthemselves; a large group probably had no permanent residence during the last decades and themajority of this group is likely to have a low social participation and integration. Thispresentation takes a closer look at the problems as mentioned and is based on a cohort study of394

323 EPA patients in care (in Amsterdam) who were interviewed in 2005/2006 and again in2010/2011 (224 out of 323 patients have participated in the follow-up assessment).168. Mental Health and Land: Indigenous Peoples and HumanRightsEthical Framework of Indigenous Peoples’ Environmental RightsFrederick Coleman, University of Wisconsin-Madison School of Medicine(Frederick.Coleman@mhcdc.org)The discussion of several specific case studies regarding indigenous people's rights regarding theenvironments in which they live with special regard to water will be framed with two differentperspectives on overarching ethical approaches. the first perspective will be a traditionalWestern system based on Individual Rights (Autonomy), Universal moral Principles (Justice),Doing Good (Beneficence), and Risk/Benefit Analysis (Non-maleficence). The secondperspective will be a Feminist and Cultural critique based on Relational Identity (Self isconstitute and maintained in overlapping relationships and communities), Analysis ofOppression (Marginalization, Exploitation, Cultural Imperialism, Powerlessness, Violence),Narrative Analysis (Case specific Stories), and Shared Discussion (Good and bad can be definedwith all voices being heard at the table).“Water is Life”: The Anxiety over Losing Water Rights of the Dine’ Peoples ofthe Southwest USAOmie Baldwin, University of Wisconsin-Madison (obaldwi1@wisc.edu; omieb@att.net)This presentation examines the stuggles of trying to hold on to resources- the water rights- ofthe Dine' Peoples of the southwest, United States, Navajos are experiencing their water rightsbeing compromised to benefit Cities, and business as the American Indian are ask to give upmore of their water resources. American Indian are concern of the survival of their futuregeneration, this is at a time when some of the American Indians do not have running water intheir homes, and water is a precious commodity. The possibility of losing their water rights, forthe Navajos of the Southwest United States is creating stress for the Tribe, the communities,families and individual.395

Sacred Sites versus Corporate Rights: Anxieties and Antidotes in a NorthAmerican Indigenous CommunityPatricia Loew, University of Wisconsin-Madison (paloew@wisc.edu)This presentation examines cultural anxiety in the Bad River Ojibwe over plans to site a largescale taconite iron mine at the headwaters of the Bad River watershed, one of the riches wildrice-producing areas in North America. Manoomin, as the Ojibewe refer to the rice, is thespiritual center of the tribe's political, historical, social, and ceremonial experience. the tribe hastaken a traditional approach to elevate understanding about its relationship to the wild rice andthe need to protect this important natural resource--storytelling. However, tradition now has acontemporary twist. Young people (ages 10-14) are creating digital stories about the mine threatthat integrate Traditional Ecological Knowledge with western science and uploading them toYou-tube. Their stories, which rely on interviews with elders and Native scientist, empower thecommunity, influence outside decision-makers, help create Native and non-Native coalitions,and ultimately help reduce cultural stress over this perceived threat to their way of life.169. Torture & AbuseThe Right to Rehabilitation in International Criminal Law and the Role ofMental Health Professionals in the Post-Conflict Reconciliation ProcessDragana Radosavljevic, University of Greenwich (rd38@gre.ac.uk)The present paper investigates the parameters of the right to rehabilitation of war criminals andveterans under international criminal law and seeks to identify specific rights in relation tohealth, in this context mental health, as means towards social re-integration and, ultimately,reconciliation. The paper highlights inherent problems associated with immediate post-warinequalities in accessing mental health resources between military personnel, veterans andconvicted war criminals on one hand and victims of the conflict on the other, who are morelikely to be recipients of reconstruction efforts and help from international organisations. Dealingwith mental health issues of those who have or are perceived to have committed crimes, or havebeen convicted of war crimes, is more difficult, as this requires greater social and political will aswell as infrastructure. The paper then explores roles and scope of mental health professionals inthe post-conflict rehabilitation process of war criminals and veterans as well as the role of thoseprofessionals in facilitating social reconciliation. Generally, military rules provide little privilegeon information offered by those seeking therapy, such as admissions of war crimes, which mayresult, through the suppression of guilt, anxiety or depression for instance, in misdiagnosis and/oraggravation of symptoms for which help is sought in the first place. Two issues are consideredhere. Firstly, the extent to which military confidentiality rules hinder psychotherapist-patient396

elationship and secondly, the impact this has on the effectiveness on collective reconciliation,coupled with issues of stigmatization of mental health.Torture-Sanctioning Health Professionals: A Case StudyPeter Golden, Victoria Coalition for Survivors of Torture, Canada (petergolden@shaw.ca)The participation of health care professionals in torture and other forms of cruel, inhuman anddegrading treatment is an on-going and increasing problem in most countries throughout theworld. Despite being contrary to international law, health care professionals continue to designand implement these practices with impunity. A proposal for an International HealthProfessionals Ethics Oversight Committee developed by the Victoria Coalition for Survivors ofTorture has been presented at previous meetings of the IALMH. The proposal continues to berevised, and to garner interest and support. This presentation will present a case study of how theOversight Committee would address the gaps in national and international regulations to sanctionhealth workers involved in unethical standards of practice. In particular, the case study considersa professional misconduct complaint against a psychologist. The psychologist is alleged to haveparticipated in the development of “enhanced” or abusive interrogation techniques used by themilitary and security forces of a western democratic country. The alleged conduct violatesvarious local statutes and falls below the standard of conduct established by the professionalgoverning body. Despite compelling and publically available evidence, the professionalgoverning body with the local jurisdiction to consider the complaint against the psychologistrejected the complaint without comment. The case study looks at what other avenues ofinvestigation and censure are available in these circumstances and underlines the shortcomingsthese alternatives present to an effective system of oversight for health professionals involved intorture or other cruel, inhuman or degrading treatment or punishment.Reflection of Legal and Social Consequences on Mental Health Condition ofVictims of Ethnic Cleansing in GeorgiaMariam Jishkariani, RCT/EMPATHY, Georgia (mjishkariani@yahoo.com)Introduction: The main goal of this study was to evaluate the effectiveness of multi-profileintervention in cases of victims of ethnic cleansing in Georgia. Methods: Multi-profile medicalfiles and several PTSD focused psychological inventories were used. Results: Based onobservation in 2011, n = 413 victims were observed. Among them 302 had experience of ethniccleansing and/or torture during conflicts in Chechnya and occupied territories of Georgia.According to the data analysis, in 266 cases (88% of 302) physical disturbances were observedtogether with psychological problems. Multi-profile treatment and rehabilitation were provided.Legal redress was not achieved. In all cases mental problems were revealed to have wavydynamics with tendencies for chronic changes in personality. Discussion: Correlations of trauma397

and stress related disorders were observed in many clinical studies, but studies on the reflectionsof legal redress on dynamics of stress-related disorders were missing. Conclusion: We concludethat legal redress is significantly important for full recovery. Consequently, legal assistanceshould be considered as part of psychological rehabilitation. We conclude that research should beaddressed to comparative study between those who have received legal redress and those whostill have not been legally recognized as victims.A Comparison of the Response of the World Psychiatric Association toPsychiatric Abuse and the World Medical Association to Organ TransplantAbuseDavid Matas, University of Manitoba (dmatas@mts.net)David Matas and David Kilgour co-authored a report which concluded that Chinese hospitalsand detention centres, since 2000, have put to death large numbers of prisoners of conscience —practitioners of the spiritually based exercise regime Falun Gong – through the harvesting oftheir vital organs, which were then sold at high prices. Ethan Gutmann later concluded that otherprisoners of conscience — Tibetans, Uighurs and house Christians — have been victims of thesame abuse. The Government of China acknowledges that almost all of its organs for transplantscome from prisoners. The Soviet Psychiatric Association withdrew from the World PsychiatricAssociation in 1983 when it faced almost certain expulsion. This paper will compare theresponse of the World Medical Association to organ transplant abuse in China to the response ofthe World Psychiatric Association to psychiatric abuse in the Soviet Union. The conclusionwould be that, even taking into account the fact that organ transplant professionals are only asmall component of the Chinese Medical Association and that China today is in a far differentsituation geopolitically than the Soviet Union was in 1983, the response of the World MedicalAssociation to organ transplant abuse in China has been inadequate.170. TraumaA Model for Understanding and Treating Burn-Out and Compassion Fatigue inForensic PersonnelLee Norton, Center for Trauma Therapy, Nashville & Melbourne, USA(norton@centerfortraumatherapy.com)The term compassion fatigue was coined in 1995 by Dr. Charles Figley (1995, CompassionFatigue: Coping with secondary stress in those who treat the traumatized) to describe thecumulative effects experienced by those who work with traumatized individuals. Compassionfatigue is sometime used synonymously with secondary trauma, but Baranowsky and Gentry398

(2002), who developed the Accelerated Recovery Program for compassion fatigue, demonstratea more edifying equation: primary trauma + secondary trauma + burn out = compassion fatigue.The unique value of this model is the inherent requirement that each care giver resolve his or herown trauma prior to and while they provide care for others. Only in this way can burn out andcompassion fatigue be mitigated or avoided altogether. In the upcoming text Encyclopedia ofTrauma (2012, Figley, ed.), Norton and Woods look at how compassion fatigue can affectindividuals involved in the court system, specifically jurors, jurists, attorneys, and court roompersonnel. Continued exposure to noxious descriptions of violence, injustice, and humiliation cancause acute and chronic traumatic stress conditions, including compassion fatigue. Thispresentation will examine the ideas and practical applications of the Accelerated RecoveryProgram for treating burn out and compassion fatigue. Assessments will be provided so thatparticipants may discover ways in which they may be vulnerable to or suffer from conditions thatinterfere with care giving or other work that involves exposure to trauma.Forgotten Victims: Psychological Impact on Children Whose Parent has BeenKilled by the PoliceJohn Burris, National Police Accountability Project, Oakland, USA (burris@lmi.net)The Forgotten Victim Study is an empirical research project examining families torn apart byviolence due to police misconduct, and focuses on children under the age of eighteen whoseparents, most commonly their fathers, have been killed or seriously injured by the police. We areexploring the short- and long-term impact of both the acute and developmental Post TraumaticStress Disorder trauma with these children, as well as in their families. We are interested in:gaining perspective on what support is needed to assist these forgotten victims, to enhance thelimited research on which to understand the short- and long-term impact on children, and todetermine whether the mental health issues presented by children in this category are more orless severe than children whose parent dies from natural causes or by fatal accident. Throughinterview and direct survey with the child’s parent or caregiver, we have studied a group offifteen children, and continue to include an average of 2 children each month. We have beenactively studying this sample for approximately five years and the study is ongoing. The benefitof the ongoing nature of this study is that we are able to capture the stages of the coping processin relation to critical stages in their human development. The study has identified a range ofmarked coping mechanisms, from psychological intervention, to divergent activities. The studyis showing that the coping process is varied, and impacted positively by the presence of a supportnetwork. The supportive network differs depending upon whether the deceased parent isperceived as a wrongdoer.Survivors of Capital Crime Traumatized by Secondary-Victimization: Exploringthe Impact of Capital Punishment on the Living399

Melodee A. Smith, Nova Southeastern University (melodee@nova.edu)Examining three cases where family members of a death row inmate, family members of amurdered victim and members of a community group struggle to make sense of capitalpunishment carried out by the State over their objection, this project explores the trauma thatsurvivors experience as secondary-victimization. Drawing on the research of post-victimizationand double-victimization (Doerner, 2012), this study explores how survivors of capital crimewho oppose the death penalty are traumatized when they are taunted, for example, for notwanting the worse possible punishment for the murdered victim’s killer – and are, therefore,accused of not truly loving or caring for the life of the murdered victim. Addressing traumaexperienced as secondary-victims, survivors opposing capital punishment also reported that theyexperienced the trauma of being blamed for the murder, either because of their relationship to thevictim or to the killer, and/or as a member of the community in which the victim and/or killerlived. Discovering the increased intensity of suffering experienced by a survivor of a capitalcrime who opposes executions contributes to a greater understanding of the harmful policydecisions to seek capital punishment without regard to the needs of or impact onsurvivors. Recommendations for considering ways to mitigate or eliminate the traumatic impactof secondary-victimization in capital cases emerging from this study are discussed.171. Treatment ProgramsA Prison Transition Support Service for People with Mental Illness Dischargedfrom Prisons in South East Queensland (Australia)Kingsley Bedwell, Richmond Fellowship Queensland (hq@rfq.com.au)Robert King, Queensland University of Technology (robert.king@qut.edu.au)The prevalence rate of psychosis in the prison population is 30 times higher than the non-prisonpopulation (Vicserv, 2008). Upon release from prison the experience of people with mentalillness has been characterised as "extreme social disadvantage". People are seen to be at anincreased risk of premature death and often face significant difficulties accessing communityresources and having their basic rights respected (Kariminia et al, 2007; Kinner et al, 2006). Theprovision of re-entry support for people with mental illness leaving prison is clearly a socialinclusion imperative in an urgent area of need. Richmond Fellowship Queensland (RFQ) hasbeen delivering a prison Transition Support Service to such people in South East Queensland(Australia) for over four years. RFQ works to address different aspects of social exclusionthrough provision of direct support and counselling and by working with community servicesand the Prison Mental Health Service. This paper describes the service model and programstructure of the Transition Support Service. Referral trends, activity to date and client outcomeswill also be discussed. The paper will include a case example and provide some brief reflectionson RFQ's experience.400

Parolee Treatment Outcomes: The Impact Of Programs, Practice andPractitionersJo Brocato, California State University at Long Beach (jo.brocato@csulb.edu)Ryan Fisher, California State University at Long Beach (ryan.fisher@csulb.edu)Connie Ireland, California State University at Long Beach (connie.ireland@csulb.edu)Aili Malm, California State University at Long Beach (aili.malm@csulb.edu)In recent years the evidence indicates that the consequences of inadequate treatment forsubstance use disorders among parolees re-entering the community pose significant public safetyand health risks. In response to high rates of recidivism among drug using parolees, Californiaimplemented a statewide in-prison drug treatment and community aftercare program intended toreduce drug use and recidivism. This study examines the effect of the workforce compositionand standards of care on parolee outcomes following program completion. The program leveldata is derived from interviews conducted with program directors and counselors at 90community based programs across the state and the participant-level data used to answer theresearch questions are from the 1,200 parolees who completed baseline surveys. A logisticregression model determined that parolees in programs that included stress management groupswere less likely to successfully complete the program and those that were in programs thatincluded cognitive behavioral criminal thinking groups were also less likely to complete. Howaftercare retention and program completion are influenced by program, practitioner, and the useof evidence based practices, predict completion and recidivism with implications for practice arediscussed.Experiences of Liberty Deprivation by Inmates in a Penitentiary HospitalNatalia Joelsas Timerman, University of Sao Paulo (natimerman@usp.br)This study, a master's level ongoing project in Clinical Psychology at the Institute of Psychologyof University of Sao Paulo, comprises a phenomenological approach towards the differentexperiences of liberty deprivation by inmates in a penitentiary hospital. Semi-structuredinterviews were conducted with previously selected individuals representing different types ofliberty deprivation due to being both imprisoned and ill. Those individuals were: an inmate witha clinical disease that does not offer major current or future risk; an inmate with a terminaldisease; an acutely psychotic inmate; an inmate who had suffered a stroke; an inmate currentlyaddicted to psychoactive substances; and an inmate in what is known as the "safe area" (thehospital wing reserved for those at risk of being threatened by other prisoners because of theirtype of offence or membership in a different criminal gang). These interviews were analyzed in401

light of the question of liberty in Hannah Arendt, aiming to answer whether it is possible,through the approach of liberty in its ontic meaning, to know its ontological meaning.Implementation of Occupational Therapy in the Mental Health Unit at thePenitentiary System Hospital CenterLilian Caldas Ribeiro Ratto, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil(lilian.ratto@gmail.com)Gilma Alencar, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil(gilmaregina@hotmail.com)Quirino Cordeiro Jr, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil(qcordeiro@yahoo.com)Cristiane Orsetti, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil(crisorsetti@terra.com.br)Marta Rudge, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil (marudge@gmail.com)Priscilla Spinola, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil(prisci.to@gmail.com)Thais Valente, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil (thais.rv@gmail.com)Ariana Zocaratto, Brotherhood of Santa Casa of Mercy of Sao Paolo, Brazil(ariana_santiago@hotmail.com)Objective: To present the process of implementation of Occupational Therapy (OT) in theMental Health Unit at the Penitentiary System Hospital Center. Method: The mapping of thepopulation for the investigation of demands, creating a specific screening instrument for OT.Results: The mapping was performed with hospitalized patients between August 2009 toDecember 2011. Among women, there was a high prevalence of histories of illicit substance use,anxiety and depressive symptoms. Among men, there was a predominance of young people and ahigh prevalence of persecutory thoughts, illicit substance use and depressive symptoms. Mainindication criteria for OT monitoring were: difficulty in adapting to imprisonment; suffering;conflicts in interpersonal relationships; and lack of treatment adherence. Conclusion: Due to theparticularity of the prison population in this Hospital, needs were evaluated to expand and createmore flexible forms of OT assistance for group and individual assistance for women (pregnantand puerperal women) and for patients with infectious diseases. For the male population,membership of rival criminal factions precluded group treatments, and only individual assistancewas evaluated.Doing Justice in Prisoner Rehabilitation: Relapse PreventionMargaret Severson, University of Kansas (mseverson@ku.edu)402

Chris Veeh, University of Kansas (veeh1221@gmail.com)Kim Bruns, University of Kansas (kbruns@ku.edu)Jaehoon Lee, University of Kansas (jaehoon@ku.edu)To date in the United States, the prisoner reentry literature largely points to an overall failure ofnationwide reentry programs to effectively reduce recidivist behaviors. Despite the millions ofdollars poured into the early 21st century reentry-rehabilitation efforts, most programs yielded atbest, ambiguous results. This paper presentation reports on multiple measures used to assess thesuccess of a statewide and a local prisoner reentry program, with success defined as offendersincurring fewer incidents of recidivism than matched reentering prisoners who received a lessstructured course of reentry services and/or reentering prisoners who received no reentry servicesat all. In addition, a subsample of offenders participated in the same reentry program at leasttwice, making it possible to test a relapse prevention hypothesis, i.e., that rehabilitation involvesa process that extends over multiple failures and multiple program exposures. The results of thelarge scale program evaluation and of the multiple exposure analysis suggest the need for a moredynamic approach to offender rehabilitation, involving the whole of the offender: mind, body,assets, and liabilities; and the whole of the community: economic resources, public policy, and aspirit of patience and tolerance.172. Two-Stage SentencingTwo-Stage SentencingAlbert Kruger, High Court, Bloemfontein, South Africa (albertkr@vodamail.co.za)Traditionally courts sentence a person for a criminal act. The act is the basis for sentencing. InSouth Africa section 286A of the Criminal Procedure Act makes provision for an indefinitesentence to be imposed on a dangerous criminal. Dutch TBS legislation and psychopath laws inother countries can usefully be compared to section 286A. After the period determined by thejudge imposing the sentence (usually between 10 and 20 years) the convicted person has to bebrought before the same judge again. At that stage the judge gets a report from the prisonauthorities, dealing with rehabilitation. The judge then re-assesses the sentence, and can at thatstage impose further imprisonment, or order release. The Children’s Act 75 of 2008 provides insection 76 that the court sentencing a child under 21 years can direct that the child be broughtbefore the court when the child reaches the age of 21 years. The court then re-assesses thesentence.Two-stage sentencing procedures create the means for the court to impose a sentence, and todetermine later whether the sentence has had the desired effect. The two-stage sentencingprocedure should be encouraged and expanded.403

Renewing and Prolonging Sentences: Dutch Variations on South African Two-Stage SentencingMarijke Drost, Sub Rosa Psychiatric Expertise, Utrecht, Netherlands (deweertdrostm@ziggo.nl)Similarities and differences between Section 286A of the South African Criminal Procedure Act(two-stage sentencing) and the Dutch law for mentally ill offenders (adults and minors) will bediscussed. The TBS-system for adults and the PIJ-measure for children and adolescents aged 12-23 share the dual purpose of protecting society and treatment/rehabilitation for the mentally illoffender or disturbed child. If the risk of serious reoffending remains unchanged, the TBSmeasurecan last for life, sometimes in a special longstay unit without the perspective ofrehabilitation. The TBS-measure for adults will be regularly evaluated by a judge, even in alongstay situation. Assessment by an independent psychologist and psychiatrist will be done atthese occasions. The PIJ-measure will expire at the age of 23, without re-assessment of theoriginal sentence. Some politicians have proposed to increase the maximum sentence for 16-and17-year-olds, and to make it possible to convert the PIJ-measure into a TBS-measure for adults.A child could thus remain in the system for a very long time. These proposals have met withmuch criticism.Section 76(3) of the Child Justice Act 2008: A Disguised Route to Prison or anIncentive for a Child to Improve and be Able to Benefit through an EarlyRelease?Annette van der Merwe, University of Pretoria (Annette.vandermerwe@up.ac.za)The Child Justice Act 2008 (s 76(3)) introduced a new type of sentence applicable to childoffenders who commit serious crimes in South Africa, and which, if committed by an adult,would have justified a term of imprisonment exceeding 10 years. In such cases, the court may, ifsubstantial and compelling circumstances exist, in addition to a child and youth care sentence (s76(1)&(2)), sentence the child to a period of imprisonment to be served after completion of thetime at the child and youth care centre (CYCC). The child will, however, first appear before thechild justice court for reconsideration of the sentence of imprisonment in the light of a reportprepared by the head of the CYCC. This paper examines the following aspects: the history of andrationale for this section, the requirements for its application, the required report and the extentto which the CYCCs can make this sentence work well for young people if they can encouragethe young person to behave well during his or her time at the CYCC. Foreign jurisdictions, suchas Canada and England, are also briefly evaluated for comparison in this regard.404

173. Understanding and Improving Use of Community TreatmentOrdersThe Challenges of Applying Recovery Theory to Involuntary TreatmentMarianne Wyder, University of Queensland at Brisbane (m.wyder@uq.edu.au)Personal recovery has emerged as central concept for mental health and has now been explicitlyadopted as the guiding principle for the provision of mental services in Australia andinternationally. Personal recovery includes internal conditions such as empowerment, selfdetermination,hope, healing and connection, and external conditions such as human rights, apositive culture of healing, and recovery oriented services. Involuntary admissions, at face value,are a distinct contradiction to the concept of recovery, as mental health crises that lead to thelegal provision of involuntary treatment would appear to challenge the very principles ofrecovery. Involuntary treatment can, by definition, be a denial of agency and citizenship, adestruction of hope as well as a reinforcement of stigma associated with a mental illness. Yetinvoluntary treatment can also be a point from which the recovery journey can gain direction andmomentum. This paper presents the findings from a qualitative study investigating theexperiences of involuntary mental health admissions from the perspectives of Consumers, Carersand Health Care Professionals. This paper will focus on the key aspects of the recovery modelthat are relevant to involuntary mental health admissions. It will also seek to reconcile theperspectives of Consumers, their Carers and Health Care Professionals.Achieving Reciprocity for People on Community Treatment OrdersLisa Brophy, The University of Melbourne (lbrophy@mindaustralia.org.au;lbrophy@unimelb.edu.au)It is estimated that one in four people accessing clinical community based mental health servicesin Victoria, Australia, are on a Community Treatment Order (CTO). Concerns about CTOsinclude the potential for over use, increased reliance on coercion and for people to appear to belanguishing on these orders for many years. In the author’s experience, across multiple projectsinvestigating the experience of the implementation of CTOs, there is consistent evidence tosuggest that many people on CTOs do not gain access to the level of service delivery that it maybe argued is required both to justify a CTO and also to achieve positive outcomes. Current lawreform in Victoria is attempting to address these issues but previous attempts at law reform havetended to be unsuccessful. The introduction of statutory treatment plans appears not to have metthe aim of having more consistent evidence that people on CTOs have been collaborativelyengaged in treatment planning and goal setting. It is also apparent that many people on CTOs arenot gaining access to recovery orientated services and psychosocial interventions. Thus itappears that in many cases the principle of reciprocity, the right to adequately resourced care in405

exchange for infringement of civil rights, has not been met. This paper will discuss the meaningand implications of the evidence and make recommendations about how these problems might beaddressed beyond law reform, including the significant potential for peer support services toassist in this context.Improving Policy and Practice to Prevent the Revocation of CommunityTreatment OrdersNicolas Owens, North Western Mental Health, Melbourne, Australia (Nick.Owens@mh.org.au;nicholas73@me.com)Lisa Brophy, The University of Melbourne (lbrophy@mindaustralia.org.au;lbrophy@unimelb.edu.au)This paper will revisit the findings from an investigation the authors made in relation to therevocation of community treatment orders in Victoria, Australia. The findings confirmed thatCTOs are frequently revoked, resulting in the CTO recipient being sent back to hospital,especially in the first few months after the recipient is discharged from the acute inpatient unit.In many cases this involves the police or ambulance services and, as well as being resourceintensive, this process is often very distressing for consumers, their carers and families and staffinvolved. After undertaking a mixed methods study that included a detailed investigation of 81revocation episodes and a broader investigation of the revocation process as perceived bystakeholders in the period 2008 – 2010 the authors have developed a number ofrecommendations regarding how: 1. The revocation of CTOs may be avoided; 2. If a revocationdoes occur how police involvement may be more carefully considered and minimized; and 3.How all involved could be better supported before, during and after a revocation episode. Theseideas and recommendations have been welcomed locally and have supported a proposed changein service delivery that seeks to provide a more seamless service that discourages the silos thathave emerged through the previous separation of crisis and continuing care teams and roles. Thispaper will report on the findings of a further investigation the authors are conducting in relationto whether, based on their previous findings, there is evidence of improvements in policy andpractice and reduction in the amount of coercion experienced by people on CTOs.Community Treatment Order Oversight Hearings and Patient OutcomesSteven P. Segal, University of California, Berkeley (spsegal@berkeley.edu)The legal oversight of the use of community treatment orders has proceeded with littleconsideration of how it might be enhanced and or improved. The purpose of this study is toconsider how various components of the oversight process are related to patient outcomes. In atwenty year investigation of Mental Health Review Board Oversight of CTO utilization in406

Victoria, Australia involving almost 19,000 individual placements on orders, this study considershow review board hearing procedures – e.g. legal representation of patients, presence oftranslators, presence of significant others (professionals involved with the hearings, or friendsand relatives) – scheduling process – e.g. time to initial hearing, discharge immediately prior to ahearing – review board actions, and revocation of orders are related to patient outcomes.The Effect of Compulsory Community Treatment on One and Two-Year SurvivalSteve Kisley, University of Queensland at Herston (s.kisely@uq.edu.au)Neil Preston, Health Department of Western Australia, Perth, Australia(neil.preston@health.wa.gov.au)Alex Xiao, Health Department of Western Australia, Perth, Australia(jianguo.xiao@health.wa.gov.au)David Lawrence, University of Western Australia, Perth, Australia(dlawrence@ichr.uwa.edu.au)Sandra Louise, Health Department of Western Australia, Perth, Australia(Sandra.Louise@health.wa.gov.au)Background: There is controversy as to whether community treatment orders (CTOs) canimprove health and social outcomes including questions about their effectiveness in preventingadmission to hospital. Less is known about any effect on the increased mortality experienced bypeople with severe mental illness.Objectives: We investigated whether CTOs can reduce one- and two-year mortality over thedecade following their introduction in Western Australia (WA).Method: A population-based record-linkage analysis of all CTO cases in WA over 10 years. Wecompared one- and two-year mortality rates for CTO cases with matched controls. We used Coxregression analyses to adjust for demographics, education level, prior health service use,diagnosis and length of psychiatric history. We collected data on successive cohorts for eachyear of CTO use to measure changes in numbers, characteristics and outcomes.Findings: We identified 2,127 CTO cases from November 1997 to December 2008 along withthe same number of controls matched on age, sex and mental health diagnosis. 64% were maleswith an average age of 37 years. The most common diagnoses were schizophrenia and other nonaffectivepsychoses (76%), followed by affective disorders (14%). 476 patients (8%) died.Patients on CTOs had significantly lower mortality rates at one and two-year follow-up withhazard ratios of 0.6 (95%CI=0.5-0.7) on each occasion.Conclusions: CTOs may reduce one- and two-year mortality. This may partly be explained byincreased contact with health services in the community and better access to medically necessarytreatments.407

174. Using Mental Health Legislation and Coercive Interventions:Dilemmas for Professionals and Service UsersCaring for Distressed and Disturbed Mental Health Service Users: AnExploration of Service Users and Nurses’ Experiences of Coercive InterventionsMary Chambers, St. George’s, University of London (m.chambers@sgul.kingston.ac.uk)Across Europe enhanced community care services have enabled those with mental healthproblems to remain out of hospital for longer. Admission to hospital is required only whenindividuals become very distressed and disturbed, necessitating some compulsory detention. Dueto the acuity of their illness an individual’s safety and that of others may be at risk.Consequently, health care professionals may resort to the use of coercive interventions such asrapid tranquillization, physical restraint or seclusion. Using such methods results in both clinicaland ethical dilemmas for health care staff, mainly nurses. For service users, being subjected tothese interventions can generate negative feelings. To better understand the implications of usingsuch approaches from the perspectives of both groups two separate but inter-related studies wereconducted using individual in-depth interviews with service users (n=19) in the UK and focusgroups with nurses (n=130) in acute psychiatric inpatient units in Finland, Ireland, Italy,England, Lithuania and Portugal. Findings suggest that nurses have strong negative feelingsregarding the use of coercive interventions, including fear, discomfort, apprehension,vulnerability, intimidation, and a sense of internal struggle. Service users reported lack ofpreventative techniques and therapeutic engagement, poor staff attitudes, lack of empathy and‘us versus them’ culture. The findings from these studies will be discussed in detail and theimplications for practice and education explored.Decisions and Dilemmas Surrounding the Use of Section 136 of the UK MentalHealth Act in South West LondonMirella Genziani, St George’s, University of London (mirella@arborscientiae.net)Mary Chambers, St. George’s, University of London (m.chambers@sgul.kingston.ac.uk)Steve Gillard, St George’s, University of London (sgillard@sgul.ac.uk)In the UK individuals experiencing a mental health crisis can come to the attention of police in apublic place, be issued Section 136 (S136) of the Mental Health (1983 & 2007) and taken to ahospital place of safety. Legal decisions with the potential loss of liberty are entrusted toagencies such as police and clinicians. As such, the S136 pathway is viewed as contentious andethically sensitive and less is known about stakeholders’ experiences of this process. Findingsfrom focus groups with: (i) service users; (ii) carers; (iii) mental health professionals; (iv) police;and (v) ambulance workers in a UK National Health Services Trust revealed experiences of408

variable practice, resource constraints and lack of clarity in accountability following a S136event. This resulted in practitioners feeling pressured to make decisions impacting on the qualityof care and at times the safety of detained individuals. This presentation considers thesignificance and implications for the parties involved in following through their decisions, alongwith the need to work in unison in identifying potential resolutions.Legal Coercion to Take Medication: Mental Health Consumer PerspectivesIris Gault, Kingston University (i.gault@sgul.kingston.ac.uk)Mary Chambers, St. George’s, University of London (m.chambers@sgul.kingston.ac.uk)Ann Gallagher, University of Surrey (a.gallagher@surrey.ac.uk)This qualitative grounded theory study analyses mental health service-user and carerperspectives on medication compliance and compulsory treatment. Data were generated frominterviews and focus groups with twenty four mental health service users/carers with a history ofrepeated admission under the Mental Health Act (1983) due to medication non-compliance.Following data analysis, eight initial categories emerged to tell the story of medication noncomplianceand compulsory treatment: the experience of desperation meeting with what isperceived as professional indifference; loss of a credible identity; playing the game;medicalisation of experience; meeting therapeutic competence; enabling collaboration; oralternatively, meeting therapeutic incompetence; disabling collaboration. Although initiallyreluctant to comply, service users accepted the need for treatment but then found that thebehaviour of professionals could enhance or hinder medication compliance. Where professionalswere seen as working collaboratively the coercive effect of compulsory treatment wasminimised. Conversely, where treatment was not perceived as collaborative, this maximisedfeelings of coercion and created resistance. The core category: Negotiating the Janus Face ofMental Health Care encapsulates the substantive theory explaining the process.A Longitudinal Assessment of Outcome One Year after Being Admitted underSection 136 of the UK Mental Health ActAileen O’Brien, St George’s University of London (aobrien@sgul.ac.uk)Section 136 of the Mental Health Act is issued by police in the UK to bring people suspected ofsuffering from mental disorder to a place of safety for assessment. The 136 suite at a southLondon Mental Health Trust serves a population of one million people. Preliminary data analysissuggests that the number of Section 136 admissions is increasing. It is not clear if this is a)because the need is increasing, b) the threshold of the police to use Section 136 is changing, or c)the result of problems in community services. This study will follow six months of admissions tothe 136 suite (approximately 200 people) for one year following the initial admission. Socio-409

demographic details will be established, comparing the cohort to the wider population. Reasonsfor admission under Section 136 will be documented; in particular whether any criminal offencewas committed. The proportion of subjects intoxicated with drugs or alcohol will also beestablished. Outcome data at one year will include (for those taken on by services) whether theyare still in contact with services, whether they have been admitted to hospital in the year andmeasures of social inclusion such as employment, family relationships and housing will berecorded.Nurses’ and Patients’ Stories of How and Why Section 5(4) (Nurse’s HoldingPower) of the Mental Health Act 1983 is ImplementedRussell Ashmore, Sheffield Hallam University (r.j.ashmore@shu.ac.uk)Section 5(4) of the Mental Health Act 1983 (DH, 2007) empowers mental health nurses in theUK to legally prevent informal in-patients from leaving hospital for up to six hours for theirhealth or safety or the protection of others. Since its introduction in September 1983 there havebeen over 34,000 applications of the section, an average of 1460 per annum. Despite being asignificant coercive intervention there is a paucity of research evidence reporting on how andwhy the section is implemented. This study sought to address this deficit by examining nurses’and patients’ accounts of their experiences of the implementation of Section 5(4). Multiplesources of data were generated from case studies including narrative interviews with both nurses(n=30) and patients (n=4); and written accounts of the detention process (n=20). The findingssuggest that on the whole both nurses and patients perceived the implementation of the section tobe a negative coercive intervention. Although nurses believed that implementing the sectionserved an important function in protecting the patients and/or others they also reported strongnegative emotions associated with its use. Such emotions included; sadness, a sense of failureand fear. Patients reported that coercion started before and on admission to hospital. They alsoreported that a lack of information and choice along with discrimination and exclusion withinacute psychiatric settings impacted negatively on their relationships with healthcare professionalsand their medical and life recovery. The presentation will outline the findings of the study indetail and discuss their implications for policy, practice and education.175. United Nations Convention on the Rights of Persons withDisabilities: What Does it Mean for Mental Health Law andPracticeThe Social Model of Disability in the CRPD- From Theory to PracticePenelope Weller, Centre for the Advancement of Law and Mental Health & Monash University(penny.weller@monash.edu)410

The ‘social model of disability’ gives substance to the ‘paradigm shift’ which is hailed as thepivotal contribution of the CRPD to the human rights landscape. This paper examines theimplications of the social model of disability for the mental health law. It begins with anexamination of the theoretical and conceptual underpinnings of the social model of disability insociology and critical disability studies. It then considers the manifestation or expression of thesocial model of disability in the CRPD, with reference to the ‘definition of disability on the basisof disability’ and the concept of reasonable accommodation. The paper shows that the adoptionof the social model of disability in the CRPD marks a critical juncture in international humanrights law by recognising in an international covenant the social production of knowledge, thesocial production and reproduction of human rights abuse, and the social determinants of healthand well being. It argues that the social model of disability provides a framework within whichthe entrenched relationships, attitudes and assumptions that underpin traditional forms of socialand legal engagement with people with disabilities, including people with mental illness, may bechallenged. In practical terms this approach destabilizes ‘capacity’ as workable construct inmental health law, augmenting it with a strong preference for the principle of participation.Swedish Mental Health Law Revisited: Discrimination and Values at StakeAnna Nilsson, Lund University (anna.nilsson@jur.lu.se)Moa Kindstrom Dahlin, Stockholm University (moa.kindstrom-dahlin@juridicum.su.se)Should all people with disabilities be decision makers in their own lives, or should the decisionmakingin some cases be left to a third party with the former person’s best interests at heart? Thiswas the core question throughout the negotiations of the Convention on the Rights of Personswith Disabilities (CRPD). Even though this question is answered with ambiguous silence, thatitself is ground-breaking. Previous human rights instruments explicitly legitimized involuntaryinterventions in mental health care and focused on minimizing the use of coercion, providedsafeguards and ensured that compulsory treatment was only applied to those who needed it, i.e.those who are "really mentally ill." The CRPD is different. It contains no provisions explicitlylegitimizing compulsory psychiatric care. Instead references to equality set the limit for nonconsensualinterventions. But what does equality mean in the mental health context? And whatconstitutes legitimate interventions? To answer these questions, we explore differentunderstandings of equality as well as unveiling the values and conflicts of interests in Swedishmental health law. We argue that certain changes are urgently needed in the Swedish context,regardless of which understanding of equality one adopts.Appropriate Types of Involuntary Treatment: Can Human Rights StandardsProvide Greater Guidance?411

Jill Stavert, Edinburgh Napier University (j.stavert@napier.ac.uk)The European Court of Human Rights (the Court) has emphasised the enhanced vulnerability ofdetained persons with mental disorder. However, it has also ruled that non-consensual treatmentof such patients will not constitute inhuman or degrading treatment (prohibited under Article 3 ofthe European Convention on Human Rights (ECHR)) where such treatment is permitted by lawand therapeutic necessity is convincingly shown. That being said, although the Court has furtherindicated that excessive or unwarranted mediation may amount to inhuman or degradingtreatment or a breach of the right to respect for private life, it remains unclear as to exactly whattypes of non-consensual treatment will result in ECHR violations. The UN Convention on theRights of Persons with Disabilities 2006 (UNCRPD) reinforces and defines more specifically therights of, and responsibilities relating to, persons with mental disorders and has increasingly beenreferred to in cases before the Court. By considering literature and cases that mention theUNCRPD this paper will therefore discuss whether it has the potential to provide greater clarityand protection for patients and staff in involuntary treatment situations.The CRPD and the ECHR: Uneasy Bedfellows?Peter Bartlett, Nottinghamshire Healthcare NHS Trust & University of Nottingham, Nottingham,UK (peter.bartlett@nottingham.ac.uk)The CRPD is frequently said to introduce a ‘new paradigm’ into international law. Howeverdesirable this new paradigm may be, it begs the question of how institutions designed under theold paradigm are to adapt. An obvious example is the European Court of Human Rights, whichfor example specifically allows for the detention of ‘persons of unsound mind’ (art 5(1)(e)), indirect conflict with the prohibition of disability being used as a factor in detention in the CRPD(art 14).This paper will consider how far the ECHR can reasonably be expected to go in integrating thenew paradigm of the CRPD into its jurisprudence.Global Mental Health: The Implementation of the CRPD and Mental Health inthe New Era of Global Health GovernanceLance Gable, Wayne State University Law School & the Centers for Law and the Public’sHealth: A Collaborative at Georgetown and Johns Hopkins Universities(lancegable@wayne.edu)With the establishment of the UN Convention on the Rights of Persons with Disabilities(CRPD), persons with mental disabilities have gained an important new tool to protect and fulfill412

their human rights. The implications of this addition to the international human rightsinfrastructure have only begun to be understood and realized. An important aspect ofunderstanding the impact of the CRPD will be to determine its role and the role of internationalhuman rights law more generally within the broader context of the expanding field of globalhealth governance, which has grown in scope and direction in the early 21 st century.Growing attention to health as a global concern has led to the expansion of infrastructureimpacting health at the global level, built upon both legal obligations—of which the CRPD is apart—and economic development initiatives. These developments have led to a proliferation ofactors participating in global health governance, ranging from national governments andintergovernmental institutions to international non-governmental organizations (NGOs),philanthropic foundations, and multinational corporations. The expansion of participants inglobal health governance has in turn raised the political stakes of these endeavors andcomplicated global health governance and diplomacy in ways that defy simple description.This presentation will develop a theory of how human rights may be situated within the broaderuniverse of global health governance as a shaper of health systems and social systems. Thehuman rights model can be conceived of as a model of health governance as well as a componentof the larger universe of global health governance. The CRPD provides a relevant and illustrativeexample of how this complicated and evolving global infrastructure may impact mental health.176. Victimization and Women OffendersLinking Victimization to Perpetration: Testing the Applicability of GeneralStrain Theory to Crime and Deviance among Emerging Adult WomenArjan Blokland, Netherlands Institute for the Study of Crime and Law Enforcement(ABlokland@nscr.nl)According to General Strain Theory (GST), crime and deviance can best be viewed as ways ofdealing with negative emotions that result from the strain caused by unfavorable socialinteractions. Victimizing experiences are considered to be among the most important strainsexperienced by young people which in turn may elicit illegitimate coping behavior, thus linkingcriminal victimization to the perpetration of crime and deviance. While extant empirical researchcorroborates many of GST’s central arguments, questions remain about its generalizability togirls and women, especially with regard to the link between negative emotions and externalizingcoping behaviors. This paper therefore addresses the association between victimization in thepublic and private spheres and delinquency and substance use in a multi-ethnic sample (n = 524)of emerging adult women (ages 18-21). It also examines the extent to which this association ismediated by negative emotions (anger, anxiety, and depression) and assesses whether the indirecteffect of victimization on crime and deviance is conditional on individual and contextual factorsthat are likely to affect the perceived behavioral alternatives in dealing with the strain caused bythe victimizing experience.413

