Montreal 2001 Program
Transcription
Montreal 2001 Program
XXVIth International Congress on Law and Mental Health XXVI e Congrès international de droit et de santé mentale Montréal, Canada July 1 – 6 juillet 2001 PROGRAM and ABSTRACTS PROGRAMME et RÉSUMÉS Under the auspices of / Sous l’égide de International Academy of Law and Mental Health Académie internationale de droit et de santé mentale Institut Philippe Pinel de Montréal i Table of Contents / Table des matières International Board of Directors / Conseil d’administration international ................................... iii Acknowledgments / Remerciements .............................................................................................. iv International Scientific Committee / Comité scientifique international .........................................v Comités scientifiques francophones............................................................................................... vi Program and Abstracts / Programme et résumés Pre-Conference: “Foundations of Health Care” July 1 juillet 2001.......................................................................................................................8 July 2 juillet 2001.....................................................................................................................11 Sessions of the Academy / Sessions de l’Académie July 3 juillet 2001.....................................................................................................................14 July 4 juillet 2001.....................................................................................................................29 July 5 juillet 2001.....................................................................................................................62 July 6 juillet 2001...................................................................................................................102 List of sessions / Liste des sessions..............................................................................................135 List of chairs, speakers and discussants Liste des modérateurs, conférenciers et discutants .....................................................................137 Rooms – Salles MC NCDH–101 NCDH–102 NCDH–200 3644 Peel, New Chancellor Day Hall, Room / Salle Moot Court 3644 Peel, New Chancellor Day Hall Room / Salle 101 3644 Peel, New Chancellor Day Hall Room / Salle 102 3644 Peel, New Chancellor Day Hall Room / Salle 200 NCDH– 201 IASL106 CMEL102 CPCL101 This file last updated on 24/07/01 10:15. ii 3644 Peel, New Chancellor Day Hall Room / Salle 201 3661 Peel, Institute and Centre of Air and Space Law Room / Salle 106 3690 Peel, Centre for Medicine, Ethics and Law Room / Salle 102 3647 Peel, Centre of Private and Comparative Law Room / Salle 101 International Academy of Law and Mental Health Académie internationale de droit et de santé mentale Board of Directors / Conseil d'administration 2000-2001 Frank Beyaert Immediate Past-President University of Utrecht Leonard V. Kaplan President University of Wisconsin Law School David N. Weisstub Honorary President Université de Montréal Julio Arboleda-Flórez 1st Vice-President Queen’s University Christian Mormont 2e Vice-Président Université de Liège Terry Carney Secretary-General University of Sydney Derek Eaves Vice-President, Research and Policy British Columbia Forensic Services Commission Gilbert Sharpe Treasurer McMaster University Jocelyn Aubut Centre hospitalier universitaire de Montréal Monica Bolis Pan American Health Organization/World Health Organization Roland Coutanceau Association française de psychiatrie et psychologie légale Volker Dittmann University of Basel Marijke Drost Pieter Baan Centrum Marianne Engberg Aarhus University Jorge Oscar Folino National University of La Plata Serge Gauthier McGill University Michele Goodwin DePaul University Thomas G. Gutheil Harvard Medical School Trevor Hadley University of Pennsylvania Virginia Aldigé Hiday North Carolina State University Knud Jensen Odense University Hospital Paul-André Lafleur Institut Philippe Pinel de Montréal George B. Palermo Medical College of Wisconsin Michael Perlin New York Law School Peter Silfen University of Bar Ilan Lawrence Solan Brooklyn Law School Henry J. Steadman Policy Research Associates, Inc. José G.V. Taborda Federal Faculty of Medical Sciences of Porto Alegre David C. Thomasma Loyola University of Chicago Hjalmar van Marle Nijmegen University Thomas Wenzel University Hospital for Psychiatry, Vienna George F. Tomossy Executive Director University of Sydney iii REMERCIEMENTS ACKNOWLEDGEMENTS Nous remercions pour leur généreux soutien: We gratefully acknowledge the support of the following: Gouvernement du Québec Ministère de la Justice Canada Department of Justice Canada Solliciteur général Canada Solicitor General Canada Service correctionnel Canada Correctional Service Canada Institut Philippe Pinel de Montréal Faculté de droit, Université McGill Faculty of Law, McGill University Ville de Montréal Commission du droit du Canada Law Commission of Canada iv XXVIth International Congress on Law and Mental Health e XXVI Congrès international de droit et de santé mentale Montréal, Canada July 1 – 6 juillet 2001 David N. Weisstub Chair/Président Université de Montréal Julio Arboleda-Flórez Co-Chair/Co- Président Queen’s University Paul-André Lafleur Co-Chair/Co- Président Institut Philippe Pinel de Montréal International Scientific Committee Comité scientifique international David N. Weisstub Chair/Président Université de Montréal Julio Arboleda-Flórez Queen’s University Wendy Austin University of Alberta Peter Bartlett University of Nottingham Terry Carney University of Sydney Volker Dittmann University of Basel Michele Goodwin DePaul University Thomas Gutheil Harvard Medical School Virginia Aldigé Hiday North Carolina State University Leonard V. Kaplan University of WisconsinMadison Paul-André Lafleur Institut Philippe Pinel de Montréal John Q. La Fond University of MissouriKansas City Peter Leuprecht McGill University Christian Mormont Université de Liège George B. Palermo Medical College of Wisconsin Richard D. Schneider Ontario Court of Justice Alexander Simpson University of Auckland Bernard Starkmam Department of Justice Canada José Taborda Federal Faculty of Medical Sciences of Porto Alegre David C. Thomasma Loyola University of Chicago Thomas Wenzel University Hospital for Psychiatry, Vienna Hjalmar Van Marle University of Nijmegen v XXVIe Congrès international de droit et de santé mentale Comités scientifiques francophones Jocelyn Aubut Co- Président Centre hospitalier universitaire de Montréal Frédéric Millaud Co- Président Institut Philippe Pinel de Montréal Comité scientifique local Gilles Chamberland Institut Philippe Pinel de Montréal Gilles Côté Institut Philippe Pinel de Montréal Jean Hébert Association des médecins psychiatres du Québec André McKibben Institut Philippe Pinel de Montréal Sylvain Palardy Université de Montréal Jean Proulx Université de Montréal Monique Tardif Université du Québec à Montréal Christine Truesdell Tribunal administratif du Québec Comité scientifique international Samia Attia-Galand Centre hospitalier Pierre-Janet de Hull, Canada Roland Coutanceau La Garenne Colombes, France Bruno Gravier Université de Lausanne Liliana Lorettu Université de Sassari Guido Macias Médecin psychiatre, Mexique Christian Mormont Université de Liège Comité organisateur Martine Côté Institut Philippe Pinel de Montréal vi Danielle Séguin-Marois Institut Philippe Pinel de Montréal Pre-Conference Foundations of Health Care Co-Chairs: David Novak, University of Toronto David C. Thomasma, Loyola University of Chicago David N. Weisstub, Université de Montréal Sunday, July 1, 2001 and Monday, July 2, 2001 7 XXVIe Congrès international de droit et de santé mentale Program at a glance / Coup d’œil sur le programme Foundations of Health Care July 1 juillet, 2001 Foundations of Health Care ............................................................................................... MC 8:45 Registration / Inscription 9:30 Part I: Professional Groundings Chair: Wendy Austin, University of Alberta The conflict between duty and risk David Novak, University of Toronto The moral self: Implications for health care ethics and policy Judith Lee Kissell, Creighton University The Levinasian “One-for-the-Other” as a foundation for health care Nancy Burbidge, St. Paul University 11:30 Discussion 11:45 Break 13:45 Part II: Health Foundations Chair: Julio Arboleda-Flórez, Queen’s University The health concepts schema: A framework for clarifying the notions of health and ideas implicit in diverse approaches to health care George Khushf, University of South Carolina On health and value Lenn Goodman, Vanderbilt University Rules to remember: Competence and behavior Astrid Vellinga and Evert van Leeuwen, Free University of Amsterdam 15:45 Discussion 16:00 Conclusion 8 XXVIth International Congress on Law and Mental Health PART I: PROFESSIONAL GROUNDINGS The conflict between duty and risk David Novak University of Toronto One of the moral problems that has arisen in connection with the AIDS crisis is the refusal of many health care personnel to treat AIDS patients at all. They argue that not only is AIDS highly contagious, but the actual means of its contagion have by no means been ascertained. Without such definition, there is no real containment within predictable boundaries. Hence, the only sure way of not contracting the disease is to avoid any contact whatsoever with those who have AIDS. The question, then, is to what extent the right to preserve one’s own life and health may be invoked as being prior to the duty to treat the sick, especially when one has unique skills for this through professional training and governmental authorization. This paper will deal with this conflict, drawing upon sources from the normative Jewish tradition and attempting to use them for the sake of a philosophical argument. It will examine the whole relation of rights and duties and attempt to present a way of determining a way of deciding priority when a right and a duty conflict. It will argue that every right engenders a correlative duty. As such, the conflict is not one between a right and a duty but, rather, a conflict between two different rights, each with its correlative duty. That is, we have the right of the AIDS patient to medical treatment versus the right of the health care person to protection from risk. I suggest that this conflict of rights can be resolved by the assertion that the right that engenders more duties than the conflicting right takes precedence. The paper will conclude that, for this reason, the patient’s right to treatment takes precedence over the health care person’s right to be free of risk. The moral self: Implications for health care ethics and policy Judith Lee Kissell Creighton University This paper explores the philosophical foundations of the embedded, embodied moral self of the person–and therefore, of the patient. This “moral self” question is spurred by the clinical issue of the substituted judgment regarding end-of-life decisions for patients suffering from dementia. The paper has three parts. First I draw upon Michael Sandel’s analysis of the moral self in his criticism of Rawls. More generally, I focus on Sandel’s analysis of the deontological project in all its ramifications, insofar as they define the liberal moral self. Second, I argue that Sandel’s criticism of liberalism’s priority of the right over the good lays a foundation for a conception of a moral self constituted by her embodiment, her historicity, her self-understanding and the epistemological transparency of her interests. Third, I suggest that such an understanding of the moral self both constitutes and undermines the autonomy assumptions behind the substituted judgment question–as well as other more basic precepts of medical ethics–and lays the groundwork for social issues regarding access to healthcare. The Levinasian “One-for-the-Other” as a foundation for health care Nancy Burbidge St. Paul University Could a radical notion of responsibility for the other one that eschews the drawing of precise directives from its uncompromising philosophy be a useful foundation for the health care evolving in the 21st century? This paper will argue that the thought of Emmanuel Levinas provides correctives to a number of the assumptions which have long informed the practice of medicine, and offers paradigmatic guidance for those concerned to effect changes in a system struggling within a culture of individualism, technical imperialism and efficiency. To the Western ontological tradition of the right of an autonomous self “to be,” Levinas would oppose the heteronomous notion of a self constituted in responding to the needs of the other. Against the obsession with the dominating “totalizing” nature of theoretical construction, Levinas would oppose, in the intersubjective realm, the “anarchy” of another who calls for a compassionate response independent of a “knowing” potentially diminishing of his/her mystery. The paradigms which might be drawn from the Levinasian “ethics as first philosophy,” speak to both the micro and the macro levels of health care. At the micro level, they would suggest the tenor of the relationship that any patient should expect, and speak to issues such as gatekeeping, and selection criteria in areas of scarcity. At the macro level, they would speak to the very goals of medicine. The question as to whether scarce organs should be allocated to those who appear to have contributed to their own poor health will be used as an example. 9 XXVIe Congrès international de droit et de santé mentale PART II: HEALTH FOUNDATIONS The health concepts schema: A framework for clarifying the notions of health and disease implicit in diverse approaches to health care George Khushf University of South Carolina The introduction of a public health perspective into healthcare (as seen, for example, in managed care) involves a broadening of health concepts and a focus on the health of communities, rather than isolated individuals. As health concepts broaden, they become more controversial and are increasingly enmeshed in the problems of values pluralism that are part of our multicultural society. The formation of health policy and health systems requires a decision (often implicit) about the breadth of health concepts, and there will be clear tradeoffs between narrow and broad concepts. Narrow biomedical health concepts tend to be less controversial since they are specified by scientific systems that are broadly supported and have cross-cultural validity. However, such narrow concepts inappropriately tend to prioritize somatic health considerations over mental and spiritual health, and usually do not include the full range of factors known to have an impact on health outcomes. On health and value Lenn Goodman Vanderbilt University People care about health, especially their own and that of their loved ones. But it is all too easy to shift the onus. Governments, businesses, insurers, have long concealed environmental and other irresponsibilities under the cover of self-help campaigns. Individuals, for their part, freely speak of health as a right–as long as someone else, preferably an impersonal someone else, foots the bill. Health, I argue, is a conative concept. Like progress and creativity, it emerges in the making. Yet it is not subjective. Health is a matter of flourishing, sustaining complexity in the face of an often indifferent environment. It involves setting out a project and making claims upon the environment in the interest of that project. Health interests always extend beyond the skin of the atomic individual. For the project of an organism is linked to that of its community and bound up indissolubly with the history and prospects of that community. And the projects of living beings are not static but grow and change over time. There is no fixed limit to their claims. It is this telic open endedness that renders health at once precious and problematic. This paper is about the relationship of health to value. It asks what health is, why health matters, how health can be deemed a right and how the value of health should be addressed in the prioritizing and the funding of health needs. Rules to remember: Competence and behavior Astrid Vellinga, Evert van Leeuwen Free University of Amsterdam The background of ethical issues concerning competence consists of institutional and legal rules that govern our behavior. In most cases we call somebody competent to make a decision when she or he is assigned to be competent to make such a decision. In moral matters, like in the case of psycho-geriatrics, we do not explicitly use an institutional or legal background. In fact, in most cases the only institutional background used is age. An individual who has reached the age of 18 is legally considered able to make competent decisions about her or his life and future. In my paper I will discuss the interaction between social rules and rule-following behavior in connection with moral questions of competence. Respecting others in the sense of a liberal economy (respect of autonomy) will be contrasted with the acceptance of otherness in meaningful relationships. The (non-)acceptance of frailty and weakness and the dominance of cognitive discursive strategies belong to different domains of social discourse. However, within the practice of psycho-geriatrics they seem to be exchangable under different circumstances. This strange intertwinement will lead us to the foundation of what it means to be morally competent in wealthy post-industrial societies. The leading question will be: can judgments of competence be made without a profoundly institutional frame of discourse, or do we have to accept that we can only think of ourselves and others in terms of social rules that we have to remember? 10 XXVIth International Congress on Law and Mental Health Program at a glance / Coup d’œil sur le programme Foundations of Health Care July 2 juillet, 2001 Foundations of Health Care ............................................................................................... MC 8:45 Registration / Inscription 9:30 Part III: Social Foundations Chair: George B. Palermo, Medical College of Wisconsin Expanding the boundaries of bioethics: Taking account of the social determinants of health Erika Blacksher, Midwest Bioethics Center, Kansas City, Missouri The Human as a natural kind: A foundation for the philosophy and ethics of medicine Daniel P. Sulmasy, New York Medical College Fundamental choices for health: Knowledge sharing Hugues Cormier, Université de Montréal 11:30 Discussion 11:45 Break 13:45 Part IV: Health Foundations Chair: David N. Weisstub, Université de Montréal Suffering and community: Developing an ethic in a world of moral acquaintanceship Erich Loewy, University of California at Davis Towards a new horizon for health care and bioethics David C. Thomasma, Loyola University of Chicago An Exchange on the Philosophical Roots of Bioethics Stephen Toulmin, University of Southern California 15:45 Discussion 16:00 Conclusion 16:15 Annual meeting of the Board of Directors of the International Academy of Law and Mental Health / Assemblée annuelle pour le conseil d’administration de l’Académie internationale de droit et de santé mentale 11 XXVIe Congrès international de droit et de santé mentale PART III: SOCIAL FOUNDATIONS Expanding the boundaries of bioethics: Taking account of the social determinants of health Erika Blacksher Midwest Bioethics Center, Kansas City This paper explores the implications of the social determinants of health literature for US bioethics. Because the field has–during its forty year history–focused primarily on developments in medicine, science and the delivery of health care, its ethical terrain has been defined by these settings and those who have access to them. The field’s mainstream questions and concerns have been confined to the goals of medicine and science, the policies and procedures of health care and research institutions, and framed in terms of individual patient-provider relationships. These boundaries have hidden from view a host of ethical questions raised by the relationship between human health and inequitable social arrangements created by class, race and ethnicity. In so doing, this nation’s most vulnerable populations have been eclipsed from systematic consideration and treatment by bioethics. If the field hopes to address the needs of vulnerable populations, it will need to look beyond biomedicine and access issues. The field will need to broaden its theoretical scope, re-examine its foundational values and build new relationships both in the policy world and in communities. In the future, bioethicists may become as involved with the formulation of education, housing and employment policies as we currently are with those governing health care and novel technologies. We will need to worry as much about the stigma associated with harmful sociological stories as we currently are about the stigma associated with harmful biological stories. Importantly, we will need to recast one of the field’s most foundational values–autonomy. In this paper, I will argue that the principle of autonomy will have to be re-examined and reframed to reflect the harm done to human agency by conditions of chronic socioeconomic stress. To guide discussions about health concepts, a three-dimensional schema is provided. A vertical, dimensions of well-being axis addresses somatic, mental and spiritual well-being. A horizontal, systems axis clarifies the range of systems whose well-being is assessed. And an etiological axis considers the types of causal factors that can be targeted in intervention strategies. The fundamental options for healthcare can be clarified by considering the tradeoffs along these three axes. The human as a natural kind: A foundation for the philosophy and ethics of medicine Daniel P. Sulmasy New York Medical College Recent work in metaphysics and the philosophy of language, especially the work of Kripke, Putnam and Wiggins, has vigorously re-introduced the concept of essentialism. In this paper, following Wiggins, the author argues that human beings are individual members a natural kind characterized by law-like principles that collect together the actual extension of that kind around an arbitrary good specimen of a human being, and that these law-like principles determine the characteristic development and typical history of the