Implications of Sexual Victimization History for Female Prisoner AdjustmentKayleen Islam-Zwart, Eastern Washington University (kislamzwart@ewu.edu)The proportional representation of women in United States prisons has been increasing since1980. Along with this growth, there has been greater attention to the adjustment process forfemale inmates. Several personal factors have been identified as impacting prison adjustment.With as many as 78% of women in prison reporting a trauma history, the impact of sexualvictimization on adjustment is of particular interest. Results from a longitudinal study involvingminimum-security women at a state prison suggest sexual assault history impacts adjustment toincarceration in a complex manner. Specifically, after controlling for physical abuse history andneed for approval, women with a sexual assault history report significantly more initial concernsabout personal safety, but less interpersonal and physical discomfort than women with novictimization history. Women assaulted exclusively as adults report more internal adjustmentproblems (interpersonal discomfort, insomnia, anger), safety concerns, and altercations thanwomen victimized as children and adults. Over time, inmates reporting a sexual assault historyshow consistent levels of internal adjustment problems (high for women with no assault historyand low for women reporting childhood and adult sexual assault) from the first to third weeks ofincarceration, while inmates without a history of sexual assault report initially higher levels ofinternal adjustment reaction that decrease to levels below that of the sexually assaulted group.Findings articulate the link between victimization history and adjustment to incarceration forfemale offenders, and highlight the importance of assessment of victimization history andtailored interventions to facilitate rehabilitation.Juvenile Victims of Sex Trafficking: Another Gendered Pathway to Crime forWomenEmily J. Salisbury, Portland State University (salisbury@pdx.edu)Criminologists continue to debate whether a single, general theory of crime is favored overtypological, or taxonomic, etiological explanations. The debate is becoming particularly relevantin the study of women’s offending patterns. For three decades, qualitative research has supporteda gendered pathways perspective, and more recent quantitative data also demonstrated empiricalsupport of female-specific trajectories toward crime. One pathway that continues to emerge inthe research involves prior sexual victimization as a primary distal factor in the etiology ofwomen’s offending. Using data from a juvenile detention facility in Washington state (U.S.), thispaper argues that within the commonly cited sexual victimization pathway is perhaps anothersub-pathway, one that reflects childhood victims of sex trafficking (i.e., commercial sexualexploitation of children or child “prostitution”).414

Mental Health Issues of Incarcerated Men and Women: Gender Differences inASPD and Psychopathy among a Sample of Incarcerated Men and WomenJanet Warren, University of Virginia (jiw@virginia.edu)Three distinct research trends have merged into a renewed interest in the relationship betweenAntisocial Personality Disorder and the construct of psychopathy as originally defined using thePsychopathy Checklist Revised (Hare, 1991). Definitional debates in the forensic field continueto focus on the significance of antisocial behavior to the core construct of psychopathy andwhether it is an inherent part of the construct or a non-essential corollary of it. Policydevelopments which use the psychopathy construct to predict recidivism have heightened thesignificance of inquiries into the applicability of these constructs to women and individuals ofdifferent racial and ethnic origins. Diagnostically, the wide reaching revisions of the DSM-5pertaining to personality disorders gave rise initially to the identification of anAntisocial/Psychopathy Personality Disorder Type (Skodol & Bender, 2009) and then thedeletion of this prototypical personality disorder type in favor of a return to Antisocial orDyssocial Personality and a reintroduction of Narcissistic Personality Disorder as one of the sixprototypical personality disorders identified.Our study seeks to inform these distinct but interrelated inquiries as they impact research andpolicy across diverse fields. Using a sample of 471 incarcerated men and women, we explore theassociation of a diagnosis of ASPD to a coding of psychopathy and the relationships of these twopersonality constructs to other PD diagnoses along with indices of psychiatric morbidity andcriminal and violent behavior. These comparisons are designed to provide an empirical snapshot of the ways that these two designations currently apply to a population with the highest ratesof both disorders and to further inform the debates surrounding the intrinsic structure, behavioralcorrelates, gender equity, and diagnostic acuity of both these crucial personality constructs..The Influence of Victimization on Involvement in the Criminal Justice Systemand Recidivism: Comparing Women in Prison to Women on ProbationStephen Tripodi, Florida State University (stripodi@fsu.edu)Seana Golder, University of Louisville (s0gold02@louisville.edu)Carrie Pettus-Davis, Washington University in St. Louis (cpettusdavis@brownschool.wustl.edu)Women are entering US prisons at nearly double the rate of men and are the fastest growingprison population. Literature focuses on the prevalence of punitive policies affecting womensuch as incarceration and community corrections, but little exists that emphasizes their differenttrajectories to the criminal justice system. This is despite women offenders experiencing morevictimization, more reports of mental health problems, and higher rates of substance useproblems than their male counterparts. Yet, despite these differences, most offender415

ehabilitation programming is based on the needs of men, indicating the importance ofunderstanding the relationship between childhood victimization and recidivism with mentalhealth and substance use issues as mediating variables for women offenders for the sake ofeffective programming. The purpose of this paper is to discuss these relationships with twodifferent samples: 240 women from one of two state prisons in North Carolina that wereinterviewed between 30 and 120 days prior to release and 354 women on probation or parole inKentucky. The presenters will: 1) compare and contrast the prevalence of childhoodvictimization, mental health problems, and substance use problems between the two samples, 2)compare and contrast pathways from childhood victimization and recidivism for women inprison to women on probation, 3) identify subgroups of women based on type of victimization,substance use, and psychological distress, and 4) discuss the importance of gender-specificprogramming that enables women offenders to resolve their trauma associated with previousvictimization and current mental health/substance use issues.177. Victimization, Workplace Aggression, Vulnerable Groups andVictim RightsHeterogeneity in Victim Participation: A New Perspective on Delivering a VictimImpact StatementKim Lens, Tilburg University, INTERVICT - Tilburg Law School(k.m.e.lens@tilburguniversity.edu)A central question in the debate about victim participation in criminal justice procedures is whichinstrument available to victims 'works'. The purpose of the presented study was to examinewhich factors contribute to the likelihood of victims delivering a Victim Impact Statement (VIS).We extend previous research in two important regards. First, we examined victims' perspectiveson the purposes and function of the VIS. Consistent with previous research (e.g., Roberts & Erez,2004), we reveal a distinction between impact-related and expression-related use of VISs.However, in this presentation, we add a third component to the existing literature: theanticipation of negative consequences. Second, we examined which factors influence thelikelihood of delivering a VIS and found three variables to be positively associated:posttraumatic stress symptoms, the type of crime, and the time of victimization. Againstexpectations, victims' perspectives did not make a unique contribution to the model. Based onthese findings, we argue that what is called for is a more heterogeneous approach to the study ofprocedural instruments available to victims.Minority Boys and Juvenile Delinquency: A Perspective of VulnerabilityEsmah Lahlah, Tilburg University, INTERVICT, Tilburg Law School(A.Lahlah@tilburguniversity.edu)416

Boys consistently report higher rates of serious offending during late adolescence than do girls(Fagan, Van Horn, Hawkins, & Arthur, 2007). This is particularly true for boys with an ethnicminority background (Rossiter & Rossiter, 2009; Van der Laan & Blom, 2011). However,research is mixed regarding the ways in which native and ethnic minority boys may differentiallyexperience risk in their families, schools, peer groups, and as individuals (see for a review,Lahlah, Lens, Van der Knaap, & Bogaerts, submitted). Given the large ‘ethnic’ disparity isjuvenile offending this lack of knowledge is surprising. Many studies include ethnicity only as acontrol variable or examine ethnic differences in only a few risk factors, lacking the possibleinterplay between different set of factors and as such the possible combination of influences onjuvenile delinquency. Likewise, only if the ethnic specific risk factors of juvenile offending areknown, can ethnic-specific prevention strategies be developed.Workplace Aggression and Victim’s Typology in Three Forensic PsychiatricClinicsFanny Klerx, Tilburg University, INTERVICT, Tilburg Law School(f.klerx@tilburguniversity.edu)Current research on workplace aggression focuses mainly on perpetrators’ typologies, theapproach of the perpetrators and context characteristics. Workplace related victim research onthe causes of workplace violence from a victim perspective is under-represented. This research inDutch Forensic Psychiatric Institutions examines individual factors in relation to workplaceaggression. In our research we assume that some individuals become more likely a victim ofaggression at work due to personal/individual characteristics. Predictors that can enhance thatchance include personality and behavioural characteristics such as childhood maltreatment andposttraumatic stress disorder in adulthood. We suppose that (physically) victimized workerssuffer more from childhood maltreatment, and PTSD than non-victimized workers and havemore inadequate coping strategies to deal with problems and to reduce (re)victimization. In thispresentation we present our theoretical framework on workplace aggression from inmates inForensic Psychiatric Institutions towards their treatment officers. Our hypotheses which arebased on the precipitation theory are tested in a longitudinal study conducted in 3 Dutch ForensicPsychiatric settings. The preliminary results will be presented. Firstly, we will describe ourrespondents according to demographical characteristics. Secondly, we will present theprevalence of workplace aggression. Thirdly, and finally, we will present causal effects of thepersonality and behavioural characteristics of the workers on victimization of workplaceaggression.Job Characteristics and Job Stress among JudgesTineke Hagen, Tilburg University, INTERVICT, Tilburg Law School (hagen8@xs4all.nl)417

For several years there has been growing world-wide awareness of the impact of the workcircumstances of judges. The growth in asylum cases and in more complicated cases is one wellknownchange. In international research one of the most reported job characteristics amongjudges is work pressure and there are indications for stress, burnout and secondarytraumatization. This study examines several job characteristics, the job demands (e.g., workpressure, work-home interference) and the resources (e.g., autonomy and social support), and therole of personality factors—using the Job Demands-Resources Model. The effects of the jobcharacteristics and the personality factors on the well-being (e.g., burnout, post-traumatic Stress,absenteeism and engagement) of judges are objects of this study. Judges of five courts of firstinstance, from the criminal law, civil law, family law, administrative law and asylum lawdivisions, participated. An online questionnaire composed of several existing questionnaires wasadministered on the above-mentioned factors, supplemented by items particularly for theprofessional group of judges. Given the results the judiciary may gain an insight into therelationship between work pressure, other organizational factors and personality factors and forinstance stress and absenteeism among judges.178. Visual Evidence: Perception, Psychology, Courtroom Practice,and PolicyNegative Evidence: The Use of CCTV (and other) Images to Identify OffendersGary Edmond, University of New South Wales (g.edmond@unsw.edu.au)This paper considers the admission and use of incriminating images in criminal trials. Focusingprimarily on expert witnesses assisting with the identification of “persons of interest,” it reviewsseveral jurisdictional approaches to opinion evidence, the way image “identification” evidence ismanaged in courts, as well as empirically-predicated concerns about the value of such“evidence.” It questions the ability of legal systems to identify and convey limitations withimage interpretations. In response, the paper highlights the importance of rules regulating theadmission of expert opinion evidence and the desirability of systematic engagement withresearch from experimental psychology and cognate disciplines. It suggests we ought to reconsiderthe value of image evidence, who we allow to interpret images, and how we use imagesin investigations and trials. It concludes by questioning whether opinions about incriminatingimages, and even the images themselves, ought to be routinely admitted; particularly if imagesare narrated by “experts” of unknown ability, integrated with other incriminating evidence,represented as corroborating this other evidence, and ultimately left to the jury or judge toevaluate.Simulating Subjectivity: Demonstrative Evidence of Perceptual Experience418

Neal Feigenson, Quinnipiac University (neal.feigenson@quinnipiac.edu)Demonstrative evidence is typically offered to represent external reality, but in a handful of caseslitigants have presented visual or auditory exhibits that purport to enable judges and jurors toexperience for themselves what it’s like to have the litigants’ subjective perceptions (such asimpaired vision due to accident or malpractice). These simulations may be derived fromlitigants’ self-reports, clinical testing, or physical measurement of their sensory apparatus. Eachtype of simulation makes a different sort of claim to provide reliable knowledge about thelitigant’s subjective experience. Yet almost all have been readily admitted as mere visual aidsrather than substantive evidence, based on litigants’ testimony that they fairly and accuratelyrepresent what the litigant sees or hears. This paper describes the various types of simulations,analyzes their epistemological bases, and argues that applying the same minimal evidentiarystandard to all, regardless of their provenance, tends to discourage careful inquiry into theirvastly differing probative values and judgmental risks.People Often See What They Want in Visual Evidence – and in “Nonvisual”Evidence, TooDan Kahan, Yale University (dan.kahan@yale.edu)I will review experimental evidence of how cultural cognition – the tendency of individuals toconform perceptions of risk and other legally relevant facts to group commitments – bears on thereliability of “visual evidence,” particularly videotaped encounters between police andpedestrians. This dynamic, the evidence suggests, can certainly distort what jurors of opposingcultural outlooks see when they observe videotape evidence of such encounters. But it can alsodistort what others – including judges and members of the public – expect jurors to see, andaccordingly distort (in the case of judges, in particular) the decisions about whether jurydeliberations are even necessary in particular cases and (particularly in the case of the public)their evaluations of whether jury verdicts that rest on jury assessments of visual evidence arecorrect and legitimate. These things are all true for visual evidence, I will suggest. But they arenot really any less true of any other form of evidence that relates to facts that are suffused withsocial meanings that tend to divide citizens of diverse outlooks.The Hidden Consequences of Racial Salience in Videotaped Interrogations andConfessionsJennifer Ratcliff, State University of New York at Brockport (jratclif@brockport.edu)G. Daniel Lassiter, Ohio University (lassiter@ohio.edu)419

Evaluations of videotaped criminal confessions can be influenced by the camera perspectivetaken during recording. Interrogations/confessions recorded with the camera directing observers’visual attention onto the suspect lead to biased judgments of the suspect. Although a cameraperspective that directs visual attention onto the suspect and interrogator equally appears topromote unbiased judgments, investigations to date have relied on videotapes that depict onlyCaucasian suspects/interrogators. The current work examined the possibility that even equalfocusvideotapes may become problematic when the suspect is a minority (e.g., Chinese- orAfrican-American) and the interrogator is Caucasian. That is, to the extent that Caucasianobservers are inclined to direct more of their attention onto minorities, an effect documentedpreviously, we expected biased judgments of the suspect to also occur in equal-focus videotapes.Three experiments provided evidence of this racial salience bias. Implications are discussed,including one practical way of avoiding the bias.Hindsight Bias: Emerging Challenges and New SolutionsNeal Roese, Northwestern University (n-roese@kellogg.northwestern.edu)Hindsight bias occurs when people feel that they “knew it all along,” that is, when they believethat an event is more predictable after it becomes known than it was before it became known.The topic of nearly forty years of psychological research, hindsight bias represents a significantimpediment to sound legal decision making, particularly in cases involving negligence ormalpractice. I will review research showing that technologies for visualizing accidents andcrimes (e.g., forensic animation) can have the unintended consequence of increasing hindsightbias, but that factors centering on the presentation format of visualizations can mitigate thiseffect. More general techniques for “de-biasing” judgment and decision making will also bediscussed.179. What the Public and the Health Care Profession Today Needsto Learn from Medical Profession Practices which Precededand Accompanied the Shoah 1939-1945Physical and Emotional Problems among Child Holocaust Survivors: Prognosisand RealityJoanna Michlic, Brandeis Institute (jmichlic@brandeis.edu)In the Spring 1944 issue of the American OSE Review, Dr G. Bychowski, a Polish psychiatrist,contemplated the potential range of mental disorders which Jewish child survivors of NazioccupiedEurope might suffer from acutely as a result of their traumatic wartime experiences.Before he fled Poland for the United Stated in 1941, first-hand medical contact with Jewish420

children in Warsaw had taught him that “loneliness, isolation, loss of parents and all the varioustraumatic shocks to which children had been exposed during the war and Nazi occupation” couldlead to traumatic neurosis, anxiety, hysteria, and acute psychoneurotic symptoms. Regarding thepotential rehabilitation of such child survivors, Bychowski attached great value to re-education,which he understood as a healing process where the children would have the opportunity toregain a sense of being human in a liberated Europe. This paper will discuss the writings ofmedical doctors published in the American OSE Review, 1944-1945 regarding the physical andmental health of child survivors, and their proposals for rehabilitations of these children. It willnext examine the health problems among Jewish child survivors as reported in the early postwarperiod in Poland by doctors, guardians, educators, and by children themselves.The Development of Informed Consent Before and in the Aftermath of theShoahRobindra Paul, Consulting Psychiatry, San Diego, USA (robindra3@yahoo.com)To provide informed consent a patient must have the capacity to make a decision. In the UnitedStates, the process of informed consent involves healthcare providers providing patients withmaterial information such that the patient can weigh the benefits, risks, and alternatives totreatment including no treatment at all. The process of informed consent, where it does exist,varies internationally. This presentation will initially focus on the development of informedconsent from the Greek philosophy to American landmark case of Schloendorff v. Society of NewYork Hospital, 211 N.Y. 125, 105 N.E. 92 (1914). There will then be a presentation on thedeparture of from the principles of informed consent during the Shoah and the lessons learned inthe aftermath of the Shoah. Finally, there will be a presentation about the process of informedconsent in selected countries.From NS-Euthanasia to Preimplantation Genetic Diagnosis: A PsychoanalyticApproach towards Ideas of Human PerfectionAngela Mauss-Hanke, Analytische Kinder-und Jugendlichentherapeutin, Germany(amh@mauss-hanke.de)Based on Darwin’s social theory, Francis Galton’s eugenics and Binding/Hoche’s ideas on “theelimination of non-liveable life” (1920), German doctors helped to develop one of the mainpillars of the national socialist ideology: “race hygiene”. Its goal was to heal the “nation’s body”(“Volkskörper”) by freeing it from all weaknesses and evil influences. In our western “cultures”today we are facing a general tendency towards physical perfection – and at the same timetowards physical excesses of all sorts. We “eat as much as we can” and we spend millions onliposuctions. Thanks to preimplantation genetic diagnosis handicapped children disappear moreand more – from life and from our minds. The paper tries to shed light on the ideal of human421

perfection from a psychoanalytic view and will figure out some questions and assumptionsconcerning the gap between our wish for perfection and reluctance against the daily effort tobecome what we are.What Can Today’s Public and the Health Care Profession Learn from MedicalProfession Practices which Preceded and Accompanied the Shoah, 1939-1945Harold J. Bursztajn, Harvard Medical School (harold_bursztajn@hms.harvard.edu)Julian de Freitas, Yale University (julzdefreitas@gmail.com)Omar Sultan Haque, Harvard Medical School (omarsultanhaque@gmail.com)What can today`s public and the health care profession learn from medical profession practiceswhich preceded and accompanied the Shoah, 1939-1945? This presentation will present lessonslearned about ethical violations, as well as lessons learned from physicians who were prisonersand the ways in which they found hope, meaning and resilience in the face of brutal oppressionand murder.From Monsters to ManagersTerry R. Bard, Harvard Medical School (terry_bard@hms.harvard.edu)Even though many examples exist of how populations make decisions to destroy others,questions still remain unaddressed and unanswered about why people who seem to be sound,kind, and generous can commit such atrocities. Even with a burgeoning scientific understandingabout human brain functions, many aspects of the human mind remain enigmatic. Individualsmay act idiosyncratically and often pose legal and medical issues relating to mind and action,often comprising the focus for forensic psychiatrists and psychologists. Populations that makesuch decisions have been studied less. This presentation will focus on psycho/social componentsof populations other than prejudice, envy, and hatred that may contribute to their capacities totaunt, beat, terrorize, and murder others. Social practices, laws, and understandings of mentalhealth will be identified and analyzed in an effort to create societies that mitigate the potential forpopulations to commit wanton human destruction.Why Did So Many German Doctors Join the Nazi Party Early?Harold Bursztajn, Harvard Medical School (harold_bursztajn@hms.harvard.edu)Julian de Freitas, Yale University (julzdefreitas@gmail.com)422

Omar Sultan Haque, Harvard Medical School (omarsultanhaque@gmail.com)Ivana Viani, Farleigh Dickinson University (ivanaviani@gmail.com)During the Weimar Republic in the mid-twentieth century, more than half of all Germanphysicians became early joiners of the Nazi Party, surpassing enrollment for any otherprofession. From early on the German Medical Society went on to play the most instrumentalrole in the Nazi medical program, starting with marginalization of Jewish physicians, proceedingto coerced “experimentation,” “euthanization,” and sterilization, and culminating in genocide viathe medicalization of mass murder of Jews and those others caricatured and demonized by Naziideology. Given the medical oath to “do no harm,” many postwar ethical analyses have strainedto make sense of these seemingly paradoxical atrocities. Why did physicians act in such amanner? Yet few have tried to explain the self-selected Nazi enrollment of such anoverwhelming proportion of the German Medical Society in the first place. This article lendsinsight into this paradox by exploring some major vulnerabilities, motives, and rationalizations -professional vulnerabilities among physicians in general (valuing conformity & obedience toauthority, valuing hope and empowerment including prevention of contamination and fightingagainst mortality, and possessing a basic interest in biomedical knowledge and research),economic factors and motives (related to physician economic insecurity and incentives foreconomic advancement), and Nazi ideological and historical rationalizations (beliefs aboutSocial Darwinism, eugenics, and the social organism as sacred)-that may have predisposedGerman physicians to Nazi membership. Of particular significance for future research andeducation is the manner in which the persecution of Jewish physician colleagues was rationalizedin the name of medical ethics itself. Giving proper consideration to the forces that fueled “NaziMedicine” is of great importance, as it can highlight the conditions and motivations that makephysicians susceptible to misapplications of medicine, and guide us toward prevention of futureabuse.180. Witnesses and Expert EvidenceBehind Closed Doors: What Expert Witnesses Can Teach us About DrugCompany ActivitiesDavid J. Rothman, Columbia College of Physicians & Surgeons (djr5@columbia.edu)Sheila Rothman, Columbia College of Physicians & Surgeons (smr4@columbia.edu)In light of the growing number of lawsuits against drug companies for their marketing ofpsychiatric drugs, it is important for a conference on law and mental illness to explore whatresearchers may learn from these cases. From 2010 to 2012, Sheila Rothman (Mailman School ofPublic Health, Columbia University) and I served as consultants to the Texas State AttorneyGeneral's Office in its successful suit against Johnson and Johnson for Medicaid fraud inpromoting Risperdal. This presentation will draw on our experience to illuminate the following423

issues. First, an explanation of the database of materials that is made available to consultants andits organization. Second, an analysis of the unique opportunities presented by such lawsuits toexamine source materials otherwise unavailable to researchers. Pharmaceutical companies, likeother commercial enterprises, guard their internal operations closely. Only when forced throughlegal "discovery" does this type of information become available. Third, a discussion of whatsuch lawsuits can teach us about the role of drug companies in the formation of psychiatrictreatment guidelines. Finally, an analysis of what such lawsuits can teach us about the role ofdrug companies in the publication of articles in psychiatric journals, including ghostwriting.Automatism: The Different Definitions in Case Law and Expert Evidence andHow this Impacts on the Sleepwalking DefenseJohn Rumbold, Keele University (j.rumbold@ilpj.keele.ac.uk)There are several subtly different definitions of legal automatism and the literature on forensicsleep disorders, recorded instructions to the jury and my research interviews suggest that there isconfusion among expert witnesses and lawyers. This has implications for the expert evidencegiven and how it is treated by the courts. The difficulty in defining automatism satisfactorily ispartly related to the difficulty in defining voluntariness. In addition, many cases described asautomatism are in fact decided on unconsciousness rather than involuntariness. The definition ofautomatism as "total loss of control" is controversial and academics debate whether thisdefinition applies to all offences or just driving offences. Sleepwalking is universally accepted asa state of automatism even though the range of actions seen is incompatible with the "total lossof control" definition. They would not be accepted as automatistic with other disorders likediabetes. A more sophisticated definition of automatism based on current neuroscientificunderstanding, expert evidence and the work of legal philosophers HLA Hart and RF Schopp isoffered as a solution. This would result in greater consistency by the courts regardless of theunderlying disorder causing automatism.Effects of Suspect Demeanour on Eyewitness JudgmentsTomoko Nishizawa, Flinders University (tomoko.nishizawa@flinders.edu.au)Neil Brewer, Flinders University (neil.brewer@flinders.edu.au)Matthew Palmer, University of Tasmania (matt.palmer@utas.edu.au)Eyewitness evidence plays a crucial role in forensic investigations. It can also be unreliable, witheyewitness reports and identifications vulnerable to distortion by various biasing influences. Weinvestigated how eyewitness identification decisions are biased by subtle behavioural ordemeanour cues. Specifically, a smiling face has been shown to enhance feelings of familiarity;consequently, the presence of this cue could make a lineup member appear more familiar than424

other non-smiling members. Witnesses viewed two mock-crimes for either a short or longexposure duration and attempted an identification of the culprits from culprit-absent photolineups.In one condition, all lineup members had neutral facial expressions; in the other, one hada smiling face. For witnesses with a weak memory of the culprit (due to a brief exposure at thetime of the crime), the smiling (innocent) lineup member was more likely than other lineupmembers to be the one rated as being most like the culprit. The biasing effects of suchdemeanour cues increase the risk of mistaken eyewitness identifications. The broaderimplications of these findings for how judgment and decision-making in other forensic contexts(e.g., clinical forensic interviewing, evaluating the veracity of testimony) may be biased bydemeanour cues will be discussed.Why Do Witnesses Withhold Information?Nicole Reid, Flinders University (Nicole.reid@flinders.edu.au)Neil Brewer, Flinders University (neil.brewer@flinders.edu.au)Nathan Weber, Flinders University (Nathan.weber@flinders.edu.au)Eyewitness reports provided during forensic interviewing are often the key to prosecuting asuspect: the more detail, the stronger the leads available to investigators. During an interviewwitnesses have the option of providing a very detailed, or fine grained response (e.g., he wore adark brown leather coat), or a much less detailed, or coarse grained response (he wore a darkcoat). Often witnesses withhold coarse-grain details despite the fact that these can offer vitalinvestigatory leads; they apparently prefer to provide fine grain information or be maximallyinformative. We investigated social psychological mechanisms that may explain why witnessesmay withhold such information. Experiment 1 examined whether characteristics of the audienceor interviewing context explained the apparent drive for informativeness reflected in theprivileged reporting of fine grained information. The results questioned whether informativenessis the driving force underlying information withholding. Experiment 2 manipulated the value ofcoarse grained information (using situations where the only possible response was a coarsegrained one) to determine whether coarse-grain information would be withheld even when it wasthe informative response. The implications of our findings for maximising the amount ofmeaningful information that witnesses provide in forensic interviewing contexts will beexamined.Practical Thoughts on Experts in Mental Disability Law CasesRichard Friedman, New York Law School (rfriedman@nyls.edu)There are special advocacy skills needed by lawyers and expert witnesses that are essential incases involving persons with mental disabilities. Among the most important elements for425

attorneys working with experts and equally for experts working with attorneys is preparation. Itis essential for attorneys working with experts. It makes no difference if the expert is yours ortheirs. Preparation is the key. For experts, without adequate preparation, advocacy for theiropinions would be inadequate. But before this key can be used, there are issues that must beaddressed: what does your client want? What is the theory of your case? What type of expert doyou need? Where will you find the expert? What does the expert need to do to work successfullywith the attorney? Once those questions are answered, there is more to consider.Junk Science Case Of Serotonin Syndrome In CourtSteven Fayer, Mount Sinai Hospital, New York, USA (Stevenfayer@gmail.com)A medical malpractice case involving allegations of improper prescribing as the cause of deathdue to seratonin syndrome, was shown to be a false accusation. The case went to a trial and thispresentation will describe the case as an example of junk science. I will define junk science andalso discuss the Daubert ruling as a means of maintaining the standard for the proper inclusion ofscientific principles in the legal system. This case and the jury verdict will be discussed.181. Women and Families in Adverse Life SituationsEggshells in the NestDebra Bastien, University of New Brunswick (dbastien@unb.ca)Combat-induced PTSD has historically generated psychological casualties of war and has beenan ongoing concern for Canadian Forces (CF) personnel, their wives and families. There hasbeen extensive media coverage on the escalating number of PTSD diagnoses since deploymentsto Afghanistan, however little attention has been given to CF families at risk for “secondarytraumatisation” (Hoge, 2010). 70.8% of military personnel are married and 54% of these familieshave children, the majority of which are under the age of 11 (Triscott & Dupres, 1996). Violenceand instability create upheaval amongst families dealing with PTSD (Harrison & Laliberte,1994). Croatian authors, Franciskovic et al. (2007) recommend that treatments offered toveterans with PTSD must also be offered to their families. Veterans with PTSD return from warexpecting home to provide safety and security, yet stress can intensify when they have difficultyreintegrating into spousal and parental responsibilities. Spouses are generally unprepared for theunpredictable and violent reactions that may emerge when traumatic memories are triggered. Allmembers of the family walk on eggshells in navigating this unknown high risk terrain. To date,few studies have addressed this complicated family dilemma. In this narrative inquiry the silentand secret stories of the trauma and healing of military wives are examined. Narrative offers ameans of giving voice to personal experiences. Uncovering the private realm of these intimatestories can provide health care workers and policy makers with a deeper understanding of how426

PTSD disrupts the dynamics of home and family. In this presentation I will discuss some of thesewomen and family’s stories, as well as the insights and recommendations gleaned from them.Health PIES for Disadvantaged ChildrenMary Lou Batty, University of New Brunswick (mbatty@unb.ca)It is well documented that health professionals and educators often work intimately with childrenwhile ironically being oblivious to the adverse circumstances these children live with at home orwithin other parts of their lives. Their ability to learn at school may be diminished by chronicstress and self-care deficits (e.g. poor hygiene and nutrition); they may be unable to self-regulateor establish healthy friendships. Because many of their situations will never be identified, theywill miss access to support and resources that could change the course of their health. Thesubsequent costs to the children and to the health care system cannot be ignored. Therefore andby way of reaching out to these children, the Health Promotion in Elementary Schools (HealthPIES) initiative was developed. Using a strength-based universal approach to build relational andhealth promotion capacity, Health PIES provides a cost-effective way to help children, and byextension, their families. Within this initiative, nursing students engage with children, staff, andthe school community in classroom work, and also work with children in small groups who havebeen identified as “at-risk” for developing health challenges. Activities conducted by the nursingstudents are inclusive of family structure and describe community supports which are accessibleto families regardless of income level, culture, learning style, and family circumstances. Thisenables the children to draw on the information to meet their own needs. Children who receivelittle support at home tend to build skills in resilience and independence. Such children havereported learning the connection between hygiene and infection prevention and that materialpossessions do not equate to happiness. The children acknowledged that the activities theylearned through participating in Health PIES helped them through difficult times at home.Hallowed Be Thy Name: Women’s Stories of Surname ChangeKathryn Weaver, University of New Brunswick (kweaver@unb.ca)A name is a symbol of self and a large part of the construction of one’s identity; however, littleattention has been given to the topic of women’s surname change. Thus, women whocontemplate entering or leaving marital relationships can experience a quandary as to whetherthey will take their husbands’ surnames or retain their birth surnames. To understand women’sexperiences with surname change or retention and the meanings women draw from theseexperiences, a narrative approach was used to elicit women’s stories and explore individualperspectives within the broader beliefs and values of family, culture, and society. Fourteenwomen in the process of surname change were interviewed. In addition, collateral interviewswith 14 family members were conducted to add validity and richness to the developing core427

narrative. Analysis involved examining stories for elements of temporality (past, present, future),relationships (marital status; nuclear, extended, or family of origin), and voice (dominant socialdiscourse, individual motivations, social pressures and values). The experiences of womenconcerning surname change reflected interaction, critical thinking, and at times, sheerunreflectiveness wherein women did not give thought to decision making. Women who kepttheir birth surnames chose to retain their professional identity, preserve relational equality, orhonour their parents. Women who took their husbands’ surnames did so for tradition and toestablish a new shared identity. While most divorced women did not return to their birthsurnames because they wanted the same name as their children, women who did reclaim theirbirth surnames after marital dissolution described a time of joy and empowerment. The findingssuggest that taking their husbands’ surnames can lead to loss of identity and marital inequalityfor women, and may negatively influence their health, well-being, and family relationships.Positive Practice Environments: Millennium MandatesDolores Furlong, University of New Brunswick (dfurlong@unb.ca)The World Health Organization’s professional member groups (i.e., World Medical Association,International Council of Nurses, and World Federation for Physical Therapy) have focused theirattention on an unusual international phenomenon – unhealthy workplaces across the world thatresult from bullying and unmanageable occupational stress. To this end these organizations havedesigned educational initiatives and performance directives under the umbrella of “positivepractice environments”. Due to downsizing of personnel (mostly women) in health care, thediminished resources and increasing expectations for those aging workers (women) left on thejob, workers in today’s health care organizations face burnout and mental health issues not seenin previous generations. With a loss of confidence, and often hope, in their leaders’ ability toguide them through the looming crises in health care workplaces (as described by WHO, ICN,and WFPT, to name a few), female professionals in health care are facing caregiving exhaustionnot only for others – their patients – but also for themselves. In this presentation, I will discussthese adverse workplace dynamics, some of their causes and casualties, as well as some of theprograms that have shown initial success.Career Development Behind Bars: The Future of Criminally Involved YouthJennifer Bartlett, University of New Brunswick School of Graduate Studies – Faculty ofEducation (jenn.bartlett@unb.ca)José F. Domene, University of New Brunswick School– Faculty of Education(jfdomene@unb.ca)428

The juvenile justice system is designed to promote rehabilitation among criminally involvedyouth and to aid in their reintegration into society. Obtaining gainful employment is a criticalcomponent to successful rehabilitation, and, by understanding the impact that the juvenile justicesystem has on adolescent career development, we can promote the formation of vocational goals,promote job-seeking behaviour and help these adolescents overcome the obstacles they mayotherwise face. Unfortunately, very little is known about the career development of adolescentswho are involved with the juvenile justice system, their career goals for the future or the factorsthat influence their choices. The present study was designed to begin to address this gap byqualitatively exploring the types of goals criminally involved youth hold for their futures, and touncover both helping and hindering experiences that contributed to the development andachievement of their goals. Specifically, the Enhanced Critical Incident Technique (ECIT) willbe used to interview a sample of male and female criminally involved youth between the ages of16 and 18 in the province of New Brunswick, Canada. A structured content analysis, followingthe principles of ECIT, will be used to identify participants’ career aspirations and specific kindsof experiences that influenced the formation of those aspirations. The anticipated results are thatcriminally involved youth have a wide range of aspirations that are similar to other people oftheir age, but these aspirations have been negatively affected by their involvement in crime andthe prison system. The implications of these findings for career counselling practice and policiesand programming within juvenile justice institutions, particularly the need to spend more timeand resources to facilitate concrete educational and career planning, will be discussed.Therapeutic Jurisprudence Sessions182. Achieving a More Therapeutic Health Care SystemMeeting the Needs of Patients and their Families in the Aftermath of SeriousClinical Adverse Events/ Medical Errors: Results from a Qualitative EmpiricalEnquiryLodewijk Smeehuijzen, VU University (j.l.smeehuijzen@vu.nl)It is estimated that in Dutch Hospitals each year more than 38,600 patients are confronted withavoidable damage of which more than 1,900 people die. Recent reports show that the needs ofpatients being confronted with adverse outcomes of treatment are often poorly addressed. Thismay result in additional physical and emotional damage and inadequate financial compensationof victims. This paper reports the results of a qualitative empirical study conducted in theNetherlands aiming at identifying the specific needs of patients harmed by treatment andexploring ways to improve the position of patients in the aftermath of (potential) medical errors.Based on 45 interviews with patients and focus groups with stakeholders and expertsrecommendations are formulated to foster effective incident disclosure and to improve themedical injury compensation process.429

The Power of Energy Healing: Using Therapeutic Jurisprudence Principles toInform the U.S. Affordable Care Act in Support of Complementary Medicine forEnd-of-Life and Chronically Ill PatientsCarolyn E. Hansen, Attorney at Law & Mediator, Stone Ridge, USA (AttyHansen@earthlink.net)Brennan Healing Science and other modalities of complementary medicine are increasinglyunderstood to produce beneficial results. While use of these therapies is rapidly expanding,health care institutions and regulatory bodies have been slow to include Brennan HealingScience and other forms of energy healing as a recognized therapy.The presenter will report on studies and surveys of Brennan Healing Science Practitioners,patients and health care administrators as relevant, on the benefits and effectiveness of BrennanHealing Science and other energy healing modalities. Benefits reported may be physical,emotional, mental, psychological and/or spiritual. In the physical area they may include painreduction, decreased recovery times, decreased or avoided hospitalization or institutionalization,decreased use of medications, increased mobility and others. The analysis of effectiveness willbe in two categories: 1) care for those at end of life; and 2) care for those facing a healthchallenge which is not, or turns out not to be, terminal. Effects of research study designrequirements and the movement to accept other methods of qualification will also besummarized. She will then analyze the therapeutic jurisprudence aspect of the creation of theCenter for Medicare & Medicaid Innovation under the US Patient Protection and AffordableCare Act. The presentation will end by discussing how research under this Center may result inpatients having greater access to Brennan Healing Science and other complementary medicinemodalities.A Therapeutic Jurisprudence Analysis of the POLST Paradigm: Do PhysicianOrders for Life-Sustaining Treatment “Work”?Marshall B. Kapp, Florida State University (marshall.kapp@med.fsu.edu)In the United States, the Physician Orders for Life-Sustaining Treatment (POLST) modelrepresents the next frontier, beyond traditional patient-executed advance directives such as livingwills, in the quest to assure that patients with advanced critical illness who are presently unableto speak for themselves receive exactly the kind of medical care they want (and only such care)consistent with their own values and preferences. There are approximately fourteen states withestablished statewide POLST programs, encompassing several different combinations ofstatutory and regulatory frameworks; many other states are in various stages of development interms of acceptance and implementation of the POLST concept. Both public policy and clinicalpractice regarding the care of individuals with advanced critical illness should be informed by430

evidence about what legal models “work” best in terms of furthering the important social,ethical, and medical goals implicated in this context. This presentation will critically review theavailable literature and other evidence describing the identified actual benefits and shortcomingsof the POLST paradigm thus far. It will then outline a preliminary research agenda that ought tobe pursued as we seek to collect and analyze additional knowledge about the measurabletherapeutic impact of the POLST paradigm on its intended beneficiaries.The Right Not to Suffer in Italy: Insights from the Point of View of TherapeuticJurisprudenceFederico G. Pizzetti, University of Milan (federicogustavopizzetti@gmail.com)This proposal will use the theoretical framework of therapeutic jurisprudence to offer someinsights into the “right not to suffer” in Italy.Moving from a broad legal definition of “health,” as accepted by WHO, and also acomprehensive of psychological and socio-relational welfare, the constitutional roots of the“right not to suffer” may be found in Article 32 of Italian Constitution, where the right of healthis defined as a fundamental right of the citizen and of general interest, and in Articles 2 and 3 ofthe same Constitution, where the state must recognize and promote the global development ofthe “person” in its morally, physically and mentally dimensions, under a regime of equality andsocial dignity.Particular attention must be given to the application of a “right not to suffer” in the case of endof-lifedecision making because of the high level of physical, moral and psychological sufferingof those decisions: because of its constitutional weight, the “right not to suffer” may be used inorder to scrutinize the behavior of legislature and administration. While the state may causesome pain to its citizens (let us remember criminal punishment), should the state, in the exerciseof this duty, act in order not to cause excessive suffering or undue pain? And should it fulfill thisduty without frustrating citizen's aspiration with over-burdensome bureaucratic procedures andwithout announcing a legislative initiative that may cause extreme fear or angst in the citizenswho are asking their rights to be recognized and enforced?This author’s proposal will provide some considerations in the context of two famous Italiancases of withdrawal of artificial life support, to demonstrate that both the administrative powersand the legislative ones were exercised in an anti-therapeutic way and therefore in anunconstitutional manner.A Non-Lawyer Health Practitioner Perspective on Reasonable Belief: BalancingNurses’ Welfare with Public Safety in a Regulatory EnvironmentGreg Miller, Victorian Board of Nursing and Midwifery Board, Melbourne, Australia(greg.miller@mh.org.au)431

Nursing, as with other health professions in Australia, is regulated by the Health PractitionerRegulation National Law Act 2009 which is administered by the State and Territory Boards ofthe Nursing and Midwifery Board of Australia (NMBA)in conjunction with a governmentfunded Australian Health Practitioners Agency (AHPRA) which provides infrastructure andadministrative resources to the Boards.The Victorian Board of NMBA registers over one quarter of the country's nurses and midwives,and is responsible for the management of notifications regarding conduct, health andperformance that are considered detrimental to their practice and to the safety of the public. TheVictorian Board receives up to 30 complaints relating to nurses' and midwives’ practice eachworks with the AHPRA staff to manage the process.This paper explores, from the perspective of a practitioner member of the Board, the complextask of assessing the relative merits of complaints about practitioners’ conduct, the decisionmakingprocess required at each stage of an investigation, and the process of determiningdisposition of the matter explored.The presentation serves to demystify the systems in place to manage complaints about nurses andmidwives in practice Victoria. The presenter uses case study to illustrate aspects drawn from theethics, power, authority and decision-making literature that relate to this regulatory process andreflects upon his Board experience of balancing the protection of the public, the standing of theprofession, and the welfare of the nurse or midwife within an ethico-legal framework.183. Changing the Profession and the Law School Experience – PartITeaching Modern Legal Skills to Law Students in a Comprehensive Law Course,Part OneMichael Jones, Phoenix School of Law (mjones@phoenixlaw.edu)Comprehensive Law is an upper-division course designed for second and third year law studentsat the Phoenix School of Law. The course provides exposure to modern therapeuticjurisprudential legal theory, practice, and skills of law as a helping or healing profession. It usespsychology to assess the consequences of law and legal procedures on people in an effort tomake law have a positive effect, and examines and teaches more effective communication andinter-personal skills for the students to use as they begin to practice law. The course focuses oncreative problem-solving, restorative justice, transformative mediation, preventive law,therapeutic jurisprudence, and law and socioeconomics. The lecturers, Jones and Cole, willcritically assess and discuss their teaching goals, methods, exercises, and the students’expectations and reactions. Jones and Cole will offer suggestions for improving the law schoolcurriculum by inclusion of a comprehensive law course component.Discussant: Dave Cole432

Teaching Modern Legal Skills to Law Students in a Comprehensive Law Course,Part TwoDave Cole, Office of the Arizona Attorney General, Phoenix, USA (drcoleua@gmail.com)Comprehensive Law is an upper-division course designed for second and third year law studentsat the Phoenix School of Law. The course provides exposure to modern therapeuticjurisprudential legal theory, practice, and skills of law as a helping or healing profession. It usespsychology to assess the consequences of law and legal procedures on people in an effort tomake law have a positive effect, and examines and teaches more effective communication andinter-personal skills for the students to use as they begin to practice law. The course focuses oncreative problem-solving, restorative justice, transformative mediation, preventive law,therapeutic jurisprudence, and law and socioeconomics. The lecturers, Jones and Cole, willcritically assess and discuss their teaching goals, methods, exercises, and the students’expectations and reactions. Jones and Cole will offer suggestions for improving the law schoolcurriculum by inclusion of a comprehensive law course component.Discussant: Michael JonesPreparing Law Students for the Emotional Dimensions of Lawyering: TwoStudents’ Perspective for Needed Change in Legal Education (Part One)Kim Culver, Phoenix School of Law (kkculver@phoenixlaw.edu)Empathy, active listening, compassion…these are traits which law school, in its traditionalsocratic form, fails to instill in its students. Legal education should prepare students for theemotional dimensions of lawyering; that is, for the impact that a client’s emotional well-beingwill have upon their lawyer’s practice of the law. Studies have shown that students are critical ofthe content of legal education, calling it “too theoretical” and “indifferent to real world issues."This is why legal education needs to shift from the traditional framework and seek creative,collaborative, holistic, and positive, client-centered solutions to legal disputes. By incorporatingthese principles of therapeutic jurisprudence and comprehensive law into the classroom, lawprofessors can provide their students with important insights into some of the difficult problemsraised when dealing with clients. Rather than teaching law students to “think like a lawyer,”students will learn to identify in their clients critical issues such as grief, anxiety, depression,anger, etc. In doing so, they can develop a plan to assist the client in resolving and/or dealingwith such issues; as well as better understand how these issues will affect the clients’ case andthe way the lawyer should handle it. In this forum, we hope to give attendees the law student’sperspective as to ideas and suggestions for influencing this change in legal education. This ispart one of a two-part presentation.433