members of this extension. Following Lisska, the author calls these law-like principles the “dispositional predicates” that govern what human beings are as a natural kind. The author then argues that these dispositional predicates must therefore also govern what is required to heal biologically defective members of this natural kind. The task of medical science is thus to understand the law-like principles that govern the biological aspects of this natural kind and the law-like principles that govern deviation from its characteristic development and typical history. The task of medical practice is to use this understanding to restore, to the extent possible, damaged individual members of this natural kind to the characteristics, development, and history that are typical of good specimens of the human, considered as a natural kind. This, in turn, as MacIntyre has argued, specifies certain normative ends for medical praxis that form the possible substrate for a philosophically grounded medical ethics. Such a foundation seems perfectly natural and could not reasonably be considered fallacious. Fundamental choices for health: Knowledge sharing Hugues Cormier Université de Montréal The theme of the XXVIth International Congress on Law and Mental Health, “Fundamental Options in Health Care” is, it seems to me, fundamental to start the XXIst century. A fundamental insight to start the XXth century was the importance of the unconscious in and for the life of individuals and their mental health. It seems to me that today, we are confronted with other fundamental insights as the importance of knowledge sharing in and for the life of individuals and their health, as in and for the life of collectivities and their health, “societal health”. What do we mean by “Knowledge Sharing”? Promoting “Common Knowledge” shared by individuals, communities, societies. This knowledge of the “Common Trunk of Human Knowledge”, the “Great Story of Humanity” insists on what unites (Big Bang and it’s variants, Globalisation etc.) both in the common and the diversity rather than on what divides by mutual ignorance of this common heritage of two individuals, societies, countries, continents, sexes, etc. What would be the ultimate effect on health of contemporaneous learning of a universal common knowledge (particularly for youth) on mutual aid between nations and societies, and this as much as on the scale of all the nations 12 XXVIth International Congress on Law and Mental Health than on the scale of two individuals (ex., yourself reader and someone else), two communities (ex.: natives and “allochtones”), two societies (ex., Québécoise and Ontarian, or the Israeli and the Palestinian, etc.), two or more continents? Inspired by Michel Serres from the Académie française and Stanford, we postulate that an increased sharing of “Common Knowledge” (especially before adult age) would bring prevention or at least an attenuation of conflicts, violence, deleterious stress and distresses all generating sufferings, delinquencies, and diseases (somatic, psychic, psychosomatic and somato-psychic). That is why, among the “Fundamental Choices for Health”, we will state as fundamental the choice of “Knowledge Sharing”, and transposing ideas of Theodore Zeldin, member of the British Academy, the European Academy and Oxford professor, we will promote “ conversation” between individuals and also between societies for more mutual understanding and consequently more health for him and them as much as for us all. PART IV: SOCIAL FOUNDATIONS Suffering and community: developing an ethic in a world of moral acquaintanceship Erich Loewy University of California at Davis This paper summarizes a theory of ethics that would posit the capacity to suffer as central to an answer to the question of what makes things morally relevant. It develops that capacity into primary, secondary and prior moral worth or standing. Since ethical standing takes place in the context of a community and is, ultimately, determined and vouchsafed by it, the constitution of community becomes a core issue. This paper, therefore, discusses the nature of community. It suggests that the shaping of an ethic is done within a framework of “existential a prioris” and by a dialogue among all concerned. In conclusion the paper suggests that different communities–if we assume that maintaining a peaceful and robust association with one another is critical– relate and must relate in ways that create a common overarching ethic within which different ways of expressing this common ethic are tolerated and encouraged. Towards a new horizon for health care and bioethics David C. Thomasma Loyola University of Chicago A search for the foundations of medicine and bioethics is both necessary and fraught with pitfalls, especially in a postmodern era. The rejection of systematic thought, the appreciation of various cultures and the celebration of difference rather than commonalities all serve to inhibit important and critical thinking this area. Yet the goals of health care, social programs and professional standards, and worldwide threats to human rights require a step beyond relativism, as Macklin so cogently argued. My presentation is the result of a dialogue with a leading social philosopher of health care in Europe, Professor Uffe Juul Jensen. It relies on the need to establish boundaries, the need for standards and expectations that are both present, but also flexible and changeable over time, a developmental bioethics and a grounding of health care in the community. I conclude by suggesting three a priori principles or universals that may function as standards in medicine and bioethics. 13 XXVIe Congrès international de droit et de santé mentale Sessions of the Academy Sessions de l’Académie Tuesday, July 3, 2001 mardi 3 juillet, 2001 14 XXVIth International Congress on Law and Mental Health Program at a glance / Coup d’œil sur le programme July 3 juillet, 2001 Plenary Session / session plénière....................................................................................................MC 8:30 Registration / Inscription 9:30 Opening / Ouverture Paul-André Lafleur, Institut Philippe Pinel, Co-Chair, XXVIth Congress/Co-Président, XXVIe Congrès Welcoming Remarks Leonard V. Kaplan, University of Wisconsin-Madison President, International Academy of Law and Mental Health Bienvenue Christian Mormont, Université de Liège 2e Vice Président, Académie internationale de droit et de santé mentale Inauguration of Incoming President / Inauguration du nouveau Président 10:00 Allocution par M. Rémy Trudel, Ministre d’État à la Santé et aux Services sociaux du Québec Address by Mr. Rémy Trudel, Minister of Health and Social Services of Quebec 10:20 Presentation of the Philippe Pinel Award Philippe Pinel Address: “Psychiatry and Liberation” Stephen Toulmin, University of South California 11:00 Attribution du Prix Yves Pélicier Allocution Yves Pélicier: “Droits de la personne et santé mentale” Address : “Human Rights and Mental Health” L’Honorable Jean-Louis Baudouin, Cour d’appel du Québec 11:40 Yves Pélicier Conclusion Parallel sessions / sessions parallèles 13:45 15:45 16:00 17:45 Making it Happen: Mental Health Reform – The Ontario Context (16)........ NCDH–201 Mental Illness, Violence and Social Protection (18)...................................... NCDH–101 Transcultural Aspects of Law and Mental Health (19)..................................... IASL–106 Psychology, History, Literature and the Law (21)......................................... NCDH–200 Break / pause Paternalism and Autonomy: A Nordic Study (23)......................................... NCDH–101 Advocacy Under Ontario’s Mental Health Act (25) ...................................... NCDH–201 Sex Offenders: Theory, Research and Treatment (26)................................... NCDH–200 The Mental Health Care System in Spain: A Chronicle of a Friendly Reform (27) ................................................................................................................... IASL–106 End / fin 15 XXVIe Congrès international de droit et de santé mentale Abstracts for July 3, 2001 Résumés pour le 3 juillet 2001 13:45 – 15:45 MAKING IT HAPPEN: MENTAL HEALTH REFORM – THE ONTARIO CONTEXT July 3 juillet 13:45 – 15:45 Room NCDH–201 Chair: Michael Bay, Ontario Consent and Capacity Board Setting the course for change: Policy, legislation and implementation Peggy Taillon-Wasmund Champlain District Mental Health Implementation Task Force, Ontario Gilbert Sharpe McMaster University Making It Happen was released by the Ontario Ministry of Health and Long Term Care in 1999. It is the template for the implementation of mental health reform across the Province of Ontario. The goal of mental health reform is to create local systems of care that ensure access to a broad range of community-based services and supports. The system will provide choices to people with mental illness, allowing them to set and realize their personal goals, and to acquire the skills and resources needed to achieve independence and well-being. In addition, service providers will be able to address the identified service requirements through a variety of service models and approaches. The province has struck nine Task Forces to provide regional leadership in bringing about change in the way mental health services are delivered across the province. The Task Forces will provide advice and recommendations for local mental health systems, and in partnership with the ministry, develop implementation plans for a restructured regional service system based on levels of need, evidence-based research and ministry policy. Legislative Reform is a central component to driving change. The Mental Health Act of Ontario, amended in December 2000, is the result of years of extensive research and consultations with mental health community agencies, consumers and those whose lives have been touched by mental illness. Brian’s law is named after Brian Smith, an Ottawa sports caster. The Bill received all-party support in the provincial legislature earlier this year. The legislation introduces community-based treatment options in response to the recommendations of several coroners’ juries. It has been one year since the enactment of Brian’s Law. Ontario can now reflect on the implementation, implications, charter challenges and the over all impact of community based legislation. Developing the structure for change: The Northeast approach to system integration–building the system around the consumer Peter Birnie, Kate Pautler Ontario Mental Health Implementation Task Force After 20 years of planning, the development of an integrated system of mental health services is on the horizon in Northeastern Ontario. This new system will focus on a recovery model of supports and service, seek efficiencies through structural changes and create new standards for service effectiveness by relying on evidence-based best practices. The presentation will provide an overview of the integrated system: the community integrated mental agencies and their connections to the Schedule 1 acute psychiatric services, and the specialised psychiatric organisation that offers long term care. The operations of the community integrated mental health agency will also be discussed in detail, relating system standards to a client-centred response. Shared mental health care: Primary care and mental health services making the links Tyrone Turner St. Joseph’s Hospital, Toronto The family physician already plays a key role in delivering mental health care in most Canadian communities. Unfortunately, the working relationship with mental health services is not always collaborative or supportive. This presentation reviews the current state of the relationship between mental health and primary care services and presents a new model for collaboration–shared mental health care–which offers many benefits to primary care providers, mental health care providers and consumers of these services. The presentation describes successful examples of projects that have strengthened collaboration, including 16 XXVIth International Congress on Law and Mental Health telepsychiatry and services to isolated communities, programs that integrate mental health services in family physicians' offices, programs that aim to improve communication between the two disciplines, educational programs aimed at family physicians and changes being made in undergraduate and postgraduate training. It also discusses how these concepts are being integrated into mental health planning in Canadian provinces examining two specific examples from Ontario–Primary Care Reform and the work of the Mental Health Implementation Task Forces. Finally, the presentation outlines key challenges for shared care over the next five years. Building community readiness for reform: Public education Gerry Cooper Centre for Addiction and Mental Health, Toronto Jean Trimnell Northeast Mental Health Centre, Sudbury, Ontario In the Northeast Region of Ontario (291,292 square kilometers, 632,200 population) there are a variety of distinct mental health services distributed across eight vast (mainly rural) districts. Within this reagion is a large provincial psychiatric hospital (PPH) in the city of North Bay. Consistent with the deinstitutionalization process, this PPH is slated for closure in 2005 when a new, much smaller facility, co-located with a general hospital will be completed. This presentation discusses how a unique public education campaign has been designed by a multi-organization partnership to assist with the implementation of such reforms. This partnership values diversity and has made extensive use of contributions from volunteers and staff members alike. The Northeast Mental Health Public Education Campaign (approved for Ontario Ministry of Health and Long-Term Care funding, October 2000) seeks to shape appropriate public attitudes regarding mental illness and to create and disseminate new knowledge about public education campaigns. It will operate as a prototype campaign over a five-year period utilizing multimedia and key-influencers’ strategies and a parallel curricula development program. This presentation will report on the project’s work and evaluation plans, consumers’/significant others’ roles and other important issues, such as how the needs of a very geographically, culturally and linguistically diverse region will be addressed. Integrating research to sustain the continuum of care: The role of evidence based planning in restructuring the Ontario Mental Health System Diane MacFarlane Centre for Addiction and Mental Health, Toronto As mental health reform continues across Canada, refocusing psychiatric hospitals and community mental health programs to more effectively meet the needs of individuals with serious mental illness has become a priority. As part of this restructuring process, the Ontario Ministry of Health and Long-Term Care funded a series of needs-based planning projects in six provincial psychiatric hospitals and these regions’/districts’ community mental health systems. The goal was to employ a consistent and sound methodology for assessing the needs of current patients/clients and for identifying additional community resources to meet those needs. The Health Systems Research Consulting Unit, the Centre for Addiction and Mental Health, was commissioned to implement these comprehensive planning projects (CAPs). While a common core methodology was employed across all the projects, adaptations were incorporated to ensure that project findings addressed local concerns and interests. The primary goals were to incorporate best practice approaches into the project methodology and to gain local support for these approaches, as articulated in the project recommendations. Reflections on implementation: Pulling the pieces together–the Centre for Addiction and Mental Health experience in mental health reform Paul Garfinkel Centre for Addiction and Mental Health, Toronto Created to improve access to quality services for mental illness and substance use problems, the Centre for Addiction and Mental Health was formed in early 1998 through the amalgamation of the Addiction Research Foundation, the Clarke Institute of Psychiatry, the Donwood Institute and the Queen Street Mental Health Centre. The Centre is a teaching hospital, fully affiliated with the University of Toronto. As the largest mental health and addictions facility in Canada, the Centre has a strong voice to ensure that services are accessible, effective and adequately funded. The Centre provides a continuum of clinical programs, support and rehabilitation to meet the diverse needs of people who are at risk and at different stages of their lives and illness– from children to the elderly. In accordance with our provincial mandate, the Centre plays a vigorous role in consultation, policy development, education, training and research at the local level in communities throughout Ontario. The merger has brought together scientists who are examining the physiological, psychological and social dimensions of addiction and mental illness. 17 XXVIe Congrès international de droit et de santé mentale MENTAL ILLNESS, VIOLENCE AND SOCIAL PROTECTION July 3 juillet 13:45 – 15:45 Room NCDH–101 Chair: Pierette Sévigny, Cour supérieure du Québec Mental health law and the protection of society Michael Chan, Dorothy Cotton, James Hillen Queen’s University The Ontario Mental Health Act, like most legislation of its kind, includes provisions that allow for the involuntary detention of individuals who are thought to be a danger to themselves or others on the basis of a mental disorder. In general, these provisions are interpreted are being applicable to circumstances in which the danger is immediate and the risk to an identified individual. But what about situations in which the risk is pervasive and ongoing? Consider the case of a young man in his early 20’s who reports ongoing and worsening pedophilic rape fantasies, along with a history of chronic dysphoria, alcohol and drug abuse, periodic suicidality, and a diagnosis of antisocial personality disorder. He also has a criminal history which includes nearly forty convictions for attempted murder, theft, and assault. Although he initially sought treatment because he feared acting on his fantasies which included extreme violence, a range of target ages and necrophilia, this individual eventually dropped out of treatment. The legal/ethical questions raised by this case are significant. Is pedophilia certifiable? What is the responsibility and liability of the treating psychiatrists and team in terms of public safety? Whose role is it to control violence in society? Are situations like this best addressed by the Criminal Code or the Mental Health Act? Are psychiatric hospitals or prisons–or the streets–the most appropriate place for individuals like this? What exactly is the role of the psychiatrist? A clinician’s review of pharmacologic approaches to violent behavior John L. Young Yale University Multiple classes of medications are now available for treating the violent behaviors of mental patients, and new suggestions are constantly being added. The cynic would say that this is because none of the treatments are very effective, a truism that does not apply here. Rather, the challenge is one of matching the unique characteristics of the lifeless chemical with those of the living human patient. The more urgent a particular individual’s need for violence reduction, the more valuable accuracy is in making this match. This presentation will offer an annotated review of the literature on pharmacotherapy of violence, written to address specifically the treating clinician’s need for details relevant to making coherent selections efficiently among the diverse options. Variables affecting police procedures when dealing with the mentally ill Scott A. Maywood Toronto Police Service Gregory P. Brown Nipissing University Nationally, and internationally, police services are reporting an increase in the number of incidents in which police officers are required to respond to mentally ill and/or emotionally disturbed people. Police are frequently criticized for the way in which these situations are handled. Most information available about police responses with persons in crisis is anecdotal and few descriptive, quantitative studies have been conducted, as police services generally do not collect data specific to interactions with emotionally disturbed persons. In the absence of good information about the characteristics of police interactions with these crises, it is difficult to imagine how police officers can be better trained to respond to these situations. In response to the need for more comprehensive information about police interactions with persons in crisis, the Toronto Police Service introduced the ‘Contact with Emotionally Disturbed Person’ form in December 1998. The form was designed to enhance communication with hospital staff and collect detailed information about the behaviors commonly exhibited by persons in crisis to which police respond. This paper will describe the experience of the Toronto Police Service in developing and implementing the EDP form for use by police officers, and will report on the data collected to date. Not surprisingly, analysis of the data points to the need for better training and coordination of responses by police, hospitals, mental health professionals and others involved in responding to the needs of emotionally disturbed persons in crisis. Help versus harm: An examination of the clinical and legal aspects of physical restraint Xavier Plaus Roberts/Smart Centre, Ottawa 18 XXVIth International Congress on Law and Mental Health R. Bernadette Brissenden Barrister and Solicitor, Toronto Agencies that provide care, management and treatment of emotionally- and behaviorally-troubled individuals are frequently required to cope with aggression. As a children’s mental health center with 27-years experience in the residential treatment of severely conduct-disordered adolescents, the Roberts/Smart Centre is continually obligated to find a balance between helping clients and the attendant risk of physical harm, to both the young person and staff. In the treatment of severely conductdisordered adolescents, the potential for assaultive or self-injurious behavior occurs daily. However, there are only three approaches to managing aggression: medication, incarceration or staff intervention. This presentation will examine the clinical and legal aspects of staff who physically intervene