Preparing Law Students for the Emotional Dimensions of Lawyering: TwoStudents’ Perspective for Needed Change in Legal Education (Part Two)Sarah Murillo, Phoenix School of Law (scmurillo@phoenixlaw.edu)Empathy, active listening, compassion…these are traits which law school, in its traditionalsocratic form, fails to instill in its students. Legal education should prepare students for theemotional dimensions of lawyering; that is, for the impact that a client’s emotional well-beingwill have upon their lawyer’s practice of the law. Studies have shown that students are critical ofthe content of legal education, calling it “too theoretical” and “indifferent to real world issues."This is why legal education needs to shift from the traditional framework and seek creative,collaborative, holistic, and positive, client-centered solutions to legal disputes. By incorporatingthese principles of therapeutic jurisprudence and comprehensive law into the classroom, lawprofessors can provide their students with important insights into some of the difficult problemsraised when dealing with clients. Rather than teaching law students to “think like a lawyer,”students will learn to identify in their clients critical issues such as grief, anxiety, depression,anger, etc. In doing so, they can develop a plan to assist the client in resolving and/or dealingwith such issues; as well as better understand how these issues will affect the clients’ case andthe way the lawyer should handle it. In this forum, we hope to give attendees the law student’sperspective as to ideas and suggestions for influencing this change in legal education. This ispart two of a two-part presentation.Psychoethical Soft Spots and Opportunities in Law School Pro Bono ProjectsChristina A. Zawisza, University of Memphis (czawisza@memphis.edu)My presentation will expand the TJ universe by applying the TJ methodology of psycholegal softspots and opportunities to “professional responsibility” by constructing psychoethical soft spotsand strategies to teach public service values to law students. I will apply this expansion to theAlternative Spring Break (ASB) model at my law school, where, for three years, I have mentoredstudents in public service projects. Rather than vacationing, students have represented lowincome people in pro se divorces, advanced directives, U-visas and community projects such ashuman trafficking legislation, predatory lending legislation, and non-profit managementcounselling. Using professionally produced video of three ASB’s, I will discuss the followingbenefits of appreciating psychoethical soft spots and opportunities: Hands-on clientrepresentation; Reconnection to the service motivations of law students; Real world training withexperienced attorneys; Modelling effective organization, management, and problem solving;Creating a lifelong desire to engage in public service as a psychoethical soft spot and strategy.434

184. Changing the Profession and the Law School Experience – PartIIChanging the Profession and Legal Education through TherapeuticJurisprudence and other Healing Approaches to LawSusan Daicoff, Phoenix School of Law (sdaicoff@phoenixlaw.edu)This presentation will focus on the effects of teaching law as a healing profession on lawstudents, lawyers, and, ultimately, the legal profession. It will explore advantages anddisadvantages of this training, for legal personnel, and obstacles to the training. Finally, it willexplore specific ways to teach therapeutic jurisprudence, restorative justice, collaborative law,preventive law, transformative mediation, creative problem solving, and more.Teaching Old Dogs New Tricks: Infusing Civility into Doctrinal CoursesLori Miller, Phoenix School of Law (lmiller@phoenixlaw.edu)As a society, we are losing civility. Being polite, kind, and compassionate is much less commonin interactions with others now than in the past. This societal shift away from focusing oninterpersonal relationships toward focusing on what is best for the self is caused in part by theisolation common in using current technology. Decreased face-to-face interaction with othersleaves persons less able to fully understand the effects of their incivility on another person. It isnot a surprising, therefore, that civility is dwindling. When students arrive in law school, they aregiven the clear message that law school is very competitive, especially in the first year, whichfurther discourages civilized behavior toward their colleagues. Incorporating and encouragingcivil behavior in law school courses is critical to engender civility in interpersonal relationships.Failure to do so will not just harm the law school’s culture, but will adversely affect the legalcommunity and society in general. But how do law professors teach civility? They don’t; theyfacilitate. The key is collective consciousness: students and teacher act as one through discussionand agreement. Together, they discover the meaning of civility in law school. By properlystructuring the curriculum, students discuss and apply civility, professionalism, and integritythroughout the course using various tools, including alternative dispute resolution methods and acode of civility. By shifting their success paradigms from winning, as in a competitive model, towin-win, students hopefully will create a more compassionate, civilized, and productive legalcommunity and society.Discussant: Brooke Megan Murphy-Porth.435

Teaching Conflict Resolution Skills: An Essential Component of the Basic LawSchool CurriculumAnn Woodley, Phoenix School of Law (awoodley@phoenixlaw.edu)Professor Woodley teaches several classes at the Phoenix School of Law which involve basic,but essential conflict resolution skills. Her classes include Mediation Advocacy, ADR, andInterviewing and Counselling. She regularly coaches the mediation teams. Her role as AssociateDean for Teaching and Learning requires that she teach the professors new ideas and approachesfor teaching law. She will present her innovative ideas and exercises that relate to the role ofincorporating conflict resolution skills into the basic law school curriculum.Helping Law Students Find Balance in Their Legal Education: TeachingMindfulness and Contemplative PracticesMary Delores Guerra, Phoenix School of Law (mguerra@phoenixlaw.edu)Professor Guerra will present on the importance of offering law students opportunities to findbalance in their legal education. She will discuss how professors and students can work togetherto reach this goal, planting seeds for students to learn how to use contemplative practices in theirprofessional lives. These practices can enhance students’ professional identities and theirpersonal integrity because students will come to know that they can be “true to themselves” andbe successful practicing attorneys. Professor Guerra has integrated and adopted manymindfulness and contemplative practices into her classes. She teaches Commercial Law,Business Associations, Alternative Dispute Resolution (ADR) and Interviewing and Counseling.She adopted several practices before she attended law school, including reflective journaling,meditation and yoga. Having benefited from contemplative practices in her own life, she wantedto share these practices with her students to help her students find balance in legal education.When she became a law professor in 2006, she was thrilled to learn that her school, PhoenixSchool of Law, was committed to transforming and humanizing legal education. She beganutilizing a reflective journal, known to her students as the Self-Assessment Book (SAB), in hercommercial law and business associations classes in the fall 2007. After attending, AALS 2010Section on Balance in Legal Education panel, she began incorporating “balance in legaleducation” questions that her students reflected upon and answered in their SAB. In Spring 2011,in her ADR class, she worked collaboratively with her students in several ways, including:allowing them to negotiate which group they would be in for their Advanced WritingRequirement (AWR) (group 1 or group 2, which had different time frames), getting frequent andsubstantive feedback from students regarding the content of the classes, discussing the quantityof pages for the class readings. The highlights of the class for the students and for ProfessorGuerra were the mindfulness exercises and speakers that she brought to class. She has thestudents take a moment of silence, while focusing on their breath, learning to be present. They436

learn active, empathic listening. They have opportunities in and out of class to reflect on theirreadings and to complete their “balance in legal education” questions. Professor Guerra alwayskeeps in mind the following questions when deciding on a class exercise or a speaker, “How willthis help the students bring balance to their busy, chaotic lives as students and how will thisinformation carry over into their lives as attorneys.An American Indian’s Perspective on Building Respect in the LawSiera Russell, Phoenix School of Law (srussell@phoenixlaw.edu)American law has historically disrespected and disenfranchised American Indians throughbroken treaties, boarding schools, forced relocation, and termination. As American Indiansexercise their inherent sovereignty and the United States respects their legal decisions asynergistic relationship evolves. In today’s world, respect must be taught. As an Indigenous lawprofessor and tribal court judge, I bring a unique perspective on this topic. Contemporary legaleducation is an excellent forum for teaching respect. It is a critical attribute, characteristic, andattitude that can be infused into the legal classroom. This lecture will facilitate a discussion onthe strategies, challenges, and rewards of building a climate of respect in any legal environment.185. A Disability Rights Tribunal for Asia and the Pacific:International Human Rights and TJ ImplicationsThe Creation of a Disability Rights Tribunal for Asia and the Pacific: The Timeis NowMichael L. Perlin, New York Law School (mperlin@nyls.edu)There is no question that the existence of regional human rights courts and commissions hasbeen an essential element in the enforcement of international human rights in those regions of theworld where such tribunals exist. In the specific area of mental disability law, there is now aremarkably robust body of case law from the European Court on Human Rights, some significantand transformative decisions from the Inter-American Commission on Human Rights, and atleast one major case from the African Commission on Human Rights.In Asia and the Pacific region, however, there is no such body. Although the ASEAN(Association of Southeast Asian Nations) charter refers to human rights, that body cannot beseen as a significant enforcement tool in this area of law and policy. Many reasons have beenoffered for the absence of a regional human rights tribunal in Asia; the most serious of these isthe perceived conflict between what are often denominated as “Asian values” and universalhuman rights. What is clear is that the lack of such a court or commission has been a majorimpediment in the movement to enforce disability rights in Asia.437

The need for such a body has become further intensified since the ratification of the UnitedNations’ Convention on the Rights of Persons with Disabilities (CRPD), the effectiveness ofwhich requires that it be enforced through a governing regional body. The creation of aDisability Rights Tribunal for Asia and the Pacific (DRTAP) would be the first necessary stepleading to amelioration of this deprivation, which could also serve as inspiration for a fullregional human rights tribunal in this area of the world, and a way of insuring the infusion oftherapeutic jurisprudential values into the entire legal process. If, however, it were to be created,it is also clear that it would be an empty victory absent available and knowledgeable lawyers torepresent individuals who seek to litigate there.Strategies to establish Disability Rights Tribunal in Asia and Pacific during theNew Decade for Persons with Disabilities in Asia and PacificYoshikazu Ikehara, Tokyo Advocacy Law Office, Tokyo, Japan (yikehar@attglobal.net)UN-ESCAP is going to launch the New Decade for Persons with Disabilities in Asia and Pacificin 2013. The New Decade aims at complete implementation of CRPD among its member states.UN-ESCAP is working out strategies for its purpose. Persons with Disabilities Organizationsurge to include DRTAP into one of goals of the strategies. Some member states seem to beagainst establishing a regional judicial system and others look indifferent to it. But it is no doubtthat DRTAP is necessary in Asia and Pacific to protect and promote disability rights like otherregional human rights courts. The point is how to put theory into practice. We have establishedDisability Rights Information Center in Asia and Pacific and we are planning a training programfor disability rights advocates among Southeast Asian countries, Oceania, Japan and US. Ouradvocates who will be trained will monitor and support an individual client in Asia and Pacific.Their repots to DRICAP will demonstrate insufficiency of a national human rights mechanismand necessity of DRTAP for complete implementation of CRPD in Asia and Pacific.The presenter organized a project to establish DRTAP in 2008 and held several conferences invarious countries to expand its network from 2009 to 2012. It gave a strong impact on the NewDecade. The presenter will show the situation of the New Decade in terms of DRTAP and basicstrategies to establish it during the decade.DRTAP and the Nature of TribunalsPenelope Weller, Monash University (penny.weller@monash.edu)The effort to establish a regional disability rights tribunal makes a practical contribution to thehuman rights effort in a region that lacks a regional human rights body, and in which severalnations have undeveloped human right institutions. The initiative provides a foundation forthinking closely about character of such a tribunal and the scope of its jurisdiction in light of the438

oader tribunal tradition. The notion of a ‘tribunal’-as opposed to a court- is associated with thealternative dispute resolution movement of the 1970s. Tribunals were established to counter theperceived limitation of adversarial justice. They are hybrid processes of adjudication that are atliberty to create innovative responses to the problems they that address. The ‘reconciliation’tribunals in South Africa and East Timor, for example, adapted themselves to their task. Thispaper argues that the CRPD provides a sound conceptual basis for a disability rights tribunal.This approach would have implications for the way in which a tribunal may choose to structureits powers, articulate its tasks, and approach its deliberations. For example, the social model ofdisability in the CRPD requires an integrated analysis of human rights that encompasses bothpositive and negative rights that is sensitive to the full social, cultural and legal context in whichthe realization of human rights may occur. This is a new field of rights jurisprudence with littleprecedent to guide it. This paper argues for an approach to DRTAP that is fully engaged withcontemporary human rights perspectives.Effective Strategies for Implementing a Disability Rights Tribunal in Asia andthe PacificHeather Cucolo, New York Law School (Heather.cucolo@nyls.edu)In all regions of the world, persons with mental disabilities – especially those institutionalizedbecause of such disabilities – are uniformly deprived of their civil and human rights. TheConvention on the Rights of Persons with Disabilities (CRPD) is, potentially, the single mosttransformative legal initiative affecting persons with mental disabilities in that it established“hard law” contributing to the international human and legal rights of persons with disabilities.The creation of a Disability Rights Tribunal for Asia and the Pacific would be the first necessarystep leading to amelioration of rights deprivation. It would be a bold, innovative, progressive andimportant step on the path towards realization of those rights. Rights are currently inadequateand severely lacking in judicial and legislative support. In order to protect and uphold necessaryhuman rights, we must address cultural, political and sanist attitudes that prevent forwardmovement. Once we investigate and accomplish a detailed understanding of these attitudesthrougha study of history and sociology - we then can design an approach that will overcomeoppositional and anti-therapeutic treatment of persons with mental disabilities. In furtherance ofthis objective, New York Law School will host a website,- the Disability Rights InformationCenter for Asia and the Pacific (DRICAP)- to catalog statutes, regulations, scholarly articles,advocacy news and case law from selected Asian/Pacific nations. The hope is that we can gathernecessary documents in order to provide resources to key individuals in the judicial, political andacademic arena who will have the means and power to turn theory into action.A Human Rights Audit of New Zealand Mental Health LawKris Gledhill, University of Auckland (k.gledhill@auckland.ac.nz)439

This paper will provide an international human rights audit of the Mental Health legislation (andalso policies and practices) in New Zealand.It is in three parts. The first will be an outline of what the human rights framework requires: thisin turn will involve an analysis of the relevant treaty provisions (mainly the ICCPR and theCRPD, supplemented by relevant “soft law” declarations and guidance from bodies such as theWHO) and of the relevant supplemental material in the form of case law from the Human RightsCommittee (and analogous case law from the European Court of Human Rights). There will alsobe consideration of the impact of the ICESCR and the growing view that it provides some "hardlaw.”The second part will be an analysis of the provisions of the NZ Bill of Rights Act, whichprovides for a non-constitutional protection for fundamental rights (via a strong interpretiveobligation on courts to construe statutes so as to comply with rights, though without any powerto strike down a non-compliant statute) and an account of the cases that have been argued in thedomestic courts raising BORA points. In addition, there will be an assessment of otherprovisions of domestic law that have a “rights” basis to them, such as the Privacy Act, and suchas the Health and Disability Commissioner’s Code of Rights, and an assessment of their role inlitigation.The final part will be an analysis of such other parts of the legislative framework as have not atthis stage been subject to litigation or are not clearly covered in a rights-compliant fashion.The assessments in the second and third parts will lead to a view as to whether or not NewZealand law is compliant with the current understanding of what a rights-based mental healthlaw framework requires.186. Examining Disability Law in Theory and Practice: ATherapeutic Jurisprudence AnalysisAn Un-level Playing Field: The Psychological and Emotional Impact of theIndividuals with Disabilities Education Act on Parents of Children withDisabilities: A Therapeutic Jurisprudence AnalysisRichard Peterson, Pepperdine University, USA (richard.peterson@pepperdine.edu)This presentation addresses the psychological and emotional impact of the Individuals withDisabilities Education Act (IDEA) upon parents of children with disabilities. In 1975 the UnitedStates Congress passed Public Law 94-142, which required on constitutional principles of equalprotection and due process that all children with disabilities have an opportunity to receive a freeand appropriate public education. The Act, now known as the IDEA, also required that parents beincluded in the decisional processes associated with a student’s educational placement andprogramming. Although Congress declared that “…30 years of research and experience hasdemonstrated that the education of children with disabilities can be made more effective by …440

strengthening the role and responsibility of parents and ensuring that families of such childrenhave meaningful opportunities to participate in the education of their children …,” this paradigmhas been resisted by educators, and fraught with conflict from the beginning. While Congressenvisioned a cooperative and collaborative relationship between educators and parents, it wasalso understood that educators would have a natural advantage over parents in the system, andthus included detailed procedural requirements meant to level the playing field. Yet parents oftenlack the knowledge and skills necessary for meaningfully participation in the processes of theIDEA and frequently experience substantial psychological and emotional consequences as aresult. This presentation will explore through the lens of Therapeutic Jurisprudence the variousfactors associated with the IDEA, and its implementation, that trigger anti-therapeuticconsequences for parents of children with disabilities.Inclusion in School Settings for Parents and Students with Disabilities Using theADA and Section 504 LitigationPaula Pearlman, Disability Rights Legal Center, USA (Paula.Pearlman@lls.edu)This presentation addresses the psychological and emotional impact of the federal antidiscriminationlaws, Section 504 of the Rehabilitation Act (Sec 504) and the Americans withDisabilities Act (ADA), upon parents with disabilities and students with disabilities who requestaccommodations in school settings. While the IDEA addresses specialized instruction and relatedservices, Section 504 and the ADA address broad anti-discrimination principles based ondisability. This discrimination takes the form of exclusion, segregation and denial of access andbenefits of the programs that schools provide. These programs include classroom learning, butalso include parent-teacher-student conferences, sports activities, graduation events, artsprograms, student government and school performances. Accommodations such as an elevatorkey, a service animal or a sign language interpreter, or physical access to the campus in general,are frequently the subject of controversy and litigation.Requesting accommodations often is fraught with conflict as school administrators, parents andstudents navigate the accommodation process from a cost/benefit perspective rather than an antidiscriminationperspective and a perspective that values inclusion and diversity.This presentation will explore through the lens of Therapeutic Jurisprudence the various factorsassociated with Section 504 and the ADA accommodations in school settings, with a particularfocus on litigation and systemic reform that both address the anti-therapeutic consequences forpeople with disabilities, as well as the positive therapeutic consequences resulting from effectiveprocedural methods resulting in appropriate accommodations and inclusion.Therapeutic Jurisprudence as a New Approach to Conflict Resolution in OurSchoolsLeah Christensen, Thomas Jefferson School of Law (lchristensen@tjsl.edu)441

This presentation will discuss the failure of the traditional legal system to prevent and deal withbullying in our schools. Bullying is one of the most damaging and pervasive problems amongour youth populations. This presentation suggests a new approach to conflict resolution—theSocial Inclusion Approach—which takes a therapeutic jurisprudence (or restorative justice) viewto dealing with bullying and violence in our schools. In essence, we need to stop resolvingdisputes by simply finding someone to blame and punish. The result of the “blame” game is thatthe accused tries to avoid punishment by claiming innocence or passing the blame onto someoneelse. The central question becomes: can we have justice without blame? The answer is yes, ifwe humanize our approach to conflict resolution. We need a whole-school approach to bullyingin which we express disapproval for a perpetrator’s actions while not seeking to apportion blame.An approach based upon the tenets of therapeutic jurisprudence deals with the conflict openlybut not judgmentally.This presentation will actively demonstrate the Social Inclusion Approach by explaining andillustrating a “No-Blame” Mediation—one that can be successfully used in schools today. Thepresenter will seek to provide the information in the presentation in an active and experientialmanner—using Powerpoint slides, hand-outs, and an active simulation as time provides.Therapeutic Jurisprudence and the Treatment of Drug Addiction in the U.S.:What the Emerging Neuroscience Research and the Recently Upheld HealthCare/Insurance Law Portend for Decriminalizing Drug Addiction in the USLeonore M.J. Simon, Simon and Associates, Johnson City, USA (simonlmj@gmail.com)Therapeutic jurisprudence suggests that we use the law as a means to improve the health andwell-being of people who find themselves in the legal system due to drug addiction. In thedistant past, we involuntarily committed drug addicts to mental hospitals for forced mental healthtreatment. Since the 1980s, the U.S. has declared a war on drug addicts and their families byconvicting and imprisoning individuals who might not otherwise find themselves in prison. Thispaper examines emerging neuroscience research that explains the neurobiology of drug addictionand its changes of the brain in conjunction with the recently upheld Obama HealthCare/Insurance Law that treats mental disorders including drug addiction like other physicaldiseases. The opportunity to transform US drug policy from one that is ineffectively punitive andnot based on science to one that is based on science and manages addiction like any otherchronic physical condition is explored.187. Expanding TJ’s BoundariesCan TJ Inspire and Inform a Healthier Culture of Legal Scholarship?442

David Yamada, Suffolk University (dyamada@suffolk.edu)The culture of legal scholarship has become preoccupied with article placement, impact andcitations rankings, and download numbers, thus obscuring a deeper appreciation for the potentialcontributions of scholarly work. This presentation will examine how therapeutic jurisprudenceprovides us with tools for understanding and changing that culture. More prescriptively, I wouldlike to apply a TJ lens to: identify a set of good practices for legal scholarship; examine the TJmovement as an example of healthy scholarly practice; and, consider how TJ can inspire lawprofessors, practitioners & judges, and law students to engage in scholarship that promotespsychologically healthier outcomes for the law and legal practice. This proposal builds upon alaw review article, David C. Yamada, Therapeutic Jurisprudence and the Practice of LegalScholarship, 41 UNIVERSITY OF MEMPHIS LAW REVIEW 121 (2010), as well as my participationin a March 2012 workshop on TJ at the University of Puerto Rico School of Law.A Therapeutic Jurisprudential Framework of Estate PlanningMark Glover, Louisiana State University (mark.glover@law.lsu.edu)The psychological consequences of the law of succession largely have been overlooked, which isconfounding given the emotionally charged contexts of the estate planning and probateprocesses. Filling this analytical void, this article examines the estate planning process from atherapeutic jurisprudential perspective and makes two primary contributions to the study of thelaw of succession. First, the article identifies the positive and negative psychologicalconsequences of the estate planning process and argues that the process has an overalltherapeutic nature. Second, the article develops these therapeutic and anti-therapeutic qualitiesinto a framework through which to analyze reforms of the estate planning process, so that thelaw’s therapeutic potential is maximized. By demonstrating the field’s analytic worth in thecontext of estate planning, this article encourages the continued use of the therapeuticjurisprudential framework to analyze a broad range of reforms of the estate planning process andseeks to inspire further therapeutic jurisprudential analysis throughout the law of succession.Capturing Human Consent through Collaborative ContractsThomas D. Barton, California Western School of Law (tbarton@cwsl.edu)“Contracts” can be valuably analyzed as comprised of three distinct relationships: (1) aneconomic relationship based on the exchange of value; (2) an interpersonal relationship of theparties, based on trust & cooperation—or its opposites; and (3) a legal relationship based on thesubstance and form of the agreement satisfying prerequisites for making the agreementenforceable by the state. Contracts are a vital form of human connection. Finding a private443

agreement—coming to mutual accommodation—is increasingly important as summoning formalstate power becomes more and more clumsy and expensive. But the potential of contracts as ameans to displace power in human problem solving is constrained by a legalistic mentalitytoward contracts itself. Lawyers sometimes cannot imagine what contracts could become,because they regard contracting so narrowly. Over the past century, for many lawyers the threerelationships of contracting have conflated into essentially one: the legal. The interpersonalrelationship of the parties has certainly been marginalized. But even the particulars of theunderlying economic exchange tend to be seen as relatively insignificant to the legal status of theagreement. Lawyers thus tend to regard contracts one-dimensionally, as essentially a set of statebackedrights to be marshalled by one person for potential use against another. This adversarial,rights-and-power approach to contracting may be stifling the broader potential of the contractingprocess. “Collaborative Contracting” is a way to change lawyers’ mentalities toward contracts,enhancing the economic and personal relationships that always have been important to contracts.My proposed presentation first would describe the need for more collaborative contracting, andthen offer suggestions for concrete steps by which all three relationships of contracting might bestrengthened.Children as Subjects of Mental Health Research: Legal, Ethical and TherapeuticJurisprudence (TJ) PerspectivesJan C. Costello, Loyola Law School (jan.costello@lls.edu)This presentation explores the legal, ethical and therapeutic issues involved when children andadolescents are subjects of mental health research, including experimental trials of medicationsor other treatment modalities. Legal and ethical issues include initial informed consent,confidentiality protections and limitations, and the choice to continue or discontinueparticipation. Key questions discussed include: From a therapeutic jurisprudence perspective, areexisting legal protections and clinical protocols adequate or unduly burdensome? Do they enablevaluable research in mental health to be done while providing genuine benefits to the researchsubjects? Moreover, where subjects are not likely to benefit from the research – are there stilltherapeutic reasons for permit the child to participate?24.5: The Current Position of Domestic Partnerships in South Africa andWhether the Proposed Recognition Thereof Will Have the Desired TherapeuticOutcomeEnid Coetzee, University of Johannesburg (ecoetzee@uj.ac.za)Cohabitation is not a legally recognised relationship in South African law. The relationship, alsoreferred to as a domestic partnership, is recognised in certain instances. The South African courts444

as well as the legislature brought about some changes to give relief for partners in a domesticpartnership. The draft Domestic Partnership Bill that was published in January 2008, yet to beenacted, will rectify the position and regulate cohabitation. Some of the objectives of the Billinclude the recognition to the legal status of domestic partners, their respective rights andobligations and the regulation of their financial matters. In the interim, until the Bill ispromulgated, cohabitants are dependent on the courts especially with regard to the division ofproperty. Partners have to apply to the court for an order to divide the joint and separate propertyof one or both of the partners. The court will then divide the property how it deems equitable andjust. Another possibility for the domestic partners is to prove the existence of a universalpartnership. The partnership gives both parties a right to share in all the property acquired duringthe relationship. However, it is difficult to prove the existence thereof and adhere to therequirements. The paper will investigate the current situation with regards to domesticpartnerships and how the proposed legislation that will recognise cohabitation will have thedesired therapeutic outcome.188. International Human Rights and Mental Health CourtsMental Health Courts and the CRPDRobert Dinerstein, American University, Washington College of Law(rdiners@wcl.american.edu)Mental Health Courts, sometimes called problem-solving courts, have evolved as an alternativeto criminal prosecution for defendants with psychosocial disorders. Ostensibly designed toprovide more thoughtful, humane and intensive treatment to these individuals than they couldreceive in jail or prison, or through traditional probation services, Mental Health Courts canexact a heavy price for this supposed benefit. For example, the requirement that individualsadmit their guilt and the high degree of state involvement in the individual’s life (possibly muchhigher than would occur if the individual served his or her time in jail) raise important questionsregarding whether Mental Health Courts are in fact overly coercive and deny individuals’ legalcapacity. This paper will examine Mental Health Courts in light of key articles of the UNConvention on the Rights of Persons with Disabilities, in particular Articles 12, Equalrecognition before the law, 14, Liberty and security of person, and 19, Living independently andbeing included in the community.Safeguarding the Rights of People Detained for Psychiatric Treatment in NewZealandKatey Thom, University of Auckland (k.thom@auckland.ac.nz)445

New Zealand’s mental health legislation provides several safeguards that are intended to protectand promote the rights of people subject to compulsory psychiatric treatment. Exactly how thesesafeguards work in practice and whether or not they meet their intended functions has receivedlittle empirical attention. This presentation will report the findings of two qualitative studiesfocused on various safeguards aimed at ensuring people have access to legal advice, advocacyand the right to appeal their status while being detained for psychiatric treatment. The trials andtribulations of carrying out the statutory watchdog role of ‘district inspector’ will be firstlyexamined by reporting the findings of a study founded on in-depth interviews, the collection ofaudio-diaries and shadowing of lawyers who undertake this role. This will be followed by ananalysis of the decision-making of the Mental Health Review Tribunal hearings based onethnographical observation, document analysis and interviews with tribunal members, applicantsand their lawyers. The paper will conclude by assessing how these safeguards measure upagainst their aims of providing pro-therapeutic, fair, respectful and dignified legal processes forusers of mental health services.Do Structural Rather than Therapeutic Factors Determine the Placement ofOffenders in Mental Health Courts?Tracy D. Gunter, Indiana University (tdgunter@iupui.edu)Eric J. Miller, Saint Louis University (emille33@slu.edu)Jails and prisons in the United States have, in effect, become dumping grounds for individualsafflicted with mental health problems. The community care-oriented goal of effectivelyintegrating individuals with mental disorders into the larger community is not matched by eitherpractice or funding. Many mentally ill individuals are simply released from hospital into thecommunity with minimal provision made for their care. These people often cycle from homelessshelter to prison to hospital, without any effective means of therapeutic support.Mental health courts have emerged as a central innovation seeking to break the cycle ofrecidivism and incarceration of the mentally ill. Although these courts are judicially supervised,they operate outside of the traditional criminal justice system and employ a "problem-solving"approach to promote compliance with community treatment in the hopes that this compliancewill relieve the primary cause of the criminal offending. The courts are designed to address“systemic failures in public mental health and the criminal justice system”: on the one hand, bychanneling mentally ill offenders away from incarceration and into community treatment; on theother hand, by motivating participants to accept the recommended treatment.Some scholars have criticized this approach as in fact enhancing the involvement of people withmental illness in the criminal justice system. They claim the courts use undue coercion andinvade the private realm of healthcare information, further stressing inadequate communityresources, and diverting local funds from community mental health treatment modalities.Our empirical research investigates five mental health courts as they exist in Missouri, todetermine whether mental health (as opposed to other criminogenic factors) is the primary riskfactor driving the creation of and referral to mental health courts. As is the case throughout the446

United States, these courts vary greatly and this study will provide the opportunity tocompare and contrast the effects of different operational strategies.International Human Rights and Mental Health CourtsAndrea Risoli, New York Law School (andrea@risolilaw.com )This presentation will address the implementation of mental health courts and whether theymight be productive in an international setting. The presence of defendants with mental illnessesin the criminal justice system imposes substantial costs on that system and substantial harm onoffenders. It is difficult, if not impossible, to provide humane and just treatment to persons withmental illnesses in prisons. Where domestic legal proceedings fail to address human rightsabuses, mechanisms and procedures for individual complaints or communications are availableat the regional and international levels to help ensure that international human rights standardsare indeed respected, implemented, and enforced at the local level. There is an inherent potentialfor abuse of these obligations in the term criminalization of the mentally ill at the local levels ofgovernment and justice systems throughout the world.By default, correctional systems have become the greatest providers of treatment for the mentallyill. But correctional systems are poorly designed to be treatment providers. There are alsousually too few mental health care professionals available to treat prisoners. In addition, turnoveramong correctional staff and mental health care staff can be destabilizing for the mentally ill andcan also lead to problems with continuity of care and recidivism. An alternative to this problemis the implementation of wide-ranging mental health courts in order to provide a least restrictivealternative and ultimate treatment regimen in lieu of the prison setting for mentally illindividuals.Mental health courts link offenders who would ordinarily be prison-bound to long-termcommunity-based treatment. They rely on mental health assessments, individualized treatmentplans, and ongoing judicial monitoring to address both the mental health needs of offenders andpublic safety concerns of communities. Like other problem-solving courts such as drug courts,domestic violence courts, and community courts, mental health courts seek to address theunderlying problems that contribute to criminal behavior.An international mental health court would reduce the number of mentally ill persons in thecriminal justice systems by improving mental health treatment at an earlier age and reducehomelessness. Nevertheless at the extreme end a mental health court can encroach upon the civilinvoluntary commitment standards already in place. But at best, mental health courts focus ontreatment rather than prison, which is a quandary to be reckoned with in any jurisdiction.Increased reliance on the criminal justice system to provide treatment to persons with mentalillnesses is almost certainly always counter-productive. Indeed, only a well-designed mentalhealth court would ensure success. A well-designed mental health court could reduce recidivismamong participants, improve mental health outcomes, and reduce the rate of incarceration forpersons suffering from mental illness. To be sure, mental health courts are a relatively newconcept that is still developing and evolving, but it is a viable alternative to an ongoing problem447

and potential for inhumane abuses to persons with mental illness.The Changing Role of Psychiatrist Members of the Parole Board for Englandand Wales as a Result of the Implementation of the European Convention onHuman RightsJohn A Baird, Royal College of Psychiatrists, Glasgow, Scotland (john.a.baird@ntlworld.com)Before the introduction of the European Convention on Human Rights, the final decision on therelease of a life sentence prisoner was taken by a senior elected politician. The Convention tookaway that right from politicians and gave it to a tribunal of members of the Parole Board whotogether have the final decision on the matter of release.Psychiatrists and Psychologists as members of the Parole Board are members of these tribunals.Along with a change in the locus of decision making came much greater clarification of the testswhich were to be applied, together with a requirement for the proceedings to include all partiesfor case papers to be shared and for the tribunal to issue their decision in writing and for theirdecision making and deliberations to be transparent. Psychiatrists and Psychologists, when theyare sitting on tribunals, have to balance their clinical role with their primary judicial function. Itcan take both time and reflection to develop these new skills.Issues of risk aversion,'re-sentencing' and the challenge of true independence all arise during thecourse of this work and will be discussed. Discretionary release of long term prisoners servingboth determinate and indeterminate sentences is a feature of many jurisdictions and this system islikely to be of interest to those who are involved with similar issues in other countries.189. International Human Rights & TJFetal Alcohol Spectrum Disorders & Mental Health LawSophie Hein, Université Laval (heinsophie@yahoo.ca)Why do Fetal Alcohol Spectrum Disorders (FASD) still seem unrecognized in Mental HealthField? What should Law be and do to capture particularities of FASD? Could Mental HealthCourts help people with FASD?This presentation looks at FASD as a spectrum of neurological disorders still largelyunrecognized by law, health and mental health practitioners, especially in Quebec. WhileCanada is seen as a leader on FASD, its province of Quebec is only starting to look at thisdisability, exploring how the law could better intervene on people with FASD and their family.Collaborative Law Movement, Therapeutic Jurisprudence, Capabilities Approach and DisabilityHuman Rights all converge by aiming improvement of the well-being of people with disabilities.448

And as such, they could certainly become promising approaches in managing long termdisabilities created by prenatal alcohol exposure by inspiring integrated health services.Applied Therapeutic Jurisprudence: Myth or Reality?Carla Rodgers, University of Pennsylvania (carlarodgers@comcast.net)The concepts of therapeutic jurisprudence are well known. As elegantly stated by ProfessorDavid Wexler, “Therapeutic jurisprudence is the study of law as a therapeutic agent.” He alsostated that “Basically therapeutic jurisprudence is a perspective that regards the law as a socialforce that produces behaviors and consequences.” (1999-Thomas Cooley Law ReviewDisabilities Law Symposium) The questions addressed by this presentation are: Does it work inpractice? If so, where and how, and if not, can the application be improved? This author hasdirect experience with drug court diversion in the United States and familiarity with drug courtsin Australia and the United Kingdom. She will discuss the moderate success of such attempts.She will also discuss where attempts, such as diversion to anger management and otherbehavioral therapies have failed. Finally she will review the inherent tension between law andmedicine and psychology that have led to less than successful interventions. That tension beingthat law requires a specific outcome in a set point of time’ whereas medicine and psychologyfocus on the process and incremental improvements, which often take years and where timelimits cannot necessarily be applied.Pragmatic Realism as Therapeutic Jurisprudence in the International DisabilityRights ContextAnne Bloom, University of the Pacific (abloom@pacific.edu)Disability rights activists emphasize the social contingency of disability. Both the definition of“disability” and the experience of “disability” depend greatly upon the particular social contextin which people live and function. A similar argument can be made about “rights.” As manycritics have argued, rights in the abstract have no meaning and, as a result, it only makes sense tospeak of rights in terms of how they operate in particular social settings. How then can wedevelop meaningful principles for adjudicating disability rights claims in an internationalcontext? This presentation will argue for a jurisprudential approach that draws upon thepragmatic realism of Oliver Wendell Holmes, Jr. to defend a more grounded approach tointernational disability rights jurisprudence that focuses on paying closer attention to individualplaintiffs’ experiences and the surrounding material conditions. It will also argue that ajurisprudence based on pragmatic realism is a therapeutic jurisprudence because it allows spacefor litigants to articulate and consider the changing ways in which they understand andexperience disability in their own lives.449

Sexuality, International Human Rights, and Therapeutic JurisprudenceMichael L. Perlin, New York Law School (mperlin@nyls.edu)One of the most controversial social policy issues is the sexual autonomy of persons withpsychosocial and intellectual disabilities. This population – always marginalized and stigmatized– has traditionally faced a double set of conflicting prejudices: on one hand, this population isinfantilized (as not being capable of having the same range of sexual desires, needs andexpectations as persons without disabilities), and on the other, it is demonized (as beinghypersexual, unable to control base or primitive urges). These attitudes have been in place forcenturies; perhaps the most famous characterization remains US Supreme Court Justice OliverWendell Holmes’s line in Buck v. Bell, a case involving sterilization of a woman allegedlyintellectually disabled: “Three generations of imbeciles are enough.”The ratification of the Convention on the Rights of Persons with Disabilities (CRPD) demandswe reconsider this issue, in light of Convention Articles mandating, inter alia, "respect forinherent dignity" (Article 3), the elimination of discrimination in all matters related tointerpersonal relationships (Article 23), services in the area of sexual and reproductive health(Article 26). Yet, the literature has been remarkably silent on this issue in general (forexceptions, see Schaaf, 2011; Stein & Lord; Sabatello, 2010), and totally silent about the issue Iwill discuss in my paper: the CRPD’s impact on the rights of persons institutionalized because ofpsychosocial or intellectual disability to sexual autonomy.My presentation will (1) review the history of how the significant legal and social issues havebeen ignored and trivialized by legislators, policy makers and the general public, (2) consider themeager case law on this subject, (3) highlight those sections of the CRPD that force us toreconsider the scope of this issue, (4) offer some suggestions as to how ratifying and signatorystates must change domestic policy so as to comport with CRPD mandates, and (5) consider theimplications of therapeutic jurisprudence insights for the resolution of these issues.Is Therapeutic Jurisprudence an Option Available to China's Criminal JusticeSystem?James Gronquist, Charlotte School of Law (jgronquist@charlottelaw.edu)Can China, a state controlled hierarchical society find a way to utilize the precepts of therapeuticjurisprudence that has been developing in primarily egalitarian societies. The Chinesegovernment continues to view law as a means of authoritarian control over its citizens.However, since the implementation of "law" in China in the late 1970's, the written law hastended to support the rights of individuals against the power of the one party system and itsinterest in maintaining its control over a sometimes restive society. That written law with its450

ever increasing adversarial aspects combined with the growing power of citizens (netizens) usingthe internet to challenge "the party line" may provide the opportunity for consideration of theintroduction of therapeutic jurisprudence into the Chinese legal system. This paper is an attemptto explore that option.190. Judging and Practicing in a Problem-Solving Court: Tips andTechniquesMainstreaming Therapeutic Jurisprudence into the Traditional Courts:Suggestions for Judges and PractitionersMichael Jones, Phoenix School of Law (mjones@phoenixlaw.edu)Therapeutic jurisprudence (“TJ”) has moved into the traditional courtroom, into the nonproblem-solvingcourts. The next challenge for TJ is to mainstream those TJ practice techniquesdeveloped in problem-solving courts throughout the court system. Judges who have learnedinnovative and effective problem-solving court techniques have matured, and through judicialrotations, many have moved on to serve on calendars that do not traditionally require problemsolving court techniques. They have carried their ‘TJ tool kits’ with them, and they cannot forgetthose techniques and procedures that made their problem-solving court experiences such asuccess. This article (published in the Phoenix School of Law, Law Review, June, 2012)contains practical tips, suggestions, and practice pointers for TJ and non-TJ judges andpractitioners from the perspective of a TJ judge assigned to a traditional court calendar. Therapid expansion of problem-solving courts throughout the United States and Canada is anendorsement and recognition of the effectiveness of TJ inspired techniques. Former problemsolvingcourt judges can contribute to the study of TJ and its practical applications through anunderstanding and sharing of effective TJ techniques. Such techniques may be just as effectivein non-specific traditional courts as in the problem-solving courts. Perhaps the most importanttechnique is that of improved communication skills. For instance, it is important to abandon apaternalistic listening and speaking style in the court room and to adopt a manner thatcommunicates respect to the litigants and attorneys; this encourages people to feel comfortablespeaking in court, giving voice to defendants, victims, and their families. In all criminalsentencing hearings, the judge can engage in active listening to aid the court in setting fines,restitution, and terms of probation. The unique concepts of the team-approach and review-typehearings can be modified and utilized successfully in traditional court proceedings.Discussant: Dave ColeMainstreaming Therapeutic Jurisprudence into the Traditional Courts:Suggestions for Judges and Practitioners, Part Two451

Dave Cole, Office of the Arizona Attorney General, Phoenix, USA (drcoleua@gmail.com)Judge Cole was among the first Drug Court Judges at the Maricopa County Superior Court. Hewill contribute to the hypothesis that former problem-solving court judges can contribute to thestudy of TJ and its practical applications through an understanding and sharing of effective TJtechniques. Such techniques may be just as effective in non-specific traditional courts as in theproblem-solving courts. Perhaps the most important technique is that of improvedcommunication skills. For instance, it is important to abandon a paternalistic listening andspeaking style in the court room and to adopt a manner that communicates respect to the litigantsand attorneys; this encourages people to feel comfortable speaking in court, giving voice todefendants, victims, and their families. In all criminal sentencing hearings, the judge can engagein active listening to aid the court in setting fines, restitution, and terms of probation. The uniqueconcepts of the team-approach and review-type hearings can be modified and utilizedsuccessfully in traditional court proceedings.Judging in a Modern Problem-Solving or Specialty Court: The Challenges andthe RewardsKeelan Bodow, Maricopa County Superior Court, Phoenix, USADrug Courts have been in existence for over twenty (20) years. During those twenty years, theDrug Courts have expanded exponentially, and there are now over 2500 Drug Courts, mainly inthe United States, but many internationally. In addition, other Specialty Courts have developedincluding DUI/DWI Courts, Domestic Violence Courts, Veterans Courts, and many more. Notonly have the number of Specialty Courts increased dramatically, but the number of participantsin these courts also has sky-rocketed. At least one Drug Court in Arizona has seven-hundred(700) participants at any one time. Based on the significant number of participants in DrugCourts and other Specialty Courts, there has been a lot learned about what is effective and whatis not effective in the Problem-Solving Courts. Since there are greater numbers of participants,the data collected can be viewed as even more statistically valid and even more persuasive. Thestatistics nationwide continue to overwhelmingly show that the programs are surprisinglysuccessful in helping participants to become drug-free, and lead productive lives that do notinclude extended incarceration. With the expansion of Problem-Solving Courts, more and morepeople are having access to services that are targeted to the conditions that lead to their negativebehavior. However, challenges still exist. Rapid growth and the sheer volume of participants canadd administrative challenges, and even challenges to the core principles of the Problem-SolvingCourts. Coordination of services becomes more challenging. Having sufficient resources posesroad blocks. Some critics have questioned whether the Specialty Courts are still worth pursuing.But most of the key components of the Specialty Courts are surviving amidst these challenges.This article will look at how Drug Courts have expanded and changed since they were originallyconceived, what has been learned over the years, and investigate whether, and what type, ofchanges may be needed in the future.452

Judging in Tribal Healing to Wellness Family Drug and Mental Health Courts:The Challenges and the RewardsSiera Russell, Yavapai-Apache Nation Tribal Court, USA (srussell@phoenixlaw.edu)Alcoholism, addiction, alcohol and substance abuse, and mental health disorders are among themost severe public health and safety problems facing American Indian individuals, families, andcommunities, resulting in devastating social, economic, physical, mental, and spiritualconsequences. American Indians and Alaska Natives are at higher risk for certain mental healthdisorders than other racial/ethnic groups. Alcohol and substance abuse, mental health disorders,suicide, violence, and behavior-related chronic diseases are devastating issues across Indianreservations. In 2005, the Yavapai-Apache Nation (YAN) in northern Arizona, a tribalcommunity of approximately 2,000 enrolled members, formed its first Healing to Wellness Court- the YAN Mental Health Court. The purpose of the Mental Health Court is to provide a processfor people with diagnosable alcohol/substance abuse and a mental health disorder to participatein a therapeutic judicial approach to rehabilitation, restoration, and recovery. The participantreceives assessments, treatment planning, and additional services determined through acollaborative, multidisciplinary team decision making process. In the YAN Wellness MentalHealth Court the judge and treatment/behavioral specialist roles are significant in establishingand maintaining the participant’s stability. However, some of the other key players in this courtinclude the community’s law enforcement, defense counsel, prosecution, education, housing, andsocial services. I am an enrolled member of the Yavapai-Apache Nation and served as AssociateJudge for my Nation. Based on my experience presiding over the YAN, Healing to WellnessCourts: Adult Drug, Family Drug, and Mental Health Court, I will share the communication andprocess strategies that proved effective and less than effective.Discussants for all presentations in this panel: Rodney Mitchell, John Houston, DeputyMaricopa County Public Defenders, supervising and assigned to the specialty courts in MaricopaCounty Superior Court; and Devra Ellexson, Deputy Maricopa County Public Defender,Juvenile Court, Maricopa County Superior Court.191. Justicia Terapéutica: Delincuencia y DrogasLa importancia de la Justicia Terapéutica en la mediación y resolución deconflictos penalesMarcos Kac, Procuraduría General de Justicia del Estado de Río de Janeiro, Brasil(mkac@globo.com)453

Este trabajo aborda el problema del alcohol y las drogas desde la perspectiva de la JusticiaTerapéutica; como la representación de la posibilidad de acceso del público a un conjunto deservicios especializados para la salud legal, social y relacionada con el uso, el abuso y la adicciónal alcohol y otras drogas. Basado en el nuevo paradigma (la restauración y no el castigo). LaJusticia Terapéutica tiene la intención de actuar como enlace entre los ciudadanos y la justicia,mediante el establecimiento de medidas judiciales y extrajudiciales con los programas de tratoespecial y personalizado, la Justicia Terapéutica es parte de la tendencia del derecho moderno,que se centra en la prevención y la rehabilitación de la administración de justicia. Otracontribución de la Justicia Terapéutica propuesta es un enfoque de no confrontación entre losprofesionales y los que tienen los profesionales técnicos y de salud. Se sabe que en casos dedrogas, la violencia doméstica, la psicopatía y algunas otras cuestiones complejas como éstas, nila salud ni la justicia puede actuar de forma aislada, ya que la solución sea efectiva depende delos enfoques intersectoriales. El propósito de la justicia terapéutica aplicada al Sistema deJusticia Juvenil es proporcionar a los adolescentes y sus familias la oportunidad de acceder a unagama de servicios y tratamientos que pueden ayudar a superar la salud legal, social y relacionadacon el uso y abuso del alcohol y otras drogas. Usted puede hacer el paralelo con la JusticiaTerapéutica que se produce en relación a las penas alternativas formuladas delincuentes másgrandes, aunque según la ley brasileña, sólo después de la llegada de las medidas de imposiciónde penas alternativas (CPMA [1]), en el año 2000, que son cada vez más eficaz. En consonanciacon la orientación del Procurador General y Justicia Subprocuraduría General para los DerechosHumanos y el tercer sector, el actual Departamento de Justicia de la terapia (TYC) es unarealización conjunta de acciones para construir canales de apoyo efectivo en el respeto de lacomunidad de los derechos humanos y la atención de las necesidades sociales y de salud de losusuarios de alcohol y otras drogas. La justicia terapéutica emerge como una prioridad en lasnecesidades de la comunidad o la complejidad del problema del alcohol y las drogas en lasociedad que implica la concesión de derechos de acceso a los servicios de salud de calidad, laeducación y el bienestar, o por aspectos relacionados con la seguridad pública y la delincuencia.Justicia procedimental, alcances terapéuticosMartha Frías Armenta, Universidad de Sonora (marthafrias@sociales.uson.mx)La investigación de la delincuencia juvenil se ha encaminado a entender cuales son los factoresque influyen en la conducta de los adolescentes, otras se dirigen la percepción que la sociedadtiene de los adolescentes que delinquen, sin embargo, pero hace falta investigar sobre lapercepción que los menores en conflicto con la Ley tienen acerca del tratamiento y el procesojudicial en el que se ven envueltos. A esta percepción se le denomina justicia procedimental. Eltérmino de justicia procedimental proviene del ámbito legal, y refiere al “control ejercido por losabogados en el juzgado para resolver los casos jurídicos” (Tyler, 2006, p. 115). Existen variosmodelos sobre Justicia Procedimental, uno de ellos es el desarrollado por Thibaut y Walker(citado en Tyler, 2006) quienes relaciona las experiencias sobre la justicia del procedimiento alas cuestiones de control de decisiones. Las investigaciones en el área indican que laspercepciones de justicia sobre el procedimiento van a influir en la reinserción social deladolescente o en la recuperación de las víctimas. En este caso, se va dirigir a la percepción de los454

adolescentes que infringen la ley penal. Partiendo de la premisa que si perciben de manerapositiva el proceso y el tratamiento, entonces se obtendrán mejorías en la conducta de los jóvenesy a su vez se verá reflejado en un beneficio para la sociedad. Por lo tanto, el objetivo de estainvestigación es analizar la relación entre justicia procedimental, adherencia al tratamiento y lareinserción social de los adolescentes en conflicto con la Ley. Lo que se consideraría que lapercepción positiva de justicia procedimental tendría efectos terapéuticos en sus conducta y porlo tanto una mejor reinserción social. La muestra se constituyó con 50 menores de edad enconflicto con la Ley que se encuentran en internamiento y 50 adolescentes que se encuentran enmedios abiertos y que han infringido la ley penal. El instrumento fue elaborado exprofeso paraesta investigación y contiene preguntas acerca dela percepción de los adolescentes de su procesojudicial y su tratamiento dentro de las instituciones. Además, de las preguntas demográficas. Losresultados nos indican que los adolescentes que percibieron el proceso como justo tuvieron unamejor reinserción social. Los resultados se discuten en función de los efectos terapéuticos depudieran tener los procesos judiciales para los delincuentes juveniles.Programa de tribunales de tratamiento de drogas: una mirada alternativa a lapenaAlberto René Amiot Rodríguez, Universidad de Chile (aramiot@yahoo.com; aamiot@pjud.cl)El presente trabajo pretende mostrar la experiencia chilena existente en materia de Tribunales deTratamiento de Drogas. Durante la sesión se expondrán los modelos epistemológicos a la base delos programas chilenos, la descripción del modelo de trabajo, los resultados de los dos últimosaños de aplicación del mismo y los desafíos que existen a nivel de país en el tema, comoasimismo las consideraciones técnicas y éticas que debieran existir para la implementación deproyectos como estos. Asimismo, se desarrollará en la exposición la importancia del cambio deparadigma que ha implicado pasar en términos históricos de un sistema de resolución deconflicto penal inquisitivo a uno acusatorio. Se demostrara la importancia de este cambio para eldesarrollo y dirección de audiencias de TTD, desde el punto de vista de la fusión del mundosanitario-jurídico, que se plasma en las reuniones de pre-audiencia con todo el equipo queparticipa en las audiencias. También se explicará la implicancia que ha tenido para los jueces encuanto a la dinámica en la dirección de audiencias, por cuanto cambia la metodología yherramientas de trabajo, ya que lo que se pretende con el seguimiento y control judicial delprograma de rehabilitación es generar espacios terapéuticos que faciliten la rehabilitación delimputado y que fundamentalmente comprenden el manejo y técnicas de asertividad, liderazgo ycomunicación efectiva. Por otra parte se exhibirán distintas experiencias en el ámbito decooperación internacional, que dicen relación con la muestra de nuestro programa de TTD haciaotros países que aun no logran implementarlo, en el entendido que CICAD OEA propicia ladifusión e implementación de este programa a nivel hemisférico.Tribunales de drogas en Brasil: En busca de una metodología uniforme455

Daniel Pulcherio Fensterseifer, Universidade Regional Integrada(danielpulcherio@hotmail.com)Gabriel Filippe, Universidade Regional IntegradaRoberto José Stefeni, Universidade Regional IntegradaAna Paula Aires de Souza, Universidade Regional IntegradaEn Brasil, a pesar de la falta de investigación para demostrar de forma segura las cifras exactassobre delitos relacionados con drogas, se sabe que hay numerosos crímenes que configuran ladroga como un factor de gran relevancia para su práctica. A partir de esta circunstancia, se inicióun movimiento por parte de profesionales del derecho con el fin de dar una respuesta másadecuada a este tipo de delito, que podría ofrecer un servicio más eficiente y más humano.También se sabe que se están poniendo en práctica algunos programas judiciales basados en losTribunales de Drogas de los EE. UU. que están sIendo destacados en sus localidades, como enPorto Alegre, São Paulo, Recife y Río de Janeiro, entre otros. Sin embargo, al mismo tiempo,tales prácticas no se basan en una herramienta común de regulación, que podría servir para laimplementación de nuevas prácticas relacionadas al programa de Tribunales de Drogas demanera equitativa en Brasil, especialmente con la observación de las prácticas de la justiciaterapéutica. Debido a esta disparidad de técnicas y procedimientos surge la necesidad deuniformidad en la aplicación de este programa, que permita una mayor eficacia y unidad entrelos diferentes discursos existentes sobre la metodología utilizada en estas prácticas, con el fin,entre otros, de la creación, por una norma regladora de un Tribunal de Drogas en Brasil. Estainvestigación se está desarrollando en la Universidad Regional Integrada - URI en la ciudad deFrederico Westphalen - ciudad con un importante número de consumidores de drogas debido asu posición geográfica, ya que es una ruta de entrega de la droga hacia el sur Brasil - y ofrecer ala comunidad local de un proyecto piloto para poner en práctica un Tribunal de Drogas, quepodrá extenderse a otras partes del país. Objetivos: El objetivo es investigar la posibilidad deimplantación de un Tribunal de Drogas en Frederico Westphalen. Serán creados los elementosclave para el desarrollo de un Tribunal de Drogas en Brasil, a partir de aquellos que prevalecenen otros países, especialmente en EE.UU., Canadá y Chile. Por último, se tratará de establecerlos criterios de elegibilidad para el individuo ingresar al programa. Metodología: se llevará acabo búsqueda en la literatura, observaciones en las audiencias judiciales y establecimientos desalud en la región de Federico Westphalen que puedan recibir a los clientes. Se considera laregión de Frederico Westphalen las ciudades que se encuentran hasta cuarenta kilómetros dedistancia. Resultados esperados: Del presente trabajo se espera crear un proyecto pilotoestructurado y que permita poner en marcha inicialmente en la ciudad de Frederico Westphalen,con un manual de creación de un Tribunal de Drogas en Brasil.Eficacia de las estrategias administrativas y penales desarrolladas paramodificar las actitudes y comportamientos de infractores graves y contumaces.Valoraciones de los infractores participantesCristina Civera, Universidad de Valencia (cristina.civera@uv.es)456

José Ignacio Lijarcio, Universidad de Valencia (jose.i.lijarcio@uv.es)Ana Martí-Belda, Universidad de Valencia (ana.marti@uv.es)Luís Montoro, Universidad de Valencia (luis.montoro@uv.es)Coautor: Francisco Tortosa, Universidad de Valencia (francisco.m.tortosa@uv.es)La actual legislación de tráfico -entre otros factores- ha tenido una fuerte incidencia en ladisminución del número de muertos durante los últimos diez años, siendo esta reducción del56%. Aquellos conductores que cometen infracciones o delitos contra la seguridad vialparticipan en acciones sensibilizadoras y reeducadoras donde se trabajan los factores de riesgoimplicados en los siniestros de tráfico. Dos ejemplos claros de estas acciones son el “Programade Intervención, Sensibilización y Reeducación Vial “(INCOVIA) y el “Taller de Actividadespara el cumplimiento de trabajos en beneficios de la comunidad relacionados con la SeguridadVial” (TASEVAL). En el presente trabajo se ofrecen datos obtenidos con la Escala de Creenciasy Valores en Seguridad Vial (Escala CRV-SV), cuyo fin es guiar al profesional hacia los temasen los que debe profundizar con cada penado para sensibilizar, concienciar y generar unapredisposición al cambio a través del trabajo. También examinamos las atribuciones causales quetienen los conductores que cometen infracciones con su conducta infractora en una muestra de196 infractores de los cursos de reeducación del Sistema de Permiso por Puntos de la provinciade Alicante. Y, por último, examinamos la valoración que hacen los conductores sancionadosque participan en los cursos de reeducación vial sobre el Sistema de Permiso por Puntos con unamuestra de 240 infractores participantes en cursos de reeducacion y sensibilización impartidos enAutoescuelas de la provincia de Alicante. Pese a los resultados positivos obtenidos hasta lafecha, es necesario promover estrategias que fomenten la formación y la sensibilización de todoslos sectores de la población en el ámbito de la seguridad vial, ya que la formación junto con laeducación es una de las claves fundamentales hacia el cambio actitudinal que mejorará la culturay concienciación vial.192. Justicia Terapéutica y entorno familiar y de parejaLa Justicia Terapéutica en procesos de separación y divorcio: el punto de vistade los jueces y magistradosFrancisca Fariña, Universidad de Vigo (francisca@uvigo.es)Mila Arch, Universidad de BarcelonaEsther González-Pillado, Universidad de VigoLa separación y el divorcio se consideran uno de los eventos más traumáticos que una familiapuede experimentar, pudiendo afectar a todos sus miembros, principalmente a progenitores, hijosy abuelos. Los expertos defienden que la forma de llevar a cabo la disolución de la parejadetermina el tipo de relación que la familia va a desarrollar en el futuro, así como sus457

consecuencias a nivel, social, emocional, de salud física y psicológica, e incluso económica. Espor ello que debería convertirse en una prioridad del Estado el promocionar procedimientosjudiciales y extrajudiciales centrados en facilitar el bienestar de toda la familia y la colaboraciónparental tras la ruptura conyugal. La Justicia Terapéutica, tal y como afirman los padres eimpulsores de la misma, David Wexler y Bruce Winick, estudia “el papel que desempeña la Leyy la aplicación de la misma en el proceso legal como agente terapéutico” centrándose en comoincide el sistema legal en la persona, a nivel psicoemocional. De esta manea, la JusticiaTerapéutica se presenta como la corriente jurídica idónea para abordar los procesos de familia engeneral, y los relacionados con la separación y el divorcio, en particular; en línea con lo expuestopor Sturgis (2003). Es importante que los operadores jurídicos, de manera principal los jueces,internalicen y promocionen los principios y procedimientos de la Justicia Terapéutica, pero paraello es necesario que los conozcan. En este trabajo se analiza el conocimiento y la opinión quetienen los jueces de Familia, del estado español, sobre la Justicia terapéutica y susprocedimientos. Para ello, se les remitió un cuestionario, creado ad hoc, a los 100 jueces deJuzgados de Familia de España.La justicia terapéutica aplicada a una buena formación del niño y/o jovenTeresa Regina Quintana, Colegio Público de Abogados (quintanayasociados@itcom.com.ar)La mayor injerencia del padre en la crianza del niño y la importancia de la familia ampliada paraproteger las raíces del niño o joven con las excepciones derivadas de un ejercicio violento a nivelfísico y/o psíquico hasta el abandono.- La intervención del Estado con un trabajo intenso a nivelinterdisciplinario y los lugares de contención que brinda para los cuidados y tratamientos de losmismos.- La realidad de los números en cuanto a población y espacio institucional.- Número decasos atendidos en el último año en Buenos Aires.- La necesidad de activar el incremento deguardas provisorias como modo más cercano a una vida en familia para el niño o joven.- Laaplicación de una justicia terapéutica cuyo objetivo principal sea desdibujar las diferencias quese ocasionan entre la formación de un niño desprotegido del que crece dentro de su ámbitofamiliar.Justicia retributiva versus terapéutica en casos de violencia de géneroFrancisca Expósito, Universidad de Granada (fexposit@ugr.es)Josefa Ruiz-Romero, Universidad de GranadaInmaculada Valor-Segura, Universidad de GranadaMaría del Carmen Herrera, Universidad de GranadaGemma Sáez, Universidad de Granada458

La ley Integral contra la violencia de género 1/2004 supuso un importante avance en la luchacontra la violencia de género y la protección de la mujer en España. Desde que se aprobara dichaLey, el número de denuncias se ha visto incrementado año tras año, sin embargo, no se haobservado un descenso proporcional en el número de víctimas. La respuesta penal comoprincipal fórmula disuasoria no parece ser suficiente en un delito con una idiosincrasia como esel caso de la agresión de un hombre a su pareja o ex pareja, como indican las cifras de segundasoportunidades que las mujeres víctimas de violencia de género dan a sus parejas. El interés deeste estudio va dirigido a indagar sobre las actitudes que la población en general, tiene acera delcarácter punitivo de la Ley 1/2004, así como, su opinión acerca de alternativas menos extremas,como la justicia terapéutica, en aquellos casos de violencia denominados, de baja intensidad. Enuna muestra de hombres y mujeres adultos/as, se ha medido la respuesta a la justicia retributivaversus justicia terapéutica en delitos de violencia de género de baja intensidad, así como larelación de tales opciones y variables ideológicas como el sexismo ambivalente y creencias en elmundo justo de los participantes.Análisis del riesgo y adherencia al tratamiento pre-intervención en penados porviolencia contra la pareja que cumplen en la comunidadRamón Arce, Universidad de Santiago de Compostela (ramón.arce@usc.es)Mercedes Novo, Universidad de Santiago de CompostelaDolores Seijo, Universidad de Santiago de CompostelaFrancisca Fariña, Universidad de VigoEl tratamiento en la comunidad de condenados por violencia contra su pareja ha pasado en pocotiempo a ser uno de los retos de los técnicos encargados de administrar el tratamientopenitenciario. Al tratarse de penados con una alta probabilidad de recaída y que cumplen lacondena en libertad, la evaluación y gestión del riesgo así como de la adherencia la tratamientoson críticos para los administradores del tratamiento. Para que el tratamiento sea efectivo y, portanto, que se comience a gestionar al riesgo de reincidencia de una manera efectiva a través de uncontrol interno (el propio penado) frente a las medidas de barrera o control externo (orden dealejamiento, vigilancia policial, pulseras electrónicas, etc.). Para que los penados se adhieran altratamiento es necesario que activen los procesos de cambio, entendidos como las acciones quepone en marcha para modificar la conducta y cogniciones que facilitan la violencia contra lapareja. Para ello se aplicó una adaptación a maltratadores del Inventario de Procesos de Cambio(DiClemente, Prochaska, Fairhurst, Velicer, Velasquez y Rossi, 1991), que se mostró fiable (α =,919) a 567) condenados por maltrato a cumplir la pena en la comunidad. Los resultadosmostraron que los maltratadores no estaban concienciados para el cambio; adolecen de unaevaluación afectiva y cognitiva del impacto de la conducta de maltrato; no reconocen lasconsecuencias positivas respecto a dichas relaciones interpersonales, familiares y de amistad, quese producirían si cesara su conducta adictiva; no informan de la sustitución de la respuestaviolenta (física, psicológica,…) por conductas alternativas; no evitan la exposición a situacionesde alto riesgo de violencia contra la pareja; los comportamientos relacionados con el cambio de459

la conducta violenta no se refuerzan; no acuden a la red social en busca de apoyo para el cambiode la conducta violenta. Por el contrario, manifiestan la experimentación y expresión dereacciones emocionales elicitadas por las consecuencias penitenciarias, de conducta violenta(efecto disuasorio de la pena) y la toma de conciencia tanto de la representación social de laviolencia contra la pareja como de la voluntad social de combatirla (efecto de la Ley 1/2004). Enresumen, los penados en la fase de acogida están en un estadio de precontemplación por lo que elriesgo de recaída es elevado, por lo que se han de implementar medidas de gestión el mismo, altiempo que no se puede esperar de ellos una adherencia directa al tratamiento, por lo que hay queejecutar un plan de adherencia previo al inicio del tratamiento a la vez que controlar el progresoen el tratamiento.Conocimiento y uso de la mediación familiar como recurso de apoyo a lasfamiliasFrancisca Fariña, Universidad de Vigo (francisca@uvigo.es)Mª José Vázquez, Universidad de VigoSandra Carracedo, Universidad de VigoManuel Vilariño Universidad de VigoLa mediación familiar es un recurso de apoyo formal a las familias que se ven inmersas enconflictos familiares, derivados de la ruptura de pareja. Entre los beneficios de la mediaciónpara las partes en conflicto, se ha señalado la mayor satisfacción y grado de cumplimiento de lassoluciones adoptadas. Sin embargo, este recurso de ayuda continúa estando escasamenteposicionado en los servicios de atención a la familia. En este trabajo estamos interesados enevaluar el conocimiento y el uso del servicio de la mediación familiar. Concretamente, contamoscon un total de 274 participantes en el “Programa Ruptura de Pareja, no de Familia”, todos ellosinmersos en procesos de separación y divorcio, a los que se aplica un cuestionario elaborado adhoc. En relación a la mediación, y antes de asistir al programa, únicamente el 10,6% afirmanconocer en qué consiste, frente el 89,5% que desconocen este servicio, sin que mediendiferencias de género. Respecto al uso de la mediación, el 8,8% precisa haberla utilizado enalguna ocasión, mientras el 91,2% refiere que nunca la ha empleado. Estos resultados ponen demanifiesto la necesidad de hacer más accesible este recurso a las familias. En definitiva,favorecer que las familias, sí así lo desean, puedan beneficiarse de una forma alternativa yterapéutica de resolución de conflictos familiares.193. Justicia Terapéutica y MisceláneasLa justicia terapéutica como respuesta ante el acoso sexualMaría del Carmen Herrera, Universidad de Granada, España (mcherrer@ugr.es)460

Antonio Herrera, Universidad de Granada, EspañaInmaculada Valor-Segura, Universidad de Granada, EspañaFrancisca Expósito, Universidad de Granada, EspañaEl acoso sexual es una de las formas más comunes de violencia de género que existen, siendoademás el reflejo de las relaciones sociales de poder entre mujeres y hombres. En este sentido, la“teoría de extensión del rol sexual” postula que los hombres trasladan al contexto laboral susexpectativas acerca de los roles de género que hombres y mujeres han de asumir, lo que les llevaen ocasiones a acosar sexualmente a las mujeres con las que trabajan. Las estrategias usadas porla mayoría de las mujeres para combatir el acoso, suelen ir desde la evitación o ignorar alacosador, hasta la confrontación o denuncia del hecho, sin embargo ninguna de estas estrategiashan mostrado ser eficaces para luchar contra las situaciones de acoso en el ámbito laboral, nipara aumentar la confianza que las trabajadoras, potenciales víctimas, esperan de sus empresas.Una alternativa menos extrema puede ser la justicia terapéutica, basada en el papel que puedejugar la víctima así como en los beneficios que ésta puede obtener mediante la reparación deldaño ocasionado por parte del autor del hecho delictivo. El objetivo de este estudio es indagar lasactitudes que la población en general, tiene acerca de la justicia terapéutica como respuesta anteel acoso sexual, frente a otras medidas de confrontación. Así mismo se estudia la relación entretales estrategias y variables ideológicas presentes en el perceptor social, como el sexismoambivalente y la aceptación de los mitos sobre el acoso sexual.¿Qué motiva a la justicia?Josefa Ruiz-Romero, Universidad de Granada, España (jruizro@ugr.es)María del Carmen Herrera, Universidad de Granada, EspañaInmaculada Valor-Segura, Universidad de Granada, EspañaFrancisca Expósito, Universidad de Granada, EspañaEl ideal último a alcanzar por la justicia terapéutica no es el castigo sino la reparación de losdiversos daños personales, relacionales y sociales que se hayan ocasionado en el contexto de unainfracción penal, procurando conseguir la máxima responsabilización del infractor. Numerososestudios tanto de naturaleza experimental (Ristovski y Wertheim, 2005), cuasiexperimental(Strang, Sherman y Angel, 2006), y de campo (Sherman et al., 2005), así como medianteencuestas (Roberts y Stalans, 2004) han resaltado la importancia que para la población engeneral tiene este concepto de justicia. El objetivo de este estudio es analizar en una muestra dehombres y mujeres adultos/as, las actitudes hacia las diferentes metas de la justicia (retributivavs terapéutica) y el papel desempeñado por las motivaciones en la predicción del apoyo a lasmedidas judiciales de diferente naturaleza que se derivan de estos modelos de justicia, en el casode la violencia de género. Para justificar las relaciones establecidas usamos diferentes marcos461

teóricos que cuentan con una gran aceptación en la literatura psicosocial para el estudio de lasmotivaciones como son la teoría de la focalización reguladora de Higgins (1997), lasmotivaciones altruistas de Batson (1998) y la teoría de los valores de Schwartz (1992). Entre losresultados obtenidos destacamos que las motivaciones focalizadas en la promoción, que activanlas metas relacionadas con los ideales, predijeron el apoyo a un modelo de justicia terapéutica; encambio, las motivaciones focalizadas en la prevención, relacionadas con las obligaciones ydeberes, predijeron el apoyo a las medidas judiciales basadas en un modelo retributivo.Protocolo psicológico-forense para la evaluación de la credibilidad deltestimonio y de la huella psíquica en víctimas de acoso escolarMercedes Novo, Universidad de Santiago de Compostela, EspañaElena Arce, Universidad da Coruña, EspañaDolores Seijo, Universidad de Santiago de Compostela, EspañaRamón Arce, Universidad de Santiago de Compostela, España (ramón.arce@usc.es)Los estudios realizados en la actualidad reflejan un aumento en las denuncias de casos de acosoescolar. Si bien se han elaborado algunos protocolos desde la administración educativa paradetectar y gestionar las denuncias de las víctimas en los centros educativos, no contamos conherramientas válidas para el contexto forense, que evalúen el daño psíquico y la credibilidad, encasos de acoso escolar. En este trabajo se presenta la propuesta de un protocolo de evaluaciónpsicológico-forense para las víctimas de acoso escolar, que permita establecer la realidad delmismo, esto es, descartando la simulación en las respuestas. Es decir, establecer si los hechosque se narran son reales, si causaron daño psicológico, y si éste es real o está sujeto a simulación.Este protocolo sirve como una herramienta de apoyo a las víctimas reales, ya que contribuye a lacarga de la prueba, que corresponde a la acusación. Por otro lado, puede contribuir de manerasignificativa a la tarea judicial, ya que la estimación de la credibilidad del testimonio y la huellapsíquica como prueba, en conjunción con otras, pueden redundar en mayores garantías dentro delámbito de la justicia para la condena de este tipo de casuísticas del ámbito escolar, que acontecenen un ámbito privado.Deontología profesional en la intervención del psicólogo forense. Estudiodescriptivo de las denuncias atendidas por la Comisión Deontológica del ColegioOficial de Psicólogos de Cataluña entre 1996 y 2011Mila Arch, Colegio Oficial de Psicólogos de Cataluña. España (march@copc.cat)Núria Calderer, Colegio Oficial de Psicólogos de Cataluña. EspañaConchita Cartil, Colegio Oficial de Psicólogos de Cataluña. EspañaPablo Hernando, Colegio Oficial de Psicólogos de Cataluña. España462

Victòria Lerroux, Colegio Oficial de Psicólogos de Cataluña. EspañaMaría Angels Llorens, Colegio Oficial de Psicólogos de Cataluña. EspañaAlba Pérez, Colegio Oficial de Psicólogos de Cataluña. EspañaPilar Solé, Colegio Oficial de Psicólogos de Cataluña. EspañaLa comisión deontológica del Colegio Oficial de Psicólogos de Cataluña, en el marco deldesarrollo de sus funciones, tiene encomendadas tareas referidas a la difusión y promoción debuenas prácticas profesionales. Sin embargo, los estudios referidos a las denuncias de losusuarios y de la deontología profesional son escasos a nivel internacional y aun en menor medidaen nuestro país, viéndose dificultado el desarrollo de una tarea pedagógica ajustada a lasnecesidades reales de los profesionales. Por este motivo, se propuso la realización del presenteestudio que nos aporta información real y sólida sobre las denuncias que se realizan a lospsicólogos forenses en Cataluña. Se procedió al vaciado de los datos según protocolo diseñado“ad-hoc” para el estudio. Posteriormente se llevó a cabo un estudio descriptivo del tipo dedenuncia recibida centrando especial atención en las relacionadas con las intervencionespericiales de los psicólogos del ámbito jurídico, detallando los artículos concretos del CódigoDeontológico que han sido vulnerados, los años de ejercicio de cada colegiado denunciado y laprogresión del número de denuncias a lo largo de los años, estableciendo de esta forma unanálisis de contenido con la finalidad de buscar relaciones entre las categorías acotadas y darlasa conocer para evitar su repetición. Con los datos obtenidos se plantean cuestiones como lavulneración de algunos principios éticos que tienen especial relevancia en las actuaciones delpsicólogo en el ámbito judicial y las propuestas desde el Colegio Oficial de Psicólogos deCataluña para garantizar la competencia profesional del psicólogo forense.194. Justicia Terapéutica y SaludAplicación y análisis del SCL-90-R en una muestra de sujetos internos en unhospital psiquiátrico penitenciarioMilagros López Martínez, Universidad de MurciaRamón Arce, Universidad de Santiago de CompostelaAngeles López, Hospital Psiquiátrico Penitenciario de Fontcalent, Alicante, EspañaFernando Barrios, Hospital Psiquiátrico Penitenciario de Fontcalent, Alicante, EspañaEduardo Osuna, Universidad de Murcia (eosuna@um.es)La OMS refiere que las alteraciones psiquiátricas en las sociedades occidentales presentan unaincidencia entre el 15 y el 65 %. La incidencia de enfermos psíquicos entre la poblaciónpenitenciaria es siete veces mayor que en la población general. Así la enfermedad mental ha sidoun factor asociado tradicionalmente a la delincuencia pues existen determinados463

comportamientos criminales que pueden relacionarse o atribuirse a anomalías mentales. Uno delos objetivos más importantes de la peritación psiquiátrica en el ámbito del Derecho Penal esestablecer las relaciones de causalidad psíquica entre el individuo y sus acciones. En estecontexto, es preciso determinar mediante una evaluación la enfermedad mental y cómo afecta alas capacidades cognitivas o volitivas. Por otra parte, para alcanzar una reinserción yresocialización efectiva de los internos es necesario identificar previamente los efectos que elinternamiento en prisión tiene sobre la personalidad y conducta de éstos, así como los factoresintra-institucionales externos e individuales que inciden en la producción de dichos efectos. ElInventario de Síntomas de Derogatis, Revisado (Derogatis Symptom Checklist, Revised (SCL-90-R) es un instrumento de autoinforme muy utilizado en estudios clínicos y constituye una delas técnicas más utilizada para la detección y medición de síntomas psicopatológicos así comopara la evaluación de supuestos casos psiquiátricos. Consta de 90 ítems (existe una versiónreducida de 52) en los que el sujeto informa de sus síntomas psicológicos, psiquiátricos ysomáticos. La escala de respuestas es de cinco puntos: “nada” (0), “un poco” (1),“moderadamente” (2), “bastante”(3) y “muchísimo” (4). Una vez puntuadas las respuestas esposible caracterizar la sintomatología del evaluado en un perfil compuesto por nuevedimensiones primarias de síntomas (Somatización, Obsesiones, Sensitividad Interpersonal,Depresión, Ansiedad, Hostilidad, Ansiedad Fóbica, Ideación Paranoide y Psicoticismo) y tresíndices globales de psicopatología: el índice de Gravedad Global (Global Severity índex, GSI), elíndice de Malestar Positivo (Positive Symptom Distress, PSDI) y el Total de Síntomas Positivos(Positive Symptom Total, PST). El objetivo de este estudio es analizar las propiedadespsicométricas de la SCL-90-R en una muestra de individuos internos en un centro psiquiátricopenitenciario, compuesta por 102 sujetos (93 varones y 9 mujeres), con edades comprendidasentre los 18 y 65 años (edad media 37,8; DS 10,6 ). En nuestros resultados observamos que laescala de “ansiedad fóbica” es la que presentó menor frecuencia sintomatológica (media 0,39;DS 0,31), siendo la escala “depresión” la que mayor puntuación media obtuvo (media 1,76; DS7,56). Destaca también la elevada puntuación en la escala “ideación paranoide” (media 1,19; DS0,85). En relación a los índices globales de malestar, el Índice de Severidad Global presenta unamedia de 0,77 (DS 0,55) , el Total de Síntomas Positivos de 31,56 (DS 17,3) y el Índice demalestar de Síntomas Positivos de 2,11 (DS0,44).Análisis de variables criminológicas y psicopatológicas en una muestra desujetos internos en un hospital psiquiátrico penitenciarioMilagros López Martínez, Universidad de Murcia, EspañaAngeles López, Hospital Psiquiátrico Penitenciario de Fontcalent, Alicante, EspañaFernando Barrios, Hospital Psiquiátrico Penitenciario de Fontcalent, Alicante, EspañaMaría Dolores Pérez Cárceles, Universidad de Murcia, EspañaEduardo Osuna, Universidad de Murcia, España (eosuna@um.es)La conducta delictiva se ha convertido en un problema de elevado impacto social y motivo degran atención por parte de los organismos públicos. El estudio de la génesis del delito y su464

prevención no es algo nuevo, sino que siempre ha sido motivo de preocupación y requiere de unabordaje inter y multidisciplinario. Una de las medidas de seguridad privativas de libertadcomprendidas en el ordenamiento jurídico español es el internamiento en un centro psiquiátrico,que cumple, además de funciones terapéuticas, una finalidad asegurativa y defensiva. Lapromoción de la salud de la población reclusa es un enorme desafío. La política de salud mentalpública oscila entre dos modelos: el modelo médico-psiquiátrico, basado en la necesidad detratamiento del enfermo mental, y el de la defensa social, basado en el criterio de peligrosidadde estos pacientes. La Ley debe conseguir el equilibrio entre la libertad del individuo enfermomental con la necesidad de su seguridad y tratamiento, pero también con la seguridad de lasociedad. El objetivo de nuestro trabajo es analizar los perfiles criminológicos y médicopsiquiátricosde los pacientes ingresados en un hospital psiquiátrico penitenciario. Se haestudiado una muestra compuesta por 82 sujetos (74 varones y 8 mujeres), con edadescomprendidas entre los 22 y 77 años (edad media 38,8 años; DS 10,09). La recogida de los datosse ha realizado mediante entrevista y análisis de la historia clínica, sentencias judiciales yexpediente penitenciario y del centro. En relación al tipo de delito cometido predomina elasesinato (21,9%), el homicidio (15,8%) y el robo con violencia (15,8%). La edad media decomisión del delito es de 31,72 años y el diagnóstico psiquiátrico predominante es laesquizofrenia y otros trastornos psicóticos (51,2%), el trastorno de personalidad (24,3%) y eltrastorno relacionado con el consumo (19,5%). Los resultados obtenidos nos podrán servir paraelaborar tanto programas de prevención como programas específicos de intervención.Programa de atención integral al enfermo mental en prisión (PAIEM) C.P.MálagaLuis Ortega Basanta, Instituciones Penitenciarias, Málaga, España (lortegabasanta@yahoo.es)Objetivo Principal: Implementar un Programa Integral que permita detectar, diagnosticar ytratar a los internos con un Trastorno Mental Grave, mejorar su calidad de vida, y optimizar sureincorporación social.Situación Actual: En mayo de 2009 se realizó un Estudio Transversal de prevalencia deenfermedad mental. 464 internos (27,3%) tenían algún diagnóstico de enfermedad mental. 45 deTrastorno Psicótico (2,64%), 218 de Trastorno Afectivo (12,8%), 106 de Trastorno dePersonalidad (6,2%) y 137 (8%) Otros diagnósticos.Bjetivos Específicos:1. Detección, diagnostico y tratamiento2. Programa Individualizado de Rehabilitación: remediar discapacidades,compensar minusvalías y conseguir la mayor autonomía posible.3. Reinserción socialContinuidad de cuidados por la red socio-sanitaría de la comunidad.465

Haciendo un seguimiento de los incluidos en el estudio de 2009, se puede decir que hasta enerode 2012 siguen incluidos en el Programa 129 pacientes (activos 113, 13 bajas).De ellos, 38 pacientes están internados en la prisión de Málaga (22 están recibiendo terapiagrupal y otros16 terapia individual).Otros 38 pacientes están en otras prisiones, sobre los que se sigue realizando un seguimientoconjunto.Otros 37 pacientes están en libertad, habiendo sido derivados a dispositivos de la comunidad.Sobre ellos se realiza un seguimiento en colaboración.Los 38 pacientes presentes en la prisión de Málaga tienen los siguientes diagnósticos: 19Trastorno psicótico, 13 Trastorno de personalidad y 6 Trastorno Afectivo. 23 de ellos hanconsumido tóxicos.En la presentación se expondrá con detalle el Programa Individualizado de Rehabilitación.La discusión de los efectos adversos psiquiátricos por Veraliprida (Agreal) en losTribunales españolesMaría Teresa Alfonso-Galán, Universidad de Alcalá (mteresa.alfonso@uah.es)Veraliprida (Agreal) fue un neuroléptico comercializado en España entre 1983 y 2005. Elprospecto indicaba su uso en "sofocos y manifestaciones psicofuncionales de la menopausia". Unúnico efecto secundario, la galactorrea, ninguna reacción adversa, contraindicación e interacción,y ningún límite temporal del consumo. Reevaluado el beneficio-riesgo, se retira en España enmayo de 2005. El 23 de julio de 2007 la Agencia Europea de Medicamentos, recabada yestudiada toda la información disponible, la retira del mercado en los cinco países de la UniónEuropea en los que aún se comercializaba. La Organización Mundial de la Salud da una Alerta(Nº 116) mundial. En países iberoamericanos se retirará en los meses siguientes, a excepción deMéxico que aún la comercializa en 2012. Cuando estos hechos trascendieron a la opiniónpública, mujeres españolas que la habían consumido y que simultánea, consecutivamente, omeses después manifestaron síndromes crónicos (extrapiramidales, neurológicos, psiquiátricos),acudieron a tribunales. La autora participa como perito farmacéutico-forense en variosprocedimientos civiles en los que se demanda al laboratorio. Su presentación pondrá énfases enla discusión entre peritos de ambas partes, en los discutidos efectos adversos psiquiátricos, y enlas dificultades reales de enfrentarse a estrategias de defensa de la Industria.195. Learning about Human Behavior and Dispute ResolutionLegal Education and Therapeutic Jurisprudence: Helping Mediators MakeSense of the Not-Always-So-Rational Brain466

Ellen Waldman, Thomas Jefferson School of Law (ellenw@tjsl.edu)This is one portion of a two-part presentation.We regularly rely on mental short cuts, known as heuristics, to help us navigate quickly throughthe mass of information we encounter in daily life. Although we like to think of ourselves asrational decision makers, many times these "cognitive biases" can lead us to quick but poordecisions. For example, we tend to rely on information that is available to our recall, althoughthat information may not be representative of reality. We search for confirming evidence of ourgut reactions, rather than evidence that might impeach them. Cognitive biases strongly influenceour behavior and our decision-making but they operate behind the scenes - most of the time weare unaware of their effect on our decisions and how these biases guide our choices. Thesereflexive biases lead to problems in the law and judicial decision-making. If we are unaware ofthe extent of impact these biases have on our decisions, we will fail to distinguish betweensituations in which their use is appropriate and those where they are less appropriate. Knowingour vulnerabilities, however, allows us to adapt our decision-making strategies.All actors within the legal system must understand their subtle but effective influence to be ableto understand how to counteract them effectively. This presentation suggests approaches forcountering the biases and enhancing cooperative dialogue when serving as a third party neutral.Legal practitioners, of course, also must be aware of the important role of cognitive biases, andanother presentation on this panel, by Marybeth Herald, will address the subject from that pointof view.Legal Education and Therapeutic Jurisprudence: Helping Lawyers Make Senseof the Not-Always-So-Rational BrainMarybeth Herald, Thomas Jefferson School of Law (marybeth@tjsl.edu)This is the second portion of a two-part presentation, led off by Ellen Waldman.We regularly rely on mental short cuts, known as heuristics, to help us navigate quickly throughthe mass of information we encounter in daily life. Although we like to think of ourselves asrational decision makers, many times these "cognitive biases" can lead us to quick but poordecisions. For example, we tend to rely on information that is available to our recall, althoughthat information may not be representative of reality. We search for confirming evidence of ourgut reactions, rather than evidence that might impeach them. Cognitive biases strongly influenceour behavior and our decision-making but they operate behind the scenes - most of the time weare unaware of their effect on our decisions and how these biases guide our choices. Thesereflexive biases lead to problems in the law and judicial decision-making. If we are unaware ofthe extent of impact these biases have on our decisions, we will fail to distinguish betweensituations in which their use is appropriate and those where they are less appropriate. Knowingour vulnerabilities, however, allows us to adapt our decision-making strategies.467