and prevent aggression by physical restraining the young person. Physical restraint will be conceptually situated within the provision of a safety net. A rationale for such interventions, as well as current practices and training, will be examined. This component of the presentation will lay the foundation for a consideration of best practices. In the use of such interventions, agency staff are confronted with allegations of physical abuse and threatened with assault charges. Agencies can be caught between “beyond a reasonable doubt” (Canadian Criminal Code) and “balance of probabilities” (civil actions). Planning for commitment: The role of the substitute decision-maker in Ontario’s amended mental health act Suzan E. Fraser Barrister and Solicitor, Toronto Modern Canadian mental health legislation traditionally sought to strike a balance between the rights of the mentally disordered individual against society’s interest in protecting the individual and other members of society. The players in maintaining this balance have been physicians and individuals alleged to have a mental disorder. Recent changes to Ontario’s Mental Health Act bring a new player to the field: the substitute decision-maker (the SDM). The amended statute grants SDM’s two significant powers: to consent on behalf of an incapable person to that person’s treatment as part of an expanded committal criteria and to consent to a community treatment order on behalf of the incapable person. The rules respecting substitute decision-making in Ontario are well established. This paper will examine the rules for substitute decision-making in the context of the new powers granted to SDM’s and how they affect pre-crisis planning by the consumer/survivor under the new legislation. TRANSCULTURAL ASPECTS OF LAW AND MENTAL HEALTH July 3 juillet 13:45 – 15:45 Room IASL-106 Chair : Mounir Samy, McGill University The religious feeling as a factor of the development of brief psychotic disorders Tsezar P. Korolenko, D.A. Pogodin Novosibirsk Medical Academy, Novosibirsk We studied a group of 20 patients, between the ages of 16 and 60, composed of nine males and 11 females. All of them had participated in non-traditional religious cults, including the “White Brotherhood”, “Church of Christ”, or “Theosophical Society”. After some time, mental disorders developed in form of paranoid reactions, out-of-body experiences, psychosomatic crises, psychotic level of anxiety and others. The duration of the registered disorders was about 14 days. In most cases the patients returned to normal after the administration of minimal doses of psychopharmacological drugs over a short period of time (3–7 days). The different dynamic and symptoms among patients of different cultures were observed. The role of religious approach in the treatment of patients with mental disorders Tsezar P. Korolenko, E.N. Zagoruyko Novosibirsk Medical Academy, Novosibirsk A group of patients with chemical and non-chemical addictive disorders, depression and schizophrenic psychoses were included in the study. It was shown that the stimulation of religious feelings effectively eliminated the addictive fixation and the onesidedness of desire. It was revealed that most cases the patient identified with him/herself in the frame of religious confession. The stimulation of religious feelings appears to be a significant element of suicide prevention in depressed patients. The possibility of danger of the activation of religious feeling in the development of archetypal paranoid construction is discussed. 19 XXVIe Congrès international de droit et de santé mentale Criminalizing tradition and building the modern state: “Witchcraft” suppression in South Africa Richard Ralston University of Wisconsin-Madison Set in a volatile period in post-colonial African history, South Africans contested not only the limits and implications of Apartheid, but also the political viability, reach and autonomy of the African social institution known as witchcraft. Under challenge from the African National Congress (ANC), the South African minority Government struggled to retain control of public power by simultaneously mounting a concerted legislative attack against private behaviors known as witchcraft. This paper addresses three broad questions related to the South African campaign: (1) why did urban professionals from law, church and medicine respond punitively to customary witchcraft practices largely found only in the rural villages? (2) why/how did these campaigns fail? (3) what politico-medical implications are raised by the vitality of these institutions and by the failed attempts to eradicate them for the modern state on the one hand, and for community leadership and contemporary public health on the other? Conclusions: Survey and individual case data suggest that anti-traditional medicine campaigns by the Government and by individual health and legal professionals experienced only modest success because they were built on conflicted policy and objectives and only imperfectly understood indigenous African institutions. The explanations why customary approaches to physical and social distress demonstrated both effectiveness and endurance in the face of concerted state assault were four-fold: (1) African patients segregated abnormalities so that “African” maladies and “Western” medical modalities did not compete; (2) modern practitioners integrated some aspects of traditional regimes within modern domains; (3) customary specialists responded to socio-political needs of their communities that conventional modalities of state, church, and medicine did not; and (4) modern “politicized” suppression movements contained contradictory goals and elements that engendered revitalization within traditional institutions. Russian folklore’s images in dreams of patients with adjustment disorder R. Ovchinnikov Novosibirsk Medical Academy, Novosibirsk The group of 10 patients (aged 20-30 years), with a mild form of adjustment disorder was studied. We observed patients who have experienced repetitive dreams about old Russian mythology that is reflected in fairy tales images of national poems and legends (“byliny”). The typical dream includes the image of hero, who can fulfill all wishes and manipulate all extreme situations; .the beautiful woman, who must sacrifice herself to save the life of her parents; and the knight, who must kill the monster and liberate the country. It was shown that the patients showed, from adolescence, a strong tendency to self-analyze and the self-identity problems, especially in time of psychosocial moratorium. They expressed negative opinions of the current social situations, contributing to their adjustment problem. Culture-bound types of mental disorders among Siberian Turks Tsezar P. Korolenko, H.M. Muhomedzanov Novosibirsk Medical Academy, Novosibirsk The paper addresses the culture-bound syndromes of mental disorders among Siberian Turks. The observed disorders were divided into four groups: mental disorders associated with the possession of Spirits; mental disorders caused by the loss of the soul; mental disorders that develop after the casting of the Evil Eye; mental disorders of other miscellaneous types. Mental disorders connected with the Spirit’s possession included, (a) possession by the Traveling Spirit who enters the woman who consumes prohibited alcoholic beverages; (b) possession by the Red Sexual Spirit, who enters women who see the copulation of the red or brown (but not black) bull; (c) possession by the Spirit of Fire, which possess people who are careless with fire; and (d) the Spirit of a man who has committed suicide (“Orak”), who persecutes the man or woman who has attended the funeral of an individual who committed suicide, and who was the last one to leave the funeral. The collected data of several types of cultural syndromes demonstrate the role of ethnic mythology and beliefs in the formation of psychopathology and its course. All patients presented with a unique clinical picture, that included common mythology, popular customs, the same language and typical forms of amateur arts and dramatic activities. The course of observed disorders were not identical with the course of schizophrenia or mood disorder, although some symptoms had traits of formal resemblance with schizophrenic or affective bipolar symptoms. Mediation–a method of psychosocial counseling Mahfuza Akram Chowdhury Bangladesh Rehabilitation Centre for Trauma Victims The paper is written from research obtained from remote rural areas of Bangladesh, for the empowerment of distressed women, who were predominently illiterate and poor. In Bangladesh, interpersonal conflict is large barrier for national development. Interpersonal conflict may be among family members or society. Mediation could resolve conflict, accelerating the development of the country. 20 XXVIth International Congress on Law and Mental Health In my practical experience, in a baseline survey conducted by the BRCT and the Naogaon Human Rights Development Association on distressed women of rural areas, I found that more than 50% of women don’t know the age at which a woman can marry, contributing to the large number of child-marriages in Bangladesh. Although the country’s laws require that every marriage be registered at local marriage registrar office, 65.88% of marriages are not registered. In addition, in more than 77% of all marriages the parents of the bride provide a dowry. Moreover, about 54% of parents don’t know that dowries are prohibited by law and that there are legal systems in place to refuse providing a dowry. Moreover, since the marriage is often not registered, these women also fail to receive post-divorce compensation. Statistics among distressed women of rural areas concerning torture (specifically mentioned in article 35(5) in the constitution of Bangladesh) show that 73% women are unaware of the article and that almost 66% don’t know that ‘woman’s rights’ are human rights. Most of these women had been tortured, and due to ignorance they failed to receive justice. Thus, a large number of distressed women become the burden of society and impede the country’s national development. In an effort to ease the problems associated with the torture of women, divorce, child bearing and violence against women, ‘Mediation’–an alternate method of dispute–resolution–may present an alternative to psycho-social counseling. Several statistics and important case studies show the effectiveness of mediation on resolving social conflict as a new method of psychosocial counseling in Bangladesh. PSYCHOLOGY, HISTORY, LITERATURE AND THE LAW July 3 juillet 13:45 – 15:45 Room NCDH–200 Chair: Peter Bartlett, University of Nottingham Covenant, law and indeterminancy: Kieslowski’s decalogue, anguish and love Leonard V. Kaplan University of Wisconsin-Madison The Ten Commandments, the gift of law from Sinai, marked a significant moment of covenant with the Jewish people and according to the rabbis with all those who could be called righteous. The promise of the covenant is the promise of meaning for those who commit to the strictures of the 10 demands. The decalogue warrants that human life is not merely absurd or meaningless but can be lived in relationship to a God who cares and has marked, if not the way, at least a way. The form of the commandments is the form of law, the sovereign is God and only God. The Book of Samuel makes clear the problematic nature of kingship interposing between God and man. According to the rabbis the theophany at Sinai also produced a significant number of other oral laws as binding as those on the tablets. The question of the binding nature of the orality of law as opposed to written law that has so entranced academic discourse with Derrida et al has been an aspect of Judaism for a couple of millennia at least. The slavish nature of adherence to law as form has always been central to the Jewish canon as well. Amos warned that legalistic adherence without spirit warrants only penalty as a nullification of covenant. The antinomian Paul does not release brother Jews from law or commandment, but he does release the gentile for a new covenant based on love and not legal form. At a time when theology is once again entering the main stream of juridical consciousness, in the United States and elsewhere, the Decalogue has become the psycho-social rallying point for fundamentalist who wish the commandments to become placed on courtroom walls, taught in public schools and become the general artifice to reinstantiate old time religion. The name of father returns. The Polish film director, Krzytof Kieslowski prepared 10 television programs, of less than an hour each, ostensibly exemplifying the application of the particular commandment to a poignant human situation. The scene for all of the 10 is confined to late 1980’s Warsaw and a particular housing unit, but the intent and appeal is beyond the Eastern bloc and toward the human condition. Kieslowski makes clear the problematic nature of the Commandments as life directing, without disparaging any divine impulse from the ten. He presents the view with concrete exemplifications of the anguish, love and perplexity that any serious encounter with covenant means for psychology and law. This paper will argue that love and forgiveness, as well as tragedy, mark the work’s interpretative frame of the gift from Sinai. It will also argue that such current notions as commidification, reification, and normalization all inhere in the commandment to not make Graven Images and runs through Kiesolwski’s work. Why believe the experts? Reflections on Victorian psychiatry and jurisprudence Tony Ward DeMontford University Criminal trials–where the defendant’s psychiatric condition is in issue–are one instance of a difficult jurisprudential problem: how can courts reach rational decisions on whether to accept expert evidence in areas in which they are not themselves expert? One advantage of reflecting on this question in a historical context is that it is relatively easy to separate the question whether lay tribunals had good reason to believe the experts from the question whether the experts’ claims were true. Another advantage, in the particular case of Victorian debates over insanity, is that both jurists and medical writers were often commendably clearheaded in their discussion of these issues–more so, at least, than some present-day English judges. Reflection on these debates 21 XXVIe Congrès international de droit et de santé mentale tends to confirm the validity of James Fitzjames Stephen’s insight that the question whether to accept expert testimony is essentially a practical one, and for that very reason is properly left to a lay jury. Shame and responsibility in Ancient Greece: The roots of ethical psychology Gabriel R. Ricci Elizabethtown College The ancient Greeks have been perceived as morally primitive in reference to modern moral standards derived from Enlightenment rationalism. When we consider the practice of slavery and negative attitudes toward women, as well as Plato’s degradation of poetry and art in the Republic, we are forced to acknowledge our cultural and moral distance from the Greeks. The culture of shame and honor associated with the ancient Greeks, compared to the standards of universality and autonomy derived from the Enlightenment, have been labelled egoistic and heteronomous. However, in adopting Bernard Williams’ analysis from his book Shame and Necessity (1993), it can be argued that the ancient culture of shame and honor, which in fact internalises the other, not only contains the germ of modern moral philosophy but presents a more robust ethics entailing at once a civic and cosmic order. Following Williams, we should avoid the progressivist conceit that the absence of critical moral terms such as individual agency, intentionality, and responsibility means that the Greeks did not conceive of these matters in their own way. Psychiatry, morality and “Ondine’s curse” Steven Manners Novelist, Montreal Ondine’s Curse is a recent novel that explores the evolution of biological psychiatry and psychopharmaceutical research in the 20th century. A TV documentary producer, Robert Strasser, is assigned a biography of Dr. Werther Acheson, a distinguished professor at a controversial psychiatric institute. But Acheson’s experience, which has seen the twinned emergence of drug research and neurobiological models of mental functioning, cannot be adequately captured by an ahistorical medium such as television. TV requires a human angle and so Strasser turns to one of the Institute’s patients. Ondine suffers from post-traumatic symptoms after witnessing the Montreal Massacre in 1989. Her recovery is haunted by her attempts to understand the experience of Shawnadithit, the last surviving member of the Beothuks, a Newfoundland tribe that was the victim of genocide in the 1820s. Acclaimed as a literary “tour de force” that “tunnels deep into the human psyche” (Toronto Star, January 28, 2001), Ondine’s Curse “treats psychiatry as an almost mythological venture into the human mind” (Montreal Review of Books, Winter 2000/2001). Repairing the past: Ethico-legal standards for the “Duplessis Orphans” Derek Jones McGill University The annals of mental health law contain many chapters on good intentions gone so far awry that they have yielded unethical or unlawful conduct in diverse countries. Such conduct may touch mental health research or treatment. Unfortunately, legal proceedings for wrongful sterilization and wrongful research on those with mental disorders in Canada indicate that it has not been immune from such historic scandals. Against this societal context, this paper focuses on a poignant and unresolved chapter of the Canadian public agenda: the so-called Duplessis Orphans story. The story involves the causes, conditions and consequences of the institutionalization and ‘treatment’ of several thousand Quebec orphans placed in psychiatric hospitals under the charge of the Catholic Church from the 1950’s to 1970’s. The orphans’ recent claims against government and the church for redress have drawn increasing national and international scrutiny. This paper examines major avenues of formal legal recourse involved in the Duplessis story–negligence, privacy, criminal, fraud, public inquiry and trustee laws–in search of legal and ethical standards to evaluate and bring closure to this story. By what norms ought we judge a story that began unfolding some five decades ago? The question reveals the strengths, limits and evolving roles of the law in addressing historic wrongs, defining professional duties, vindicating human rights, advancing public accountability, exacting apologias, and seeking reparative justice. Closure of the story remains critical to legal and moral progress in the annals of Canadian mental health law. 22 XXVIth International Congress on Law and Mental Health 16:00 – 17:45 PATERNALISM AND AUTONOMISM - A NORDIC STUDY July 3 juillet 16:00 – 17:45 Room NCDH–101 Chair: Charles Lidz, University of Massachusetts Paternalism and autonomy: A Nordic study on the use of coercion in the mental health care system Marianne Engberg Aarhus University Georg Høyer University of Tromsø Lars Kjellin Psychiatric Research Centre, Örebro Maria Sigurdjonsdottir Blakstad Mental Hospital, Asker In order to explore some of the problems related to the use of coercion in psychiatric care, a comprehensive Nordic study was launched in the mid-nineties. The study was named “Paternalism and Autonomy–A Nordic Study on the Use of Coercion in the Mental Health Care System”. The core study, which was carried-out in the same way in all of the five Nordic countries, focuses three main areas (“levels”). Level 1 addresses the justification for the use of coercion as reflected in the different mental health acts and legal documents, level 2 concerns the reliability and validity of public statistics on rates of involuntary hospitalisation, while level 3 focuses on perceived coercion according to the patients’ own experiences. All data is gathered in such a way that analysis across the three levels would be possible, as well as comparison between the five Nordic nations. All consecutive admissions were recorded over a fixed period of time in all countries (n=6162). Twelve different hospitals took part in the study. A subsample of the patients were interviewed (n= 993). The interview focused mainly the patients’ experiences of coercion during the admission process. The paper presents details of the study design and describes methods applied in the study. Predictors for perceived coercion: Results from the Nordic Study on the use of coercion in the mental health care system Georg Høyer University of Tromsø Several studies suggest that the patient’s experience of being coerced during the admission to mental hospitals does not necessarily correspond with their legal status. Instruments have been developed to measure perceived coercion, but their validity has not been thoroughly addressed. This paper compares two different ways of measuring perceived coercion used in a large scale study on the use of coercion in the Nordic countries. The instruments used in the study were the MacArthur perceived coercion scale and a visual analogue scale, called the coercion ladder. The paper offers a description of perceived coercion among patients acutely admitted to mental hospitals in the five Nordic countries. The two ways of measuring perceived coercion are compared, and predictors of perceived coercion are determined for each of the two methods. Involuntarily committed patients in the Nordic countries Carita Tuohimäki National Research and Development Centre for Health and Welfare (STAKES), Finland Riittakerttu Kaltiala-Heino University of Tampere Marianne Engberg Aarhus University Georg Høyer University of Tromsø 23 XXVIe Congrès international de droit et de santé mentale Lars Kjellin Psychiatric Research Centre, Örebro Matti Joukamaa Oulu University Maria Sigurdjonsdottir Blakstad Mental Hospital, Asker Objective: Figures on the deprivation of liberty in the patients under psychiatric care and characteristics of committed patient populations vary greatly between countries. The main purpose of this study is to describe the involuntarily treated patients in Nordic countries and determine the differences and similarities among these countries concerning involuntary treatment in psychiatric care. Method: The study forms part of the ongoing Nordic joint study “Paternalism and Autonomy”. This study is based on the standardized registration of all admissions to psychiatric hospitals over a six–month period, covering one or more well-defined catchment areas of general adult psychiatry in Finland, Denmark, Norway and Sweden. The study design was a retrospective chart review. Result: Involuntary treatment applied to over two-fifths of all the patients, varying between 32% in Finland and 53% in Norway (p=0.001). Among the formally committed, there were no gender differences among the studied countries. There were, however, differences among countries regarding age, diagnoses and previous treatment history of the committed patients. Nearly two-thirds of the committed patients had psychotic disorder in Norway and Sweden, while in Finland and Denmark, almost four–fifths of the committed patients suffered from psychotic disorder. Conclusion: Committed patient populations vary from country to country in the Nordic countries. This is partially predictable due to differing legislations. On the other hand, as the Nordic legislations on involuntary treatment are, in practice, very similar, further research regarding treatment cultures is warranted. Legal status and patients’ perceptions of being coerced at admission to psychiatric care in four Nordic countries Lars Kjellin Psychiatric Research Centre, Örebro Georg Høyer University of Tromsø Marianne Engberg Aarhus University Rittakerttu Kaltiala-Heino University of Tampere Maria Sigurdjonsdottir Blakstad Mental Hospital, Asker Great differences in civil commitment rates between and within jurisdictions have been reported. Furthermore, it has been shown that formal legal coercion is not a reliable indicator of coercion in mental health care. In several studies, some committed patients report they wanted to be hospitalized, and some formally voluntarily admitted patients report they felt coerced to enter the hospital. As a part of a Nordic study on the use of coercion in the mental health care system, the aim of this study was to compare and analyze the relation between formal legal status at admission and coercion as perceived by patients in four Nordic countries. A total of 863 patients at one psychiatric hospital in Denmark, three in Finland, four in Norway and four in Sweden were interviewed within five days of admission using the Nordic Admission Interview (NorAI), the Coercion Ladder and the Admission Experience Scale (AES). Additional information was collected from the case registers of the patients. The degree of discrepancy between mode of admission and the patients’ perceptions of coming to the hospital voluntarily or involuntarily differed between countries. Of the legally voluntarily admitted patients, 13% in Denmark, 8% in Finland, 17% in Norway and 5% in Sweden reported they came to the hospital involuntarily. Of the formally committed patients, 6% in Denmark, 33% in Finland, 47% in Norway and 19% in Sweden reported they came to the hospital voluntarily. The results will be discussed in relation to differences in legal prerequisites and commitment procedures in the Nordic countries. 