All actors within the legal system must understand their subtle but effective influence to be ableto understand how to counteract them effectively. This presentation suggests approaches forcountering the biases in legal practice to enhance therapeutic outcomes in the law. Third-partyneutrals such as mediators also must be aware of the important role of cognitive biases, andProfessor Waldman’s presentation will address the subject from that point of view.Stress and the Legal System: Dispute Systems Design Principles to Enhance thePsychological Wellbeing of People Involved with the Legal SystemDaniel Toohey, Office of the Commissioner for Body Corporate and Community Management,Brisbane, Australia (daniel.toohey@justice.qld.gov.au)We are gaining a greater understanding of the impact of stress on our wellbeing and ourcognitive abilities. Dealing with legal disputes can be highly stressful. It is thereforeunsurprising that many participants in the legal system catch a ‘mental health cold’ during thecourse of their legal proceedings. This presentation discusses recent literature on the commonbehavioural effects resulting from stress and conflict. It then suggests some dispute systemsdesign principles that can be applied to adapt legal procedures to better suit our cognitive andemotional abilities.Part I of this paper will review neuroscience and other literature that explains the typicalconsequences of stress, including typical cognitive limitations caused by stress. Part 2 will thenoutline dispute systems design principles can be used to improve fairness and effectiveness byadopting procedures that help participants to better manage their stress and emotions. There willbe particular emphasis on the opportunities available to governments as they develop moreonline dispute resolution options.Views on the Integrative Study of Law and Human BehaviorLiesbeth Hulst, VU University (l.hulst@vu.nl)The legal system is designed to "govern, regulate and control" human behavior. Laws and legaldecisions are based on assumptions of human behavior. However, those assumptions may beinadequate. This paper focuses on how insights from the modern empirical behavioral sciencesmay enhance the understanding of people's behavior in relevant legal contexts. In addition, thepaper presents some personal views on differences and concerns when combining legal,normative perspectives with empirical behavioral approaches.468

Could Problem Solving Become a Problem? The Boundaries of the SolutionFocus of Courts and Fundamental Principles of Administration of JusticeDineke de Groot, VU University (g.de.groot@vu.nl)As mainstream courts are adopting more and more elements of conflict resolution in theirpractices, the question arises whether it could become necessary to keep these developmentswithin the boundaries of the fundamental principles of administration of justice. This paperpresents the preliminary results of an explorative study consisting of a literature study and expertmeetings held among the judiciary.196. Lessons of TJ for Courts Beyond Problem-Solving CourtsIntroducing Therapeutic Jurisprudence into Mainstream Criminal Courts: ACase Study ApproachIan Dearden, District Court, Queensland, Australia (judge.dearden@courts.qld.gov.au)The challenge for therapeutic jurisprudence (TJ) has been to persuade mainstream criminal courtparticipants (judges, prosecutors, defence lawyers) of the obvious benefits TJ brings to the dailycourt process. In part, this stems from a lack of understanding of what TJ has to offer, oralternatively, an attitude that TJ is of value only in specialist jurisdictions (drug courts, mentalhealth courts, indigenous & special purposes courts etc). As a judge managing a high turnoverregional “docket” court in a socio-economically challenged district just outside a major capitalcity, I have been able to strike a balance between swiftly and efficiently disposing of the court’scriminal matters, while seeking throughout the judicial administration process, and the casedisposition proceedings, to apply TJ principles at each step. Utilising actual case studies, I seekto demonstrate the relative ease with which TJ principles can be incorporated into all aspects ofsuch a busy, indictable criminal court caseload, and the resulting benefits for all legal actors andcourt participants (judicial officers included!) It is hoped that this will assist others consideringincorporating TJ into their administrative and judicial duties.Therapeutic Jurisprudence: Action as Well as WordsMaxine Baldwin, Gympie Magistrate Court, Australia (Magistrate.Baldwin@courts.qld.gov.au)The use of therapeutic jurisprudence in the Magistrates Court is vital as it is the first point ofcontact for many offenders and often the beginning of a long association with the criminal justice469

system. Implementing the theories of therapeutic jurisprudence can assist in dealing with peoplewho are generally suffering from mental health issues, substance addiction and other issuesassociated with socio economic environments. Dealing with people in the courts is more than away of speaking and addressing them but offering real opportunity for change and providingavenues for achieving long term change. Specialist courts abound but are largely reserved forthose entrenched in the system or at the main courts. This paper seeks to address the optionsopen to small local (and often little resourced) courts. Delaying sentencing and devising bailprogrammes encourages offenders to find an avenue to step up and make some change can go along way to changing the direction of their lives. Whether it be through literacy programmes,school attendance, driver courses, pre vocational courses, giving the offender the opportunity tocommit to the first step often leads to a sense of self esteem and a realisation of potential that canbe built upon in a sentencing regime. Therapeutic jurisprudence is an avenue to unleash potentialfor real change and through practical measures can realise that potential. Utilising it at theearliest opportunity can only lead to real benefits for offenders but also the community.What are the Prospects for the Utilization of Therapeutic Principles in theTreatment of Anti-Social Behaviour Cases in the Courts in England and Wales?Jane Donoghue, University of Oxford (jane.donoghue@crim.ox.ac.uk)Anti-social behaviour and community disorder has been a central political and policypreoccupation in Britain for over a decade. A problem-solving approach to anti-social behaviour(ASB) cases has recently been embedded into magistrates’ courts in England and Wales. Thisapproach incorporates core components of the Anti- Social Behaviour Response Court (ASBRC)model and is underpinned by principles of community justice and therapeutic jurisprudence. Thispaper summarizes some of the main findings of an 18-month Economic and Social ResearchCouncil (ESRC) funded study that investigated how far the ASBRC model has been absorbedinto mainstream courts in England and Wales. This research suggests that courts have notembedded community justice/therapeutic principles, nor have they altered their focus toincorporate a significant degree of liaison with the community. The paper concludes with someobservations on the implications of the findings for the development and enhancement oftherapeutic justice principles in the lower courts in Britain.Solution Focus in the Netherlands: Recent developments in Dutch criminal, civiland administrative courtsAndrea Zwart-Hink, VU University (a.m.hink@vu.nl)In the Netherlands one can clearly discern the same kind of activities and developments thatelsewhere are labeled ‘problem solving’ or ‘solution focused’, such as court annexed mediation,restorative justice initiatives in the field of criminal law, mediation and collaborative divorce in470

family law, or the use of mediation techniques by administrative bodies in handling complaintsand appeals of citizens. Distinct developments in the role of judges in mainstream civil andadministrative procedures also implicate more involvement with the problems behind the casethan just passing judgment. The Ministry of Justice and the Judiciary are permanently lookingfor more court innovation initiatives. This paper provides an overview of the said developmentsthroughout the classic areas of criminal, civil and administrative law and evaluates them in thecontext of procedural justice and therapeutic jurisprudence literature. It also discusses themeaning of such overview and evaluation for the development of further court innovationinitiatives.The New Culture of ControlDavid Jaros, University of Baltimore (djaros@ubalt.edu)In many urban jurisdictions, courts increasingly sentence defendants to rehabilitative programs inlieu of incarceration. In New York City, there is a program for nearly every crime. Get in a barfight? You’re likely to get Anger Management. Steal from a store? You get the Stopliftprogram. Hit your spouse? Expect to be sentenced to a domestic violence program. There arein- and outpatient programs for drug related crimes; alcohol and driving classes for DWIs; andparenting classes for abusive or neglectful parents. The proliferation of sentences mandatingdefendants participate in therapeutic programs would seem to suggest that the “rehabilitativeideal,” once declared dead, has returned to the criminal justice system. Such a description,however, may mask a more complex and troubling dynamic. While commentators and scholarshave strongly criticized the mass incarceration of the urban poor, far less attention has been paidto the increasing number of individuals in poor minority communities who live under thesupervision of the criminal justice system via such rehabilitative programs. Eager to limit thedevastating impact of incarceration, progressive advocates have largely refrained from criticizingalternative sentences that, while less destructive than prison, may be ineffective and can imposetheir own significant challenges to defendants’ efforts to live productive and crime free lives.This article seeks to investigate the role that rehabilitative programs play in the criminal justicesystem and the impact that such programs have on defendants and the communities in whichthey live. Such an examination raises profound questions as to whether our system has renewedits commitment to rehabilitate offenders, or if it has just evolved a more economically efficientand politically palatable method of social control. Examining how rehabilitative sentences fitinto the broader structure of the criminal justice system not only can shed light on how thecurrent system functions, it also can inform the efforts of advocates who seek to “mainstream”new models of therapeutic jurisprudence so that they do not repeat the errors of the past.197. Manifestaciones de Justicia Terapéutica en el Proceso PenalEspañol471

Mediación Penal de AdultosEsther González Pillado, Universidad de Vigo (epillado@uvigo.es)La mediación se define como el sistema de gestión de conflictos en que una parte neutral, concarácter técnico y en posesión de conocimientos adecuados, independiente de las partes delproceso penal e imparcial, ayuda a dos o más personas implicadas en un delito o falta, en calidadde víctima e infractor, a comprender el origen del conflicto, sus causas y consecuencias, aconfrontar sus puntos de vista y a elaborar acuerdos sobre el modo de reparación. Una serie defactores han convertido en muchos casos en inoperante el proceso penal contradictorio queculmina en sentencia como medio de solución del conflicto generado por la comisión de undelito o falta. En efecto, en el proceso penal tanto la víctima como el imputado o acusado, vecómo el Estado “le expropia” su derecho a ver solventado el conflicto de manera pacífica y sin lavictimización secundaria que en muchos casos supone la confrontación de partes. No se puedeolvidar que el proceso penal, aunque es el instrumento del ius puniendi del Estado en su misiónde tutela de intereses públicos, también debe ser en todo caso un mecanismo de satisfacción delos derechos e intereses de las partes. En este sentido, es esencial la búsqueda de métodosalternativos de resolución de conflictos, incorporados al ejercicio de la jurisdicción: mecanismosfiscalizados y controlados en cuanto a las garantías de su desarrollo y en cuanto a los efectospenales por los órganos jurisdiccionales, y por tanto de naturaleza intraprocesal. En estecontexto, la mediación penal responde a estas exigencias, porque el sistema de mediación penalno es contrario a la exclusividad de la jurisdicción en el orden penal, ni al monopolio del “iuspuniendi” estatal, porque serán los Juzgados y Tribunales los que controlarán el buen desarrollodel procedimiento mediador, y no sólo para garantizar los derechos y garantías procesalesconstitucionalmente reconocidos, sino para que los riesgos que pudieran aparecer, derivados dedeterminados comportamientos tanto de la víctima hacia el acusado como en sentido inverso,puedan ser corregidos con la intervención del juez, del ministerio fiscal, del abogado defensor ydel mediador. No se trata de una forma de autotutela, ajena al monopolio estatal, judicial yprocesal, sino ante una forma autocompositiva intraprocesal que desembocará en una resoluciónjudicial motivada como es el auto de sobreseimiento por razones de oportunidad reglada o, en sucaso, la sentencia (dependiendo del momento procesal en que se desarrolle la mediación). Portanto, no se resienten en ningún caso las bases constitucionales del sistema procesal penal. Enresumen, este modelo restaurativo no es una disposición individual del derecho penal y de lapena, ni un ataque al monopolio jurisdiccional, sino la introducción en el proceso penal de unincidente autocompositivo voluntario para las partes, con todas las garantías procesales y con susconsecuencias predeterminadas en la ley. No se trata de preferir la eficacia a las garantías, sinode hacer confluir ambas finalidades.La conformidad del adolescente acusadoDolores Fernández Fustes, Universidad de Vigo, España (dfustes@uvigo.es)472

Podemos definir la conformidad como el modo de poner fin al proceso penal que supone laaceptación por el acusado de los hechos, de la calificación jurídica y de la responsabilidad penaly civil exigida. La finalidad de la conformidad en el proceso de menores no es sólo la economíaprocesal, sino también la conveniencia de evitar el menor los efectos estigmatizantes que lepodría causar el desarrollo de la audiencia. La LORPM prevé dos tipos de conformidaddependiendo del momento en que se manifieste: A. La conformidad en la fase intermedia o dealegaciones: es el primer momento en el que se puede manifestar la conformidad. Para que estaconformidad surta efecto deberán concurrir los siguientes requisitos: El primer requisito se centraen la medida sancionadora que solicita la acusación: debe tratarse de una medida que no conlleveuna restricción del derecho fundamental a la libertad. El segundo requisito consiste en que laconformidad se manifieste con el escrito de alegaciones que contenga la acusación más grave. Eltercer requisito exige que haya conformidad del menor y de su letrado. En cuarto lugar, seránecesario que haya conformidad también de los responsables civiles. El último requisito serefiere a los aspectos formales. Si se cumplen estos requisitos, la conformidad será vinculantepara el Juez, que deberá dictar sentencia imponiendo la medida más grave solicitada por lasacusaciones y aceptada por la defensa. B. Conformidad durante la audiencia. El segundomomento en el que se puede manifestar la conformidad es al inicio de la audiencia, en donde ellegislador ha previsto un trámite obligatorio que responde al principio de consenso y tiene comofinalidad determinar si el menor y su Letrado se muestran conformes con los hechos y con lamedida o medidas interesadas por las acusaciones en sus respectivos escritos de alegaciones. Enconsecuencia, ex art. 36, el secretario judicial deberá explicar al menor, en el lenguaje más llanoposible y haciendo todos los esfuerzos necesarios para hacerse comprender, cuáles son loshechos que se le imputan, la medida que se solicita, detallando su contenido, forma decumplimiento y duración, y la responsabilidad civil que se pide para él. A continuación, el Juezpreguntará al menor si se declara autor de los hechos y si está de acuerdo con las medidassolicitadas y con la responsabilidad civil. Llegados a este punto se pueden dar las siguientessituaciones. En primer lugar, que el menor muestre su conformidad tanto con los hechos comocon la medida solicitada. En segundo lugar, puede ocurrir que el menor se declare autor de loshechos pero no esté conforme con la medida solicitada por las acusaciones. En este caso, sesustanciará el trámite de audiencia sólo en lo relativo a la medida. Por último, podría ocurrir queel menor o el responsable civil no estuvieran conformes con la responsabilidad civil solicitada.En este caso, se sustanciará el trámite de la audiencia sólo en lo relativo a la responsabilidadcivil.La denominada “prisión provisional atenuada”Pablo Grande Seara, Universidad de Vigo, España (pgrande@uvigo.es)La prisión preventiva o provisional es una medida cautelar de carácter personal prevista en elsistema procesal penal español con el fin de asegurar la responsabilidad penal del imputado,evitando que éste se sustraiga a la acción de la justicia. Habitualmente, supone el ingreso delimputado en un centro penitenciario a la espera de juicio y está sujeta a unos límites máximos deduración, en función, entre otras circunstancias, de la gravedad de la pena prevista para el delitoque se imputa al sujeto en cuestión. De acuerdo con la LECrim, la prisión preventiva puede473

adoptar distintas modalidades de cumplimiento, lo que nos permite hablar de clases omodalidades de prisión preventiva. Aunque tradicionalmente se han citado tres modalidades:comunicada, incomunicada y atenuada, realmente sólo las dos primeras son verdaderos tipos deprisión, pues la última es una “medida alternativa a la prisión”, pues su peculiaridad radica enque se cumple fuera de un establecimiento penitenciario. Tras la reforma legal de 2003 (LO13/2003 y Ley 15/2003), se ha modernizado la regulación de la prisión provisional, afectandotambién a esta modalidad “atenuada”. Tras dicha reforma, esta modalidad se regula en el art. 508LECrim que, en sus dos apartados, contempla dos supuestos: a.- El denominado “arrestodomiciliario”, que se cumple en el domicilio del imputado, y requiere como presupuesto que éstepadezca una enfermedad grave, de modo que su ingreso en prisión pueda entrañar un gravepeligro para su salud. Como se ha indicado, el lugar de cumplimiento es el propio domicilio,lugar en que reside habitualmente el reo, el cual deberá comunicar inmediatamente al órganojurisdiccional cualquier modificación del mismo. Además, se regula restrictivamente cualquierposible salida del domicilio pues únicamente se justifica para el tratamiento de la enfermedad; ytanto la estancia en el domicilio como las salidas del mismo se someten a la necesaria custodia yvigilancia policial y a su fiscalización judicial; b.- La que se cumple en un centro oficial dedesintoxicación de drogodependientes, cuando el imputado se halle sometido a un tratamiento dedesintoxicación o deshabituación a sustancias estupefacientes y el ingreso en prisión puedafrustrar el resultado de dicho tratamiento. El lugar de cumplimiento de la medida es un centrooficial o una organización legalmente reconocida, de carácter público o privado, que desarrolleestos tratamientos de desintoxicación, en muchas ocasiones en virtud de planes concertados conlos poderes públicos. También se establecen unos requisitos para su concesión: a) debe estarse yarecibiendo el tratamiento de desintoxicación a una adicción y debe existir un riesgo de que sefrustre por el ingreso en prisión; y, b) se requiere que los hechos imputados sean anteriores a lainiciación del tratamiento de la adicción.Mediación con adolescentes infractoresAngela Coello Pulido, Universidad de Vigo, España (acoello@uvigo.es)Desde finales del siglo XIX se inició en nuestro entorno jurídico un movimiento tendente aextraer a las personas menores de edad del ámbito de aplicación del Derecho Penal y delDerecho Procesal de adultos. En consecuencia, en el año 2000 fue promulgada en España la LeyOrgánica 5/2000, de 12 de enero, reguladora de la Responsabilidad Penal de los Menores queconfiguró un proceso penal que resultará de aplicación para la exigencia de responsabilidad delas personas mayores de catorce años y menores de dieciocho por la comisión de un ilícito penaly cuya principal característica es su enfoque educativo orientado a la reeducación yresocialización del menor infractor. Esta finalidad reeducativa implica la conveniencia, endeterminados supuestos, de emplear métodos ajenos al proceso para la solución del conflicto.Así, la citada norma presenta las siguientes formas de solución del extrajudicial conflicto: eldesistimiento de la incoación del expediente de reforma, el sobreseimiento a propuesta delequipo técnico y la mediación. La mediación en este ámbito constituye un sistema para lasolución de conflictos por la que las partes enfrentadas en un proceso penal de menores, encalidad de víctima e infractor, con la ayuda de un tercero imparcial y neutral, alcanzan por sí474

mismas una solución que implique la reparación del daño causado. De este modo, a través de lamediación es posible alcanzar una solución que evita la estigmatización que para el menorsupone el sometimiento a un proceso judicial al mismo tiempo que constituye una herramienta degran utilidad para la reeducación y resocialización de ese menor infractor puesto que a medidaque se desarrolla el procedimiento va tomando conciencia de las consecuencias de sus actos,responsabilizándose de los mismos y manifestando su voluntad de reparar los daños causados.Del mismo modo, la víctima adquiere un especial protagonismo en la tutela de sus derechos. LaLey Orgánica de 12 de enero de 2000 permite la mediación, como manifestación del principio deoportunidad reglada, en diversas fases. Durante la fase de alegaciones o durante la faseintermedia será realizada por el Equipo Técnico que informará al Ministerio Fiscal acerca de loscompromisos que se hubiesen adquirido así como de su grado de cumplimiento de tal maneraque, si la mediación prospera, el Ministerio Fiscal podrá proceder a solicitar al Juez de Menoresel sobreseimiento de la causa. Por otra parte, la mediación podrá tener lugar una vez que lasentencia ha sido dictada, es decir, durante la fase de ejecución de las medidas impuestas aunque,en este caso, no contribuirá a evitar los efectos estigmatizadores que el proceso conlleva para elmenor de edad.198. Reconsidering “Injury”: Applying TJ Principles to Litigants inNon-Criminal CourtsUnder Construction: Dutch Self-Regulation, Pilots and other Initiatives ofPersonal Injury Practitioners to Improve Compensation ProcessAugust Van, VU University, Amsterdam (van@beeradvocaten.nl)In the Netherlands, in spite of the existence of a general no-fault compensation scheme coveringloss of income of injured employees to some extent, tort law is an indispensable source ofcompensation for the victims of road and workplace accidents and medical errors. There is ageneral awareness however, that obtaining compensation in personal injury cases is a long andarduous struggle, sometimes even causing the victim more harm than good. Over the last fewyears, this awareness has led to several initiatives, many bipartisan, that attempt to make thepersonal injury settlement process less strenuous in one way or another. This paper offers anaccount of those initiatives for a foreign audience.Privileging Tangible over Intangible Injuries: The Potential for Non-Therapeutic Outcomes for Violations of Bodily IntegrityElizabeth Adjin-Tettey, University of Victoria (eadjinte@uvic.ca)475

The paper highlights some of the ways in which law and societal perceptions about intangibleinjuries can produce non-therapeutic outcomes for those who suffer such harms compared withphysical injuries. Bodily autonomy and security are protected mostly through the trespass torts,which are actionable per se. This reflects a right-based approach focusing on plaintiffs andsociety’s interest in respecting and protecting bodily inviolability and the need for compensationwithout proof of harm. Harms resulting from wrongful interference may be tangible and/orintangible. The law’s willingness to protect bodily integrity masks the dualistic conceptualizationof the effects of wrongful interference with one’s body and the privileging of tangible overintangible harms. This is evident in the higher standard of proof and modest compensation forintangible injuries that do not result in financial losses. Some scholars and legislators questionthe propriety of compensation for intangible losses and advocate for its abolition or at bestmodest amounts. Devaluation of intangible harms is particularly problematic for plaintiffs whoseinjuries are mostly “invisible” and who are less likely to initiate suit if they are unlikely toreceive significant compensation. Findings and admissions of liability per se may havepsychological benefits, including promoting healing. However, that may not be sufficientmotivation for pursuing a tortfeasor absent the potential for significant compensation.Difficulties of proof and depressed awards for intangible harms devalue the non-corporal aspectsof human beings; it engenders an instrumentalist and commodified view of personhood in waysthat can exacerbate feelings of victimization and produce non-therapeutic outcomes for plaintiffsand a less than optimal tort system.Self-Worth Considerations in Supreme Court RulingsDoron Shultziner, Faculty of Medicine, Tel Aviv University (Shultziner@post.tau.ac.il)Self-worth or self-esteem is one of the most important basic human needs according to socialpsychological research. Positive self-esteem is essential for effective functioning, mental health,and general well-being. Conversely, negative self-esteem strongly associated with mentaldisorders, malfunctioning, antisocial behavior, suicidal tendencies, aggression, delinquency, andmore. Social-psychological studies also demonstrate that pursuit of positive self-worthcharacterizes all human societies, notwithstanding the different cultural ways and norms inwhich they do. Legal outcomes can of course greatly affect the litigants’ self-worth and impacttheir well-being. This paper examines these considerations in the rulings of the highest courts inwestern-democratic and non-Western countries. Using online legal search engines, I will identifyrulings that employ the terminology and rationale of self-worth or self-esteem. In particular, thestudy seeks to identify, through legal comparative analysis, the commonalities of such rulingsand to examine the weight that justices give to these personal-subjective, yet also objectivelyimportant, psychological considerations. Contrary to a dominant legal paradigm, the hypothesisof this paper is that it can be shown that justices both in developed liberal democracies anddeveloping non-western countries often take such considerations very seriously in weighingbetween completing right and interests, as well as in making legal breakthroughs and precedents.I will argue that opposite to what one may predict, such considerations are used rarely and theysometimes even trump rights.476

To Compensate without to Aggravate: On the Anti-Therapeutic Impact of InjuryCompensation Processes and the Responsibility of LawyersArno Akkermans, VU University Amsterdam (a.j.akkermans@vu.nl)Although there is some debate on the evidential power of the empirical studies involved, theweight of the evidence points clearly in the same direction: compensation processes have anegative effect on recovery from injury. This paper discusses current insights and explanatorytheories, and then focuses on the role of law and lawyers. What improvements could be feasible,both on the level of system design and within a given system. It is argued that there is a lot thatthe law and the legal profession could and should do to diminish the infliction of unintentionalharm in compensation processes.Breaking the Web of Needless DisabilityRobert Aurbach, Deakin University (Robert.Aurbach@deakinprime.com)Neuroscience has yielded new understandings of the way in which the mind adapts to stimuli andlearns new behaviours. This research has pointed the way toward a model of “acquired disabilitybehaviour” that both explains and guides corrective action.It is well known that some people recover uneventfully, whilst others descend into disabilityafter injury. Why does this happen?The presentation starts with an exposition of a model of how people adopt a “disabled persona”,based upon neuroplasticity research. Injured people experience sensations, thoughts and fearsthat become the center of their attention, particularly if they are left with time and circumstancesto focus on their injury and the claims process. As the person experiences these disparate inputslinked by temporal proximity, the brain forms connections of facilitated response linking them.“What wires together, fires together” has become the new mantra of neuroscience.Lawyers, doctors and claims managers all contribute to the development of this unintendedlearned behavior with additional inputs that help form a facilitated neural network of linkedmental processes and behaviours, often while completely unaware of the adverse consequencesof their actions. The traditional model of dispute resolution is a particular offender, engenderingtransference of the locus of control and prolonged modeling of disabled behavior that contributeto the formation of the mental “habit” of disability. Through these mechanisms, our systemsneedlessly disable a percentage of claimants by creating exactly those habits of thought weshould avoid. Lessons for professions engaged in the operation of claims systems are immediateand practical.477

199. Sustainability of and Lessons Learned from TJ JudicialInnovationsCan a Sixty Year Old French Re-Entry Court Remain Therapeutic in an Era ofManagerialism and Prison Overcrowding?Martine Herzog-Evans, University of Reims (martineevans@ymail.com)To our best knowledge, there has never been an attempt to determine whether problem-solvingcourts (P.S.C.) may have had equivalents in the past and/or in other cultures. At first glance,however, French sentence’s implementation courts (juge de l’application des peines: J.A.P.)seem to be sixty year old ancestors of today’s P.S.C. With P.S.C., they share a human touch, adesire to do good, rehabilitative, therapeutic and problem-solving goals and methods; they listento offenders and, in order to do so, take all the time that is needed; lastly, they abide by dueprocess principles. Contrary to P.S.C., they are not fully immersed in the community and forvarious reasons cannot work in a truly collaborative way with other agencies. Also, recentreforms have tried to marginalise judicial intervention in sentence’s implementation and haveattempted to instrumentalise it in order to free prison space in search for solutions toovercrowding.Because P.S.C. require good judges, and in view of the aforementioned reforms, it seemedimportant to determine whether J.A.P. were still such good people and whether they still behavedin a truly therapeutic manner. This is what the research on ‘J.A.P.’s professional culture’endeavoured to determine. 40 Jap were interviewed; more than 200 J.A.P. hearings wereobserved; 1,300 court cases were coded and other practitioners (solicitors, prosecutors, andprobation officers) were also interviewed. The research has found that J.A.P. are indeed, and forthe most part, problem-solvers and therapeutic humane judges. It has also confirmed that recentreforms, damaged relationship with prison and probation services, along with a terrible caseloadand dreadful working conditions, have made it increasingly difficult for them to keep theirtherapeutic compass in mind.A French Attorney Describes her Holistic and Collaborative Practice inSentences' Implementation and Re-EntryVirginie Bianchi, Lawyer, Paris, France (virginie.bianchi@wanadoo.fr)The June 15th 2000 and March 9th 2004 acts have opened the field of sentence implementationto the defence by integrating this legal field in to ordinary criminal procedure.Before 2000, the “juge d'application des peines” (sentences' implementation judge – hereafterJAP) was competent for decisions regarding short term sentences, and ruled without any478

contradictory debate, whereas decisions regarding long term sentences were taken by theMinister of Justice itself.2000 should have seen a revolution in the mentalities of both lawyers and magistrates. Sadly,however, too few lawyers are interested in this technical, underpaid legal field, in which courthearings held in camera hardly flatter one’s ego. There are even fewer of them who are willing totake long term sentences or sick detained-persons 'cases.I have chosen to focus my professional practice on these very persons, which implies a globaland long term management as well as a collaborative way of dealing with their cases.As far as I am concerned, I consider that my role consists of working in sync with my clients’families, with prison authorities, with probation services, and with the third sector. It also meansbuilding the case with – not against – the JAP and even, when it is possible, with the sentences'implementation prosecutor's office.I treat each person I take care of – and I willingly limit the number of cases I deal with – as aunique case, with which I will try to find a suitable solution, tailored to the person’s needs, this,in a collaborative and therapeutic manner.The Small Claims Court in France (Juge de la proximité)Chantal Mahé, VU University Amsterdam (c.b.p.Mahe@vu.nl)In 2003, the Juge de proximité was instituted in France in order to fasten and to improve citizen’saccess to justice in minor criminal and civil cases. Another aim was to involve the civil societyinto the administering of justice. The Juge de proximité is not an ‘official’ judge, but is recruitedfrom the civil society on the basis of his or her practical experience in some legal profession.This paper offers a description of this new French institution and reports on recent evaluations ofthe current practice of the Juge de proximité.Sustainable Justice: Connecting Principle in the Worldwide Wave of CourtInnovation of the Last Decennia and Inspiring Focus-Concept for CourtInnovation PolicyAlexander F. de Savornin Lohman, Center for Sustainable Justice, Utrecht, Netherlands(alexlohman@me.com)Since the end of the 80 th of the last century a wave of court innovation spreads across the world.Mediation (privately or judge-led), judge-led settlement negotiations, Drug Courts, ProblemSolving Courts, Neighborhood Justice, Restorative Justice, Intercultural Justice and many otherinnovative forms of justice developed. In all of these initiatives the justice system shifted focus479

from what went wrong in the past to what will be the best future, for those involved with thejustice system, and for society as a whole.This presentation will observe the different forthcomings of court innovation from theperspective of the sustainability movement and societal ecology, and the significance of thesustainability-focus for court innovation policy.Learning From Drug Courts around the WorldLiz Moore, University of Tasmania (emoore@utas.edu.au)This presentation will compare and contrast aspects of the following: 1. Research conducted in2011 into the Court Mandated Drug (CMD) program in Tasmania, Australia (the drug court).Data from court sessions and interviews with 22 practitioners was analysed to makerecommendations for the future development of the program. 2. Material obtained in 2012 fromvisits to drug courts and treatment programs internationally. Various courts and associatedprograms were visited and interviews were conducted with a wide range of stakeholders. Therelevant countries include Chile, the USA, England, Wales, the Netherlands, Belgium, Franceand Austria. The particular focus of my research is on capturing the impact of drug courts andhow success can be measured and demonstrated. My experiences in the various drug courts andprograms have also provided me with many useful learning opportunities which could be appliedto enhance the CMD program in my own jurisdiction.200. Therapeutic Jurisprudence and Criminal Court ProceedingsEyewitness Misidentification: Determining and Confirming Correlates throughan Experimental DesignVictoria Simpson Beck, University of Wisconsin at Oshkosh (beckv@uwosh.edu)Chris Rose, University of Wisconsin at Oshkosh (rosech@uwosh.edu)Lynda Crane, College of Mount St. Joseph (lynda_crane@mail.msj.edu)According to the Innocence Project (2011), a reliance on eyewitness testimony is the leadingcause of wrongful convictions in the United States. Wise and Safer (2003) found judicialknowledge of factors influencing the accuracy of eyewitness accounts to be correlated withjudicial beliefs and behaviors that may be necessary to reduce wrongful convictions.Nonetheless, research has also found that most judges tended to have limited understanding ofthe factors influencing eyewitness testimony (Wise & Safer, 2003; Wise, Gong, Safer & Lee,2009) and judicial knowledge tended to contradicted expert knowledge (Wise, et al., 2009).Perhaps equally disconcerting are research findings indicating that, when compared to legal480

professionals, potential jurors tended to be even less knowledgeable about such factors (Benton,Ross, Bradshaw, Thomas & Bradshaw, 2006; Magnussen, Melinder, Stridbeck & Raja, 2009).Thus, identifying the correlates of eyewitness misidentification and disseminating thatinformation may result in reducing wrongful convictions. This research incorporates anexperimental design to examine factors that influence the reliability of eyewitness testimony.Subjects will be assigned to a variety of experimental conditions wherein they will witness afictional crime, be asked to recall elements of that crime and identify the perpetrator. Theindependent variables of race of perpetrator, race of witness, change blindness, distance from thefictional crime, and recall time are among some of the variables that will be manipulated. Afterthe experiment, subject interviews will also be held to ascertain the subject’s level of confidencein her/his eyewitness testimony. Results will be reported.Solutions-Focused Sentencing: A Mainstream TJ ApproachGreg Connellan, Magistrates’ Court of Victoria, Melbourne, Australia(gtc@magistratescourt.vic.gov.au)Recent years have seen the emergence of a range of specialist problem solving courts in manyjurisdictions. Specialist courts include drug courts, community courts, family violence courts andindigenous courts. Specialist problem solving courts are characterised by legislative reform,specialist staff and judiciary, multi-disciplinary teams, tailor made processes and additionalresources. The majority of cases however continue to be dealt with in mainstream court settings.Mainstream courts are characterised by large caseloads, limited time, backlogs, scare resourcesand generalist staff and judiciary. Despite this there are significant opportunities for sentencingprocesses in particular to apply TJ principles. Many examples exist but they tend to arise in anad hoc manner. This paper will on the practical experiences of the author in the developmentand implementation of the “Solutions Focused Sentencing Process” at the DandenongMagistrates’ Court, Victoria, Australia. This example will be used to explore the difficulties ofapplying solution focused judging in the mainstream and identify strategies to enable greaterapplication of therapeutic jurisprudence principles in mainstream court settings. The paper willexplore the challenges faced by those wishing to develop and sustain such approaches at a locallevel. It will discuss the types of networks, institutional support and systemic changes needed tonurture and support local solutions-focused initiatives and build a solutions-focused cultureacross a court.Institutionalizing TJ Approaches in Mainstream CourtsPauline Spencer, Magistrates’ Court of Victoria, Melbourne, Australia(pts@magistratescourt.vic.gov.au)481

Recent years have seen the emergence of a range of specialist problem solving courts in manyjurisdictions. Specialist courts include drug courts, community courts, family violence courts andindigenous courts. Specialist problem solving courts are characterised by legislative reform,specialist staff and judiciary, multi-disciplinary teams, tailor made processes and additionalresources. The majority of cases however continue to be dealt with in mainstream court settings.Mainstream courts are characterised by large caseloads, limited time, backlogs, scare resourcesand generalist staff and judiciary. Despite this there are significant opportunities for sentencingprocesses in particular to apply TJ principles. Many examples exist but they tend to arise in anad hoc manner. This paper will explore how TJ approaches can be institutionalised in thesentencing processes of a mainstream court. It will focus on the systemic changes needed in theareas of policy, legislation, administration, and in the judiciary - for this to occur.Mapping Canadian Law and Psychology ScholarshipLouise Belanger-Hardy, University of Ottawa (lbelhard@uottawa.ca)This paper presents a map of Canadian law and psychology scholarship published over the lasttwenty years. Although the psycho-legal field has evolved tremendously over the last century,the work of scholars, often published in non-legal and hybrid journals, is not as well-known as itshould be in the legal sphere. The paper’s objective is to summarize, assess and map relevantresearch with a view to creating a general guide for legal professionals seeking information onpsychological phenomena touching upon various broad areas of law. To achieve this goal, anumber of selection criteria were established and selected articles and books were divided incategories discrete enough to make sense to legal professionals as distinct areas of law impactedby psychological research. Examples of selected themes include policy, triers of fact anddecision makers, evidentiary issues, criminal law and forensic psychology, family law andchildren, victims of sexual trauma and sex offenders, psychological injury, therapeuticjurisprudence, and ethics. Scholarship was summarized and key developments and findings werehighlighted. Finally, after assessing the overall status of law and psychology in Canada, areaswhere further research would prove useful were identified. The hope is that the map will help todisseminate law and psychology scholarship as widely as possible to legal practitioners andacademics.201. Therapeutic Jurisprudence and Multisensory LawA Visual Guide to Swiss Protection of Adults and Children Law (2013): AppliedTherapeutic Jurisprudence and Multisensory LawCaroline Walser Kessel, University of St. Gallen (caroline.walser@vtxmail.ch)482

Visual law, a branch of multisensory law, and therapeutic jurisprudence exist to demystify, calm,and comfort. As a guide to a Swiss Protection of Adults and Children Law (PACL)demonstrates, pictorial explanations, coupled with talking techniques from psychology and othertherapeutic arts, can make complex legal directives more comprehensible, less stressful andfrustrating, and more effective overall. In illustration, PACL concerns largely unprotectedindividuals: the abandoned or mistreated young and old, weak, infirm, disabled, mentally ill, oraddicted. Its aim is to institute rights and interventions among persons often unable to grasp evensimple text. By use of pictures, photos, cartoons, comic strips, diagrams, and careful colorchoices, a PACL guide introduces self-recognition, accessibility, assurance, encouragement, andtrust within its intended audience; assistance and relief among workers, including guardians,social workers, police officers, and the judiciary, who serve such clientele. It also introduceslegal educators to an innovative methodology how legal contents could be conveyed to laypeople.Impulses from Multisensory Law and Therapeutic Jurisprudence for BetterCoping with Client’s Stress during Separation and Divorce ProceedingsErna Haueter, Lawyer, Zürich, Switzerland (info@haueteradvokatur.ch)As is weIl known, separation and divorce can cause a lot of emotional, cognitive, and physicalstress for the parties involved. Although therapeutic jurisprudence has already developed helpfulsolutions for lawyers in general and for family lawyers in particular to cope with their client’sstress, there is still a great need to search for further helping tools and methods to alleviate thisstress. Therefore, the question needs to be raised what impulses an integrated multisensory lawand therapeutic jurisprudence approach would give to better coping with a client’s stress,especially in the family law practice. Within this setting, this paper will focus particularly on therelationship between unfulfilled needs and stress, on stress that cannot or could not be reduced sofar until the break-up of the client’s marriage, and on possible solutions to reduce or eveneliminate her or his stress. Together, multisensory law and therapeutic jurisprudence providesuch solutions. The suggested tools and methods range from imagination techniques, pulsationexercises, miracle-question coaching, scaling questions, and so forth. Drawing on case studies,the purpose of this paper is to demonstrate that these kind of tools and methods contribute to thefamily law client’s feeling better or even well-being, despite her or his predicament of having togo through separation or divorce. As a result, the non-verbocentric impulses from multisensorylaw and therapeutic jurisprudence expand the family lawyer’s possibilities to deal with her or hisclient’s stress and therefore with her or his own. These impulses call for practical application andcritical examination.Promoting the Well-being of Persons with Aphasia: Integrated CommunicativeApproaches from Therapeutic Jurisprudence and Multisensory Law483

Georg Newesely, Zentrum für Gesundheitsberufe Tirol GmbH, Innsbruck, Austria(georg.newesely@fhg-tirol.ac.at)According to WHO’s International Classification of Functions (ICF), the ability to organize lifeaccording to one’s individual needs and wishes is an essential aspect of social participation.Ensuring this ability is thus a key issue in rehabilitation. Moreover, the legal capacity of adults islinked with their ability to make free choices and to freely declare their intent. However, neuropsychologicalillnesses can impede or fully constrain this freedom. Speech and languagedisorders, such as aphasia, are of particular importance in this respect. Persons suffering fromexpressive aphasia might nevertheless be able to state their contractual intent, provided that theyreceive appropriate communicative tools. Therapeutic jurisprudence and multisensory law mightprovide such tools. Thus, persons with expressive aphasia might complement residual languagefunctions with signs and media that go beyond verbal language. These media and signs would bevisual, audiovisual, tactile-kinesthetic, and multisensory. Persons suffering from receptiveaphasia have difficulties in understanding written or spoken language. Therefore, the questionarises whether and, if so, to which extent aphasic persons are able to understand legal or legallyrelevant contents, such as legal transactions? Receptive aphasia affects decision-making, whichis relevant in the legal context since descriptions of legal and legally relevant contents are as arule highly abstract and complex. Persons with receptive aphasia may not understand thequestions involved in the course of legal and administrative procedures. Nor might theyunderstand the legal or legally relevant facts needed to make legal decisions. This shortfall maybe due to aphasic persons lacking the legal requirements to freely declare their intent. As a result,courts or agencies could deprive them of their legal capacity. This paper will demonstrate thatspecific cases of aphasia might benefit from the communicative tools offered by therapeuticjurisprudence and multisensory law.Introducing Multisensory Law and Therapeutic Jurisprudence into EuropeanLegal Education: Problems, Questions, and Tentative AnswersColette R. Brunschwig, University of Zurich (colette.brunschwig@rwi.uzh.ch)This paper attempts to contribute to introducing multisensory law (MSL) and therapeuticjurisprudence (TJ) into European legal education. In doing so, it draws particularly on presentand future Swiss legal education as a case in point. Given the ongoing Europeanization andinternationalization of law and business, there is an intense debate on the indispensable subjectmatters of law in Switzerland and other European countries. To date, MSL and TJ are not taughtat Swiss law schools, not even in postgraduate legal education. Despite their great relevance forlegal practice and scholarship, MSL and TJ are hardly known at Swiss law schools and in locallegal practice. Since law students should learn how to work efficiently and effectively both aslegal scholars and legal practitioners, this immense gap in legal education contradicts thesethoroughly legitimate requirements. On that account, the following questions need to be raised:1. How are MSL and TJ already taught at other law schools, especially in the English-speakingworld? 2. How could MSL and TJ be taught at European, in particular at Swiss law schools? As484

egards the second question, further questions need to be addressed, such as: Could Europeanand Swiss law schools adopt the existing MSL and TJ curricula or at least some pertinentcourses of other law schools? If so, how could or indeed should the teaching of MSL and TJ beadapted to the specific characteristics and needs of European, and more specifically, of Swisslegal (further) education? Should MSL and TJ be taught together or separately? What would bethe pros and cons? Could MSL and TJ also be integrated into the teaching of other disciplines,such as legal psychology, legal pedagogy, and legal theory? If so how? What would be the prosand cons? In tackling these questions, the purpose of this paper is to foster the introduction ofMSL and TJ as legal disciplines to be taught not only in European universities but also in furtherlegal education, law firms, state agencies, courts, and so forth.202. Therapeutic or Anti-Therapeutic? Health Care Policy Choicesin the United StatesPhysician-Patient Communication … Now Against the law?Monica Broome, University of Miami (mbroome@med.miami.edu)In January 2010, Florida House Bill 155 was filed to prohibit licensed practitioners from askingand or documenting whether a person owns a gun. The bill also prohibits licensed practitionersfrom dismissing a patient who refuses to answer questions about gun ownership. Breaking thislaw would be a 3 rd degree felony, with punishment up to five years jail time and a five milliondollar fine, no exceptions. This presentation will provide a brief history of House Bill 155, thesubsequent amendments, and current standing. It will then engage participants in a livelydiscussion of the legal and medical issues regarding interference in the practitioner-patientrelationship related, but not limited, to the following questions:How is this law possible, and how did its passage happen?What are the stakes?What about concerns for safety?Are we interfering in a relationship that has always been seen as exempt from such interference?Do we need to limit physician autonomy?Is patient privacy being protected with this law?Are we protecting patients from discrimination?The Therapeutic Value of Mandated Reporting of Poor Diabetes Control: theCase of the New York City Department of Health’s A1C RegistryAlina M. Perez, Nova Southeastern University (amp@nova.edu)485

As diabetes continues to affect the population of the United States in epidemic proportions,public health officials from the various states have launched initiatives designed to curtail thestaggering toll in resulting diabetes complications, disability and mortality. In 2005 the NewYork City Board of Health approved the implementation of a diabetes registry, mandatinglaboratories to report all A1C levels of diabetic patients to the city’s Department of Health andMental Hygiene. The department would then contact those patients, whose A1C valuesexceeded the 8% marker (indicative of poor diabetes control) and their physicians to suggestmodifications to their course of treatment. Under established registry procedures, information iscollected without the patient’s explicit consent, using opt-out procedures. Although this initiativewas designed to cover the entire population in the city of New York, it was piloted first in alargely African- American and Hispanic- American community with high rates of diabetes.While disease registries are well recognized and accepted surveillance tools used in publichealth, the mandatory nature of this diabetes surveillance system raises issues of privacy, socialjustice and governmental authority to intervene in the clinical management of non-infectiousdiseases. This presentation will address the possible psychological impact of this chronic diseasemanagement measure on those affected by it: patients of ethnic and racial diversity, physiciansand the health care system in general, seeking to guide public health policy makers in the furtheruse of such registries in other states.Therapeutic Implications of Value-Based Insurance Design and Attaching“Value” to Health-Related BehaviorsAmy T. Campbell, SUNY Upstate Medical School (campbela@upstate.edu)“Value-based” behavior is increasingly sought when making health insurance coveragedecisions, including through use of financial (dis)-incentives. A longstanding approach, forexample, is to offer lower co-pays for generic (or “lower tier”) medications. However, thedemand for “value” in health insurance is growing given recent trends, including: a rise in theevidence base on which to base treatment decisions; the influence of behavioral economics inhealth care; and economic pressures across nations where health care systems face agingpopulations, a growth in expensive technology, and greater awareness of the role of preventiveand public health measures to address many health woes.In the US, “value based” purchasing has begun to take hold across the states (e.g., Oregon andConnecticut) and at the federal level. This presentation will discuss these trends and situate themwithin a global context. The emphasis, however, will not be on the merits per se of theseapproaches; rather, the goal will be to highlight how the term “value” may embed within it biasesor judgments masked behind the language of cost-effectiveness and data-driven (i.e., seemingly“objective” terms). Using obesity as a case study, this presentation will discuss the therapeuticimplications of adopting “value based” approaches (and terminology) in coverage decisions, andpotential disparate impact or unintended costs of adopting these approaches (e.g., costs to whom,as perceived by whom). Therapeutic jurisprudence will be offered as a potential means to486

eframe discussion of value-based insurance design to make transparent these impacts and costsso as to better address the “health” impacts of health insurance policies.Therapeutic Value: Expanding Access to Hospice Care as a High-Relative-Value End-of-Life OptionKathy L. Cerminara, Nova Southeastern University (cerminarak@nsu.law.nova.edu)Hospice care, a subset of palliative care, provides physical and psychological benefits to patientsnearing the end of life, their families, and their caregivers. In the United States, however, accessto hospice care near the end of life is neither universal nor usual. Most citizens’ access to anytype of health care depends on being able to pay for it, and being able to pay for it usuallyrequires health insurance coverage of the care in question. Most people under the age of 65 whohave health insurance receive it through group plans established by their employers, while othermajor sources of health insurance are the federal Medicare system, the federal-state Medicaidsystem, private individual health insurance policies, and health insurance policies obtainedthrough exchanges. Only some of these options cover hospice services, and those that do haveestablished coverage rules that often place barriers in the way of access to it. Because hospicecare produces great therapeutic effects at relatively low cost, coverage of that care shouldbecome routine. This presentation will explain why policymakers in the United Statesestablishing coverage rules for Medicare, Medicaid, and individual insurance policies (whetherobtained through exchanges or not) should assure access to hospice care for patients near the endof life.Respecting People with Disabilities in Health Care Policy: A TherapeuticApproachElizabeth Pendo, St. Louis University School of Law (ependo@slu.edu)Disparities in the health and health care experiences of people with disabilities raise seriousethical, social and legal issues. The persistence of barriers and inequities, and the continuingfailure to ameliorate even seemingly simple problems -- the lack of accessible exam tables,scales, and x-ray equipment, for example – suggests deeper issues. In the United States, thePatient Protection and Affordable Care Act (ACA) offers a new approach to addressing thesedisparities. The provisions of the ACA focus generally on expanding coverage, controllingcosts, and improving the quality of the health care delivery system. The ACA also includesseveral provisions aimed at improving the health and health care of people with disabilities.Although the ACA holds great promise for persons with disabilities, its success depends uponthe development of implementing regulations to “flesh out” details and gaps in the legislation,and the response of states to the new mandates. This presentation will introduce a theoreticaland practical framework for including the experiences and perspective of people with disabilities487

in the development of the Affordable Care Act, and health care policymaking, generally. In sodoing, I will draw upon principles of therapeutic jurisprudence as well as insights from DisabilityStudies to acknowledge the experiences and expertise of people with disabilities, including asexperts in developing regulations and programs.203. Thinking about Victims from a TJ Vantage PointProcedure Without Substance: False Hope for Victims of Crime?Tyrone Kirchengast, University of New South Wales (t.kirchengast@unsw.edu.au)The rise of procedural justice for the integration of victims into processes from which they areotherwise excluded has been met with widespread praise. The ability to participate in court andassociated processes where, formerly, no role was accorded has challenged those normativeassumptions that see the victim relegated to the sidelines of justice. New and innovativeprocesses such as mediation, conferencing and intervention programs provide victims with ameans of participation that affords victims the option of making a substantive contribution thatstands the change of affecting the outcome of the matter. Other processes, however, have beencreated to better integrate the victim without the ability to affect the outcome. This paper willoutline to rise of ‘therapeutic processes’ that provide no opportunity to contribute to substantivedecision-making. The victim impact statement movement will be discussed with a view tochallenging the tendency to acknowledge such statements as providing a therapeutic processdespite such statements not being taken seriously, and in some instances, being disregarded asprejudicial to the objects of sentencing and justice. The consequences for victims will becanvassed.STATE vs. VICTIM: The Victim’s Survivors’ Experience of Conflict in aCapital Case, Examined through a Therapeutic Jurisprudence LensMelodee A. Smith, Nova Southeastern University (melodee@nova.edu)Murdered victims’ survivors must not only survive the loss of loved ones to capital crime, theymay also experience conflict as participants in a capital case. Investigating the case of State v.Campbell, the research design provides natural boundaries to explore the victim’s survivors’experience of conflict where the State sought the death penalty for the victim’s killer over thevictim’s survivors’ objection.This study seeks to present coherently, comprehensively and clearly the phenomenon of being avictim’s survivor in a contentious capital case where the State and the Victim, as well as hissurvivors – in this study hereafter, co-researchers, held different positions about capitalpunishment.488

Approaching this case study with a qualitative research methodology, InterpretivePhenomenology Analysis, data has been collected, analyzed and reported to interpret how the coresearchers’make sense of their conflict experience. Employing a double hermeneutic process,this researcher views and interprets the co-researchers’ sense-making through a therapeuticjurisprudence lens.Conducting semi-structured open-ended interviews with co-researchers, this study was enhancedby court records and other relevant documents to provide the basis for understanding andinterpreting co-researchers’ experiences. To assess the quality of the research, practices wereestablished to address sensitivity to context, commitment and rigor, transparency and coherence,and impact and importance.Contributing to an increased understanding into how victims’ survivors experience conflict in thecriminal justice system as well as the therapeutic nature of capital litigation laws, processes andprofessionals’ behavior, this researcher develops recommendations to train professionalsworking with victims in conflict cases.Youth Sexual Aggression and VictimizationChristian Diesen, Stockholm University (christian.diesen@juridicum.su.se)During the period 2010-2013 an EU research project - “Youth Sexual Aggression andVictimization” (Y-SAV) - has investigated the problem of sexual aggression towards youngpeople (12-25 years). The first aim of the project has been to create a knowledge base of studieson the prevalence, incidence, risk factors of sexual aggression as well as legal and public healthresponses, covering all 27 EU states. The collection of these data shows that there is a greatvariety between different regions and cultures: The awareness of the problem, the reporting ofrape, the legal, research and policy standards vary. In general it can be stated that the attention tothe problem is proportional to the incidence, i.e. that the countries that have most rape reports percapita also have most research and policies on the issue. On the other hand the prevalenceresearch shows that the risk for a young woman of being raped seems to be on a relatively highlevel in all European countries. The second aim of the project is to create a European action planfor dealing with youth sexual aggression, in which the similarities and differences between thestates are taken into account. The basis for this action plan is the conclusion that sexualvictimization of teenagers is a growing problem that needs more attention. The connectionsbetween these research findings and proactive legal strategies will be discussed from a TJperspective.Therapeutic Jurisprudence: An Appropriate Framework for Law Reform inMatters Involving Indigenous Women and Sexual Violence?Erin Mackay, University of New South Wales (e.mackay@unsw.edu.au)489

In this presentation, I propose to discuss the findings of my doctoral research into therapeuticjurisprudence and Indigenous women who have experienced sexual violence.In Australia, Indigenous women are overrepresented as victim/survivors of sexual violence, andthe criminal law currently falls short of providing an adequate response to this type of violence.In my PhD thesis, I argue that the law, broadly construed, requires further development andbetter implementation before it can deliver justice to these victim/survivors. I outline currentlegal shortcomings including attrition and matters leading to low legal engagement andretention—such as the re-victimisation that frequently occurs through the legal process—beforediscussing whether therapeutic jurisprudence has the capacity to provide an adequate frameworkfor reform in this area.In this presentation, I propose to engage with therapeutic jurisprudence on a theoretical level andground this analysis with a discussion of the case study investigated in my PhD thesis. I plan toprobe some of the underlying assumptions of therapeutic jurisprudence from the perspective ofthis ‘difficult’ case study. I will consider how therapeutic jurisprudence can inform a legalresponse to victim/survivors structured in accordance with gender and race, where harm usuallyis committed within trusted relationships, and in an intra-cultural context.Victims of Violent Crimes, Punishment of Offenders and Early-ReleaseProceedingsAnnette van der Merwe, University of Pretoria (Annette.vandermerwe@up.ac.za)South African victims of violent crimes, such as rape and murder, can currently expect lifeimprisonment as the most severe sentence possible to be imposed on their wrongdoers. Once thesentence is determined, the actual term of incarceration to be served is of import not only to theoffender but also to the victim. The Argentinean film The secret in their eyes provides a poignantillustration of the betrayal experienced by a man when the state fails to fulfill its obligation toproperly punish the killer of his wife, and in the pursuit of justice he himself becomes trapped invictimhood. The film raises awareness with regard to the rights of victims and offenders duringthe post-sentence phase. Current rights pertaining to this phase are examined, including victims’legitimate expectations from the state, their empowerment through rights (such as the rights toreceive and provide information concerning parole proceedings), and available support structuresto address the effect of violent crime. In addition, the rights of offenders serving life sentences,such as the right to dignity and human interaction as well as the rules pertaining to sentenceduration and parole, are evaluated. The film re-affirms the rationale underpinning a rights culturefor both victims and offenders. It further illustrates the inherent tension between rights of victimsand offenders and the acute need to strike a balance between them. However, the question isposed whether exercising the right to present impact evidence at parole proceedings does notperpetuate victimhood, thereby negatively influencing victims’ long-term well-being.490

204. TJ & Criminal Procedure: International Perspectives“Idiots” and “Lunatics”: Are These Two Now Pejorative Terms Still Viable inDistinguishing Competency and Insanity in the Criminal ContextPatrick D. Reilly, New Jersey Public Defender, Trenton, USA(Patrick.Reilly@advocate.state.nj.us)For centuries idiots and lunatics were terms that would entitle criminal defendants or civillitigants to specific treatment in the Anglo-American court system.Idiots would be incompetent to retain property for themselves and their progeny. They wereentitled to the protection of the sovereign. They could not be tried for criminal activity. Finallytheir condition was considered unchangeable.Lunatics were also entitled to protection of the sovereign, but only during periods of lunacy.Their condition would be considered to be variable. Therefore their property was to be preservedand returned when their lunacy subsided. They could be tried in criminal court when sane, butcould not be convicted if the lunacy controlled their behaviour at the time of the alleged criminalact.As words took on pejorative meanings and were changed, as diagnoses proliferated, as statutoryand case law developed, separating intellectual deficiencies from mental illness may no longer bepossible. We will discuss how and why this happened both in psychiatry and law.International Human Rights, Mental Disability Law, and the Dilemma ofCriminalizationBruce Borkosky, Independent Practice, Sebring, USA (drborkosky@gmail.com)Nations vary considerably in the percentage of their population that they incarcerate, the lengthof those incarceration periods, and in the quality of the incarceration (punishment vs.rehabilitation). These policy decisions have far ranging direct and indirect consequences on thenation and the inmate. The negative consequences of long term punishment / criminalization ofthe mentally ill are yet more severe and long-lasting, made all the more poignant due to thereduced responsibility caused by their mental illness.Mitigation Practices in Death Penalty Cases: An International Human RightsPerspective491

Valerie R. McClain, Neurology and Physical Therapy Centers of Tampa Bay, USA,(vraemac@aol.com)This presentation will focus broadly on mitigation practices typically applied to death penaltycases from a forensic psychological perspective to include: (1) the identification of commonfactors qualifying as mitigators in the defendant’s life history from a legal standpoint; and (2)how to present these factors when assisting in death penalty cases. As a related and far reachingissue, the application of mitigation on an international level will be addressed by presentingcurrent international human rights perspective on the reformation and restriction of the deathpenalty.“I Hear Einstein and Freud Corresponding in the Ether”J. Tyler Carpenter, FAACP, Hyde Park, USA (jtcarpenter30@hotmail.com)The UN Declaration of Human Rights rose phoenix-like out of the ashes and war crimes trials ofthe shared global tragedy that was World War II. Like all true creativity and progress, thedeclaration was created by the tensions of individual authors' mutual cultural differences,sustained through 60+ years of intermittently incendiary and destructive nationalist conflict andbreakdowns; and now it struggles to manifest itself in the evolution of a common framework forinsuring these individual rights through the collective construction of processes which define thenature, treatment, and therapeutics of criminally and mentally deviant behavior. This brief talkwill introduce the basic elements of this challenging and evanescent process, how it is bothabstracted and concretized, and encourage a group discussion of basic principles.Brain Injuries and Criminal LawIan Freckelton, Monash University (I.Freckelton@vicbar.com.au)The impact of brain injuries (BIs) upon criminal responsibility and criminal culpability has beeninadequately recognised by courts in many countries. Utilising cases, particularly from Australia,the author argues that there needs to be greater consciousness amongst expert assessors and bythe courts of the subtle disinhibiting and potentially exculpating aspects of ABIs. He drawsattention too to the problematic phenomenon of foetal alcohol syndrome and its relevance to thecriminal conduct of numbers of indigenous persons in a number of countries, includingAustralia, as well as to the lack of appropriate treatment and care facilities in many jurisdictionsto persons who neither conform to the mentally ill nor intellectually disabled stereotypes ofcriminal offender of which there is greater awareness and to which there tends to be greaterresponsiveness.492

205. TJ and the Judicial Process in Cases Involving ChildrenMore Therapeutic, Less Collaborative? Asserting the Psychotherapist-PatientPrivilege on Behalf of Mature MinorsBernard P. Perlmutter, University of Miami (bperlmut@law.miami.edu)This presentation examines several cases upholding an adolescent’s right to assert thepsychotherapist-patient privilege, over objections by parents or guardians, in juvenile and familycourt litigation. Promoting the child right to assert this privilege allows the child to maintain aconfidential relationship with the therapist unimpeded by parental assertion or waiver of theprivilege. The presentation examines these issues in light of state and federal law, public healthpolicy and medical ethics, developmental psychology, and through the dual lenses of proceduraljustice and therapeutic jurisprudence. It argues that appointing counsel to advocate for thechild’s private therapeutic interests is pivotal to the promoting the child’s interests as a privilegedstakeholder in the proceeding. This argument dovetails with a central purpose of therapeuticjurisprudence: to promote positive therapeutic outcomes for participants in legal proceedings,which necessarily includes zealous legal advocacy for a patient’s articulated interest inunimpeded access to psychotherapy. But at what cost? Is there a danger that upholding thechild’s right to assert the privilege will provoke collateral ”anti-therapeutic” damage that deepensthe parent-child conflicts rather than alleviates them? How do we define “therapeutic”? Will thechild and the parent be estranged and their relationship irreparably damaged? Is this “antitherapeutic”?Will the ruptures in these important relationships, brought about by the stresses anddisagreements in the course of a full-tilt adversarial litigation over access to the child’s treatmentrecords, harm the child or inhibit the child’s healing process.Expert Testimony in Pursuit of Just Outcomes and Well-beingBarbara J. Sturgis, University of Nebraska (Bsturgis1@unl.edu)Therapeutic Jurisprudence pursues a project of research and law reform intended to promote thewell-being of those affected without violating other values embodied in law. It examines theimpact of laws, legal procedures, and legal actors on those who participate in the legal system,looking at how these can be modified to enhance well-being and minimize negative effects of thesystem, also increasing the perception of fairness on the part of the participants. Children whohave been sexually abused suffer in secret often for lengthy periods of time. When childrendisclose they often encounter skepticism on the part of family members and the community, aswell as protracted involvement with the legal system. Sometimes those who prosecute thesecrimes are the sole source of support for these children. I will describe general frameworktestimony that explains children’s patterns of disclosure of sexual abuse, and I will discuss the493

manner in which that researched-based testimony has been used to support victims’ testimonyand to counter potential juror misperceptions about the disclosure process. Although dealingwith the legal process is often stressful for children, this testimony promotes the ability ofprosecutors and courts to promote just outcomes and to protect the well-being of these childrenby providing them with an opportunity to tell their stories to officials who are willing to listen, totake them seriously, and to protect them.Redress Packages for Institutional Child Abuse: A More ‘Healing’ Approach?Exploring the Grandview AgreementJane Wangmann, University of Technology, Sydney (Jane.Wangmann@uts.edu.au)Over the last decade many countries have faced revelations about the harms suffered by childrenin institutional settings. In turn many governments have responded by putting in place a range ofredress measures, incorporating measures such as: apologies, financial compensation,counselling programs, family reconnection programs, education and training and other healinginitiatives. This paper focuses on one such redress package implemented in Ontario, Canada in1994 – the Grandview Agreement. The paper presents findings from a research projectconducted by Professor Reg Graycar, Faculty of Law, University of Sydney (Chief Investigator)and Jane Wangmann funded by the Australian Research Council (ARC). The GrandviewAgreement was designed to respond to the harms perpetrated on women and girls who had beenheld in the Grandview Training School for Girls. This Agreement is widely seen as an instanceof redress – one that demonstrates an intention to develop and put in place alternative processesto address the harms arising from systemic injuries such as institutional child abuse. We explorethe way in which the Agreement, informed by feminist insights about the experience of violenceagainst women within the criminal and civil legal systems, was designed to remove some of theanti-therapeutic consequences of the civil legal system (for example the negative impacts ofdelay and adversarial processes such as cross examination, and particularly those experienced byvictims of sexual assault as re-traumatising), and in turn aimed to incorporate other measures thatare seen as possessing potentially ‘therapeutic’ outcomes/ effects for the victims/survivors.The Challenges of Setting up the First Family Drug Treatment Court inAustralia: Creating a Collaborative Environment in Cases of Parental SubstanceAbuseGregory Levine, Children’s Court of Victoria, Melbourne, Australia (gjzlevine@gmail.com)Parental substance abuse is a serious problem requiring urgent attention worldwide. Increasingnumbers of children in Victoria, Australia are being removed from their parent’s care, oftenpermanently. The goal of family reunification – which is recognised to be in the best interests of494

the child – is rarely achieved through traditional adversarial court processes. In March-April2012, I was awarded a Churchill Fellowship to do an in-depth study of problem-solving FamilyDrug Treatment Courts (FDTC) in the US and UK, the most effective intervention a court canprovide to enhance rehabilitation and family reunification. This paper will report on thatanalysis, conducted in collaboration with Emeritus Professor Barbara Kamler, and our earlyefforts to establish the first FDTC in Australia as a three-year pilot in the Children’s Court ofVictoria, Melbourne. While TJ principles find easy application in problem-solving courts, theprocess of setting up these courts has not been closely examined. The FDTC presents significantchallenges to current practice in Australia, including the need to (a) develop more collaborativeways of working between the judiciary, social work, drug addiction and legal professionals; (b)introduce a docket system to ensure judicial continuity, frequent court hearings and a new rolefor the judicial officer in motivating parental recovery (c) build a court-based MultidisciplinaryTeam for delivering more intensive, closely coordinated treatment and rehabilitation to bothparents and children. These challenges will be discussed in light of our efforts to set up aSteering Group and to advocate for the social, therapeutic and economic benefits of the FDTC ina restricted funding environment.Post-Adjudicatory Juvenile Defense Attorneys: Exploring the New Wave ofTherapeutic Jurisprudence LawyeringMegan F. Chaney, University of La Verne (mchaney@laverne.edu)The article, Keeping the Promise of Gault: Requiring Post-Adjudicatory Juvenile Defenders,explains that the purpose of juvenile court is rehabilitation, and is therefore a problem-solvingcourt that uses law as a therapeutic agent for change. I propose in order for the juvenile courtsuccessfully to achieve its stated goal, a new type of lawyer must be installed to represent thechild client after he has been adjudicated delinquent. Etching out a new defense attorney role isproblematic because in an effort to address social welfare issues, juvenile court participantstacitly agree to restrictions on client liberty. Securing liberty has traditionally been the main goalof criminal defense attorneys. Juvenile court provides a different end game — therefore requiringan entirely new lawyering role – one that ironically has not yet been contemplated. In thispresentation, I will explore the tensions of post-adjudicatory juvenile defenders and howtherapeutic jurisprudence can provide guidelines for adopting an ethical defense role withoutsacrificing what has been traditionally seen as the defender’s first prerogative: zealousrepresentation of stated interests. What ethical rules would govern this attorney's conduct? Howwould those ethical guidelines differ from that of a traditional criminal defense attorney? Thepurpose of the discussion is to create an entirely new lawyering role steeped in principles oftherapeutic jurisprudence without sacrificing the tradition of zealous criminal defense lawyering.The continued success of the juvenile justice system relies on it.206. TJ & Legal Education495

Therapeutic Jurisprudence and Intellectual ActivismDavid Yamada, Suffolk University (dyamada@suffolk.edu)Intellectual activism is the term I use to describe an ongoing process of applying scholarlyfindings and insights to social change. Applying insights from adult education, publicintellectualism, social network media, and legal & political advocacy, I will examine ways inwhich TJ scholars can take their work beyond the academy and engage legal stakeholders andgeneral public. Specific topics will include the role of traditional law review articles andscholarly books, the use of blogs and social media, affiliation with advocacy groups to advancelaw reform initiatives, outreach to and collaborations with non-legal and non-academicstakeholders, accessing the media. In addition, drawing upon work I have been doing for the pastdecade on developing law & policy responses to workplace bullying, I will consider strategies,opportunities, and tradeoffs in conducting one’s work in this mode. After analyzing potentiallegal protections under American law for targets of bullying and psychological abuse at work, Idrafted a model statute – now dubbed the Healthy Workplace Bill – that is being introduced instate legislatures across the country. This work has brought me into an interdisciplinary group ofscholars, practitioners, and advocates addressing workplace bullying, and it has taught me manylessons about how to engage with a broader public on issues of social concern.Teaching Cross-Cultural Competence in Law Schools: Understanding the“Self” as “Other”Christina A. Zawisza, University of Memphis (czawisza@memphis.edu)This presentation focuses on methods to teach cross-cultural competence to enhance thepsychological well-being of lawyers and clients in order to more creatively solve problems.Three law professors, two who teach clinically, and one who teaches doctrinally, will expandupon the classic attributes of culture defined by Susan Bryant and Jean Koh Peters byincorporating research gleaned from an exercise recently administered to younger generations oflaw teachers. The results of this exercise demonstrate that, as we find ourselves in a globalcommunity, “culture” encompasses the intersection of the different attributes or categories thatdefine a person. Thus “self” is always “other.” We then see the attorney-client relationship as“self” coming together with “other.” We will discuss the “whys” and “hows” of teachingcultural competency from this healing perspective. Professor Zawisza will share exercisesapplied to individual client cases; Professor D’lorah Hughes from the University of ArkansasSchool of Law will address exercises in systemic cases; and Professor Tienne Anderson from theUniversity of Memphis School of Law will discuss teaching doctrinally. A curriculum modulethat envelops their three perspectives will result.496

Using Communication Models to Teach Relational Competencies in Law SchoolSusan Brooks, Drexel University Earle Mack School of Law (susan.brooks@drexel.edu)Legal educators are partnering with practitioners and judges to humanize law school and to useexperiential and public service opportunities to prepare students. Movements such as ClinicalLegal Education and Therapeutic Jurisprudence have generated scholarship that explores theunderpinnings of this new partnership. A prime example is “Relationship Centered Lawyering,”(“RCL”) a holistic framework developed by Susan Brooks and Robert Madden, both of whomare credentialed in law and social work. RCL focuses on three areas of competency everyeffective lawyer needs: (a) understanding theory about the person-in-context, (b) promotingprocedural justice, and (c) appreciating interpersonal, cultural, and emotional issues. This paperand workshop, co-authored and co-presented by Susan Brooks and David Boulding(www.davidboulding.com), will advance the understanding of relational lawyering bydemonstrating how to teach relational competencies using an integration of several welldevelopedcommunication models. These models include the Haven Communication Model,developed by Drs. Jock McKeen and Bennet Wong, the Coordinated Management of Meaning(CMM) Model, developed by Drs. Barnett Pearce and Vernon Cronen, and the AppreciativeInquiry Model, originally developed by Dr. David Cooperrider and his colleagues. All of thesemodels share three characteristics. First, they recognize that each individual brings a context intoevery interaction. Second, they encourage a posture of curiosity and mindfulness. And third,they embrace the idea that language choices matter, and that effective communication can createpositive change in individuals, groups, and larger communities. After introducing the models,the paper/workshop will provide examples of how law students can practice using these models.Diversity and Higher Education: Exploring Therapeutic Jurisprudence as anOrganizational Development StrategyJacqueline S. Dejean, Massachusetts School of Professional Psychology(Jacqueline_dejean@mspp.edu)Recent US Supreme Court decisions have altered the definition of legally actionable diversityand with it complicated the ability of higher education institutions (HEI) to respond withpsychologically beneficial strategies. With diversity as the change stimulus and higher educationas the organizational system, this paper evaluates current diversity law and race-based diversityresearch with the intent of building a case for using therapeutic jurisprudence as anorganizational development (OD) tool for assessment of organizational psychological wellness.In the past decade, precedent setting lawsuits brought against HEIs, coupled with a changingsociopolitical landscape, have resulted in universities striving to defend their diversity practices.Empirical research by social psychologists increased our understanding of this changinglandscape. Their research identified compelling reasons to not only support diversity initiatives,but also expand diversity efforts to encourage interaction of people from many and varying497

ackgrounds. While the traditional structural definition of diversity, i.e. diversity by sheernumbers, remains a meaningful basis of diversity practice (building critical mass and avertingtokenism), diversity as an issue of compelling constitutional interest now mandates substantivecross cultural interactions with measurable benefits for both majority and minority populations. Iwill review the highest court’s mandate, address higher education diversity within the currentsocial climate, and lastly, consider an OD approach to creating solutions for these organizations.Specifically, I will summarize four recent Supreme Court decisions relevant to the interpretationof diversity related regulations and explore therapeutic jurisprudence, and its potential forserving as a tool for organizational development consultants.207. TJ and Mental Health LawWith the Best of Intentions: Public Health, Therapeutic Jurisprudence andMental Health CourtsChelsea Davis, Columbia University (cbd2116@columbia.edu)The political issues surrounding therapeutic jurisprudence (TJ) and mental health courts (MHCs),including coerced treatment, social control, and the role of psychiatry in courts are hotly debatedin the context of today’s justice system, the current state of the criminalization of mental illness,and the current public mental health system. However, TJ, MHCs, and their critics haveideological progenitors in the mid twentieth century. This paper will discuss in what ways TJ andMHCs represent a break from earlier debates regarding psychiatry, social control, and coercedtreatment in the legal context started by Karl Meninger, Thomas Szasz, Nicholas Kittrie, andJudge Bazelon. TJ and MHCs constitute both continuity and change in criminal justiceparadigms, mental health policy, and the relationship between psychiatry and the law. Thoughthe same problems had by the therapeutic state do not arise in this context as TJ is by no means acall for deference to any public health establishment, today’s ideologies do have reluctant rootsin the rehabilitative ideal. Thus, critiques of and advocacy for the therapeutic state find their ownexpression in TJ. Additionally, TJ has integrated aspects of public health into its formulation andapplication. Mental health courts are explicitly designed with the aim of affecting the root causesof the criminalization of mental illness and thus seem to share a common purpose with publichealth, which also focuses on distal causes of social problems. With this historical perspective inmind, we must ask whether MHCs can be conceptualized as a public health intervention andwhat the answer to this question means for the relationship between TJ, MHCs, and publichealth.Overhauling a State's Mental Health Code: The Texas ExperienceBrian D. Shannon, Texas Tech University (brian.shannon@ttu.edu)498

In November 2010, the Hogg Foundation for Mental Health awarded a two-year grant to TexasAppleseed and Disability Rights Texas to develop a report to outline issues and suggest revisionsto the Texas Mental Health Code to better reflect the state’s current behavioral health system.The grant was an outgrowth of a recommendation by a state continuity of care task force that thestate’s code was in need of a full-scale revision. In fact, the Texas Mental Health Code has notbeen substantially revised since 1985 – more than a quarter century ago. In contrast, behavioralhealth care standards, practices, and services have seen dramatic changes during this period. Thegrantees retained Dr. Susan Stone (an attorney/board certified psychiatrist) as a consultant. Sheformed a Steering Committee, composed of judges, attorneys, law professors (including thispresenter), and clinicians. In addition, she facilitated forty-plus public meetings across the statewith over 5,000 participants. Because of complexities, out-of-date provisions and terminology,the retention of legal standards inconsistent with modern treatments, a significant increase of lawenforcement and criminal justice overlap with behavioral health issues, and an array of otherconcerns, the Steering Committee recommended a wholesale repeal of the 1985 code, andrecommended enactment of a new structure. The report will be submitted in final form to theTexas Legislature in advance of the next legislative session which commences in January 2013.By the time of the conference, it is hoped that a new mental health code will have been enacted.Predictors of Criminal Justice Outcomes Among Mental Health CourtParticipants: The Role of Perceived Coercion and Subjective Mental HealthRecoveryChristina Pratt, Nathan Kline Institute for Psychiatric Research, USA (cpratt@nki.rfmg.org)Research on mental health courts (MHCs) to date has been disproportionately focused on thestudy of recidivism and re-incarceration. Despite the strong conceptual links between the MHCapproach and recovery-orientation, the capacity for MHCs to facilitate recovery has not beenexplored. This user-informed (MH/CJ) community based participatory (CBPR) study assessesthe extent to which MHC practices align with recovery-oriented principles. We report on theexperiences and perceptions of 51 MHC participants across four metropolitan Mental HealthCourts, specifically: 1) how defendants’ perceptions of court practices, particularly with regardto procedural justice and coercion, relate to perceptions of mental health recovery and psychiatricsymptoms, and, 2) how perceptions of procedural justice and mental health recovery relate tosubsequent criminal justice outcomes. The authors hypothesized that perceived coercion andmental health recovery would be inversely related, that perceived coercion would be associatedwith worse criminal justice outcomes, and perceptions of mental health recovery would beassociated with better criminal justice outcomes. Results suggest that perceived coercion in theMHC experience was negatively associated with perceptions of recovery among MHCparticipants. Perceptions of “negative pressures,” a component of coercion, were importantpredictors of criminal justice involvement in the 12 month period following MHC admission,even when controlling for other factors that were related to criminal justice outcomes, and that anincrease in procedural justice was associated with a decrease in symptoms but curiously not to anincrease in attitudes toward the recovery. Implications and future directions are discussed. Co-499

Investigators: Joshua Koerner, Center to Study Recovery in Social Contexts, Nathan KlineInstitute for Psychiatric Research, Philip T. Yanos, Ph.D. and Sarah Kopelovich, ABD, CityUniversity of New York, John Jay College of Criminal Justice. This project was supported by theNIMH sponsored Center to Study Recovery in Social Contexts (MJ Alexander, PI,P20MH078188).Recovery Concepts and Mental Health Legislation: A Mismatch?Leanne Craze, Craze Lateral Solutions, Glen Alpine, Australia (leanne.craze@bigpond.com)Australian governments through the 4th National Mental Health Plan are developing a NationalRecovery-Oriented Mental Health Practice and Service Delivery Framework. It is intended thatthis framework will span all levels of mental health service delivery and will guide reformnationally. The Framework will seek to align the practice of all people working in the specialistmental health system with recovery principles - across clinical and non-clinical practice settings,in hospital settings or in the community, in government, non-government/not-for-profit andprivate sectors. Aims of a recovery-oriented approach to mental health practice include tosupport people to build and maintain a (self-defined and self-determined) meaningful andsatisfying life and personal identity, regardless of whether or not there are ongoing symptoms ofmental illness. The term “recovery-oriented practice” describes an approach to mental healthcare, that encompasses principles of self-determination, autonomy and personalised care.Recovery-oriented practice emphasises wellbeing, hope, social inclusion, communityparticipation, and self-management. Recovery-oriented approaches also place emphasis onpractitioner and service partnerships and collaboration. However, much of our mental healthlegislation focuses on deficits and risk. Frequently the onus proof is on person to establish thatshe or he can safely exercise self-determination and personal choice. Legislation also oftenunwittingly places significant barriers to service collaboration and partnerships. This paperidentifies a number of ways in which mental health legislation might be amended so that greaterrecognition of recovery principles is achieved.How Can Lawyers, using a Therapeutic Jurisprudence Perspective, ApplyKnowledge and Skills from other Specialized Areas of Law Practice to BetterRepresent Clients in Involuntary Commitment Proceedings?Robert L. Ward, Public Defender’s Office, Charlotte, USA(Robert.ward@mecklenburgcountync.gov)Using the theory and practice framework of Therapeutic Jurisprudence to identify ways toimprove representation, practice methods and outcomes for clients facing involuntarycommitment proceedings, what can lawyers learn from other areas of legal specialization such asSpecial Education Law, Drug Treatment Courts, Lawyers Assistance Programs, Preventative500

Law or Sentencing Advocacy? Involuntary Commitment legal proceedings are by nature bothparallel to, and intertwined with, a medical and community support process. These proceedingsare an intersection and linkage of law, medicine, family and community and as such presentmore subtle and complex issues that can confound and discourage lawyers who seek to do wellby their clients and profession. Compounding the problem, the general public and legal culturecan be less perceptive or unable to benefit from the profound improvements in understanding andtreating the human brain and human behavior. Yet, there are lawyers, judges and otherprofessionals who out of interest or necessity have been able to branch out to expand theirrepertoire of counseling and advocacy skills and messages. By effectively adapting appropriateskills and messages, civil commitment lawyers have an opportunity for greater success for theirclients, the justice system and possibly their own lives.208. TJ, Parenting and Best Interests of the Child in Family LawThe Conflict-Reducing Effects of the Dutch Compulsory Parental PlanEmpirically Tested: Results from a Study of 600 Divorce Case RecordsMarit van der Lans, VU University Amsterdam (m.vander.lans@vu.nl)In 2009 the Dutch Government has enacted a law making a parental plan (agreement on childresidence, contact arrangement, information and child maintenance) compulsory for separatingparents in formal and informal relationships. The main objective of the new law was reducingpost-separation parental conflicts. Several other jurisdictions have also introduced compulsorymeasures in order to reduce such conflicts, e.g. compulsory mediation (Norway), compulsoryparental plan (Catalonia), combinations of (semi) compulsory parental plans, mediation andparental education programs (United States). The conflict reducing effects of the Dutch parentalplan have been studied through a longitudinal study of a stratified sample of 600 divorce caserecords in three Dutch courts. The results of this study and the results of empirical research onthe effects of compulsory measures conducted in Norway and the US will be discussed.Assessing the Therapeutic Benefits of Supportive Supervised AccessShelley Kierstead, York University (skierstead@osgoode.yorku.ca)Within the context of domestic family law questions of post-separation care for children,supervised access is available as a short term mechanism to facilitate contact between noncustodialparents and their children in situations where there is a perceived risk to the child inhaving unsupervised contact with this parent. While access on a supervised basis is intended tobe short-term, pending a transition to unsupervised access, supervised access programsfrequently do not offer supportive services to assist non-custodial parents to acquire the skillsrequired to transition to an unsupervised access status. As such, the purposes of supervised501

access are, arguably, not as well-facilitated as they might be with the inclusion of supportiveparenting programs. Incorporating available feedback from one “supportive supervised access”pilot program that will be offered over the next twelve months by a Toronto-based supervisedaccess program, I propose to discuss the therapeutic benefits of supportive supervised access tochildren and parents, and to explore the countervailing rationales for not having such servicesincorporated as an ongoing element of supervised access services.Stopping Psychological Child Abuse with Proper Court OrdersJoan T. Kloth-Zanard, PAS Intervention, Southbury, USA (PASIntervention@aol.com)Parental Alienation is a form of psychological abuse where one person impedes the relationshipbetween children and parent. Stuck in the anger stage of grief, they cannot move forward. Theyhave no understanding that their emotions are theirs and not those of others. I call it BorderlessBoundaries.Courts and counselors do not understand PAS enough to apply proper prevention andintervention protocols. Inadvertently ordering counseling for the targeted parent and children,but forgetting the aggressor needs counseling or the children will continue to be barraged.Inclusion of Therapeutic Jurisprudence in PAS cases would enable healing and help families tomove forward in a positive healthy way. If issues of grief and anger are worked through, thechildren would not be affected, thus not need counseling. Key is for unilateral inclusion ofcounseling for parents and orders for therapists to report back to courts on counseling progress.If a parent is not working as evidenced in behaviors or denial of access, then penalties must be inplace to ensure cooperation. Adding these steps results in less trauma/damages, with the cost ofdivorce dropping dramatically. Best of all, we might not need to see the children in counseling.Legitimacy Challenges in Child Protection: Comparative Observations betweenSweden and AustraliaPernilla Leviner, Faculty of Law, Stockholm University (pernilla.leviner@juridicum.su.se)Most developed countries have a system for child protection which also is a responsibilityaccording to the UN Convention on the Rights of the Child. Encompassed in that of protectingchildren from abuse and neglect is a balancing act between children’s rights to protection andparent’s right to private- and family life. The assessment of what situations are to be consideredharmful and therefore a risk for a child’s health and development is complex and requiresknowledge from other fields of science such as medicine, behavioural science and social work.In that sense child protection entails a meeting between the law and other sciences. In this paperlegal aspects of child protection are discussed by taking the Swedish system as an example, butalso by contrasting this system with the one in place in Victoria, Australia. Both systems have502

een heavily and recurrently criticised, more or less constantly reviewed and partly reformedduring the last decades. This indicates that the legitimacy of the systems is being questioned.When comparing the systems, with different legal cultures and traditions but with more or lessthe same kind of challenges, some overall aspects that have a fundamental impact on thelegitimacy of any child protection system can be observed. In this paper questions about accessto justice, the role of the courts as well as prerequisites for correct and just decisions will bediscussed with TJ as a theoretical starting point.Developing Swedish Legal Scholarship: TJ’s Theoretical PotentialMoa Kindström Dahlin, Faculty of Law, Stockholm University (moa.kindstromdahlin@juridicum.su.se)In our work as Swedish legal scholars in the areas of child protection and mental health law, wehave come to realize that we, from a meta-perspective, are faced with the same kind ofdifficulties: When the law aims to secure individual’s right to protection or care, the corequestion is how to balance these values against conflicting interests of integrity and autonomy.This balancing is to be solved by a proportionality-test which often demands more than legalknowledge, regarding e.g. risk and capacity.Balancing is a complex activity and there is a risk that every decision is bad in some way. Thereare especially two categories of anti-therapeutic effects that have to be considered. Either, theresult might be that the authorities do not succeed in offering the protection that an individual isentitled to (i.e., needs). Or, the authorities might trespass individual rights in a way that are notproportionate.We will explore how TJ could serve as a theory to (1) evaluate the application of the law, (2)evaluate the efficacy and adequacy of the regulation and, (3) produce new alternative legalsolutions. We will argue that TJ has a valuable potential as a theoretical starting point in Swedishlegal scholarship, especially in social law. We will show that this potential is partly different inSweden compared to other countries since the Swedish legal tradition and the role of the lawyersare different from common law systems with adversarial procedures.209. TJ & Restorative Justice: Exploring LinkagesRestorative Justice: Piloting Programs in Hawai’iLorenn Walker, Friends of Justice and Civic Education, Waialua, USA (lorenn@hawaii.edu)Pilot restorative justice (RJ) programs in Hawai'i have benefited people harmed by crime but donot know who caused it; people who want to have "protective orders" amended or withdrawn;juveniles charged with crimes and status offenses; juveniles and adults reentering the community503

after serving time incarcerated and their loved ones; defendants who plead guilt to violenceagainst others including household members. Additionally RJ rituals mark important events andHawai'i's experiments in this area are significant not only for the subjects but the professionalsworking with them including judges and lawyers. Research shows people experience emotionalhealing and reduced recidivism with RJ practices.Restorative Justice in Alaska: A Design ApproachBrian Jarrett, University of Alaska Fairbanks (bnjarrett@alaska.edu)This paper discusses the need for a design approach to restorative justice. Dispute SystemsDesign, as a discipline, empowers local organizations or communities to develop their owntailored approach to dispute management. The need for a ground-up design approach is as true inthe criminal justice area as it is in others. The paper reviews the current restorative justiceprograms in Alaska and demonstrates the need to refine these programs through a ground-updesign approach. It also shows how a ground-up design approach is not incompatible with theinterests of the court and the rule of law.Forgiveness in Restorative Justice Processes: Therapeutic and Anti-TherapeuticConsequences for Victimized YouthTali Gal, University of Haifa (tali.gal.04@gmail.com)Restorative justice (RJ) addresses crime by gathering offenders, victims and their communitiesof support to participate in a safe and open discussion about ways to repair the harm. In RJprocesses victims can ask questions and receive answers; express their wishes, and have theirbehavior validated. In most RJ processes offenders also apologize, and this is an importantturning point in the process. Sincere, unconditional and complete apologies can fulfill victims’need for vindication and condemnation of the crime. Apologies also open the door for victims toforgive, a choice that offers therapeutic virtues. Concurrently, conditioned or partial apologiesmay have anti-therapeutic outcomes. This paper examines the therapeutic potential of apologiesand forgiveness in RJ processes involving juvenile victims. Victimized children require specialattention to their evolving capacities and unique needs. They have more difficulties engaging inthe intense RJ processes. They are often over-protected or overlooked by the other participants.They are more likely to be silenced, manipulated, or dominated in RJ processes. But victimizedyouth value apologies and often want to be heard and have their harm acknowledged. The paperconsiders these issues and proposes analytical and practical parameters for identifyingtherapeutic RJ processes for children.504