24 XXVIth International Congress on Law and Mental Health ADVOCACY UNDER ONTARIO’S MENTAL HEALTH ACT July 3 juillet 16:00 – 17:45 Room NCDH–201 Chair: James Mendel, Ontario Medical Association Role of advocacy in Ontario’s comprehensive mental health system Lora Patton Psychiatric Patient Advocate Office of Ontario The Psychiatric Patient Advocate Office (PPAO) provides independent advocacy services to patients within the current and former provincial psychiatric hospitals. We empower our clients to make informed decisions about their care, treatment and legal rights. We provide instructed, non-instructed and systemic advocacy. The existence of an independent advocacy program ensures that consumers maintain a strong voice when dealing with the government, hospitals and service agencies. No current program exists outside of the provincial psychiatric hospitals to ensure that mental health consumers have access to specialized advocacy services. With health care restructuring shifting mental health service delivery to public hospitals and community-based centers, advocacy services must respond in kind. The changing healthcare environment requires a responsive advocacy program that can assist mental health consumers regardless of where they receive their care and treatment. Such an advocacy program will truly protect the rights of patients and the integrity of the system. Ontario needs to move quickly to enshrine advocacy in the service delivery system to protect those with serious mental illness. The presenter will draw on case examples to demonstrate the importance of a strategically placed, provincial advocacy program to all mental health consumers. Examples will include: how public scrutiny through the coroner inquest process promotes the protection of client/patient rights how inquests become a means to promote systemic change and increase accountability and how a constant review of “past practices” and promotion of “best practices” provides an internal risk-management process. Rights advice under Ontario’s Mental Health Act Linda Carey Psychiatric Patient Advocate Office of Ontario Under Ontario’s MHA, rights advice is a legislated process by which patients in psychiatric facilities and persons subject to Community Treatment Orders and/or their substitute decision-makers are informed of their legal rights when a change in legal status occurs. It is an important component in the protection of individual rights. A Rights Adviser explains the significance of the situation and the options available. Upon request, the Rights Adviser assists the person in applying to the Consent and Capacity Board, in retaining a lawyer and applying for Legal Aid. The recent amendments to the MHA in December 2000 strengthened the nature and scope of rights advice delivery. The Psychiatric Patient Advocate Office (PPAO) was instrumental in influencing both the legislative amendments and the regulations to ensure improved protection for individual rights. Qualifying as a Rights Adviser now requires the completion of a training course approved by the Minister of Health. The Minister has approved PPAO’s training program. A Rights Adviser must confirm that rights advice is provided by completing a “Confirmation of Rights Advice” form, which is an approved form under the MHA. As well, where a Rights Adviser believes that it is in the best interest of the person to receive rights advice from another Rights Adviser, he or she must arrange for such services. And finally, psychiatric facilities now have the option of designating the PPAO to provide rights advice. The PPAO is now preparing to fulfill this role. The use of restraints and seclusion in psychiatric facilities in Ontario: Patient and clinician perspectives David Simpson Psychiatric Patient Advocate Office of Ontario The Psychiatric Patient Advocate Office (PPAO) in Ontario was the first province-wide advocacy program for psychiatric patients in Canada. It was established in 1983 as a quasi-independent program of the Ontario Ministry of Health, to advance patients’ legal and civil rights in the provincial psychiatric hospitals. Issues related to the use of restraint and seclusion in psychiatric facilities have been raised by PPAO’s clients. In order to identify violations of patients’ rights and entitlements under Ontario’s Mental Health Act, the PPAO took a snapshot view of facility practices regarding restraints/seclusion from the patients’ and clinicians’ perspectives. The PPAO interviewed patients and clinicians and conducted a chart audit to (1) identify issues related to the use of seclusion and restraint in select facilities–’who is being restrained and why’; (2) identify the level of care and observation offered to the patient in seclusion/restraints; (3) compare patient and clinician perspective on the use of restraints and support provision; and (4) identify systemic advocacy issues with respect to the use of restraints/seclusion. Although the study is limited, some thought provoking questions have been raised, which warrant further study and discussion. 25 XXVIe Congrès international de droit et de santé mentale SEX OFFENDERS: THEORY, RESEARCH AND TREATMENT July 3 juillet 16:00 – 17:45 Room NCDH–200 Chair: Lisa Heslop, London Police Service, Ontario Attachment deficits in sex offenders Barry Anechiarico Counselling and Psychotherapy Center, Needham, Massachusetts The character traits found to be significant risk factors in both adult and juvenile sex offenders: low and fragile self-esteem, vulnerability to humiliation, inability to tolerate strong negative emotions, absence of empathy and difficulty forming intimate attachments, can be seen as a cluster of traits that constitutes the narcissism and attachment disorder in sex offenders. This cluster of traits can be addressed in treatment both with cognitive therapy interventions that aims at the primary cognitive schemas that present in sex offenders–a sense of entitlement, the experience of emotional deprivation and feelings of defectiveness–and from a self psychological perspective that uses the self object function to facilitate the treatment process. These schemas support the interpersonal dimension of relapse prevention formulated by Barry Anechiarico to address the fragile self-esteem and attachment. Treating severely traumatized juvenile sex offenders Craig Latham Forensic Psychologist, Natick, Massachusetts Current sex offender treatment techniques borrow heavily from the adult corrections and substance abuse treatment literature. Although there is not an explicit “one size fits all” rule, few, if any provisions are made for individual differences among offenders, and certain practices are assumed to be appropriate for all. Cognitive/behavioral groups form the core of virtually all treatment programs, and many practitioners claim offender treatment that does not focus on deviant arousal is not true sex offender treatment. Even though many offenders have been victimized and some have a history of extreme trauma, we explore the trauma late in treatment, if at all, because we fear offenders will use their own victimization as an excuse for their sexual aggression. While experience has shown that these are the most effective practices for many offenders, there is increasing evidence that different techniques are required with some clearly identified groups, such as mentally ill or developmentally delayed offenders. Nowhere is recognition of individual differences more important than with juvenile offenders, who have a wide array of cognitive, emotional and developmental vulnerabilities. This workshop presents a classification scheme of five types of juvenile offenders based on their distinct treatment needs. A case study with videotaped interviews will be used to explore the treatment of a severely traumatized juvenile offender, where the approach is most different from standard practices with adult offenders. The new Salem witch trials: The crippling effects of sexual predator statutes on the treatment of sex offenders Daniel Kriegman Massachusetts Institute for Psychoanalysis The most exciting innovations to generate the greatest interest among psychotherapists are coming from new approaches to treating the human relational psyche. While the content that is the focus of relapse prevention and cognitive-behavioral models must play a significant role in any attempt to treat sex offenders, the relational context in which those issues are processed may be just as, if not more significant. We know that humans are possibly the most social creatures of all. We know that humans are the most neotanized species with the longest period of childhood dependency in close kin environments. Finally, it is clear that the explosive growth of the human brain had little to do with technology or science; the human brain developed into its current form long before complex technological innovation occurred. The human psyche is an organ that evolved to deal with the incredible complexity of kin and reciprocal relatedness and conflict in a relatively reliable tribal web of social connections (Kriegman 1988, 1990). In this context, sexual offenders (and other criminals) are seen as relational breakdown products, ie, “tribal misfits” that attempt to go outside the bounds of the social rules in order to get their needs met. Treatment approaches that deal with the core problem–poor social skills coupled with profound disconnection and hopelessness about attachments and losses–are most likely to yield success. However, despite the deep value we find in genuine relatedness, attachments also inevitably yield painful disappointments and loss. It becomes almost impossible to open up and attach (and explore the difficulties and dangers involved), when the other party is highly likely to use your vulnerability and openness to cause you severe pain. This is the state of the current treatment programs operating under the sexual predator laws in the United States. In this paper, I will examine the bizarre, Kafkaesque world of sex offender treatment in Massachusetts with its Sexually Dangerous Persons day-to-life civil commitment statute. 26 XXVIth International Congress on Law and Mental Health The psychodynamics of sexual offending George B. Palermo Medical College of Wisconsin This presentation is an attempt to formulate a theory of sexual offending that might explain the offenders’ disturbing sexual behavior. One may think of these offenders as immature, maladjusted and unable to reach out for the other in a normal way. Their aggressive or seductive behaviors are the childish expression of a basic inadequacy, which under stressful conditions reawakens their atavistic ambivalence towards women and their bodies, or towards the bodies of prepubertal children who are viewed by them as non-competitive and non-challenging to their masculine impotence. The latter is a type of cop-out to avoid facing the important other, a silent sign of their basic fear of women. In addition, since children were seen in the past as property and were disposed of at their father’s whim, this belief may still be present at an unconscious level in the sexual offender. It is postulated that at times the stress produced in some sexual offenders by their inner conflicts brings about the eruption of repressed sexual feelings leading to a dissociative state or, better, a destructuralization of their ego, which allows their unbridled search for pleasure. These are people who seem to act like drug addicts, except that in their case the drug consists of the anticipation of sexual pleasure. They, like the addicts, are repetitive in their unconscionable behavior and, like the addict, they seem to need a fix, a fix which has no lasting effect. The dilemma of the sexual offender is basically an issue of sex, of reawakened atavistic ambivalence, of displacement, perhaps made more acute by the contemporary competitive roles of men and women. Obviously, the feelings of love, resentment and anger are intertwined. The child molester and the rapist seem to be the prototypical expressions of immature behavior: attacking or seducing the object of their desire. It is proposed that the awareness of humankind’s cultural and social past is essential in the assessment of sexual offenders and the assessment should be a multifaceted exercise that should include not only mental-health and legal professionals but cultural historians and sociologists. This would help us to devise better preventive and therapeutic approaches to such behaviors, which are certainly not acceptable and not to be condoned. THE MENTAL HEALTH CARE SYSTEM IN SPAIN: CHRONICLE OF A FRIENDLY REFORM July 3 juillet 16:00 – 17:45 Room IASL-106 Chair: Federico Allodi, University of Toronto Coordination of Mental Health Services in the Age of Managed Care: The Spanish Experience Federico Allodi University of Toronto Antonio Escudero-Nafs Hortaleza District Mental Health Service, Madrid The entrance into modernity of the Spanish health care system took place in 1985 with the proclamation of the Health Reform Law. This paper follows the process of its implementation, great achievements and side effects at the levels of clinical service organization and delivery, professional participation and training and governmental policy and planning activities. As a result, an archaic system of asylum-rooted custodial care was transformed into a community-centered service, multidisciplinary and broadly oriented to the support of the beneficiaries in their own environments. Some of the phenomena concomitant to deinstitutionalization have been observed, such as rotating door readmissions and homelessness. Retraining programs have accentuated entrenched territorial disputes, and the split of the professions into a bio-medical and psychosocial dualism has become more complex with the presence of the pharmaceutical companies in the field. Some other phenomena of great import to clinical care, to the planning of services and to the public at large are mostly unrelated to the changes brought about by the reform or entirely new, such as the prevalence of delinquency and substance abuse, and the presence of large minority immigrants groups in mentally disordered populations. The response of the Spanish society and government to those problems is consistent with democratic procedures and humanitarian concerns. The arguments of this paper are supported by existing statistics and clinical epidemiology data. In summary, the mental health reform initiated a decade and a half ago brought the care of the mentally ill to the level of other European and industrialized countries. Differences worth reporting exist in some sectors. From law to reality: Community clinics, their capacity and evaluation Marifé Bravo Universidad Autonoma de Madrid Mariano Hernández-Monsalve Universidad Nacional de Educacion a Distancia 27 XXVIe Congrès international de droit et de santé mentale In 1985, the Ministry of Health gathered a number of recommendations from a wide group of mental health professionals, that were later (in 1986) incorporated in Article 20 of the General Health Act of Spain (Ley General de Sanidad). The Act followed community health principles and specifically promoted the transformation of the mental hospitals and their integration into the health care system. Its implementation has faced challenges in the uneven development across the various Spanish regions, which is, in turn, related to their administrative and financial dependency on the central structures, limited budget allocations specially for the social and rehabilitation programs and insufficient training of professionals along the community model. Demographic and clinical statistics are provided for a district mental health community service in Madrid. Patterns of mental health care in the age of globalization: The Spanish experience Alberto Fernández-Liria Universidad Alcalá de Henares Following the launching of the reform of the health care system in Spain and in the age of globalization, powerful international currents swept through all the fields of the system. These currents had a prominent impact on the causative models of severe and minor mental disorders, and the appropriate treatment and care of these disorders. They have affected training, research and distribution of resources, teaching of psychopathology and sharpened some ethical dilemmas. The paper documents observed patterns in the inpatient and community services of the health region of Madrid and specifically compares them to those present in the European Union. Support systems in mental health care: Informal and formal sectors Abelardo Rodríguez González Social Services Council, Madrid Antonio Escudero-Nafs Hortaleza District Mental Health Service, Madrid Marifé Bravo Universidad Autonoma de Madrid The Mental Health Reform of 1985 was institutionally launched with the creation of the mental centers across the various regions of Spain. At the same time, the reform promoted a national training program for psychiatrists (largely, but not exclusively) who were to be human resources for the new ambulatory community clinics. Except for a small number of sheltered residences, the family constituted the main environment of support for the mentally ill outside the hospital. For many, this, in fact, resulted in a gap between inpatient and ambulatory care. Social and occupational rehabilitation services have been the least developed. The support system is described for Spain, in general, and, more specifically, for the region of Madrid. The paper describes the movement of family associations for the mentally ill and the concern for the well being of the new immigrant populations in Spain 28 XXVIth International Congress on Law and Mental Health Sessions of the Academy Sessions de l’Académie Wednesday, July 4, 2001 mercredi 4 juillet, 2001 29 XXVIe Congrès international de droit et de santé mentale Program at a glance Coup d’œil sur le programme July 4 juillet, 2001 Parallel sessions / sessions parallèles 8:30 10:00 10:15 12:15 13:45 15:45 16:00 17:45 Bilingual Forum /Forum Bilingue: Will We Criminalize Pedophiliac Sexual Behaviours on the Internet? Criminalisation des comportements sexuels pédophiles sur Internet (31).................. MC Sex Offenders: Public Policy Dilemmas (32) ................................................ NCDH–201 Social and Historical Dimensions of Torture (until 12:15) ( 33)................... NCDH–200 Ontario’s Community Treatment Order Legislation: From Legislative Policy Development to Constitutional Change (until 12:15) ( 36) ........................... NCDH–101 Break / pause Itinérance (38) ............................................................................................................ MC Pédopsychiatrie I (39) ....................................................................................... IASL-106 Communications libres I (40) ........................................................................ NCDH–102 Social and Historical Dimensions of Torture (cont’d) (33) ........................... NCDH–200 Ontario’s Community Treatment Order Legislation: From Legislative Policy Development to Constitutional Change (cont’d) (36).................................... NCDH–101 Law, Justice and Genetics (41) .......................................................................CMEL–102 Innovations in Mental Health Systems (43)................................................... NCDH–201 Break / pause Pédopsychiatrie II (45) .................................................................................. NCDH–102 Communications libres II (46).................................................................................... MC Coercion (47)................................................................................................. NCDH–101 Competence Assessment and Guardianship: Retrospective and Prospective (until 13:45) (49)........................................................................ NCDH–200 Suicides in Custody I: Increasing Incidence and Concern (51) ......................CMEL–102 Promoting Mental Health and Decision-Making in Children and Adolescents (53) ............................................................................................ NCDH–201 Atelier I: L’échelle de psychopathie de Hare: questions et perspectives (se termine à 16:45) (54)............................................................... IASL-106 Break / pause Réflexion sur la psychiatrie légale et le leadership psychiatrique (55) ...................... MC Communications libres III (56)...................................................................... NCDH–102 Competence Assessment and Guardianship: Retrospective and Prospective (cont’d) ( 49) .............................................................................. NCDH–200 Suicides in Custody II: Is Prevention Possible? (57) ......................................CMEL–102 Outpatient Commitment ( 58) ....................................................................... NCDH–101 Diagnosis and Treatment of Sequels to Torture (59)..................................... NCDH–201 End / fin 30 XXVIth International Congress on Law and Mental Health Abstracts for July 4, 2001 Résumés pour le 4 juillet 2001 8:30 – 10:00 BILINGUAL FORUM /FORUM BILINGUE WILL WE CRIMINALIZE PEDOPHILIAC SEXUAL BEHAVIORS ON THE INTERNET? CRIMINALISATION DES COMPORTEMENTS SEXUELS PÉDOPHILES SUR INTERNET July 4 juillet 2001 8:30–10:00 Bilingual forum / Forum bilingue Simultaneous translation / Traduction simultanée Room / Salle MC Modérateur/Chair: André McKibben, Institut Philippe Pinel de Montréal Discutant/Discussant: Mario Tremblay, Ministère de la Justice, Québec Activités pédophiles sur Internet / Pedophiliac activities on the Internet Stéphane Lapointe Sûreté du Québec, Montréal Objectifs de la présentation: Le milieu scientifique en est encore à ses premiers pas dans l’étude des activités pédophiles sur Internet. Cette présentation se veut donc une introduction au phénomène et vise l’atteinte des objectifs suivants: • Sensibiliser les participants aux avantages qu’offre Internet aux pédophiles; • Sensibiliser les participants au déplacement des activités à caractère pédophile vers cet univers virtuel qu’est Internet; • Présenter brièvement quelques-unes de ces activités. Thèmes abordés et démarche de la présentation: Les activités des pédophiles sur Internet sont nombreuses et diversifiées. Nous aborderons les thèmes suivants: • Survol des principaux avantages qu’offre Internet aux pédophiles; • Aperçu des différents services d’Internet qui sont utilisés par les pédophiles; • Survol des activités à caractère pédophile réalisées sur Internet; • Distribution de pornographie juvénile; • Échange d’information; • Contact avec des victimes potentielles. Si le temps le permet, nous traiterons aussi de ces sujets: • Adaptation des pédophiles aux stratégies policières; • Exploration de certains sites Web à caractère pédophile; • Aperçu des techniques utilisées par les corps policiers dans les enquêtes liées à la pornographie juvénile. Apport scientifique: Malgré la médiatisation des activités à caractère pédophile sur Internet, leur examen, tant d’un point de vue scientifique que policier, en est encore au stade exploratoire. Les informations transmises aux scientifiques et chercheurs sur ces activités inciteront peut-être ceux-ci à explorer plus à fond cette nouvelle problématique. Criminalisation des comportements sexuels pédophiles sur Internet Will we criminalize pedophiliac sexual behaviors on the Internet ? Julius H. Grey Avocat, Montréal 1- La liberté d’expression 31 XXVIe Congrès international de droit et de santé mentale La jurisprudence de la Cour suprême et l’arrêt R. c. Sharpe en particulier; jusqu’où peut-on supprimer ces défenses « artistiques » et « scientifiques » ? 2- Les problèmes constitutionnels posés par l’Internet Quel gouvernement peut légiférer?; L’efficacité; La possibilité des accords internationaux. SEX OFFENDERS: PUBLIC POLICY DILEMMAS July 4 juillet 8:30 – 10:00 Room NCDH–201 Chair: Ivan Zinger, Department of Justice Canada The hare and the tortoise: American and Canadian approaches to sex offender policy Michael Petrunik University of Ottawa Sex offenders are arguably the most feared and/or loathed category of offender in society. With the perceived failure of clinical and justice model approaches of social control to protect the community from the enduring risk sex offenders are thought to pose and the call by victims’ advocacy groups for zero-tolerance, a politics of dangerousness centered on community protection in a risk society swept across the United States. This approach was pioneered in Washington State’s Community Protection Act of 1990 which set up post-sentence civil commitment procedures for sexually violent predators, a sex offender registry, and a threetier approach to community notification based on perceived offender risk. In 1994, the community protection movement gained impetus when New Jersey passed its influential Megan’s Law and the US federal government passed the Jacob Wetterling Act following the tragic abduction, sexual assault, and murder of the young victims commemorated in these pieces of legislation. Canada and the UK have also developed their own approaches to community protection from sex offenders that reflect the politics of dangerousness in a risk society. The result of these developments is the existence of a panoply of controls against sex offenders that aim to either separate sex offenders from the community or subject them to perpetual surveillance from within. Forced to wear the equivalent of a scarlet letter, sex offenders are likely to find reintegration into the community following incarceration extremely difficult. In this paper, I take a critical look at the politics of dangerousness with regard to sex offenders in the context of the late 20th and early 21st century. What are the factors that shape community protection approaches to sex offenders and what are the consequences of these approaches for sex offenders and society? What is the feasibility of restorative justice alternatives to a community protection approach? Prevalence of childhood sexual and physical abuse among sex offenders Lea H. Studer Alberta Hospital, Edmonton Many studies have now demonstrated a high prevalence of childhood sexual and physical abuse amongst sexual offenders. Our samples consist of 382 adults and 104 adolescents who sexually assaulted children. Seventy percent of the adult offenders reported having been physically or sexually assaulted as children, while 92.5% of adolescent offenders reported the same. Rates of sexual and/or physical abuse were not significantly different when compared across victim gender categories. There were some interesting trends in recidivism data for certain adult offender subgroups. For example, abuse towards a male child, in and of itself, was not significantly related to recidivism. However, offenders who abused a male child and reported no history of abuse themselves recidivated at the greatest rate. Just sign here: The false promise of sex offender registries Mary Campbell National Judicial Institute, Ottawa The post-sentence registration of convicted sex offenders has enjoyed a particular vogue in the United States in the past decade, and was adopted in the UK in 1997. Calls for such registries have been pressing in Canada for several years. Several provinces have now announced that registries will soon be created, including the American-style “Christopher’s Law” in Ontario. While the various models differ in terms of content, enforcement, and public accessibility, all traffic on the rhetoric of increasing public protection, and preventing and solving crimes. This rhetoric is resilient even though unsupported by analysis, sex crime patterns, or program evaluation. This presentation will compare the experiences of the US and UK models with the Canadian proposals, and examine whether there is any role for registries in the effective treatment and management of sex offenders or in the public’s 32 XXVIth International Congress on Law and Mental Health perception of and confidence in that treatment and management. Are registries at worst a benign distraction, or insidious pandering to public fears? How worried should legal and health professionals be? Sex offender punishment: changing values Alan D. Eisenberg Attorney-at-Law, Milwaukee Sex offenders are treated unlike any other criminals, especially in the area of punishment and rehabilitation. For example, drug dealers are released into the community after completion of their sentences with little ado. They can return to neighborhoods ripe with drug contacts and teeming with eager customers. Likewise, bank robbers can live beside banks, “hate criminals” can live among the targets of their anger, and batterers can return home to their wives. For a so-called sexual predator, however, release from prison is not the end of the punishment. Releasing a sex offender into the community creates concerns not associated with the release of other criminals. Sex offenders create a fear of further criminal activity; a fear that is not associated with other types of crimes. These fears have led to different policies on sex offender releases that have undoubtedly added to the offender’s punishment. Meghan’s Law legislation, for example, requires community-wide announcement in the location an offender is placed after incarceration and release. Some jurisdictions believe that this community stigmatization promotes offender rehabilitation and inhibits recidivism. More recently, community outcry has even forced sex offenders who have served their terms to remain incarcerated simply because no community wants them. Inherent in the punishment of a sex offender is the ideal of rehabilitation: the belief that whatever psychological need or drive compelled him to commit his crime can be squelched with proper intervention. Indeed, sex offender rehabilitation programs are standard for these criminals. However, if the goal is rehabilitation, or giving an offender an opportunity to put his past behind him and begin anew, the recent treatment of sex offenders is completely contrary. However, a released sex offender’s punishment no longer ceases when he completes his sentence. A policy of fear holds the sex offender up to public attention and public scrutiny, even after he is “rehabilitated” by the system. Is this disparate treatment, the unequivocal categorization of all sex offenders as potential re-offenders, fair? Some would argue that sexual predators deserve these open-ended penalties because their crimes are so heinous. However, a more concrete question may be posed: are such punishments legally permissible? Indefinite sentences are almost universally abhored; they are contrary to the ultimate ideal of rehabilitation. However, sex offenders are quickly slipping through the cracks of this ideal as the punishment of sex offenders becomes increasingly extra-judicial. Discussant: Joceyln Aubut, Centre hospitalier universitaire de Montréal SOCIAL AND HISTORICAL DIMENSIONS OF TORTURE July 4 juillet 8:30 – 12:15 (extended session) Room NCDH–200 Chair: Thomas Wenzel, Université de Montréal T 4 and the ethics of medicine Thomas Wenzel University Hospital for Psychiatry, Vienna Susanne Bisko University of Vienna H. Pochieser Independent Lawyers Association, Vienna Rarely have medical ethics been abused as systematically as in the case of the NS reign of terror in Europe. In addition to the well-known human experiments, murder, ill-treatment and torture of alleged mentally handicapped patients became a far-spread practice with several centers, including Vienna`s “Spiegelgrund” hospital, serving as focal points in the networks of destructive “medical” practices. The rationalisations that permitted this special form of “Euthanasia” are discussed on the background of the continuous suffering of present day child survivors in the present situations. Legal measures taking into account the protection and compensation of survivors constitute a neglected issue that links present and past threats to survivors. 33 XXVIe Congrès international de droit et de santé mentale Legitimacy, decency and the state: Historical aspects of the application of torture Ingrid Sibitz, Monika Krautgartner, Wolfgang Prause, Thomas Wenzel University Hospital for Psychiatry, Vienna Torture has been understood as a legally “correct” method of sanction or criminal persecution not only in modern totalitarian governments, but also in European history. Practical or “humanitarian” reasoning required that physicians participate in torture. This reasoning also provided physicians with excuses, in spite of their contradiction with the basic concept of medical ethics: not to cause intentional suffering or harm to the patientThe understanding of historical arguments to support such an–as we would say nowadays–abuse of medicine is much different from the modern arguments used in the support of torture or other debatable practices, such as the death penalty and mutilating punishment. Recent international legislation stressed the univerality of human rights in spite of regional laws, but usually focuses on areas outside the scope of professional conduct. The Nuremberg trials set a special example, and while it has not always been followed in recent years, it might be used to understand the basic reasoning. Trust in the patient-doctor relationship can be a direct victim of the condonement of such lack of establishment of practices. Treatment for victims of torture: Health care network and transcultural aspects Thomas Wenzel, Hemma Griengl, Ingrid Sibitz, W. Prause University Hospital for Psychiatry, Vienna In a study conducted by our group, diagnostic practices and perceptions of disorders related to governmental torture in different countries were gathered by questionnaire. Research appears to have a high importance in the perception of many treatment facilities, though means are targeted and not sufficiently funded in regard to primary treatment concerns. Psychiatric symptoms are listed as important in most centers, and a majority of centers supplyservices in this regard, although regional needs reflect specific common physical forms of torture in some countries. In many countries, the continued threat lurking behind day-to-day work is an aggravating factor that extends persecution from the direct victims to physicians and other health care specialists, creating a treatment structure that differs from those in economically rich countries. Training, as a factor of mutual support, and quality control would strengthen strategies that support the treatment and prevention of sequels to social violence. Home visit–A process of psychosocial counseling for the victims of secondary traumatisation due to torture Akram H. Chowdhury Bangladesh Rehabilitation Centre for Trauma Victims The paper is written on the basis of experiences at BRCT. BRCT is the first and only organization of its kind in Bangladesh providing treatment, legal aid and rehabilitation services to victims of torture perpetrated by the members of law enforcing agencies. Torture not only affects a victim, but also affects the members of the family in the form of secondary traumatization. To cope with the situation BRCT conducts a home visit program. During the home visit BRCT counselors and related persons visit the victim’s house and meet with the victim’s family members and relatives as a part of the psychosocial counseling. The home visit is a unique method used to prevent the effects of secondary traumatization on the family members of the torture victims. Several statistics and important case studies will show the effectiveness of the home visit as a preventive approach to secondary traumatization of the victims of torture in Bangladesh. The evolution of psycho-social services for persons having been subject to organized violence: Canada and Quebec. Angelica Marin-Lira Intervention Network for People Having Been Subjected to Organized Violence, Montreal Cécile Rousseau McGill University For some decades now, refugees who have experienced persecution and tortureare requesting hosting countries to show flexibility and a capacity of adaptation to face their needs. Canada, as a country that offers immigration and asylum, welcomes a great number of refugees. These people from different backgrounds have specific needs connected to their past. Official health and social services have little or nothing to offer to these refugees, leaving non-governmental organizations (NGO) to responde to their suffering. In 1983, CCTV began in Toronto. Since then, the ResCan–Canadian network for the health of survivors of torture and organized violence has grown to 12 agencies that are intended to provide therapeutic services to this group. In Montreal, with a provincial mandate, the RIVO began in the 90’s offering therapeutic services and sensibilization-training, while conducting research. Although government support is virtually non-existent, RIVO’s services are frequently used by both 34 XXVIth International Congress on Law and Mental Health formal health and social systems, and also by other authorities. Its network design allows it to face support and training demands while ensuring essential support to their workers. The globalization of human rights: Epilogue to the Pinochet Affair Federico Allodi Ontario Consent and Capacity Board The government by military dictatorship that was instituted in Chile from 1973 to 1990 was associated with massive human rights violations. At the same time and as consequence, a struggle for the protection and vindication of human rights was conducted at national and international levels. This paper reviews this movement of human rights solidarity, reaching across several continents, and specifically the contribution of the health and legal professions to this movement. Medical techniques and, above all, medical language, de-politicized and stretched to the limits of its metaphors, were used by the medical and health professions in the service of victims. The spirit of solidarity with the legal, in particular, and other professions materialized in concrete projects of victim support and human rights promotion. The indictment of general Augusto Pinochet for crimes committed against foreign and Chilean citizens represents a major step in the effective utilization of universal and national legal instruments for the protection and promotion of human rights across the globe. However, vigilance must be exercised to the dangers of the application of human rights legislation under double standards or for nationalistic purposes. The effect of isolation on prisoners: A subtle method of torture? Patrick Frottier, Reinhard Eher, Norbert Benda, K. Ritter, F. Koenig, Stefan Frühwald University Hospital for Psychiatry, Vienna In order to evaluate the phenomenon of prison suicides, a study was conducted using the case notes of all suicides having occured in Austrian prisons between 1947 and 2000, as documented by the Ministry of Justice. All personal records of all known cases were taken from the archive of each prison. Although some of the records were no longer available, the necessary information for this study was obtained. All records included the suicide verdict. In 1975, there was an important legislational reform of the criminal law in Austria. One of the major aims of this reform was the reduction of the total inmate population. Certain former offenses were no longer punishable, and suspended sentences could be more readily imposed. The average daily inmate population decreased significantly, providing penal institutions with more room, especially single-cells, per inmate. Furthermore, the education of the prison security staff was improved, and prison officers began to cooperate with the psychological staff. The psychological, psychiatric and social work staffs were increased, and better therapeutic treatment facilities were implemented. It was, therefore, expected that the incidence of suicide in jails and prisons would decrease. Method: We calculated the time dependent suicide rate/100,000 inmates per year using a Poisson-regression-model and defining different dummy-variables. Furthermore, we investigated different parameters, chosen from the case records, to determine if single-cell use has an effect on prison suicide rates. Results: (1)The only dummy-variable of significance was the year 1975 (p<0.001), meaning that between 1947 and 1975 we have a stable suicide rate. After 1975, the suicide rate increases steadily and significantly. (2) Suicide in single cells has increased significantly among prisoners on remand over the last 25 years (p< 0.05). (3) Seventy percent of suicides occured in single cells. Conclusion: The increased provision of single cells after 1975, seen as an improvement and privilege in modern times, has to be regarded as isolation and deprivation (N.B.: in former times single cells were used as severe punishment.) Origin and development of psychosocial services of torture and organized violence in Canada Joan Simalchik University of Toronto In the modern condition of “the age of refuge”, Canada has become a major country for refugee resettlement. Among these refugees are an increasing number of people who have survived torture and organized violence. In response, psychosocial services dedicated to meet the needs of this population were first established in Toronto, in 1983. Ten years later, 12 centers and programs for survivors have formed the Canadian Network for Health and Human Rights of Survivors of Torture and Organized Violence. The presentation will discuss the development of the Canadian model of care through an examination of the centers’ origins, mandates, structure, clientele and programs of service. The data presented is based primarily on a survey conducted in 2001. Similarities and dissimilarities within the range of service delivery in programs across Canada are included as are the issues identified by the centers as significant for their current activity. The changing context in