Restorative Justice in Northern Ireland: Ten Years OnJohn E Stannard, Queen’s University, Belfast (j.stannard@qub.ac.uk)The first day of December 2013 marks the tenth anniversary of the coming into force of theprovisions relating to youth conferences in Northern Ireland. The effect of these provisions,which were set out in Part 4 of the Justice (NI) Act 2002, was to put the principles of restorativejustice at the very heart of the system for dealing with young offenders in that jurisdiction. Sincethen these provisions have been operating alongside other community based restorative justiceschemes, so making the province of Northern Ireland a key focus for those interested in theoperation of restorative justice in the practical context. The purpose of this to compare andcontrast, in the light of the relevant academic literature, the operation of these two frameworksfrom a restorative justice perspective, the aim being to identify the strengths and weaknesses ofeach approach, and to consider what lessons might be learned for the future.210. TJ & Victims’ RightsDomestic Violence Murder – New Example of Sweeping Improvements to the‘Slayer Statute’ to Better Prevent Killers from Profiting and Help Families toHealR. Keith Perkins, Never Again Foundation, Phoenix, USA (keith@neveragainfoundation.org)Nearly every state in the United States has a “slayer” statute with the intent to prevent killersfrom financially profiting from murder. Unfortunately, significant loopholes have existed fordecades in most slayer statutes which permit a large percentage of killers to still financially profitor direct financial profits from homicide. In 2012, the Never Again Foundation (which representsfamilies in civil actions to prevent killers from profiting from domestic violence murder)successfully led a sweeping legislative update in which the Arizona legislature unanimouslybanned these loopholes and simultaneously provided victims with unparalleled civil remediesagainst killers. With more than 100 domestic violence murders each year, Arizona’s new slayerstatute is now the strongest against killers in the United States, and serves as a potential modelfor other jurisdictions, including: 1) the imposition of a constructive trust on ALL killer’sproperty (i.e. such as life insurance) for payment of damages to victims; 2) specific inclusion ofmanslaughter; 3) specific inclusion of murder/suicide; 4) specific inclusion of guilty but insane;and 5) retroactive application. The results provide a new model to help families of domesticviolence murder better obtain therapeutic jurisprudence through hope, justice, and healing.Therapeutic Jurisprudence: Facilitating Healing in Crime Victims505

Jamie Balson, Never Again Foundation, Phoenix, USA (jamie@neveragainfoundation.org)While crime victims’ rights have made significant strides in the past decade on behalf of victims,much more can be done to promote additional healing of crime victims. Victims still encountersecondary victimization at the hands of the justice system, yet secondary trauma can beidentified and eliminated. More can be done by prosecutors and courts to scrutinize their currentpractices regarding victims and identify areas where they can improve victim interaction. Evenbetter, prosecutors and courts can adopt a therapeutic jurisprudence model of victim interactionto promote the psychological healing of crime victims. Therapeutic jurisprudence can beeffectively redefined and utilized in the criminal justice system as a method of enhancing justicewhile it simultaneously promotes healing and empowers victims.21 st Century Slaves: Children Reduced to Products, Captured in the Business ofSupply and DemandSarah Murillo, Phoenix School of Law & The Juvenile Court - Maricopa County Superior Court,Phoenix, USA (scmutillo@phoenixlaw.edu)Domestic Minor Sex Trafficking (“DMST”) affects hundreds of thousands of children. The sexindustry is an underground operation and most crimes go unreported which makes it difficult tocalculate the exact number of exploited children. In the United States, only five states havepassed laws establishing children exploited through sex trafficking as victims. These statesprovide a child protection response rather than a criminal justice response to sexually exploitedchildren. The remaining states, including Arizona, continue to criminalize child prostitutiondespite strong federal regulation labeling all internationally trafficked minors victims. Resourceshave been allocated to international sex trafficking; however, despite the increasing number ofchildren being prostituted within the borders of the United States, minimal resources have beenallocated to this cause. The history of prostitution, its current prevalence in Phoenix, Arizona,and the legal consequences for juvenile prostitutes will be explored. The business of prostitutionwill be explained. An analysis of DMST laws will be completed. Additionally, current lawssurrounding DMST in Arizona will be analyzed. A best practices Phoenix, Arizona model forDMST is proposed using a holistic approach to this epidemic. The suggested model includes anidentification system and collaborative approach amongst agencies to deal with childprostitution, an awareness campaign for DMST including education and training of agencies whocome into contact with child prostitution, treatment programs including alternatives to detainingchild prostitutes, and suggested legislative changes targeting domestic minor sex traffickers andcustomers and labeling child prostitutes as victims.The Law Review Project: A National (Federal) Victims’ Rights Amendment,Part One506

Jason Holmes, Phoenix School of LawA very special law review project: the writing and editing of an amendment to the United States’Constitution, and preparation of a series of articles addressing and weighing the arguments infavour and against a national Victims Rights amendment. This is part one of a two-partpresentation.The Law Review Project: A National (Federal) Victims’ Rights Amendment,Part TwoAndrew Hanna, Phoenix School of LawA very special law review project: the writing and editing of an amendment to the United States’Constitution, and preparation of a series of articles addressing and weighing the arguments infavour and against a national Victims Rights amendment. This is part two of a two-partpresentation.211. Understanding and Testing the Theoretical Underpinnings ofTJAn Analysis of Client Realism, Virtue Ethics & Therapeutic JurisprudenceDale Dewhurst, Athabasca University (daled@athabascau.ca)In this paper I assert that at the foundations of Therapeutic Jurisprudence and the ComprehensiveJustice Movement (Comprehensive Law Movement / Non-Adversarial Justice) lies the interplaybetween client realism and the natural law virtue theory of justice. This paper seeks to examinethat relationship in more detail by expanding our understanding of what is involved in clientrealism and examining how it harmonizes with Aristotelian virtue ethics and more contemporaryconceptions of virtue ethics. This analysis follows upon my previous argument that TherapeuticJurisprudence (TJ) can be seen as a normative system on two of three important levels. At Level1 – Legal Practice, TJ asserts normative standards of practice. At Level 2 - Legal Theory, TJdelineates systemic developments that are required to achieve higher order goals of the justicesystem. However, at Level 3 – Legal Order, TJ does not mandate higher order normativestandards, dictate overall purposes of law or define the overarching norms of justice. This is dueto TJ’s respect for client realism: i.e. the idea that justice must be determined from clients’ needsand values, based upon clients’ choices regarding which rights to pursue or waive and whichvectors are best employed to achieve the desired ends.Through a better understanding of clientrealism and contemporary analyses of natural law virtue theories of justice, it is hoped that the507

normative status of TJ at Level 3 will be clarified and TJ’s relationship amongst the variousvectors of the Comprehensive Justice Movement will be more fully understood.Why Be Healthy When You Can Be Normal? How Normative AdversarialismKeeps Us SickNigel Stobbs, Queensland University of Technology (n2.stobbs@qut.edu.au)The adversarial paradigm is grounded in a long-established political and economic liberalworldview. This worldview, heralded by Fukuyama as ‘the end of history’, manifests itself in thelegal system as a normative adversarialism—with an assumption that contests are normal andnecessary models of social organization. The liberal political order, with its almost exclusivefocus on the rights and liberties of the individual as the benchmark for human flourishing, is seenas the most natural for human societies. Within this worldview, some scholars argue that legaladversarialism and a culture of conflict have become seen as not only endemic but asparadigmatic, to the extent that to question them is to attack the very core of modern liberalsociety. In that context, some see therapeutic jurisprudence as ‘profoundly dangerous’ and that itthreatens the rejection of ‘fundamental constitutional principles that have protected us for 200years.’ They are, of course, correct. Therapeutic jurisprudence represents, not just a tinkeringwith the edges of legal practice and procedure, but a mortal threat to adversarialism and theliberal worldview. An adversarialism that has kept civil society sick and adrift on a sea ofjuristic paradigms for centuries. It represents an alternative worldview which threatens theexisting political and social order. This paper explains why this creates great fear for both theadvocates of, and opponents of, therapeutic jurisprudence.The Theoretic Foundation of Therapeutic JurisprudenceHadar Dancig-Rosenberg, Bar Ilan University (Hadar.rosenberg@biu.ac.il)Is Therapeutic Jurisprudence a theory or is it just a practical approach that affects theimplementation of legal action and legal reasoning? One of the arguments of TJ’s critics suggeststhat TJ is not a structured and coherent theoretic framework, but a set of ideas which can beimplemented in various fields of law. Therefore, it is doubtful whether it is correct to call itjurisprudence. My lecture will seek to examine this question, and to convince that TJ is a theory,namely a systematic array of ideas that describe and explain the phenomenon which we call"Law." TJ seeks to add to the classic goals of law another goal - benefit the well being of itsparticipants. Although TJ is not a perfect theory and it has its lacks and difficulties, it provides ageneral framework for thinking, from which to draw deductive reasoning.508

Therapeutic Jurisprudence: An Empirical Analysis of its TheoreticalUnderpinningsSaskia Righarts, University of Otago (saskia.righarts@otago.ac.nz)The application of Therapeutic Jurisprudence (TJ) continues to grow, with an increasing numberof jurisdictions incorporating aspects of this field of law into their legal system (for example,New Zealand is presently trialing the use of specialist drug courts in their criminal jurisdiction).While this field continues to be incorporated into “mainstream law”, the theoreticalunderpinnings of this area remain hotly debated. In fact, some authors claim TJ is not a theory oflaw at all; rather it is a “way of thinking.” The aim of the present research, therefore, is tocritically examine TJ by gathering empirical data to test its theoretical underpinnings. In thepaper, I will outline research I am conducting to test the robustness of theory of TJ. Specifically,I am interviewing 100 individuals about their emotional health and views and interactions in thelegal system (focused on the three main tenants of TJ – the impact of rules, processes and actors)using a mix of qualitative open-ended questions and more scientifically rigorous stress ratingquestionnaires as their case progresses. Further, having obtained this data, I will then examinethe robustness of the theory of TJ. Specifically, I will examine whether it is feasible toincorporate therapeutic outcomes into legal policy, or whether in fact legal tradition or law(common law and statute) restricts its application.Standards in the Problem-Solving CourtsSean Bettinger-Lopez, University of Miami (slopez@law.miami.edu)My presentation will take the form of a “report back” from a Colloquium on Standards in theProblem Solving Courts that will be held on October 5, 2012, at the University of Miami, inhonor of the late Professor Bruce J. Winick. It is expected that the Colloquium will be attendedby approximately 60 academics, judges, practitioners, court professionals, and policy makers,many of whom are leaders in the field, who are engaged with problem-solving courts and theissues surrounding such courts. The Colloquium will focus on both legal and therapeuticstandards and issues that arise when these very different kinds of standards collide, or conflict,with each other. The role of empirical social science research in the development of both legaland therapeutic standards will be explored, as will questions relating to professional ethics. TheColloquium is designed to bridge theory and practice, and to generate a productive dialogue thatmoves beyond the often polarizing perspectives that have characterized much of the debatesurrounding these courts. Emphasis will be placed on the judicial perspective. At theColloquium, a panel of active judges will weigh in on how current standards, or questions andconcerns over absent or inadequate standards, affect or inform the legal, therapeutic, andpractical functioning of their courtrooms. My IALMH presentation will cover the key issuesgenerated by the Colloquium participants, and will highlight any points of progress or impasseobserved.509

212. Using TJ to Improve the Criminal Justice System IToward a Model TJ “Code” of Criminal Processes and Practices: First BabyStepsDavid B. Wexler, University of Puerto Rico (davidbwexler@yahoo.com)Therapeutic jurisprudence has developed using some simple conceptual frameworks, such aslooking at the "law" as a potential therapeutic (or anti-therapeutic agent), and conceiving of the"law" as "legal rules", "legal procedures", and "legal roles"(the behavior and practices of lawyersand judges). There have been important TJ insights about each of the above categories, andsometimes the concepts of rules and procedures have been combined and called the "legallandscape" or the "bottles" of TJ, and the concept of legal roles has been thought of as the"lawyering" or the "liquid" of TJ. Recent interest in the 'new lawyering' has paid special attentionto the liquid. This presentation will take us back to the basics--the legal rules and the legalprocedures. It will demonstrate how the legal landscape itself can promote or inhibit therapeuticresults. And it will then show how the more TJ-friendly legal structures--the better "bottles" onthe landscape--can be filled with the TJ "liquid", with judicial and lawyer practices, so as tocreate maximum therapeutic results. By canvassing the legal landscape for TJ-friendly features,we can in essence create and propose a preliminary model TJ "code" of criminal processes, andby specifying the judicial and lawyer practices called for to take advantage of those processes,we can basically create an accompanying commentary to guide the operation in practice of thecode. This presentation will give only a handful of examples of legal provisions and suggestedpractices, opening up the task of creating a comprehensive code and commentary--a project thatwould obviously take much time and effort from a large number of participants.Civil Commitment, Post- Insanity Acquittal Commitment, and the ExpressiveFunction of PunishmentRobert F. Schopp, University of Nebraska (rschopp1@unl.edu)Therapeutic Jurisprudence pursues a project of research and law reform intended to promote thewell- being of those affected without violating other values embodied in law. Civil commitment,criminal prosecution with the possibility of an insanity acquittal and post- acquittal commitment,and mental health courts provide three alternative forms of police power intervention applied topsychologically impaired individuals who harm or endanger others. A variety of practicalconsiderations, such as the individual’s competence to proceed in the criminal process and theindividual and public interest in providing treatment in a timely manner might support a decisionto apply one of these institutions, rather than the alternatives, to a specific individual in specificcircumstances. In this presentation, I direct attention to the expressive function of criminal510

punishment as an additional source of relevant reasons for selecting the appropriate institution ofpolice power intervention. As presented by Joel Feinberg, criminal punishment differs from civilpenalties or interventions in that it expresses condemnation as reprobation and resentment. Thus,the justification for applying, or withholding, condemnation to a particular individual fulfils animportant role in selecting the most justified form of coercive intervention when that personharms or endangers others. I do not contend that this consideration necessarily controls eachspecific case or provides a formula that can be mechanically applied. In any specific case, acomplex set of considerations can apply. I contend, however, that reflection on the expressivesignificance of the decision to apply one institution, rather than the alternatives, should be animportant component in selecting the most justified institution of police power intervention ineach case.Humanity and Dominance in Police Interviews; Interview Outcome andPsychological Well-BeingUlf Holmberg, Kristianstad University (Ulf.Holmberg@hkr.se)Kent Madsen, Kristianstad UniversityThe amount and the quality of provided information in a police interview can be seen as thelifeblood of a crime investigation where a Therapeutic Jurisprudential approach may act as afacilitating factor. The aim of the present experimental study was to investigate the causalrelationship between the humanitarian respectively the dominant interviewing approach andinterview outcome. Interview outcome means the memory performance and psychological wellbeing.The experiment comprised three phases where 127 subjects between 17 and 70 years oldparticipated. The first phase was an exposure where the subjects acted against each other in pairsin a computer simulation with a scenario symbolizing a crime event. A week after the exposurephase, the subjects were interviewed in a humanitarian or a dominant style symbolizing a policeinterview after a crime event. Sex month later, the subjects were interviewed again in the samemanner, symbolizing the interview in the court proceeding. Before and after every phase, theparticipants completed Antonovsky’s sense of coherence questionnaire and Spielberger’s STAI –the state form. The results from the two interview phases will be discussed in terms ofinterviewing styles, memory performance, that is the amount and quality of providedinformation, and psychological well-being.Therapeutic Jurisprudence and Waiver: Revamping India’s Juvenile JusticeSystemAnkita Gupta, NALSAR University of Law (gupta.ankita.12@gmail.com)511

The Juvenile Justice (Care and Protection) Act, 2000 of India treats a person less than eighteenyears of age as a juvenile, regardless of the kind of offence committed. Overall crime rates,including crime by juveniles, have greatly risen in India and heinous offences such as murderand rape have been committed by children aged as young as ten years. There is no concept ofwaiver proceedings as in the United States of America. There are three kinds of waiverlegislativewaiver, judicial waiver and prosecutorial waiver. These waiver proceedings allowcertain juveniles, based on factors such as the crime committed, their age etc., to be treated asadults and not as juveniles. The power to decide upon the issue lies with the legislation, the judgeor the prosecutor depending on the kind of waiver. The need is to incorporate the policy ofwaiver in the Indian law, keeping in mind the principles of therapeutic jurisprudence. The use oftherapeutic jurisprudence in the juvenile system would require ensuring that the juveniles believethat their point of view is being taken seriously. This is primarily because people valueprocedures in which they are treated with respect and given a say in matters pertaining to them.This results in greater compliance with the decision. A combination of legislative and judicialwaiver that would involve a direct interaction of the judge with the juvenile and hence result ingreater participation of the juvenile in deciding upon his future would thus be the best system.The paper would be dealing with the incorporation of such a system in the Indian law and wouldalso critically analyze guiding decisions such as Kent v. United States.Mitigating Evidence in Juvenile Sentencing and the United States SupremeCourtBeth Caldwell, Thomas Jefferson School of Law (bcaldwell@tjsl.edu)The United States Supreme Court has recognized that juveniles are categorically lessblameworthy than adults. Most recently, in Miller v. Alabama (2012), the Court found thatmandatory life without parole sentences for juveniles violate the Eighth Amendment. Inreaching this conclusion, the opinion draws from death penalty cases that “requir[e] thatsentencing authorities consider the characteristics of a defendant and the details of his offensebefore sentencing him to death.” Miller equates juvenile life without parole cases with the deathpenalty and requires courts to engage in “individualized sentencing decisions” that consider their“age and age-related characteristics and the nature of their crimes.” The new rule seems torequire the presentation of mitigating evidence for juveniles facing the possibility of life withoutparole. This is an important step towards creating a more holistic sentencing framework becausepreviously, mitigating evidence has only been explicitly required in capital cases. Therapeuticjurisprudence recognizes the importance of mitigating evidence in criminal defense advocacy.The Court’s recent opinion is an invitation to develop more comprehensive strategies fordeveloping and presenting mitigating evidence for juveniles facing lengthy prison sentences inadult court. This presentation will explore inter-disciplinary approaches to uncovering andpresenting this type of information with a particular emphasis on juvenile offenders.213. Using TJ to Improve the Criminal Justice System II512

TJ and the Treatment of Combat Veterans Enmeshed in the Criminal JusticeSystem as a Result of Untreated Mental Health ConditionsMajor Evan R. Seamone, U.S. Army, USA (evan.seamone@us.army.mil)NOTE: All perspectives are those of the author in a personal capacity and not the officialposition of any government or military organization.While commentators may debate whether the war in Afghanistan or Vietnam qualifies as“America’s longest war,” the longest wars in any nation are those continually waged by veteranswith untreated service-connected mental illness, most notably Posttraumatic Stress Disorder(PTSD). A 2010 study in the Journal of the Royal Society of Medicine revealed that the stigmaspreventing combat veterans from seeking help for their symptoms are common in the militariesof five countries, highlighting an immediate concern of global dimension. For many of these“wounded warriors” who fail to seek help, PTSD often materializes in the loss of impulsecontrol, self-medication, and interpersonal violence. Because such behaviour is, at once,symptomatic and “criminal,” for many, interface with the criminal justice system (either inmilitary or civilian settings) is necessarily part of the process of re-integrating from a combat“survival” mode.The U.S. Department of Veterans Affairs has coined the phrase “justice-involved veteran” todescribe this offender with very special needs. This presentation: (1) explores the reality of the“justice-involved” veteran, with special emphasis on the emerging rehabilitative ethic that hasenabled formalized treatment alternatives in the United States and the United Kingdom; (2)suggests that all nations should consider the nature of their combat veterans’ involvement in thecriminal justice system; and (3) emphasizes the active duty armed forces’ ability to incorporateTJ in its disciplinary structure closer to the origin of these mental conditions—for the benefit ofall members of society.Practical application of Therapeutic Jurisprudence in SaskatchewanMansfield Mela, University of Saskatchewan (mansfieldmela@gmail.com)In Canada, the USA, Australia and a few other developed countries, the concept of specializedcourts; problem solving courts and mental health courts, have grown in practice over the pastdecade or so. This stems from the realization that the existing system of sentencing andimprisonment has not been effective in promoting community safety. Several provinces inCanada have established specialized courts. In Saskatoon, Canada, a 2011 conference of theprovincial Judges focused on Mental Health Courts, stimulated discussion on the idea of havingone in Saskatoon. An interprofessional Advisory committee has also existed for about three yearswith the main aim of discussing the practicality of having a specialized court. Following asystematic review of the current literature on specialized courts, a student was assigned to thecourt room to review the relevant cases and interview respective Judges about their experiences513

and desires for meeting the needs of those accused coming before them with mental illness. This‘needs assessment’ was instrumental in gathering the right stakeholders for planning purposes.The experiences of an existing Drug Treatment Court in the adjoining city of Regina in the sameprovince, the Forensic Center in the University of Saskatchewan as well as the establishedForensic Psychiatry program all gave impetus to the movement towards creating and operating amental health court. We conducted a systematic review of the existing evidence on therapeuticjurisprudence methods with a view to applying the evidence based practices in Saskatchewan,Canada. The steps to applying the evidence, obstacles and challenges will be discussed in thesessions. This involves youth, adult and system factors of success, involvement of stakeholdersand involvement of policy makers. The key elements in service development cut across mostcomponents of the Criminal justice system and add benefits to the socioeconomic aspect ofjustice administration.Systematic Literature Review of Topics on Therapeutic JurisprudenceGlen Luther, University of Saskatchewan (glen.luther@usask.ca)The existing system of sentencing and imprisonment has not been effective in promotingcommunity safety. As such, model initiatives, from the 1990s, introduced different approachesfor dealing with offenders within the Criminal Justice system. The sum total of using the Law asa treatment approach for the whole person is embodied in the principles of therapeuticjurisprudence. The current level of evidence is equivocal as to the effectiveness of the methods inoutcomes. This may be as a result of the varying goals and outcomes with varying degrees ofstudy participants. Such variations defy direct comparison. Having secured funding from theForensic Center of the University of Saskatchewan, we conducted a systematic review of theexisting evidence on therapeutic jurisprudence methods and outcomes. The process of literaturesearch included the legal and medical topics contained in major search engines and governmentas well as non peer reviewed publications. The findings of the different types of specializedcourts, the changing roles of the protagonists of the Courts and the recidivism outcome from thevarious aspects of the criminal justice system will be presented in the session. The implicationsof the loss of the ‘impartial’ Judge and the ‘zealous’ defence lawyer will be discussed andapproaches will be suggested to address the criticisms levied against the problem solving courts.The paper will describe the results and implications of the systematic search and servicedevelopment and delivery.Clinical Management of Justice Referred Drug Users: Influence ofProhibitionist Practices on HealthManuela Leal, Bahiana School of Medicine and Public Health (manuela.telles@hotmail.com)Esdras Moreira, Bahiana School of Medicine and Public Health (esdrascabus@terra.com.br)514

Since the law 11.343/06, Brazil has reduced the penalty of drug users, who are now submitted toalternative penalties, such as psychoeducative interventions. This study, co-authored with EsdrasMoreira, analyses the impact of a local new group intervention, called “Grupo de Justiça”(Justice Group), on adhesion to treatment among substance users referred by justice to anaddiction center in Salvador, Brazil. The Justice Group works with 10 to 15 individuals todiscuss issues related to drug use in four weekly sessions. In observing this group, the authorstried to identify sociodemographic profile, social behavior, exposition to police violence,motivational speeches to chance and stigma perception. The coordinator of the intervention wasinterviewed. Clinical files data was collected and added to the qualitative material. Contrary tothe idea of the justice referral as a window of opportunity to treatment, it was observed to be anenhancement in resistance to change by the subjects attending the Justice Group because of theviolence of the police, the coercive nature of the approach, and related stigma. Considering thelength of the intervention, it was impossible to deal with such resistance. On the other hand, thediscrepancy between the justice view of an ideal treatment (abstinence) and the nihilism of thehealth professional about the positive results of a coercive intervention, made both lose theopportunity to treat such population. Besides, in an unequal society, such intervention tends tocatch the most vulnerable ones and to increase social exclusion and suffering.The Modus Operandi of the Liberty Tribunal (Italy)Sara Quiriconi, Tonucci & Partners, Florence, Italy (saraquiriconi@yahoo.it)This paper focuses on the so called “Tribunale della Libertà” (Liberty Tribunal) which hasintroduced in Italy a particular system of “reconsideration” for those judical measures limitingthe personal liberty of the indictee. The Liberty Tribunal, primarily thought as a centralizedcontrol body, has reached a remarkable level of development and, moreover, it has constitutedone the most efficient court able to pass a judgment on the legal title of the committal, in respectof the art. 5 of the European Convention of Human Rights. The incidental proceedings of thisTribunal is a complementary and collateral diversion from the traditional court, which remainscompetent for the principal proceedings. The composition, the working and, in general, themodus operandi of the Liberty Tribunal permit us to consider it one of the most outstandingexamples of TJ principles.214. The Well-Being of Clients and VictimsChild Participation in Family Disputes and the Well-Being of ChildrenTamar Morag, Striks Law School (tamar.morag@gmail.com)The right of children to participate in adversarial legal proceedings has gained increasingrecognition in recent years. This trend, rooted in court verdicts and state legislation, has led to a515

ise in the scope of child participation in family courts proceedings in many countries. Yetpractice in this area varies between various courts due to lack of clear judicial guidelines orlegislation. While child participation in adversarial proceedings has increased significantly, theparticipation of children in non-adversarial procedures for managing and settling family disputesis still negligible, and suggestions to advance their participation in such proceedings have metwith significant opposition. The Lecture will discuss empirical data relating to the impact ofchild participation in adversarial and non -adversarial proceedings relating to family disputes onthe emotional life and psychological well-being of children. Special emphasis will be put on theempirical findings of an evaluation study relating to an Israeli interdisciplinary pilot project onchild participation in family courts. Discussion of the research data will relate to issues such asthe effect of participation in reducing stress and allowing children to regain a sense of controlover their lives as well as the way children perceive the experience of participation. Primaryimplications of the of the empirical data regarding the need to promote programs aimed atfacilitating child participation in both adversarial and non- adversarial proceedings relating tofamily disputes will be discussed.The Use of TJ to Promote Child Participation in Processes Involving FamilyDisputesKarni Perlman, Bar-Ilan University (Karnip1@netvision.net.il)The management of family disputes in Western countries is currently undertaken in a variety ofways, ranging from adversarial proceedings in the court to cooperative proceedings outside it,such as mediation and collaborative divorce. Accumulated experience indicates that children’sparticipation in court proceedings improves their mental condition and contributes tostrengthening family ties. Nevertheless, children’s participation in legal procedures takes placeonly to a limited extent and, for the most part, under a discourse of rights. This lecture willpropose making use of the principles and insights of Therapeutic Jurisprudence in order toadvance the participation of children in family disputes. It will argue that TherapeuticJurisprudence can provide a conceptual framework as well as practical tools for implementingqualitative and efficient programs of child participation in court proceedings. Using TherapeuticJurisprudence principles and methods can emphasize the advantages and therapeutic benefits ofthe concept of child’s participation, thereby strengthening its application in both adversarial andnon-adversarial proceedings, including mediation. It can address concerns and dilemmas thatinhibit further development of appropriate programs for this purpose. For example, in regard toFamily Courts, there is genuine concern about the ability of judges to conduct a proper childhearingprocess. Adopting the Therapeutic Judge model and therapeutic judging methods thatare used in Problem-Solving Courts can reduce this concern.What Do We Know about Compensation Being ‘Bad For Health’? Taking Stockof the Available Empirical Evidence516

Nieke Elbers, VU University (n.elbers@vu.nl)Quite some empirical studies have investigated the effect of being involved in compensationprocesses on well-being and recovery of claimants. Some studies concluded that compensationprocesses did not have an effect on health. The majority of studies, however, found that injuredpeople who are involved in a compensation claim process recover less well, and have reducedphysical and mental well-being compared to people with similar injuries who are not involved incompensation. Studies often give two explanations for the compensation effect: the first is thatclaimants may unconsciously perpetuate illness behavior for as long as the compensation processlasts (secondary gain). This theory may imply that claimants would recover as soon as theyreceive their compensation. Some studies indeed found that settlement of the claim improvedhealth compared to pending claims. Other studies, however, did not show a relation betweenclaim settlement and mental health or recovery. The second explanation for the fact thatclaimants recover less well is that they may experience renewed victimization because of thestressful elements of the compensation process (secondary victimization). This paper discussesthe available evidence for the anti-therapeutic effect of compensation processes, attempts toidentify its strengths and weaknesses, and makes suggestions for future research.Minimising Re-Traumatisation: ‘Trauma-Informed’ Resolution ofCompensation Claims by Survivors of Sexual Abuse Perpetrated by ClergyNicola Ellis, Legal Practitioner, Sydney, Australia (nicola.ellis@optusnet.com.au)In 2007, the Court of Appeal in New South Wales (NSW, Australia) held that for survivors of‘historical’ sexual abuse by catholic priests, there is ‘no one to sue’ (Trustees of the RomanCatholic Church v Ellis [2007] NSWCA 117). There being no legal entity accountable for abuseby priests is due to the particular legislative constitution of the Catholic Church in NSW (RomanCatholic Church Trust Property Act 1936). The Catholic Church in Australia has established acomplaint process called ‘Towards Healing’. However, anecdotal reports indicate that fewclaimants have a positive experience of that process; most report it was “re-abusive… almostworse than the original abuse… anything but ‘healing.’” The plaintiff in the litigation thatculminated in the 2007 Court of Appeal decision was John Ellis, a legal practitioner. NicolaEllis, also a legal practitioner, is his wife and together they travelled the ‘awfulness’ of theprotracted litigation and church processes. In 2008, a group of men abused by a priestapproached John and Nicola and asked for help. Since that time, they have successfully resolvedcompensation claims for approximately 200 survivors of sexual abuse by clergy throughoutAustralia (despite the ‘Ellis defence’). This paper describes the resolution process emerging fromJohn and Nicola’s lived experience: a ‘trauma-informed’, TJ process which minimises risks ofre-traumatisation and aspires to ensure clients are fully heard, respected, consulted: afforded‘voice and choice’. This paper will describe this process through the voices of John, Nicola,survivors, and church representatives.517

The Needs and Concerns of Victims of Crime in Ireland: Justice asAccommodationShane Kilcommins, University College Cork (s.kilcommins@ucc.ie)If the “paradigm of prosecution” in the seventeenth and eighteenth centuries was the victims ofcrime, the story of criminal justice and criminal for much of the 19th and 20th centuries mightbest be told as the rise of institutionalized justice. This new institutional pattern quicklytranscended the victim’s interaction with the crime conflict. Within such a depersonalized,bureaucratized system, the victim’s space for negotiation and participation in pursuing his or herown interests was dismantled. From being a cornerstone in the regulation of relations concerningthe conflict, victims increasingly found their individual experiences (such a vital currency in thepursuit of justice in the pre-modern era) assimilated into general group will – the public interest.This marked the shift from victim-mediated justice to bureaucratized State/accused mediatedjustice. But State/accused mediated justice is now beginning to creak and strain, however, asnewly “discovered” competing narratives emerged. Justice is thus partially being reconstructedin Ireland as it demonstrates, among other things, an increased sensitivity to the influx of newissues and value orientations and a willingness to accommodate a range of standpoints ratherthan engage in debilitating stereotyping. The purpose of this paper is to discuss the increasedaccommodation of victims employing therapeutic jurisprudence as a throughline.215. The Well-Being of LawyersLawyer-Client Relationships and WellbeingPaola Cecchi Dimeglio, Harvard Law School (pcecchidimeglio@law.harvard.edu)Over the last decade there has been increasing attention paid to the relationship between lawyerclientrelationships and wellbeing. A growing body of literature demonstrates that lawyers as agroup score lower on wellbeing questionnaires than other professionals. Other studies on healthand wellbeing in the workplace demonstrate a positive correlation between the level ofunhappiness of lawyers and their client’s satisfaction and vice-versa. This study investigates therelationship between lawyer’s happiness levels and client’s satisfaction levels.To draw lessons for the legal profession, this paper compares empirical findings on wellbeing inthe lawyer-client relationship with findings on client-lawyer experiences.The Effects of Collaborative Lawyering on Lawyers’ WellbeingPeter Kamminga, VU University (y.p.kamminga@vu.nl)518

In identifying what may increase lawyer and client levels of happiness, one approach isidentifying the kinds of legal practices that are most likely to contribute to levels of satisfaction.The field of Alternative Dispute Resolution and especially the practice of Collaborative Law isan example of a practice that seems to lead to higher clients’ as well as lawyers’ satisfaction.Both actors seem to be content with the process and the outcomes. This paper studies thedrawbacks and benefits of collaborative law and its contribution to wellbeing of lawyers.What’s Spirituality Got to Do With It?Marjorie A. Silver, Touro College, Jacob B. Fuchsberg Law Center (msilver@tourolaw.edu)Therapeutic Jurisprudence is an inquiry into the therapeutic and anti-therapeutic consequences oflaws, legal actors and legal processes. Its genesis in mental health law reveals no spiritualunderpinnings, and none are required for lawyers and other professionals who seek to maximizetherapeutic outcomes for their clients. Yet TJ has special resonance for many of us who areinspired by traditional religious belief systems and other spiritual practices and callings.This presentation will explore the relationship between TJ and spiritually-inspired lawyers. Itwill also demonstrate how the Project for Integrating Spirituality, Law and Politics (PISLAP), onthe Board of which this speaker serves, and which includes activists in many facets of theComprehensive Law Movement, is serving to advance the development of legal education, legalpractices and law to enhance therapeutic outcomes for all stakeholders, in furtherance of whatMartin Luther King, Jr. called “the Beloved Community.”Exploring Lawyer-Client Interaction in Personal Injury Cases: A QualitativeStudy of Positive Lawyer CharacteristicsKiliaan van Wees, VU University (k.a.p.c.van.wees@vu.nl)Personal injury (PI) victims who are involved in a claims settlement process have a worserecovery than those involved in a compensation process. One predictor for worse recovery islawyer engagement. The lawyer-client relationship has been discussed from a law- andpsychology perspective in procedural justice (PJ) and therapeutic jurisprudence (TJ) literature.However, the victim’s perspective has not yet been fully explored. This paper presents the resultsof a modest but nonetheless informative qualitative study: twenty-one traffic accident victimswere interviewed about their lawyer. From these interviews, five desirable lawyer characteristicsare derived: communication, empathy, decisiveness, independence, and expertise.Communication and empathy correspond with aspects discussed in TJ and PJ, whereasdecisiveness, independence, and expertise have not been addressed in literature yet.519

Happiness—or Else: Revising Our Expectations for Law Students and LawyersCorie Rosen, Arizona State University (corie.rosen@asu.edu)In The Myth of Sisyphus, Camus famously wrote, “There is but one truly serious philosophicalproblem, and that is suicide. Judging whether life is or is not worth living amounts to thefundamental question of philosophy.”Lawyers and law students, a notoriously depressive population with unusually high rates ofsuicide and related ills, have provided fertile soil for some of the most recent depressionresearch. Dr. Martin Seligman, one of the people credited with the invention of positivepsychology, studied depressive thinking in law students at the University of Virginia. Theresulting article, “Why Lawyers are Unhappy,” established, albeit inadvertently, the foundationsof an increasingly widely-held view that, for some, depression is perhaps a necessary ill and mayeven be crucial to the success of those who work in judgment-driven fields like law. This articlewill explore the findings of the University of Virginia study and its impact on the current popularconception of lawyer and law-student psychology.This presentation will explore sources of depression in lawyers and law students and, usingempirical and anecdotal data, will argue that students manifesting defensive pessimism may notnecessarily be at risk for depression, though they may not manifest "happiness" or "optimism" aspsychology currently defines those concepts.French Language Sessions216. La gestion de la perception du risque de violence enpsychiatrie: des alternatives à l’atteinte aux droits despersonnesUn centre d’étude : dans quel but ?Nathalie Baba, Université de Montréal, Montréal, Canada (nathalie_baba@hotmail.com)T.B.E.Pertinence d’une base de données commune pour mieux interpréter les tauxd’isolement et de contention des Instituts de santé mentale du Québec520

Caroline Larue, Université de Montréal, Centre de recherche Fernand-Seguin, Montréal,Canada (caroline.larue@umontreal.ca)T.B.E.Implantation et évaluation du retour post-isolement en santé mentale : un levierpour modifier les pratiques cliniquesMarie-Hélène Goulet, Université de Montréal, Montréal, Canada (mariehelene.goulet@umontreal.ca)T.B.E.Ordonnance de traitement au QuébecAlexandre Dumais, Institut Philippe-Pinel de Montréal, Centre de recherche Fernand-Seguin,Montréal, Canada (adumais.hlhl@ssss.gouv.qc.ca)T.B.E.Perception des acteurs clés du système de santé sur la gestion de la violence parles proches aidantsCaroline Larue, Université de Montréal, Centre de recherche Fernand-Seguin, Montréal,Canada (caroline.larue@umontreal.ca)T.B.E.217. Les problèmes de santé mentale en milieu carcéralTroubles mentaux en milieu carcéral 1988-2010G. Côté, Université du Québec à Trois-Rivières & Institut Philippe-Pinel de Montréal, Canada(gilles.cote@uqtr.ca)A.G. Crocker, Université McGill & Institut universitaire de santé mentale Douglas, Canada(anne.crocker@douglas.mcgill)521

M. Daigle, Université du Québec à Trois-Rivières & Institut Philippe-Pinel de Montréal &Centre de recherche et d’intervention sur le suicide et l’euthanasie, Canada(marc.daigle@uqtr.ca)J. Toupin, Université de Sherbrooke & Institut Philippe-Pinel de Montréal, Canada(jean.toupin@usherbrooke.ca)G. Gobbi, Université McGill, CanadaG. Turecki, Université McGill & Institut Philippe-Pinel de Montréal, CanadaT.B.E.Évaluation de la déficience intellectuelle en milieu carcéral fédéral Canadien :une enquête épidémiologiqueA.G. Crocker, Université McGill & Institut universitaire de santé mentale Douglas, Canada(anne.crocker@douglas.mcgill)G. Côté, Université du Québec à Trois-Rivières & Institut Philippe-Pinel de Montréal, Canada(gilles.cote@uqtr.ca)D. Farthing, Université McGill & Institut universitaire de santé mentale Douglas, CanadaJ. Toupin, Université de Sherbrooke & Institut Philippe-Pinel de Montréal, Canada(jean.toupin@usherbrooke.ca)M. Daigle, Université du Québec à Trois-Rivières & Institut Philippe-Pinel de Montréal &Centre de recherche et d’intervention sur le suicide et l’euthanasie, Canada(marc.daigle@uqtr.ca)T.B.E.Trouble déficitaire de l’attention/hyperactivité, trouble de personnalitéantisociale et adaptation sociale chez des détenus adultesJ. Toupin, Université de Sherbrooke & Institut Philippe-Pinel de Montréal, Canada(jean.toupin@usherbrooke.ca)G. Côté, Université du Québec à Trois-Rivières & Institut Philippe-Pinel de Montréal, Canada(gilles.cote@uqtr.ca)A.G. Crocker, Université McGill & Institut universitaire de santé mentale Douglas, Canada(anne.crocker@douglas.mcgill)522

M. Daigle, Université du Québec à Trois-Rivières & Institut Philippe-Pinel de Montréal,Canada (marc.daigle@uqtr.ca)T.B.E.Fréquence et lieux d’apparition des comportements suicidaires chez lesdélinquantsM. Daigle, Université du Québec à Trois-Rivières & Institut Philippe-Pinel de Montréal &Centre de recherche et d’intervention sur le suicide et l’euthanasie, Canada(marc.daigle@uqtr.ca)G. Côté, Université du Québec à Trois-Rivières & Institut Philippe-Pinel de Montréal, Canada(gilles.cote@uqtr.ca)A.G. Crocker, Université McGill & Institut universitaire de santé mentale Douglas, Canada(anne.crocker@douglas.mcgill)C. Wright, Université du Québec à Trois-Rivières & Institut Philippe-Pinel de Montréal &Centre de recherche et d’intervention sur le suicide et l’euthanasie, CanadaM. Brouillard, Université du Québec à Trois-Rivières & Institut Philippe-Pinel de Montréal &Centre de recherche et d’intervention sur le suicide et l’euthanasie, CanadaT.B.E.Les hormones stéroïdiennes et le comportement violentA. Dumais, Université McGill & Institut Philippe-Pinel de Montréal, Canada(alexandre.dumais@hotmail.com)S. Potvin, Université de MontréalG. Gobbi, Université McGillG. Turecki, Université McGill & Institut universitaire de santé mentale Douglas, CanadaT.B.E.Spanish Language Sessions523

218. Bioética y Toma de Decisiones en la Práctica MédicaAsistencialEl principio de Autonomía del Paciente en la Práctica MédicaIsabel Ballesta Rodríguez, Centro de Salud Federico del Castillo, Jaén, España(isabelballesta@gmail.com)La bioética, o ética de la vida atendiendo a sus raíces etimológicas, surge como un diálogonecesario entre las ciencias de la vida y los valores humanos. Se ocupa del estudio sistemático dela conducta humana, en el ámbito de las ciencias de la vida y de la salud, analizado a la luz de losvalores y los principios morales. Se consolidó, siguiendo a Altisent en torno a tres factoresdecisivos: 1- los avances científico-técnicos de la medicina, 2-La conciencia y desarrollo de losderechos del paciente (concepto de Autonomía) y 3- la organización sanitaria con sus nuevosmodelos sociales (concepto de Justicia Social). Se concibe la bioética como “una ayuda para latoma de decisiones en los dilemas éticos que se plantean en medicina y biología; y se entiendepor dilema ético, la situación que se produce cuando los principios éticos entran en conflicto”. Elprincipio de Autonomía afirma la capacidad que la persona tiene sobre su autodeterminación. Seexpresa como el respeto a la capacidad de decisión de los pacientes, y propone tener en cuentasus preferencias en aquellas cuestiones de salud relativas a su persona. Se define como personaautónoma aquella que tiene capacidad para obrar, facultad para enjuiciar razonablemente elalcance y significado de sus actuaciones y responder por sus consecuencias. Significa que en larelación sanitario-paciente, la prioridad en la toma de decisiones sobre la enfermedad, es la delpaciente, cuando se trate de decidir lo que es conveniente para él. Significa dar valor y considerarlas opiniones y elecciones de las personas y abstenerse de obstaculizar sus acciones, a menos queéstas produzcan un claro perjuicio a otros.Adaptación y Validación al Español del Cuestionario “Aid to CapacityEvaluation”, para la Valoración de la Competencia del Paciente en la Toma deDecisiones MédicasSandra Moraleda Barba, Centro Salud de La Guardia, Jaén, Spain (smoraleda71@gmail.com)El consentimiento informado es el modelo de relación entre personas en el marco de procesos detoma de decisiones donde participan profesionales. Se trata de la explicación a un pacienteatento y mentalmente competente, de la naturaleza de su enfermedad, efectos de la misma,riesgos y beneficios de los procedimientos diagnósticos y terapéuticos, para solicitar suaprobación a ser sometido a cualquiera de ellos. La competencia es la capacidad de la personapara comprender la situación a la que se enfrenta, los valores que están en juego, los cursos deacciones posibles y las consecuencias previsibles para, a continuación, tomar, expresar ydefender una decisión que sea coherente con su propia escala de valores . El requisito de524

competencia o capacidad es uno de los elementos clave de un proceso de consentimientoinformado. La Ley catalana sobre los derechos de información establece, de forma explícita, eldeber del profesional de valorar la capacidad del paciente pero no da orientación alguna sobre lamanera adecuada de hacer esto, y tampoco sobre el momento y forma en que su obligaciónexcede sus atribuciones, y deben intervenir por ejemplo los jueces. Se considera que la mejorherramienta disponible, en la asistencia médica, para la valoración de la capacidad de tomardecisiones medicas es el cuestionario validado en otros países llamado Aid to capacity evaluation(ACE). Este proyecto tiene como objetivo adaptarlo y validarlo al español, a través de un estudioobservacional transversal. El ámbito será el hospital, centro de salud, domicilio y residencias.Participación de los Profesionales de Salud Mental en la Determinación deCapacidad y Competencia para Consentir LibrementeFrancisco Torres González, Universidad de Granada (ftorres@ugr.es)Drane publicó, en 1985, afirmó que la competencia de una persona no es un valor genérico niestable, y que dependía en esencia del tipo de decisión que deba tomar, y sobre todo de susconsecuencias. En función de ellas, las demandas funcionales (las aptitudes o habilidadespsicológicas necesarias) cambian, y por tanto los requerimientos que exigimos para aceptar lacompetencia del paciente. Drane clasifica las distintas tipologías de decisiones en el marcosanitario en: decisiones difíciles, fáciles y de mediana dificultad. A éste modelo se le denominó“escala móvil de la competencia”. Más tarde, en 1988, Appelbaum y Grisso publicaron suscriterios de competencia: 1. La habilidad o capacidad de expresar una elección; 2. La capacidadde entender la información relevante para la toma de la decisión; 3. La capacidad de valorar elsignificado de esa información en relación con la propia situación, especialmente en lo referentea la propia enfermedad y el significado personal (valores) de las probables consecuencias de lasopciones de tratamiento; 4. La capacidad de razonar, manejando la información relevante, paradesarrollar un proceso lógico de adecuada consideración de las opciones terapéuticas. Desde estalógica, la adecuada comprensión de la información por parte del paciente se convierte en unacondición muy relevante del proceso. No basta con emitir el mensaje, también se debe procurarsu adecuada recepción. El requisito de competencia o capacidad es uno de los elementos clave deun proceso de consentimiento informado. Sólo si el paciente es competente podrá tomardecisiones autónomas sobre su salud. Sin embargo éste es, con toda seguridad, el elemento delconsentimiento informado que plantea mayores dificultades. La evaluación y determinación de lacompetencia de un paciente es una tarea que entraña una enorme responsabilidad ética y jurídica.Los profesionales sanitarios no tienen potestad para establecer por su cuenta la capacidad deobrar legal de un paciente. Éstas son cuestiones que vienen dadas por el ordenamiento jurídico.La modificación más importante de dicha capacidad de obrar, la incapacitación, es -comoestablece claramente el artículo 199 del Código Civil- una potestad y una responsabilidadexclusiva de los jueces. Los profesionales sanitarios no quedamos al margen y somos requeridoscomo peritos expertos para medir y evaluar la Capacidad. Abordaremos la aportación desde loscampos de la medicina de familia, psiquiatría y neurología y las distintas herramientas y mediosde mayor aceptación y uso internacional.525

Tratamientos no consentidos hospitalarios y ambulatorios: Aspectos ético-legalesLuis-Fernando Barrios, Universidad de Alicante (luisfbarrios@ua.es)La normativa española sobre tratamientos sanitarios involuntarios es muy escasa. Se aprecia,sobre todo la inexistencia de criterios para la imposición de los mismos. Parece recomendablepor ello la aplicación de los estándares internacionales, especialmente los contenidos en losprincipales instrumentos internacionales de referencia de Naciones Unidas y del Consejo deEuropa. Igual déficit es constatable en relación con los internamientos involuntarios por razón detrastorno psíquico. A dicho déficit se añade el inadecuado rango normativo para la regulación delos mismos, lo cual ha llevado a un importante pronunciamiento del Tribunal Constitucional. Sepropone la implantación de unos criterios básicos ético-legales para la aplicación de tratamientosinvoluntarios y de otros medios coercitivos en el ámbito de la salud mental. Por su parte, laimplantación en España de los denominados “tratamientos ambulatorios involuntarios” (TAI) hagenerado un importante debate en el ámbito social, judicial y parlamentario. Aunque se hanrechazado hasta ahora varias iniciativas legislativas, periódicamente aparecen nuevas propuestasal respecto. Se defiende la innecesaridad de regulación de los TAI, básicamente por no constituir,de hecho, la alternativa menos restrictiva, aunque también por otras razones.219. Chile: Innovaciones legislativas, mobbing político, y permisosmédicos psiquiátricos: ética institucional, confidencialidad,calidad de las prestaciones en saludReposo Laboral por Enfermedad Mental en ChileVilma Ortiz, Médico Psiquiatra CETEP (dravilma@gmail.com)Juan Pablo Osorio, Universidad de ChileDentro del Derecho laboral, los trabajadores chilenos cotizan el 7% de su salario en algúnsistema de salud: Instituto de Salud Previsional (ISAPRE) o en el Fondo Nacional de Salud(FONASA) que actúan como aseguradoras de Salud, y tienen derecho a permanecer ausentes desu trabajo, por presentar alguna enfermedad que requiere de este reposo, previa certificación deun médico-cirujano, odontólogo o matrona. Durante esa ausencia mantienen sus ingresos que sonlas instituciones antes mencionadas. Para la administración de este seguro se requiere, en el casode que la causa del reposo laboral sea una enfermedad mental, una evaluación (peritaje) deltrabajador por un médico psiquiatra, quien emite un informe sobre el diagnóstico, tratamiento,pronóstico de la enfermedad y reinserción laboral. En el presente trabajo se realiza una revisióny análisis descriptivo de los informes periciales realizados en las entrevistas psiquiátricas a526

personas que cursan con reposo laboral debido a una enfermedad mental, entre los años 2010 y2012 en Chile.Acoso Laboral, seguimiento de casos asociado a cambio de gobierno: MobbingpolíticoVerónica G. Wall Ziegler, Universidad Austral de Chile (vwallz@yahoo.com.ar)Mauricio Jeldres Vargas, Servicio Médico Legal, Osorno, Chile (maujeva@yahoo.com)Se presenta el seguimiento de directivos y profesionales calificados, afectados, desde el 2010 ensu estabilidad laboral al ocurrir el cambio de gobierno, ya que se les vinculó políticamente algobierno anterior. Los afectados, desempeñaban funciones de estado, no adscritas a los partidospolíticos. Los evaluados tienen como factor común ser de demostrada competencia laboral ylealtad institucional, que entregan su inteligencia, creatividad, integridad, talento y dedicación, albien superior del Servicio Publico. Con la llegada de nuevas autoridades a las Instituciones delEstado, se les desvinculó con hostilidad y humillación, fueron denostados en su integridad moral;denigrados y marginados de sus cargos, con un afán antidemocrático y fundacionalista. Con elpropósito de demostrar lo pernicioso de estas prácticas, tanto para las instituciones y sobre todopara las personas, presentamos las características clínicas y socio laborales, antes y dos añosdespués de estos afectados, aplicando un instrumento de evaluación cualitativa en amboscontroles de salud mentalLa nueva Ley chilena sobre Derechos y Deberes de los Pacientes. Progresos ycontroversiaEnrique Sepúlveda Marshall, Universidad de Chile (sepu49@yahoo.com)Mauricio Jeldres Vargas, Servicio Médico Legal, Osorno, Chile (maujeva@yahoo.com)El Gobierno y el Parlamento chilenos han aprobado recientemente una nueva ley sobre Derechosy Deberes de los pacientes en general, y de los pacientes mentales en particular. Esta nueva leyrefuerza aspectos relativos al consentimiento informado, pero entreabre espacios para laliberación de información confidencial a los prestadores institucionales de salud, privados opúblicos, al mismo tiempo que descarga en la responsabilidad individual del médico suseventuales quiebres o incumplimiento. No se establecen los grados y tipos de responsabilidadinstitucional en la formulación de guías de procedimiento, y la constitución de comités de éticaen los diferentes organismos prestadores, no se especifica. Tampoco se define la participación yresponsabilidad de las sociedades científicas, del colegio médico, o de las escuelas de medicina.Aunque esta ley entraría en vigencia en Octubre 2012, ha sido objetada en medios legalesvinculados a la defensa de médicos. Esta presentación pretende resumir los aspectos positivos ylos lados controversiales de este nuevo cuerpo legal527

Aspectos Controversiales de la Nueva Ley de Licencias Médicas en ChileMauricio Jeldres Vargas, Servicio Médico Legal, Osorno, Chile (maujeva@yahoo.com)Enrique Sepúlveda Marshall, Universidad de Chile (sepu49@yahoo.com)El Gobierno y el Parlamento chilenos han aprobado recientemente un nuevo cuerpo legalorientado a evitar y sancionar la extensión fraudulenta de licencias médicas. Este nuevo cuerpolegal ha sido cuestionado por el Colegio Médico y algunos integrantes de su Consejo General,objetando su carácter punitivo, que incluye severas multas económicas a los médicos que seansorprendidos extendiendo licencias (ausencia a trabajar temporalmente por razones de salud) demanera fraudulenta, aunque sin establecer con claridad organismos, condiciones, y requisitos deespecialización deberán tener los contralores encargados de detectar y fundamentar estos ilícitos.Por más necesario que sea evitar la extensión fraudulenta de licencias con los costos que estasconllevan, los mecanismos a través de los cuales se pretende este resultado, no parecenconsiderar el conjunto de actores, su calificación profesional, o las instancias superiores deapelación o arbitraje, ni considera responsabilidades más allá del médico individualmenteconsiderado. Este trabajo pretende contribuir a ampliar la perspectiva con que se ha consideradoel problema.Las posibles injusticias que sufren los trabajadores ante la Justicia del Trabajoen los peritajes de casos de depresionesJúlio César Fontana-Rosa, University of Sao Paulo (fontanarosa@usp.br)Márcia Vieira da MottaJúlia Tasso Fontana-RosaHay singularidades que contribuyen a una evaluación no satisfactoria. Entonces tenemos elriesgo de la injusticia. La depresión no es algo que necesariamente salta a los ojos (se haceevidente). Los trastornos depresivos no son siempre fácilmente visibles. A menudo seconfunden con un mal momento con algo que SE PUEDE CAMBIAR SI la PERSONA SEESFUERZA, ETC. Muchas veces hay diferencias en el diagnóstico de los sub tipos. Losperitajes son realizados en espacio de tiempo corto (no siempre suficiente para una correctaevaluación). En un rango de tiempo que suele ser de pocos minutos, el evaluador tiene quedefinir: 1 – si hay o no trastorno, 2 – si hay trastorno, lo mismo puede traer incapacidad para lasdemandas 3 – si hay relaciones con el trabajo 4 – si es permanente o puede tener mejor resultadocon los tratamientos. Las depresiones, así como en la mayoría de los trastornos mentales notiene un factor etiológico establecido: luego: problemas con el nexo de causalidad o influencia,debido a falta de pruebas concretas como las que existen para un hueso roto: rx; o528

diabetes; glicemia en sangre, etc. A lo anterior debe agregarse que muchos peritajes sonrealizados por peritos no conocedores del tema (psiquiatría).220. Chile y Argentina: Indicadores de Abuso Sexual, Parricidio-Filicidio, y aspectos deontológicos de nuevas leyes regulatorias,derechos del estado vs. del pacientePerfil socio-demográficas de pacientes abusados sexualmente, que consultan porpatología psiquiatrica general en una consulta privada, Osorno, Chile, Abril2005 a Abril 2013Mauricio Jeldres Vargas, Servicio Médico Legal, Osorno, Chile (maujeva@yahoo.com)Verónica G. Wall Ziegler, Universidad Austral de Chile (vwallz@yahoo.com.ar)El abuso sexual constituye uno de los temas dolorosos de los pacientes y que deja su marca, conuna serie de cuadros psiquiátricos; en Chile se desconoce la magnitud del problema, porque nohay estudios de prevalencia ni de incidencia, sólo se dispone de investigaciones parciales. ElServicio Nacional de Menores (SENAME), en un corte transversal efectuado en el año 2001,encontró que de los 57.957 niños que tenía bajo su protección, 45,6% eran víctimas de maltrato yabuso sexual. De los pacientes consultantes por cuadros de Psiquiatría General, en una consultaprivada, se pesquisa un 26%, que refieren haber sido abusados sexualmente, de un universo de6000 pacientes. El objetivo es describir el perfil de las personas abusadas sexualmente, susvariables socio-demográficas, antecedentes clínicos y familiares. Se describe el motivo deconsulta, síntomas y signos sugerentes de abuso sexual, que llevan a confesar y confirmar eldiagnostico.Análisis de variables clínicas y sociodemográficas de Imputados por delito deParricidioRamón Elgueta (ramonelgueta@gmail.com)Vilma Ortiz, (dravilma@gmail.com)Javiera Rojas,Sandra Moglia,Berta Muñoz,Denisse Acevedo,Patricio Quiroga,Jaime Herrera.529

En el contexto de la reforma procesal penal chilena, se crean cuatro unidades de evaluación depersonas imputadas (UEPI) a lo largo del país, destinadas a dar opinión clínica específica apreguntas establecidas desde el poder judicial, secundarias a una sospecha de presencia depatología mental en el imputado. Asimismo, cumplen la función de dar tratamiento, bajo régimende internación, a imputados que requieran de compensación psiquiátrica. En el contexto descrito,el presente trabajo tiene como objetivo cuantificar y caracterizar los componentes clínicos,socioculturales y ambientales en los cuales ocurre el delito de Parricidio, contrastándolos conla literatura internacional. Se analizaran casos de personas imputadas por este delito evaluadasen la unidad clínico forense UEPI, Instituto Psiquiátrico “Dr. José Horwitz Barak”, desde el año2007 hasta la fecha.Análisis de Filicidio Materno en usuarios del Servicio de psiquiatría forense enSantiago de ChileAndrea Gonzalez Gatica (andreagonzalezgatica@gmail.com)Ramón Elgueta,Loreto Plaza,Loreto Neves,Vilma Ortiz,Marco González,Pablo PalmaEl presente trabajo busca analizar múltiples características del filicidio cometido por madres.Dicho análisis se realizara en personas que han cometido este delito y que han recibido atenciónentre los años 2006 y 2011 en el servicio de Psiquiatría Forense del Instituto Psiquiátrico “Dr.José Horwitz Barak” de Santiago de Chile. Se analizaran Características de las Victimas,Características de las ofensas y características del perpetrador, con énfasis en la relación deldelito con el estado morboso del perpetrador y se comparará con los distintos tipos declasificaciones psiquiátricas existentes para este delito en literatura internacional.Los Deberes del Estado, la Deontología Médica y Derechos del Paciente, en elmarco de la Reforma de la Salud: De la Ley Nº 19.937 a la Ley Nº 20.584, Chile,del 2004 al 2012Mauricio Jeldres Vargas, Servicio Médico Legal, Osorno, Chile (maujeva@yahoo.com)Verónica G. Wall Ziegler, Universidad Austral de Chile (vwallz@yahoo.com.ar)530

Gonzalo Arroyo Curutchet, Hospital San José, Osorno, Chile (gonzalo1@elsur.cl)Se presentan los hitos políticos e históricos, que han marcado el Sistema de Salud Chile, desdelos años cincuenta, con una fuerte presencia publica, de grandes logros sanitarios, a los ochentaque caracterizó por una dualidad público-privada, de escasa complementariedad y altos nivelesde discriminación, inequidad y segmentación, para los noventa el gran desafío fue la formulaciónde la reforma, estableciendo los objetivos sanitarios para la década. Luego, desde el 2000, sepromovieron los principales elementos de la reforma al sistema de salud, con la Ley de GarantíasExplícitas; modificando la institucionalidad, con la Ley de Autoridad Sanitaria el 2004 y la Leyde Derechos y Deberes de las Personas en Acciones Vinculadas a la Atención de Salud el 2012.El objetivo es ver como desde la perspectiva de los derechos humanos, la reforma al sistema desalud chilena contribuyó a la realización del derecho a la salud, junto a las obligaciones delEstado con los instrumentos internacionales y nacionales que regulan el derecho a la salud.Sobre el Desafio Pericial en los Casos de Asi (abuso sexual infantil)Claudio Enrique Habijan, EPAASI del Poder Judicial, Mendoza, Argentina(chabijan@jus.mendoza.gov.ar)El problema del Abuso Sexual infantil como acto agresivo/delictivo que vulnera los derechosbásicos de todo infante que es expuesto a alguna forma de práctica victimizante sexualmente,viene ocupando en nuestras sociedades un lugar preponderante, no solo por la denuncia públicacada vez más frecuente, sino también porque a partir de ese reconocimiento social, nos exigecomo individuo y como sociedad, adoptar una posición frente al fenómeno. En éste trabajo nosocuparemos del rol que cumple una persona, que en calidad de perito experto aportará unelemento crucial, “el informe”, a un proceso socio-judicial, que se ocupará del tema. De hecho segenerará una influencia decisiva ya que será parte activa del diseño de un resultado finalmediante el que se considerará por ejemplo la existencia o no del daño, y a partir de allí lanecesidad o no de aplicar una sanción penal al acusado y una medida reparatoria a la víctima.Rol que para cumplirse deberá enfrentar cada día más exigencias, producto de la participación aveces involuntaria, de un proceso macro, de “escalada simétrica”, en el que ambos ladosaparentemente enfrentados, conforman la escalada, aumentado en forma simétrica el grado decomplejidad. Frente a ésta ineludible realidad proponemos al perito no solo contar con losdebidos conocimientos en su materia, sino con las habilidades correspondientes para exponer susconclusiones y defenderlas al momento en que se le exijan argumentos sólidos que ilustren aljuez en la etapa de valorar los hechos. En este sentido venimos planteando que el perito debeestar consciente de ser parte de ese proceso simétrico, de que mientras más se especialice másexigencias se le aplicarán, esto tiene que ver con las responsabilidades de una materia que nomuchos deciden desempeñar y menos aún en estos temas tan complejos, como los casos en losque un informe psíquico forense termina siendo si se quiere la prueba más sustancial a la hora decomprobar la existencia del hecho victimizante.531

221. La Enfermedad Mental y sus Cuidados en las PrisionesPrevalencia de Trastornos Mentales en PrisionesRubén Alvarado, Universidad de Chile (ralvarado@med.uchile.cl)Los estudios de prevalencia de trastornos mentales en poblaciones encarceladas son escasos, enespecial en países de bajos y medianos ingresos, lo cual limita el desarrollo de servicios paraatender las necesidades de cuidados de estas personas. Se realizó un estudio transversal, en unamuestra aleatoria estratificada por macro-zonas, de 1.008 personas recluidas en diferentescárceles del país. Se utilizó la versión informatizada del CIDI 3.0, que permite diagnósticos CIE-10 para 24 tipos diferentes de trastornos mentales. Se encontró una prevalencia de último año de:8,1% para cualquier trastorno afectivo, 8,3% para cualquier trastorno de ansiedad, 12,2% paracualquier trastorno por uso de sustancias, 0,8% para posibles casos de psicosis y 7,2% para otrostrastornos. Un 26,8% de los encuestados tuvo algún tipo de trastorno mental en el último año. Laprevalencia para cualquier trastorno en el último año fue similar por sexo (26,8% vs 26,5%).Hubo diferencias según zonas del país (desde 40,5% en la macro-zona centro norte hasta 21,5%en la macro-zona centro). Las personas que llevaban menos de 12 meses recluidas tenían unacifra significativamente más elevada (35,7% vs 23,1%). Los resultados permiten concluir queesta población tiene importantes necesidades de cuidados en salud mental.El Uso de Medidas Coercitivas por Indicación Médica en Prisiones y HospitalesPsiquiátricos PenitenciariosEloy Girela-López, Universidad de Córdoba (ft1gilpe@uco.es)Hemos estudiado el empleo de medidas coercitivas (medicación forzada, aislamiento ycontención mecánica) por indicación médica en tres prisiones y dos Hospitales PsiquiátricosPenitenciarios españoles. Analizamos las variables relacionadas con la medida coercitivaempleada, opinión del interno-paciente y opinión del personal médico. Tras estudiar 209pacientes, 108 de Hospitales y 101 de Prisiones, los resultados más relevantes fueron que elaislamiento era la medida más frecuente (41.35%), seguida de la contención (33.17%) y de lamedicación forzada (25.48%). Mayoritariamente (87%) se adoptaron conjuntamente dos o másmedidas. Los tipos de medidas coercitivas no diferían significativamente en cuanto a la mayoríade variables estudiadas. No obstante, el tipo de centro sí tenía alguna influencia; con menorriesgo de sufrir aislamiento y contención en prisiones, aunque mayor riesgo de medicaciónforzada. El hecho de vivir en pareja antes de su ingreso reducía el riesgo de medicación forzada yla comunicación con la familia disminuía el riesgo de aislamiento. Con respecto a las escalaspsiquiátricas empleadas, el incremento en las puntuaciones del Global Assessment ofFunctioning (GAF) disminuía el riesgo de sufrir cualquier medida coercitiva, mientras que elincremento de la puntuación del Modified Overt Aggression Scale (MOAS) incrementaba elriesgo de contención.532

Hospitales Psiquiátricos Penitenciarios y Necesidad de Medidas AlternativasÁngeles López , Hospital Psiquiátrico Penitenciario de Alicante, España (angeles@ua.es)En España quien, en el momento de cometer un delito, padece una anomalía o alteraciónpsíquica que le impide comprender la ilicitud del hecho o actuar conforme a esa comprensión,recibe un tratamiento penal y penitenciario diferenciado: sometimiento a alguna/s de las medidasde seguridad, privativa o no privativa de libertad, contempladas en el Código Penal. La medidade internamiento para tratamiento médico, por lo general, se cumple en establecimientosgestionados por la Administración Penitenciaria (dos hospitales psiquiátricos, una unidadpsiquiátrica y una unidad para discapacitados). Estos establecimientos especiales están enocasiones masificados y provocan el desarraigo familiar y social. El perfil sociodemográfico delos pacientes, es semejante a los pacientes psicóticos de la comunidad. La incapacitación civil yel suicidio tienen una incidencia específica en este contexto. Se aprecia últimamente unincremento de pacientes diagnosticados con trastorno de personalidad y abuso de múltiplessustancias. Tras la promulgación de la legislación sobre maltrato en el ámbito familiar, se haincrementado el número de internamientos de corta estancia, acompañados de órdenes dealejamiento, incluso tras el cumplimiento de la medida de internamiento. Todo ello invita a unarevisión de la situación actual y plantear medidas alternativas al internamiento.El Trastorno Mental Grave y el Riesgo de PrisiónFrancisco Torres González, Universidad de Granada (ftorres@ugr.es)Se acepta que entre 50 y 70% de los diagnósticos de esquizofrenia evolucionan hacia lacronicidad y más de 1/3 no reciben tratamiento. Un estudio patrocinado por OMS (Demittenaerey cols, 2004) identificó las prevalencias más frecuentes y más severas entre las enfermedadesmentales; entre los Trastornos Mentales Severos (TMS), 35-50% estaban incursos en brechaterapéutica (BT) en países desarrollados. Otro estudio (Kohn y cols, 2004) mostró que el 32% delos diagnosticados de esquizofrenia estaban en BT. Siguiendo la política recomendadainternacionalmente por OMS 1 y otros organismos internacionales, se están cerrando hospitalespsiquiátricos o reduciendo sus camas. Sin embargo, el cierre de camas no es reemplazado porrecursos comunitarios alternativos. Esta carencia de continuidad terapéutica hace del TMS ungrupo altamente vulnerable y en números casos su destino alternativo termina siendo la cárcel.Ya en1998 Lamb y cols. advirtieron sobre el incremento en el número de TMG en prisión enrelación con las prevalencias que se comunicaban en la década de los 70. Un nuevo artículo delmismo grupo (2001) planteó la posibilidad de que la atención a enfermos mentales estuviesesiendo transferida a las cárceles; preocupación compartida por otros autores (Priebe y cols.2005).533

222. La Hospitalización Involuntaria y otras Medidas de CoerciónIntroductionJulio Arboleda-Florez, Queen`s University (julio.arboleda-florez@queensu.ca)La Coerción es el acto de ejercer el poder y se define como la acción de un agente quienintencionalmente busca influir la conducta de los otros. El agente coercitivo lo puede hacerusando la persuasión, pero si ésta falla, el agente recurrirá a imponer sus órdenes contra lavoluntad del otro a través de amenazas, el uso de la fuerza física, o de la extorsión. La coerciónpuede que necesite del uso del dolor físico o psicológico que se utiliza para dar credibilidad a laamenaza. La Coerción es un elemento intrínseco en las relaciones humanas. Las personas concierto nivel de autoridad tratan de explicar sus mandatos y buscan el soporte de los subordinados,pero éstos saben muy bien que si las órdenes no se cumplen o los pedidos no se atienden, o seobedezcan, habrá que atenerse a las consecuencias. La coerción, entonces, se manifiesta a travésde la persuasión o imposición y como tal se contrapone a la libertad no importa como ésta sedefina. Si la libertad se define en términos positivos tal como “ser el amo de uno mismo”,entonces si se siguen las órdenes de algún otro, la libertad personal sufre coerción. Pero si sedefine la libertad en términos negativos tal como “no poder evitarse que uno escoja como losdemás” entonces, órdenes de no hacer algo son coercitivas. En Psiquiatría, aún en casos cuandoel paciente se somete al tratamiento voluntariamente, hay siempre una amenaza de que medidascoercitivas se puedan usar en cualquier momento dado si las circunstancias así lo requieren. Lacoerción es una característica constante de la Psiquiatría.La Hospitalización Psiquiátrica InvoluntariaMauricio Gómez, Hospital San Luis, Buin, Santiago, Chile (mgomezch1@hotmail.com)La hospitalización involuntaria en psiquiatría existe en el mundo pese a constituir una privaciónde libertad, lo cual afecta un derecho humano principal. En general se intenta aplicar basada enlos “Principios para la protección de los enfermos mentales y para el mejoramiento de laatención de la salud mental”. “La Convención de Derechos de las Personas con Discapacidad”expresa el derecho a ser tratado sobre la base de la voluntariedad y que las personas condiscapacidad no pueden ser privadas de su libertad fuera del marco de la ley. La aprobación de laCDPD ha permitido que se cuestione la legitimidad de este procedimiento. El presente trabajoanaliza la realidad de la internación involuntaria, su estatus legal y las controversias que genera.Asimismo, se estudian los casos de internación involuntaria generados en un servicio depsiquiatría en Chile, el perfil de las personas afectadas, las razones de su aplicación, la evoluciónde los usuarios y la capacidad de las redes de salud mental para evitarlas. Se concluye que suexistencia en muchos casos esconde una realidad de carencia de recursos para la atención clínicay soporte social a las personas con discapacidad mental.534

Coerción percibida y Efectos Psicológicos durante la HospitalizaciónPsiquiátricaFermín Mayoral-Cleríes, Hospital Regional Carlos Haya, Málaga, España(fermin.mayoral.sspa@juntadeandalucia.es)Las consecuencias de la utilización de medidas coercitivas en el tratamiento psiquiátrico comoson el ingreso involuntario, el aislamiento, la contención física y la medicación forzada aunplantean grandes incógnitas y abren la puerta a un intenso debate entre juristas, clínicos yasociaciones de familiares y usuarios. Un estudio llevado a cabo en 13 centros de 12 paíseseuropeos (EUNOMIA)(1) mostró una amplia variabilidad tanto en el marco jurídico como en elterreno empírico de su aplicación. Las principales cuestiones que aún quedan abiertas son:¿Existen algunas características socio-demográficas y/o clínicas de los pacientes que los haganser candidatos de sufrir medidas coercitivas durante su tratamiento?¿Cómo son percibidas por los pacientes tales medidas coercitivas en relación con el tratamiento?¿Cuáles son los resultados a medio plazo de la aplicación de medidas coercitivas en los pacientesa los que les son aplicadas en comparación con los que no se le aplican?La hospitalización Involuntaria y Otras Medidas de Coerción por RazonesMédicas en Enfermos no MentalesClaudio Hernández-Cueto, Universidad de Granada (chc@ugr.es)El empleo de medidas de coerción (ingresos y tratamientos forzosos, sujeción física, reclusión ycoerción química), se realiza con más frecuencia en la atención psiquiátrica, donde ha sidoestudiado, pero no es exclusivo de ella. Hemos preparado un protocolo de recogida de datossobre uso de las mismas en hospitales públicos españoles (Granada, Oviedo, Málaga, Barcelonay Madrid) en servicios distintos a los psiquiátricos: Medicina Interna (incluyendo MedicinaGeriátrica), Pediatría, Trastornos de la Alimentación y Servicios de Urgencia, para conocer:frecuencia de aplicación de medidas coercitivas, características del paciente y su patología, rolesde los profesionales sanitarios en relación a la aplicación de la medida y efectos de dichaaplicación. Analizamos con ello el posible beneficio o no de uso y si suponen la generación deuna daño de los derechos fundamentales de la persona, para elaborar una Recomendación deaplicación de medidas coercitivas necesarias en algunos casos estableciendo: tipo de paciente ypatologías, tipos de medidas aplicables, personal autorizado para ello, control durante laaplicación, causas que justifican finalizar la misma y protocolo general de regulación de lasmismas, que sirva de base a una propuesta de regulación legal de aplicación de medidas decoerción en los hospitales públicos.535

223. Legislación, Derechos Humanos y Discapacidad Mental enAmérica Latina y el Caribe, y en EspañaEl Derecho Internacional de Derechos Humanos Como una HerramientaFundamental Para el Desarrollo de Estrategias de EvaluaciónJavier Vasquez, Pan American Health Organization, USA (vasquez@paho.org)El uso de los principios internacionales de derechos humanos, tratados y estándares, estáevolucionando como una estrategia eficaz para mejorar la salud de las personas en todo elmundo. Conocemos que las violaciones de los derechos humanos pueden tener efectosdesfavorables para la salud física y mental de los individuos. Por otra parte, también sabemosque las políticas, leyes, programas y planes pueden tener un efecto positivo, al allanar el caminopara que las personas, particularmente los grupos vulnerables, ejerzan sus derechos humanosbásicos y sus libertades fundamentales, incluido el derecho al goce del grado máximo de saludque se pueda lograr (“derecho a la salud”), a pesar de sus condiciones económicas o sociales. Encuanto a la salud pública y los derechos humanos, desde siempre se ha prestado más atención alas violaciones de los derechos humanos relacionadas con enfermedades o deficiencias físicasque a aquellas relacionadas con la salud mental y los trastornos psiquiátricos. Esta situacióncontribuye a que se margine y discrimine aún más a las personas con trastornos o discapacidadmental, si lo comparamos con aquellas personas que tienen discapacidades físicas. Estapresentación ofrece un enfoque distinto para remediar este problema.La Discapacidad Mental en la Experiencia Chilena: El Derecho a Vivir enComunidadAlberto Minoletti, Universidad de Chile (aminolet@vtr.net)El sistema de salud público chileno, que provee servicios a alrededor del 75% de la población, harealizado profundas transformaciones en la atención psiquiátrica en los últimos 21 años,disminuyendo significativamente el número de personas recluidas en hospitales mentales, almismo tiempo que fortaleciendo y descentralizando los servicios ambulatorios y comunitarios.La presencia de equipos especializados con mayor accesibilidad, programas de rehabilitaciónpsicosocial basados en la comunidad y los hogares y residencias protegidas insertos en cualquiervecindario han facilitado que miles de personas con discapacidad mental de causa psíquicapuedan ejercer su derecho a vivir en la comunidad. No obstante los avances logrados, lalegislación chilena no ha realizado los cambios necesarios para favorecer este proceso y cumplircon el artículo 19 de la Convención de las Naciones Unidas sobre los Derechos de las Personascon Discapacidad, de la cual el país es signatario. La existencia de vacíos y contradicciones con536

dicha Convención, exponen a un debilitamiento en el desarrollo de apoyos comunitarios y adificultades en la inclusión social. El presente trabajo expondrá algunos indicadores sobre losavances, retrocesos y amenazas del derecho de las personas con discapacidad mental a vivir en lacomunidad en Chile.La Discapacidad Mental en el Ordenamiento Jurídico EspañolLuis-Fernando Barrios, Universidad de Alicante (luisfbarrios@ua.es)En España el trastorno y el retraso mental tienen incidencia en diversos ámbitos jurídicos.Penalmente pueden comportar desde la exención de responsabilidad hasta la atenuación de lamisma. En uno y en otro caso, las consecuencias son notablemente diferentes respecto adelincuentes no pacientes mentales (tanto por el tipo de consecuencia penal, como por el lugar decumplimiento de la medida). Civilmente, trastorno y retraso mental pueden conllevar elinternamiento (voluntario/involuntario), la incapacitación (total o parcial) u otras medidas deprotección. Administrativa y laboralmente, existe un sistema de incapacidades específico.Especialmente en los ámbitos civil y penal se aprecian relevantes disfunciones provocadas por ladesconexión existente entre el teórico marco jurídico de garantías y su plasmación en la práctica.Así, en el plano civil, recientemente se ha producido un importante pronunciamiento declarandola inconstitucionalidad de parte de la regulación del internamiento involuntario por falta deadecuado rango normativo. En el ámbito penal existen importantes déficits institucionales (derecursos y organizativos). La ratificación por España de la Convención de Nueva York de 2006,ha planteado la interesante problemática de la adaptación del ordenamiento jurídico español a lamisma. Tal cuestión ha llegado a nuestros más altos Tribunales recientemente.224. Title T.B.A.Intervención en Desatres Naturales para Evitar Estrés – Post Traumático enComunidades AndinasMaría Victoria Arévalo Prieto, Universidad Católica del Perú (mvarevalop@pucp.pe)Jorge Yamamoto, Pontificia Universidad Católica del Perú (jyamamo@pucp.edu.pe)El 15 de agosto del 2007 se produjo un terremoto en el Perú, el epicentro fuen en eldepartamento de ICA, en el distrito de Pisco, pero los estragos de éste sismo de 8.9 según laescala de Mercali se extendieron a otras distritos ubicados en provincias aledañas aldepartamento de Ica, es así que el Distriro de Ticrapo y la Comunidad Campesina de Astomarcaubicados en el departamento de Huancavelica sufrieron derrumbes de casas y apertura de latierra, lo que significó pérdida económicas y reacciones emocionales y conductuales relacionadas537

a los desastres naturales, reacciones que han sidoreportads por la Organización Panamericana deLa Salud. OPS. El 07 de octubre del 2007 los autores de éste estudio acompañados por unequipo de trabajo realizó la medición de los síntomas de estrés en ambas localidades utilizandolos criterios de la OPS y adpatándolo a la población que iba a ser entrevistadas. Los resultadosarrojaron que la población sufrió síntomas como: ansiedad, tristeza, culpa por estar vivo,cansancio, insomnio o problemas para dormir, pérdida de apetito y los ni ños presentaron temora dormir en las carpas ante el pensamiento de que podría ocurrir otro terremoto. Se realizó unaintervención en grupo en ambas localidades. Se reforzó la estrategia de soporte social que lapoblación usó para limpiar la localidad, es decir retirar los escombros para que pudieran darsecompañía, ayuda y actividades de distracción y ayuda mutua. Se les enseñó la técnica derelajación usando la respiración y las estrategias de solución de problemas. Para los niños seentrenó a las madres la técnica de desensibilización sistemática en vivo. Los resultados fueronque la población de ambas localidades reportaron sentirse aliviados y satisfecho de que se leshaya considerado en la ayuda psicológica.Mundo Interno y Factor de Riesgo en Niños con Vivencia de Calle y Niños deCasa: Rorschach, sistema comprensivoAurea Alcalde, Universidad Nacional Mayor de San Marcos (aurealcalde@gmail.com)Perú, país con economía expectante en términos de desarrollo -condición que le ha permitidosoportar con cierta fortaleza la crisis económica mundial- aún no ha logrado disminuir los altosíndices de precariedad e incluso de extrema pobreza existente, en ciertas zonas rurales y urbanomarginales,hecho que afecta fundamentalmente a los derechos del niño. Con el objeto derealizar un estudio comparativo sobre el mundo interno de dos grupos de niños, asociado alfactor de riesgo, se ha trabajado con un diseño descriptivo-comparativo, en una muestra de 70niños no-pacientes, varones, de 12 a 14 años de edad, de Lima Metropolitana. Los grupos deestudio están conformados por: A) Niños con vivencia de calle (34), que constituyen el grupoemblemático de riesgo. B) Niños de Casa (36), que viven con sus familiares, asisten a unaescuela estatal; de bajo nivel socio-económico, que los ubica en una potencial situación deriesgo. El instrumento utilizado ha sido el Psicodiagnóstico de Rorschach, a través de tresperspectivas de evaluación: A) Agrupación de Afectividad y Variables Relacionadas (SistemaComprensivo). B) Contenidos Rorschach, desde un enfoque cuantitativo (SistemaComprensivo). C) Contenidos Rorschach, desde un enfoque cualitativo (autores rorschachianosde diferente orientación).Impulsividad y bienestar en mujeres encarceladas en LimaRafael Gargurevich, Universidad Peruana de Ciencias Aplicadas(rafael.gargurevich@gmail.com)538

El aumento de la proporción de las mujeres que se encuentran en la cárcel genera la necesidad deestudiar la salud mental de manera específica en este grupo. Las teorías que explican elcomportamiento delictivo resaltan el rol de la impulsividad en la explicación del origen de ladelincuencia, ya que se la ha relacionado con conductas agresivas y como un componente clavede la psicopatología. Diversas investigaciones parecen comprobar una calara cercanía entre laimpulsividad y el afecto negativo. Sin embargo diversas teorías han comprobado que laimpulsividad no siempre posee alcances negativos sino que más bien permite el desarrollo o elcrecimiento, lo que también podría llamarse bienestar. Sin embargo estas propuestas han sidoestudiadas en población comunitaria y no con población forense. Es así que se estudiará larelación entre la impulsividad y el bienestar en una población de mujeres encarceladas, en lasque se supone deberían mantener altos niveles de impulsividad “negativa”. Es especialmenteimportante estudiar estos constructos en estos grupos para poder dilucidar mejor la relación entrebienestar e impulsividad.¿En qué época de la vida somos más felices? La psicología positiva o de lafelicidad y logros en las distintas etapas evolutivasMatilde Ráez, Pontificia Universidad Católica del Perú (mraez@pucp.edu.pe)La Psicología Positiva o de la Felicidad señala que los factores que nos hacen felices cambiansegún la etapa evolutiva (Alarcón, 2003; Martínez, 2004, Ráez, 2003), que los rasgos de lapersonalidad ayudan a utilizar de manera más saludable o más negativa los eventos, y que lafelicidad varía según la persona, la cultura y el país. Interesada en el tema, que investigo desdehace algunos años. (Ráez, 2003, 2006, 2007). en esta oportunidad el interés se centra en estudiarla relación entre el “ser feliz” y los rasgos más representativos en las distintas etapas evolutivas.El presente trabajo es un estudio empírico con una población limeña no paciente, constituida por200 participantes, entre 18 y 65 años, divididos en 4 grupos etarios: 18-25, 26 a 39, 55, y 56-65en adelante. Este grupo es representativo de la población peruana que es mayoritariamente joven.El 55% son mujeres y el 45% hombres, y todos provienen de diversos niveles socio culturales.Empleamos como instrumento el Rorschach, porque siendo una técnica inestructurada, se evita lainterferencia de la deseabilidad social (Ráez, 2007). Se presentarán y se discutirán los resultadosdentro del marco de la psicología positiva y de los datos proporcionados por la psicología deldesarrollo, como representativos de las distintas etapas evolutivas.Italian Language SessionsT.B.E.*539