which this work is conducted will be analyzed and implications for the future design of appropriate interventions will be drawn. Torture: The unspoken pain Teresa Dremetsikas, Mohamed Ahmed Canadian Center for Victims of Torture, Toronto 35 XXVIe Congrès international de droit et de santé mentale This paper will review the principles and good practices in service delivery that the Canadian Center for Victims of Torture has developed over the years. It will also review the concept and components of Psychosocial Trauma and it will build on it to provide a context to illustrate different levels at which torture operates: At the level of the individual, the family and the community. A consistent approach to the issue of torture following the same format will also be analyzed. ONTARIO’S COMMUNITY TREATMENT ORDER LEGISLATION: FROM LEGISLATIVE POLICY DEVELOPMENT TO CONSTITUTIONAL CHALLENGE July 4 juillet 8:30 – 12:15 (extended session) Room NCDH–101 Chair: Pierre Dalphond, Cour supérieure du Québec Brian’s Law: Amendments to Ontario’s Mental Health Act and Health Care Consent Act Janice Blackburn Barrister and Solicitor, Toronto This paper will describe the model of community treatment orders established in Ontario’s Bill 68 (Brian’s Law). It will attempt to describe (anecdotally) the experiences of health care practitioners who work with the new law, and (conceptually) how this model differs from others that exist in other jurisdictions both within and without Canada. Brian’s Law: Implementation issues and challenges Dennis Helm, Allen Prowse Ontario Ministry of Health and Long-Term Care Amendments to Ontario’s Mental Health Act and Health Care Consent Act received third reading in the Legislature on June 23 and were proclaimed on December 1, 2000. The amendments refined existing involuntary status and consent provisions and added a comprehensive scheme for community treatment orders for the most seriously mentally ill. The passage of new legislation is the beginning of a process which must define how the spirit and intent of the lawmakers will be translated into administrative structures. The challenges involved in implementing legislation range from the most practical questions about how to deliver services to the development of accurate monitoring and evaluation processes to assess whether the legislation is producing the results and effects that its authors intended. This paper will examine the numerous issues which were assessed and addressed during implementation of the amendments. Key elements to be reviewed include: the issues and style of needed regulations; how current regulatory processes which are a source of difficulty can be improved; the practical impact of the legislative changes on care delivery systems; what services and systems will experience pressures; what types of services will offset undesirable pressures; who needs to be consulted to identify best practices; the definition of an appropriate payment vehicle for physicians; and the overall cost of a new system of care based on available data. The challenges from June 23 to December 1 were both technical and human. Developing an effective implementation plan within rigid time lines involved managing a complex set of relationships. Internal and external stakeholders were brought together in a constructive way, mobilizing their perspectives in a cooperative and value-added fashion. The many important lessons learned in the process with respect to planning structure, process and communications will be reviewed. Brian’s Law: Constitutional challenges to community treatment order legislation in Ontario Diana Schell Ontario Ministry of Health and Long-Term Care Ontario’s community treatment order legislation came into effect on December 1, 2000 and has already been the subject of challenge under the Canadian Charter of Rights and Freedoms. This is not a suprise given the unique and highly litigious legal climate the province enjoys in respect of mental health matters. Ontario has a vigorous patient-side bar committed to opposing the legislation. It is anticipated that legal challenges will continue until such time as jurisprudence under the Act authoritatively determines how the legislation should be applied and whether there are any constitutional flaws. Ontario’s community treatment order provisions are found in amendments to the Mental Health Act and Health Care Consent Act know as Brian’s Law (Mental Health Legislative Reform), 2000. This paper will examine how Brian’s Law addresses the requirement that community treatment order legislation conform with the principles in the Charter of Rights and Freedoms In particular, the paper will examine the tension between the need to provide care and treatment for the seriously mentally ill, while respecting individual rights. The paper will also examine the relationship between detention under civil commitment legislation and consent to treatment. Increasingly, the courts are turning to mental health institutions, agencies and professionals with the expectation that 36 XXVIth International Congress on Law and Mental Health they will perform the difficult task of protecting the seriously mentally ill and others where there is a concern about individual or public safety. One way to perform this task is to provide care, treatment and supervision under the terms of a community treatment order, as an alternative to detention in a psychiatric facility. This principle is clearly articulated in the purpose section of Ontario’s community treatment order legislation. The experience with constitutional litigation in Ontario is that detention of the seriously mentally ill may be justified under the Charter, in part, so that treatment may be provided. At the same time, the courts have given constitutional protection to the notion that a mentally capable person may express wishes about future treatment which will bind health professionals, families and others during any future period of incapacity. Brian’s Law attempts to address these competing and sometimes inconsistent expectations and values and to ensure that the legislation will withstand review under the Charter. Whether the attempts are successful will ultimately be determined by the courts. Community treatment orders in clinical practice: “The rubber hits the road” Richard L. O’Reilly University of Western Ontario Bill 68, which included legislation to support community treatment orders (CTOs), was proclaimed in Ontario on December 1, 2000. This presentation uses a case-based method to examine the types of patients for whom CTOs are used in practice, the reasons for their use, the reactions of patients and their relatives to CTOs and the problems which have arisen as a result of the use of CTOs. We also examine situations, where patients subject to CTOs, have applied to the Consent and Capacity Board for a review. Finally, the presentation will outline reasons why physicians have elected not to pursue the use of CTOs inpatients who meet the legislated criteria. The historical, legal and sociological context to Ontario’s mental health reform Liam Scott Ontario Ministry of the Attorney General In 2000, Ontario enacted legislation proclaiming significant and profound changes to its mental health system. The introduction of community treatment orders and the expansion of the civil committal criteria appeared, at least on the surface, to be unabashedly simplistic, recent and largely media driven–fuelled by several high profile Coroner’s Inquests and an increasing disquiet among health professionals and lay persons alike as to the inadequacies of the involuntary civil commitment criteria. Yet, the actual evolution of Ontario’s ultimate mental health reform was far more complex, and rooted in international as well as domestic trends towards a more societal, quasi-paternalistic, conception of mental health and well being, and away from the absolute protection of individual liberty and self-determination even at the cost of diminished quality of life and even selfdestruction. Ontario, far from being revolutionary, was arguably embracing more serious, and long standing global and domestic trends in this regard. These trends will be analyzed, with particular reference to their genesis and influence in the Ontario context, and the precursors leading to Ontario’s mental health reform legislation will be assessed. Changes to Ontario’s mental health law: An update on developing interpretation of Brian’s Law at six months after proclamation D’Arcy J. Hiltz Barrister and Solicitor, Toronto Ontario’s Provincial Government enacted Bill 68, known as Brian’s Law, effective December 1, 2000. The changes to the Mental Health Act, as amended by this Bill, are the most wide-reaching and significant changes in twenty-three years. Committal criteria are expanded to allow for the involuntary psychiatric hospitalization of persons who would not have met the “dangerousness” criteria of pre-existing legislation. Justices of the Peace, Peace Officers and physicians are given broader powers to bring about an examination which could result in the involuntary psychiatric assessment of individuals with mental disorder. The new law also introduces Community Treatment Orders (CTOs) to Ontario. While similar statutory provisions exist in a few other provinces in Canada, there appears to have been very little judicial or tribunal consideration of the legal or constitutional issues raised by such legislative regimes. In Ontario, however, the CTO provisions of Bill 68 were immediately challenged by some subjects of such Orders. These constitutional and other legal challenges have proceeded before the Consent and Capacity Board of Ontario (the CCB), a quasi-judicial administrative tribunal. Some of the questions in the interpretation of complex new legislation are being answered. Many more remain. In the first six months of Brian’s Law coming into force, the CCB has heard argument on the interpretation of provisions of Ontario’s CTO regime in the context of the stated purpose of the legislation to provide a least restrictive alternative to psychiatric hospitalization to subjects of such Orders, for example. What have we learned in the process about the impact of the new law on stake-holders in the system? Where do we go from here? 37 XXVIe Congrès international de droit et de santé mentale The author is the former Senior Vice Chair of the CCB and was the Presiding Lawyer Member in all cases heard by the Board where a CTO was under review. This paper examines the new provisions of Bill 68 in light of the decided cases to date and how the rights and obligations of physicians, substitute-decision-makers and patients will need to be clarified as the process of interpreting this complex legislation continues. Discussants: Terry Carney, University of Sydney Anita Szigeti, Mental Health Legal Committee, Toronto 10:15 – 12:15 ITINÉRANCE July 4 juillet 10:15–12:15 Salle MC Modérateur: Pierre Gendron, Institut Philippe Pinel de Montréal Itinérance Marie Carmen Plante Université de Montréal La problématique de l’itinérance telle que définie par le Comité des sans-abri de la Ville de Montréal en 1987 et révisée par le Comité Interministériel sur l’itinérance en 1993 décrit «une personne itinérante est celle qui n’a pas d’adresse fixe, de logement stable, sécuritaire et salubre pour le jour à venir, a un très faible revenu, une accessibilité discriminatoire à son égard de la part des services, a des problèmes de santé physique, de santé mentale, de toxicomanie, de violence familiale et/ou de désorganisation sociale et est dépourvue de groupe d’appartenance stable». Depuis les années 70, le phénomène n’a cessé de s’amplifier, de se complexifier et de se diversifier. La prévalence de la pathologie mentale sévère est bien réelle dans cette clientèle et le taux évalué selon les pays étudiés, serait de 10 à 30%. À cela s’ajoutent les problématiques d’abus et de dépendance à l’alcool et aux substances de même qu’une comorbidité physique élevée et de mortalité augmentée. La criminalité est aussi très présente parmi cette population. Nous aborderons donc l’épidémiologie de ce phénomène, les causes connues et les approches pertinentes pour rejoindre et traiter ces personnes. Une approche novatrice: Outreach ou «repérage actif des patients dans la communauté» Geneviève Bouthiller Université de Montréal Susser a écrit «que les approches traditionnelles auprès de la clientèle des sans-abri sont nettement insuffisantes, qu’un changement radical s’impose et qu’une adaptation ethnographique est essentielle». «L’outreach» est considéré comme l’étape critique pour entrer en relation ou établir un lien avec un individu vivant dans l’itinérance en besoin criant de soins physiques ou mentaux. C’est un processus pour repérer les personnes les plus démunies et les plus vulnérables et désaffiliées qui n’utilisent aucun service et même les évitent complètement. C’est aussi la première étape du traitement pour les patients mentaux vivant sur la rue, menant vers un engagement à un traitement. C’est un processus qui peut être lent, ardu, fragile et qui se base sur des valeurs fondamentales et certains principes d’intervention qui doivent guider nos actions. Nous développerons dans cette présentation ce modèle différent et des applications cliniques que nous voulons partager avec vous. Problématique de la criminalité liée à l’itinérance Natasha Dufour Université de Montréal Plusieurs études ont été consacrées à l’activité criminelle des personnes sans adresse fixe et le résultat démontre que plusieurs d’entre elles détiendraient un dossier d’arrestation. Le taux de criminalité de ces personnes serait de 2 à 5 fois plus élevé selon les 38 XXVIth International Congress on Law and Mental Health catégories d’âges (Fournier 96). La plupart des crimes seraient relativement mineurs mais ces personnes «itinérantes» sont sujettes à un plus grand nombre d’accusations et de condamnations et ont plus d’antécédents criminels que les personnes avec domicile, selon les études. Est-ce un facteur de risque pour l’itinérance ou une conséquence sérieuse de la vie sur la rue? Il existerait aussi une interaction entre la vulnérabilité des malades mentaux «psychose et double/diagnostic» l’itinérance et la criminalité. Notre présentation élaborera sur ces importantes questions et tentera de démystifier cette problématique. PÉDOPSYCHIATRIE I July 4 juillet 10:15–12:15 Salle IASL-106 Modérateur: Frédéric Millaud, Institut Philippe Pinel de Montréal Soutien aux familles et aux parents en difficultés confrontés aux violences parents-enfants Jean-Pierre Vouche Antenne de psychiatrie légale de La Garenne Colombes, Paris L’intervention ambulatoire est une intervention contribuant à contenir la fonction parentale et à préserver des liens éducatifs, familiaux, utiles au développement basal du jeune enfant ou adolescent lorsque des violences intra familiales apparaissent. Ce travail clinique en proximité (à domicile) des parents les plus en difficultés a pour finalité de conforter les liens familiaux dans les familles avec enfants en bas âge. Après une analyse des comportements familiaux déstructurants et par anticipation de leurs conséquences pour l’enfant (violence, échec scolaire, comportement de retrait, etc…), nous pensons qu’il est souhaitable de préserver son équilibre et son épanouissement. Ce travail permet d’aider les familles à être conscientes des responsabilités à assumer vis-à-vis de leurs enfants et de voir si celles-ci, quand elles sont démunies repèrent mieux les «personnes-ressources» qui pourraient les accompagner dans le sens d’une autonomie de vie familiale. C’est aussi favoriser la transmission des avoirs entre générations. Cette création de «consultation ambulatoire spécialisée» repose sur des éléments de diagnostic élaborés auprès de collectivités locales et de leurs partenaires. Des groupes de réflexion de quartiers composés d’acteurs sociaux et d’habitants développèrent ces constats: • Les parents en difficultés devant des conduites agressives, violentes, inciviles de leurs enfants ont du mal à entrer en contact avec les services institutionnels. • Les services institutionnels déplorent l’absence des familles les plus en difficultés dans leur service. • Les enseignants et responsables d’établissements scolaires ont des indicateurs de dysfonctionnement, de dérive éducative, de souffrance des membres des familles. • Les parents délèguent leurs responsabilités, d’autant moins assumées que leur structure sociale est fragilisée, aux enseignants et aux professionnels chargés de la régulation sociale. L’encoprésie comme résultat d’aliénation parentale : étude de cas Lucia Fernandez de Sierra Pratique privée, Montréal Les cas d’aliénation parentale durant les procédures de divorce a augmenté depuis les années 1970 (Falkner 1999). Les enfants soumis à ce type d’agression, présentent une variété de symptômes autant psychologiques que sociaux, notamment le trouble réactionnel de l’attachement (RDA) et d’autres comportements reliés (Stinger 1999, Van Bloem 1999). Dans un contexte d’expertise psycho-légale pour garde légale et/ou droits d’accès (mais sans allégations de sévices sexuels), nous présentons le cas de dix enfants âgés de 5 à 8 ans, souffrant d’encoprésie, alors que, au moins un des deux parents présentait des symptômes d’aliénation parentale sévère (Relation particulière entre un enfant et un seul des parents, dans le but d’exclure l’autre parent dit «parent cible» Ward, 1993). Dans tous les cas, sauf un, tous les membres de la famille de chaque enfant ont complété des tests psychologiques et des entrevues cliniques. Les résultats révèlent que dans la plupart des cas, le parent aliénateur souffre de troubles de personnalité (paranoïque, narcissique ou antisociale) et/ou a des liens intenses avec un autre pays. Le trouble factice par procuration: aspects cliniques et légaux Florence Chanut Institut Philippe Pinel de Montréal Johanne Boivin Hôpital Ste-Justine, Montréal 39 XXVIe Congrès international de droit et de santé mentale Objectifs pédagogiques: 1. Sensibiliser les psychiatres à l’existence du trouble factice par procuration; 2. Présenter les critères diagnostiques du DSM-IV, décrire la présentation clinique, les démarches diagnostiques et les modes d’intervention; 3. Recommandations pour faciliter l’identification des parents à risques de violence; 4. Procédures légales à faire dans de tels cas. Pour poser le diagnostic selon le DSM-IV, il faut qu’il y ait production ou feinte intentionnelle de symptômes ou signes physiques ou psychologiques, en l’absence de motifs externes à ce comportement, chez une personne qui est sous les soins d’un autre individu. La motivation est d’assumer indirectement le rôle de malade. Le trouble est actuellement à l’étude sous l’appellation de trouble factice non spécifié (par procuration). Épidémiologie: la prévalence exacte est inconnue, mais serait rare si l’on respecte une définition stricte, quoique des centaines de cas soient rapportés dans la littérature pédiatrique. Généralement le trouble implique une mère et son enfant, dont l’âge au diagnostic va de 1 mois à 21 ans, en moyenne 3 ¼ ans. L’intervalle entre le début des symptômes et le diagnostic est long. Une bonne part de la morbidité est iatrogène sous forme de tests diagnostiques invasifs ou douloureux, de chirurgies non indiquées, etc. Présentation clinique: elle est généralement multisystémique, quoique tout symptôme ou maladie puisse s’y prêter. Les plus fréquents concernent le SNC, les saignements ou l’appareil gastro-intestinal. Les moyens pris pour fabriquer les symptômes sont très variés. Les signes d’appel seront élaborés au cours de cette présentation avec le support d’une présentation de cas. Conduite: minimiser le délai avant d’évoquer le diagnostic avec l’objectif prioritaire de protéger l’enfant ainsi que sa fratrie, puisque le pronostic est souvent sombre. Des informations collatérales sont nécessaires et le travail en équipe multidisciplinaire est recommandé. Un suivi est primordial, en lien avec le pédiatre traitant, le travail social et la DPJ. Le rôle du psychiatre sera exploré, à la fois auprès des parents et de l’enfant, mais aussi auprès de l’équipe traitante. La procédure légale recommandée sera développée, ainsi que les obstacles les plus souvent encourus dans cette démarche. COMMUNICATIONS LIBRES I July 4 juillet 10:15–12:15 Salle NCDH–102 Modérateur: Gilles Côté, Institut Philippe Pinel de Montréal Un patient souffrant d’un double diagnostic, d’une déviance sexuelle et/ou d’un problème psychiatrique, peut-il être déclaré irresponsable suite à une évaluation psychophysiologique? Hendrik J. Bütter, Samia Attia-Galland et Ginette Pharand Centre Hospitalier Pierre-Janet, Hull, Québec Introduction: Un désaccord existe souvent entre les professionnels de la santé mentale et ceux du domaine légal à savoir si un patient souffrant d’un trouble mental est apte à comprendre la légalité ou l’illégalité de son geste et s’il avait l’intention de planifier et de perpétrer ce geste inapproprié. Objectif: Le but de cette recherche était d’évaluer ces groupes de gens manifestant: (1) un double diagnostic (n=11); (2) les déviants sexuels (n=16) et (3) syndrome psychiatrique (n=19). Les trois groupes de patients furent comparés par: comportement phénotypique et leur intelligence émotionnelle et cognitive, leur tempérament, leur personnalité et psychophysiologie. Méthode: Tous les patients furent évalués afin de déterminer leur capacité de compréhension et leur aptitude à planifier. Tous les indices psychophysiologiques, le tempérament, la personnalité et l’intelligence furent analysés avec «Multiple Discrimination Analysis» (SPSS. 1999 p.244-292). Résultats: L’analyse Discriminante Multiple révéla que les patients du groupe psychiatrique étaient: a) moins intelligents (QI) (p 0.5), b) introvertis (p 0.001) et c) émotionnellement moins stables (p .06) que les gens composant le groupe de double problématique de même que ceux du groupe présentant des déviances sexuelles. De plus, les patients du groupe des déviants sexuels et du groupe de double problématique démontrent une attitude significativement plus négative face aux traitements et au travail lorsque comparés aux personnes du groupe souffrant d’un syndrome psychiatrique. Conclusion: Les résultats préliminaires de cette étude confirment notre expérience clinique en ce sens que l’évaluation ne démontre pas un manque de compréhension ni d’intentions des actes inadéquats commis par les personnes de ces trois groupes. Finalement un profil comportemental de chacun des groupes sera discuté. 40 XXVIth International Congress on Law and Mental Health Psychopathie et justice réparatrice Hubert Van Gijseghem Université de Montréal Il y a une insatisfaction grandissante par rapport au système pénal actuel auquel on reproche, outre sa lenteur et ses problèmes organisationnels, le fait que les doléances des victimes ne soient pas suffisamment prises en compte et que, sur le plan de la réhabilitation du délinquant, le système expérimente donc à plusieurs endroits avec la déjudiciarisation ou la dépénalisation du moins lorsqu’il s’agit d’infractions mineures. On parle alors de traitements alternatifs ou d’autres mesures de rechange. Si un impact important a été observé sur la justice des mineurs d’abord, les traitements non-judiciaires ont aussi été progressivement tentés aussi là où il s’agissait du contrevenant adulte. L’acte criminel est toutefois malheureusement souvent commis par un être particulier, celui que nous appelons le psychopathe ou, selon une autre terminologie, l’individu aux prises avec un trouble de la personnalité antisociale. Selon les recherches récentes sur les hommes reconnus coupables d’actes criminels, la prévalence de la psychopathie dans cette population se situerait entre 15 et 30%. Il a été démontré aussi que le psychopathe commet un nombre de délits significativement plus élevé que les autres délinquants. On peut donc estimer que la plupart des délits sérieux sont l’œuvre de la personne aux prises avec une personnalité antisociale. Compte tenu de ces facteurs, il est fort à parier que, lorsqu’on flirte avec l’idée d’une généralisation de la justice réparatrice, on pourrait bien donner dans la promotion d’une dangereuse illusion. Couple et comportements antisociaux Guillaume Galbaud du Fort et Lucy J. Boothroyd Hôpital Général Juif, Montréal Roger C. Bland, Stephen C. Newman Université de l’Alberta Cette étude s’est intéressée à la ressemblance entre conjoints pour les comportements antisociaux sur un échantillon de 519 couples de la population générale. Pour déterminer s’il existait une ressemblance prémaritale pour les comportements antisociaux, nous avons d’abord examiné les comportements antisociaux présents avant l’âge de 15 ans. On observait une ressemblance conjugale significative pour l’existence d’au moins trois types de troubles des conduites, avec un odd-ratio (OR) égal à 4.02 (IC 95%: 2.03, 7,96). Pour les comportements antisociaux survenus à l’âge adulte (18 ans ou plus), on observait une ressemblance significative pour l’existence d’au moins quatre types de comportements antisociaux (OR = 20.1 [5.97, 67.5]). Deux hypothèses peuvent être proposées pour expliquer la ressemblance conjugale très forte pour les comportements antisociaux de l’adulte: (1) une ressemblance prémaritale (assortative mating) pour les comportements antisociaux de l’adulte, les sujets antisociaux ayant tendance à choisir pour conjoints des personnes présentant elles-mêmes des comportements antisociaux; (2) une contamination postmaritale, les conjoints de sujets antisociaux développant progressivement au fil de la vie conjugale des comportements antisociaux. Les arguments en faveur de chacune de ces hypothèses seront présentés et discutés. LAW, JUSTICE AND GENETICS July 4 juillet 10:15 – 12:15 Room CMEL-102 Chair: Beverlee Ann Cox, University of Hawaii Using analogies to explain genetic concepts to lawyers Hamish McCallum University of Queensland This paper will explore the teaching of genetic concepts to lawyers, suggesting that a useful teaching tool is the use of analogies. The particular analogies utilised are that of language, that of law and that of manufacture. These are utilised in the following way in this paper: (1) DNA-RNA-Protein: language analogy. DNA and RNA are like dialects of the same language. They “understand” each other, although DNA uses deoxyribose sugar and adenine pairs with thymine while RNA uses ribose sugar and adenine pairs with uracil. The DNA/RNA (nucleotide) language has four letters, adenine, thymine/uracil, guanine and cytosine. Words are three letters long. Protein is a different language, which is translated from the RNA dialect using the ribosome as translator. The 64 three-letter words of the nucleotide language represent the 20 amino acids of the protein language, plus words which signify the beginning and end of a particular sentence. (2) Function of DNA: a legal analogy. DNA is transcribed (“written over”) to RNA, since both are in the same language–nucleotides. It is translated into protein, since protein is written in a different language–amino acids. DNA is written in the legalese of legislation (whereas, inasmuch as, heretofore). It is like the constitution. RNA is in simpler language and contains shorter documents which appropriate people can understand and act upon. The number of copies of RNA needed depend on how much of the translated protein is required, whereas there only 41 XXVIe Congrès international de droit et de santé mentale needs to be one full master copy of the DNA at head office. (3) Function of DNA: a manufacturing analogy. DNA is the master blueprint for construction of a car (the whole organism). Copies of the whole master plan are kept in each of the factories involved in making the car (cells). Each factory then makes multiple photocopies of the part of the plan necessary for that factory’s task (RNA). So different factories would make copies of the plan relevant to the metal work, upholstery, engine, tyres, brakes, paint etc (structural proteins). The plan also specifies the construction of machines to carry out the construction (enzymes) and mechanisms for communicating between factories to ensure that production of car components is co-ordinated. Reflections on genetics and genocide from Down Under: Can Australia take stock of the past as it constructs the building blocks of the future? Barbara Ann Hocking Queensland University of Technology Compensation is a primary legal mechanism to provide recompense for harm. It is a feature of both common (Anglo-Celtic) law and of civil (European) law systems. In both systems it deals with harms that occur across the world. It has featured, in particular, in claims for product liability, vehicle accident- and workplace accident-related harm. This form of claim is common to both the common law and the civil law system, although each system of law has developed distinctive features. While there are differences between the common law and the civil law jurisdictions in this context, there have been distinctive, new and common features to emerge from the concept of compensation over the past decade. Chief among these is the search for a unifying principle of compensation, one that can encompass the most recent pressure upon this area of law: compensation that reflects reparation for wrongs, now the subject of broad human rights or humanitarian concern. Such wrongs include criminal actions by the state and breaches of duty of care by state bodies leading to abuse and neglect of children. This paper will canvass some recent cross-jurisdictional cases with a view to establishing commonalities in the quest for a global shift from compensation to reparation. It will look, in particular, at the situation in Australia where there have been concerted calls for compensation for the ‘stolen generation’ of Aboriginal children removed from their families under government policy during many decades of the 20th century. The communal and inter-generational effects of this breach of their human rights continue to resonate today, and the eugenic aspects of the policy continue to be debated and disputed. In the compensation context this situation raises problems about entitlement to compensation, particularly since claims for compensation may involve injured individuals and injured communities. This paper looks at the eugenics issues and the compensation issues arising from this key unresolved human rights dilemma. Using genetics for the identification of missing children Michele Harvey-Blankenship University of Toronto Mary-Claire King University of Washington Genetic techniques can aid in the documentation of war crimes and the identification of the victims of human rights violations. To this end, we have been using genetic sequencing techniques to assist in the identification victims of war crimes, genocides and kidnappings. In particular, we have genetically identified of victims of genocide from Bosnian, Croatian and Rwandan mass graves, and missing children from Argentina and El Salvador children. On a case by case basis, we sequence DNA from bone of the victims or blood spots of the children, and from blood from their potential maternal relatives to determine possible biological relationship. Specifically, we are sequencing the hypervariable regions, HRV-1 and HRV-2, of the mitochondrial origin of replication, a 1200-base pair region that can be used to distinguish maternal families. Continuing analysis of cases and the establishment of a mitochondrial DNA sequence database will assist in future identifications and the historical documentation of these gross human rights violations. Defining Genetic Information: Volume, Depth and Speed Trudo Lemmens, Lisa Austin University of Toronto In dealing with the emerging concerns regarding genetic information, the first question policy makers need to address is whether and how genetic information is unlike other health information, posing problems that require a unique regulatory response. This paper first analyzes traditional arguments invoked to distinguish genetic information, showing that many regulatory approaches uncritically assume differences where there are none. It is claimed that the combination of the following three elements constitutes the primary reason why we have to develop appropriate regulatory measures or adapt existing ones to deal specifically with the challenges of genetic information: the volume of information that can be extracted from one sample; the speed of testing; and its link with computer technology. These features do not raise new concerns so much as augment traditional concerns regarding the uses of health information. But even if these concerns are not in themselves new, the new contexts in which they are raised may require different types of responses, or additional responses, than those pertaining to more traditional health information. Examples of novel types of genetic research will be given to highlight particular ethical issues raised by the new genetics. 42 XXVIth International Congress on Law and Mental Health Patenting the human genome: The colonization of health in a new global era Albert Wallrap York University The law of intellectual property provides a means by which the most wealthy nation states and multinational corporations can colonize other nations, minority groups and individuals. Referring to international law, these corporations and nations have imposed onto others their political ideologies concerning the role of human genetics in society. With growth in knowledge of the human genome–or the “human cartography”–these corporations and nation states have gained unprecedented control over responses to health and environmental concerns. International and global interests may supersede national and local interests. Health care systems, in particular, seem susceptible to colonizing forces that claim new areas of the public sphere in the name of private, for-profit corporations. Patent law may protect corporate control over new innovations and improvements in the application of knowledge about human genetics. By separating nature and human invention (culture), the law may provide corporations with the ability to control and exploit the “humanness” of the human body as a commodity. Patent law presupposes the separation of: subject (inventor) and object (patentable subject matter); the new and unobvious and the old and obvious; and utility and non-utility. This paper challenges the democratic legitimacy of the current international system of patent law where wealthy nation states and multinational corporations have substantial control over resolving disputes between local and global views, particularly those concerning public interests in the patentability of human genetics and in the compulsory licensing of a patented invention. INNOVATIONS IN MENTAL HEALTH SYSTEMS July 4 juillet 10:15 – 12:15 Room NCDH–201 Chair: Trevor Hadley, University of Pennsylvania Risking rights: Proposed reform of English mental health law Peter Bartlett University of Nottingham In December 2000, the government published its white paper on the reform of mental health law, heralding the most significant reconsideration of mental health law in England and Wales in almost half a century. The expert panel established to advise the government on these reforms had based their approach on a variety of principles. Insofar as possible, treatments for mental disorder were to be treated in the same way as physical disorders (a principle of non-discrimination). Values such as autonomy figured highly. Differential standards of intervention were proposed for those of differing decision-making capacity, and due process safeguards were introduced. The government’s response takes a markedly different tack. Non-discrimination, autonomy, and capacity have all been abandoned as principles at the base of the legislation, and due process safeguards have been considerably reduced. Instead, the government’s objective would appear to be expanded enforcement of treatment regimes. In the words of the Minister of Health, “Non compliance can no longer be an option when appropriate care in appropriate settings is in place. I have made it clear to the field that this is not negotiable.” The white paper adopts a variety of strategies to justify the more restrictive approach. Chief among these is the appeal to risk: wider powers are said to be necessary to prevent violence by people with psychiatric problems. However, closer examination of this claim exposes it as problematic. Homicides by people with mental disorders are lower than they have been for decades, and there is little evidence to demonstrate that the increased powers proposed would reduce these rates appreciably. Further, the proposed amendments do not concern merely those at risk. The proposed criteria for coercive orders may be justified not merely by risk to the individual or to others, but alternatively on an ill-defined concept of ‘best interests’ of the individual concerned. The focus in the white paper on the prevention of risk draws attention from this considerably broader function of the proposed legislation. Personal and legal constructions of ‘care’ in mental health Jeannette Henderson Open University The construction of ‘care’ in the professional and the UK legislative and policy arenas has been the focus of much interest in recent years. The introduction of the Carers Act and the strategy document ‘Caring for carers’ highlight the importance government places on the ‘carer’ role. In mental health a ‘carer’ may also be a nearest relative as defined by the Mental Health Act 1983 and have rights and powers under that Act. Growing attention to the needs of ‘carers’ in their own right and a recognition of the conflicting needs of ‘carers’ and users of services informs practice in health and social care, whereas discourses of care focus on ‘care’ as duty, burden and responsibility. The complexity of the roles and tasks that make up the lived experience of someone who ‘cares’ for and about another is well documented, especially in the areas of older people, physical disability and learning disability. This paper seeks to locate individual experiences of ‘care’ in mental health alongside the construction of ‘care’ in policy and legislation within mental health in the UK. It is argued that discourses of ‘care’ developed in 43 XXVIe Congrès international de droit et de santé mentale relation to, say, older people or people with learning disabilities do not fit easily in mental health. Professional and legal expectations of the role of a ‘carer’ of people in a relationship where one or both partners have a diagnosis of manic depression may not be shared by the people themselves. The paper draws on preliminary research with partnerships and couples, and an analysis of the development of ‘care’ in policy and law to suggest that, while practitioners in health and social care recognise the needs of people who consider themselves to be ‘carers’, not all people subscribe to the identity of ‘carer’ or ‘cared for’ in their relationship. Those involved in Mental Health Act assessments and appeals against detention need to ground approaches in people’s own experiences and meanings. Human rights v. public protection: English mental health law in crisis? Laura Davidson University of Cambridge In England, the government is currently undertaking root and branch reform of the law relating to mental health. This paper will investigate the rights of the mentally disordered in the context of this reform, critically examining the extent to which the shift towards change has been caused by a crisis in mental health law. It will suggest that the lack of faith in relation to the current framework for the detention of the mentally disordered which has led to the call for reform has been fuelled by the media, rather than by true failings in the law. Of particular controversial significance is the government’s intention to introduce a new indefinite (though reviewable) detention order for those with severe personality disorder who are considered dangerous. The fact that such orders are intended to apply to offenders and non-offenders alike has caused concern. Indeed, there is evidence that the medical profession has been thrown into disarray, with a claim that the new order may be boycotted (see BMJ, 7 April 2001 (Volume 322, Issue 7290)). It appears that ‘treatment’, hitherto the key to the lawfulness of detention on the basis of mental disorder, is rapidly being replaced by ‘management’. The inevitable tension between the right of the mentally disordered person to liberty and that of the general public to protection is becoming heightened; indeed, the recent incorporation into English law of the European Convention on Human Rights and Fundamental Freedoms by way of the Human Rights Act 1998 is already having an impact on mental health law. Innovation with regards to Alberta Mental Health Forensic Psychiatry Services delivery model: Emphasis on community forensic psychiatry geographic teams’ delivery of services Denis Morrison, Kenneth Hashman University of Calgary In Alberta, forensic services have been recently integrated as part of a provincial forensic psychiatry program. The Provincial Forensic Psychiatry Program focuses on integrating services with the community and facilities across the province. The Provincial Forensic Psychiatry Program of Alberta has to provide expert and specialized inpatient and community assessment, treatment, rehabilitation, follow-up, consultation and education-research services for, or related to, adults and adolescents with mental health problems who are in conflict with the law. The target population includes adults and adolescents who are 12 years of age or older, in conflict with the law or thought to have mental health problems, legally mandated for assessment and treatment services and require assessment and treatment for mental health or behavior problems. Priority is given to individuals who are on probation, those with court-ordered treatment conditions, sexual and violent offenders and individuals with severe or persistent mental illness. Community Forensic Psychiatry Services are to be developed in partnership with the Government Ministries inclusive of Justice, Regional Health Authorities, Alberta Mental Heath Board, Community Mental Health clinics and provincial programs. Interdisciplinary team members of the community geographic teams will be part of, and coordinated through, one of the clinical core centers of the Provincial Forensic Psychiatry Program. Mental health treatment services are to be provided in the community whenever possible for forensic psychiatry clients. These services would include individual, family and group therapies for violent, sexual, mentally ill, not criminally responsible, and other adult and young offenders, and psychiatric clinics in correctional facilities and group homes. Community geographic teams will be developed to work in conjunction with core forensic psychiatry services situated in Edmonton and Calgary. Community geographic teams are defined as dedicated resources that will be developed in partnership with Regional Health Authorities, existing Community Mental Health clinics and other provincial programs. These resources will include direct and indirect services in other regional centers and rural areas for those individuals who have difficulty with assessment and treatment due to distance, transportation, lack of forensic psychiatry expertise in more remote areas. Consultation-liaison services would be available for clients who access the general mental health crisis services that are available in all regions, thereby diverting clients who would have previously been directed to the forensic system. Other specialized services which would be offered would consist of provincial family violence treatment programs and diversion strategies which would, again, divert mentally ill individuals from the justice system to the general mental health system. Alberta’s Partnering Deputies approach to issues of mental health and justice Ken Tjosvold Alberta Ministry of Justice 44 XXVIth International Congress on Law and Mental Health Ken Sheehan Alberta Mental Health Board In recognition of the shared responsibility between ministries and the community, with respect to mental health and justice related issues, Alberta has adopted a unique approach. A Partnering Deputies Committee for Mental Health and Justice has been created to support the delivery of services at a provincial level. Working in partnereship as government ministries (Alberta Health and Wellness, Children’s Services, Justice, Community Development, Human Resources and Employment) with non-government board organizations; namely the Alberta Mental Health Board and AADAC, there is a commitment to collaboratively plan, develop and implement an integrated approach to improving service delivery/support to Albertans with mental illness and involved, or with the potential to involved, with the justice system. The purpose of the Partnering Deputies Committee is to provide mental health and justice initiaves with an authoritative and decision-making body to ensure successful implementation, consistent with strategic direction and policy framework. The authors will describe the process used to develop an integrated service delivery model, and teh Terms of Reference of the Partnering Deputies Committee, Mental Health and Justice. Examples of four provincial initiatives that have been developed from this approach will also be presented inclusive of a Provincial Family Violence Frameweork, Provincial Diversion Strategies Framework, Young Offender Services and a provincially focused Forensic Psychiatry Program. Sydney Magistrates’ Court Psychiatric Service: The first year Jonathan Carne University of New South Wales The Australian state of New South Wales has a population of 7.5 million, the capital, Sydney, a population of 4.5 million. Central Local (Magistrates’) Court is the court of summary jurisdiction for the inner city area covering the major hotel, business and tourist district, a number of residential areas, and a deprived inner city area with a number of hostels for the homeless and a significant population of itinerant street dwellers. The court processed more than 4000 cases in 1998, the most recent year for which statistics are available. In February 2000, a new psychiatric assessment service was established in the Central Local Court covering the inner city region of Sydney. Central Local Court Psychiatric Service is manned by a full-time psychiatric clinical nurse consultant, a part-time consultant forensic psychiatrist and a roster of on-call trainee forensic psychiatry registrars. In its first year of operation, the Central Local Court Psychiatric Service received more than 200 referrals. This paper will present an analysis of the first year of operation of the service, look at some of the issues raised in the process and the implications for the future of this and similar services. 13:45 – 15:45 PÉDOPSYCHIATRIE II July 4 juillet 13:45–15:45 Salle NCDH–102 Modérateur: Sylvain Palardy, Université de Montréal Prévention chez le très jeune enfant (0-6 ans) de troubles graves du comportement: une clinique d’attachement Yvon Gauthier, Gloria Jélius et Gilles Fortin Hôpital Ste-Justine, Montréal La théorie de l’attachement développée par Bowlby dans les années 60-70 a conduit à d’importantes recherches longitudinales qui démontrent l’importance de la qualité de l’attachement d’un enfant pour son développement ultérieur. Plusieurs patterns d’attachement ont été décrits par Ainsworth, mais plus récemment Main et Solomon ont décrit le pattern d’attachement “désorganisé-désorienté” (D), que l’on retrouve surtout en milieu de maltraitance. Le suivi de ces enfants démontre la présence de comportements agressifs à 5 et à 7 ans. Le suivi à plus long terme démontre la présence de réactions de dissociation à plusieurs moments du développement. C’est sur ce fondement théorique et clinique que nous avons développécette clinique d’attachement où, suite à une demande d’un intervenant des Centres Jeunesse concernant un enfant 0-6 ans qui lui pose problème, pédiatre et pédopsychiatre évaluent le développement de l’enfant, tout en observant ses liens d’attachement à sa famille biologique et à sa famille d’accueil. Les recommandations auxquelles nous en venons ont pour principal objectif de favoriser la continuité des liens d’attachement et d’éviter au maximum les séparations avec les personnes significatives, pour que le développement de cet enfant puisse se poursuivre ou qu’il puisse réparer les dommages affectifs déjà présents. 45 XXVIe Congrès international de droit et de santé mentale Quelques illustrations cliniques permettront de rendre compte du travail fait depuis 6 ans dans cette clinique. Le rôle préventif d’une telle approche à l’intérieur des Centres Jeunesse sera particulièrement souligné, ainsi que son influence en Chambre de la Jeunesse où le concept de “parent psychologique” vient graduellement à prévaloir sur celui de “parent biologique” dans les décisions prises par le Tribunal. COMMUNICATIONS LIBRES II July 4 juillet 13:45–15:45 Salle MC Modérateur: Monique Tardif, Institut Philippe Pinel de Montréal Analyse des traits pervers chez les délinquants sexuels: étude exploratoire à l’aide du test de Rorschach Joanna Smith Antenne de Psychiatrie et de Psychologie Légales, Paris En complément de l’analyse à l’aide de la méthode Exner, une grille de lecture des traits pervers au Rorschach a été construite à partir des éléments de réflexion proposés par C. Merceron, O. Husain et F. Rossel dans leur travail portant sur les organisations perverses de la personnalité à travers le Rorschach (1985). Ce travail exploratoire teste l’hypothèse selon laquelle les délinquants sexuels présenteraient davantage de traits pervers que les délinquants non sexuels. L’analyse des traits pervers de huit protocoles de délinquants sexuels comparés à huit protocoles de délinquants non sexuels va à l’encontre d’une telle hypothèse, et tendrait à montrer que la différence entre les deux groupes se situe davantage à un niveau qualitatif. En effet, les délinquants sexuels semblent se distinguer des délinquants non sexuels par leur attitude spécifique face à la problématique du manque. Il existe plusieurs questionnaires pour évaluer la problématique des délinquants sexuels. La limite de ces outils réside néanmoins dans la facilité avec laquelle certains délinquants sexuels peuvent «truquer» leurs réponses. Le test de Rorschach nous semble sur ce point un intéressant outil complémentaire aux questionnaires. C’est pourquoi nous avons cherché à développer des grilles de lectures du Rorschach plus spécifiques à la délinquance sexuelle, comme la grille de traits pervers présentée ici. Le traitement pharmacologique des agresseurs sexuels: sur quoi appuyons-nous notre pratique ? France Proulx et Benoit Dassylva Institut Philippe Pinel de Montréal Le traitement pharmacologique des agresseurs sexuels suscite de nombreuses questions que ce soit dans le milieu légal, le milieu thérapeutique ou dans la société en général. Ces questions pourraient être résumées ainsi: 1. Quels agresseurs sexuels devraient être traités pharmacologiquement ? 2. Quel(s) médicament(s) choisir? 3. Pour quelle durée et à quel dosage? 4. Quels en sont les effets indésirables ? 5. Quelles sont les preuves de leur efficacité? 6. Qu’en est-il de l’observance et du consentement au traitement? Afin de répondre à ces questions, nous présenterons une revue critique de la littérature, en portant plus particulièrement notre attention sur les caractéristiques des études (contrôlées ou non) en ce qui concerne l’échantillon examiné, les médicaments utilisés, les mesures de leur efficacité et la durée du suivi. Ainsi nous pourrons déterminer quelles questions peuvent être répondues scientifiquement dans l’état actuel de nos connaissances et lesquelles demeurent sans réponse. Nous examinerons également quel serait le devis de l’étude idéale, en le comparant aux devis des études actuellement publiées. Une bibliographie des études répertoriées sera fournie aux participants. La carrière criminelle des agresseurs sexuels Jean Proulx, Marc Ouimet, Sandra Boutin et Patrick Lussier Université de Montréal Les études concernant la récidive chez les agresseurs sexuels sont nombreuses (Proulx, Tardif, Lamoureux et Lussier, 2000). Cependant, cette dimension de la carrière criminelle est très limitative. En conséquence, le but de la présente étude est de fournir un tableau détaillé des caractéristiques de la carrière criminelle des agresseurs sexuels et ce, à partir des indices opérationnels suivants : la fréquence, la variété, la précocité, la lambda, la spécialisation et l’évolution de la gravité. Les données concernent la 46 XXVIth International Congress on Law and Mental Health carrière criminelle officielle (SED) de 550 agresseurs sexuels. Les résultats indiquent que les pédophiles commettent moins de crimes violents et économiques que les violeurs. Également, ils sont moins violents lors de leurs crimes sexuels et leur degré de spécialisation est plus élevé. Finalement, les pédophiles qui agressent une victime inconnue sont plus souvent des récidivistes sexuels. Les implications théoriques et pratiques de ces résultats seront abordées. COERCION July 4 juillet 13:45 – 15:45 Room NCDH–101 Chair: Virginia Aldigé Hiday, North Carolina State University Mental health advance directives in civil commitment John Q. La Fond University of Missouri-Kansas City Over the last decade or so, researchers and policy-makers have become especially interested in determining the extent to which mentally ill patients who are civilly committed or voluntarily hospitalized perceive their experience as coercive. This topic has become more salient with the increased use of outpatient commitment by different states. The MacArthur Research Network on Mental Health and the Law Coercion Study has conducted extensive research on this topic. It concluded, inter alia, that the “amount of coercion experienced is strongly related to a patient’s belief about the justice of the process by which he or she was admitted.” Policy-makers, clinicians and others are interested in determining whether treatment outcomes for patients who are hospitalized or committed as outpatients might be enhanced if steps were taken to minimize patients’ perceptions of coercion in this process. During this period there has also been a great deal of interest in the use of Mental Health Advanced Directives (MHADs) by consumers of mental health services. This instrument allows a patient to state his treatment preferences in writing for use at a later time during the hospitalization and treatment process, should he become incompetent to express those preferences. MHADs may also reduce patient perceptions of coercion by increasing their “voice” in the commitment decision and thereby affording them a greater sense that they have been accorded “procedural” justice. Many observers argue that use of MHADs can increase patient autonomy and may also enhance treatment outcomes by providing care that is both more appropriate for the patient and more accepted by the patient. Both of these factors should increase the probability that the treatment provided is more effective. This paper will explore ways in which MHADs may increase patient autonomy during the commitment process, thereby minimizing patient perceptions of coercion. It will also explore ways in the use of MHADs can themselves be coercive by limiting patient decision-making authority, thereby potentially increasing patient perceptions of coercion. Finally, it will suggest ways in which MHADs can be used so as to maximize patient perceptions of procedural justice and non-coercion and increase therapeutic outcomes. Implementing mental health advance directives: Legal and practical issues Debra Srebnik University of Washington The presentation will focus on legal and practical issues that arise in implementing mental health advance directives (MHADs) in a community mental health system. MHADs are written statements, made by clients, about their treatment preferences, chosen during a time they are able to make these decisions, anticipating a time when they have reduced capacity for communication and decision-making. MHADs will be discussed within the context of, and as a response so, coercive methods in mental health care. We will then focus on findings from the first year of a five-year research grant from the National Institute of Mental Health to examine feasibility and utility of MHADs in two sites in Washington State. Discussion will review issues raised by staff of outpatient, crisis and inpatient services including: perceived and real conflicts with regulations and statutes, circumstances for MHAD ‘activation’ and ‘deactivation’, competency issues in execution and activation, staff involvement in MHAD execution and logistical issues in executing and using MHADs. Use of seclusion and restraints in psychiatric treatment Riittakerttu Kaltiala-Heino University of Tampere Jyrki Korkeila National Research and Development Centre for Health and Welfare (STAKES), Finland Carita Tuohimäki, Ville Lehtinen, Matti Joukamaa Oulu University The use of seclusion and restraint was analyzed in a 6-month admission sample of three psychiatric university clinics in Finland. The three centers are responsible for all psychiatric inpatient treatment of working-aged patients from their catchment areas. 47 XXVIe Congrès international de droit et de santé mentale There were 1543 admissions during the study period. Of the treatment periods, 6.6% included one or more episodes of seclusion and 3.8% included at least one episode of mechanical restraint. The mean of the total time spent in seclusion or restraint was 29 hours (SD, 63 hours), median time was 12 hours. In relation to the inmate population, seclusion or restraint was applied to 81.2/100,000 people per year (95% CI, 72.4-91.1). Involuntary committment and previous commitments, but not ICD-10 diagnosis of the patient, could predict seclusion. Restraint could be explained only by committment. Seclusion and restraint were predicted by committment, having experienced previous commitments, and having a diagnosis of substance use-related disorders (f10-f19). Adding the treating center to the models revealed a significant facility effect on the use of seclusion and restraint. The annual rate of use of these coercive measures is high. The fact that the facility was more powerful a predictor of use of seclusion restrains than psychiatric diagnosis warrants attention. Perception of coercion in psychiatric, clinical and surgical inpatients José Geraldo Vernet Taborda Federal Faculty of Medical Sciences of Porto Alegre Márcia L. F. Chaves, João P. Baptista, Denise A. R. Gomes, Luciano Nogueira Brazilian Psychiatric Association Two hundred five inpatients hospitalized at “Hospital de Clínicas de Porto Alegre”, a large university hospital, were studied. The sample involved 64 psychiatric patients, 58 surgical patients and 83 clinical patients who were admitted on a voluntary or involuntary basis. The psychiatric patients’ willingness to be admitted was determined by their legal status; surgical or clinical patients’ willingness by the elective or emergency nature of their hospitalization. The psychiatric patients were younger, of a higher educational level and achieved higher scores in the SRQ scale than the surgical and clinical patients. MMSE score did not vary among psychiatric patients, surgical patients and clinical patients. The Admission Experience Survey: Short Form, an instrument used in The MacArthur Coercion Study, was given to all patients. The preliminary results indicate that a) psychiatric patients hospitalized in either a voluntary or involuntary manner, felt more coerced than the surgical and clinical patients; b) surgical and clinical patients did not differ from each other regarding the perception of coercion; and c) logistic regression analysis indicates that the variables related to the issue of involuntary hospitalization include the scale of perceived coercion scores, cognitive status and schooling, all of which produced positive correlation coefficients. Should use of coercion towards the mentally retarded be morally and legally accepted? Aslak Syse University of Oslo Use of force and coercion in delivering services to people with general learning disabilities, especially people with challenging behavior, is widespread. Both the coercive measures and the goals to be obtained vary. Up until the deinstitutionalisation process of the early 1990’s, which Norway was forced to adopt through an Act of Parliament, the most coercive measures were used in relatively closed institutions. A popular conception was that coercive measures were a necessary component of the institutional care itself. It was a common view that a more “normalized” way of living would lead to the termination of most coercive measures. Others believed that even in a communal setting, some constraint would be necessary. Some empirical works of the mid-90’s showed that both trained staff and untrained assistants applied a variety of coercive measures, partly to control challenging behavior and partly to help people manage their daily activities. Similar measures and reasons were also used in community-provided home-based services. It appeared that legal instruments were necessary to restrain the malpractice of coercive measures. At the same time, such legal instruments would legitamize some coercive practices. This paper deals with the pro and con arguments and the legislation for using force and coercive measures when delivering services to people with general learning disabilities. This debate closed in Norway in 1996, when Parliament revised The Social Service Act. The newly written Chapter 6A came into force in 1999 for a three-year trial run. The chapter regulates the use of coercion when delivering services to mentally retarded persons with challenging behavior, and establishes specific and detailed procedural rules to avoid abuse of coercive measures (see paper delivered by Ole Tom Roed). Use of force and coercion towards mentally retarded in Norway Ole Tom Roed The National 6A-Board, Horten This paper is a follow-up to the paper of Aslak Syse, and presents the new Chapter 6A of The Norwegian Social Service Act. This paper deals with both the prerequisites necessary for the use of coercive measures, and the legal safeguards set forward in order to restrain the use of such measures. According to most penal codes, and from a Human Rights’ perspective, a person should be free to leave his house whenever he likes. Also, it is normally forbidden to restrain a person’s right to personal freedom within his own home, or to physically hold him against his will in order to control him or in order to make him learn more adequate modes of conduct. Adopting such measures in cases of emergency is, of course, accepted. This Act, however, empowers community service workers to utilize such measures in a wider range of situations when delivering services or providing care. Chapter 6A sets standards for when coercive measures are to be used, and establishes a comprehensive procedural system to 48 XXVIth International Congress on Law and Mental Health legalise otherwise punishable actions. A panel, The National Board, was appointed to monitor the practice of the new regulation, and to make suggestions to the Ministry as to how to regulate this field in the future. Besides giving a presentation of the specific rules appearing in the Act, the paper will disclose how The National Board has been operating in the evaluation of a community’s fulfilment of the material and procedural prerequisites. The main question to be answered is to what extent this Act has managed to reach the goal of delivering the appropriate and individual services necessary in the least restrictive environments possible. An English version of the legislation will be available. COMPETENCE ASSESSMENT AND GUARDIANSHIP: RETROSPECTIVE AND PROSPECTIVE July 4 juillet 13:45 – 17:45 (extended session) Room NCDH–200 Chair: Joseph Nuss, Cour d’appel du Québec Competence, rationality and paternalism William Harvey University of Toronto Our discussion focuses on the ethical grounds of the assessment of competence (or capacity) from two perspectives, viz., theoretical and applied. From the theoretical perspective, we discuss two leading bioethical theories on competence, viz., those of Buchanan and Brock (1987) and Culver and Gert (1990), together with the recent modification of the latter by Gert, Culver and Clouser (1997). Essentially, the two basic theories differ as to the source of decision-making authority and the grounds of justifiable paternalistic interference–the competence of persons and the rationality of decisions, respectively. In result, both theories provide an account of the relation between autonomy (or self-determination) and well-being (or beneficence). However, neither theory is effective in protecting conceptions of autonomy or well being essential to a definition of persons with fundamental interests in devising and following life plans that they determine. From the applied perspective, we apply our previous discussion to an analysis of two instruments for the assessment of competence: a structured instrument outlined and defended by Grisso and Appelbaum (1998), and an unstructured or semi-structured instrument used by assessors or evaluators in Ontario (“Guidelines for the Assessment of Capacity”, 1996). Neither instrument properly accounts for the ethical grounding of their instruments–the relation between autonomy and well being in an acceptable account of decision-making authority. Nor is there any recognition that the selection of instruments itself involves ethical choice. It is concluded that an expansive view of decision-making or choice is required in order to begin to accommodate the role of cognition, affect and volition in an acceptable account of competence and its assessment. Assisting others: A critical ethics of surrogate decision-making Lorraine Landry Marquette University How often do we deeply reflect about what or whom the laws serve? In particular, what does legislation about surrogate decision making and the institutions implementing and administrating them tell us about ourselves, our neighbours, and the boundaries of our social expectations and entitlements? Such concerns aim at the heart of the individual and at the social values which permeate our lives. To a greater extent than is cursorily thought, these values and their institutional embodiment define and mediate our life experiences. This core insight and the far-reaching implications that stem from it are discussed in light of the normative commitments of the reigning orthodoxy and competing heterodoxy of ethics of substitute decision making. Clinical cases and reference to current health law governing surrogate (and interchangeably, substitute) decision making in Canada and the United States ground the practical implications of the ethics of substitute decision making. For the purposes of this paper, the term “surrogate decision making” covers choice of a place of residence, choice of medical treatment, durable power of attorney for health care and guardianship for personal care as important species of decision making with which others may be entitled to assistance, including the important advocacy functions entailed by serving the autonomy, well-being and value of those persons. Of particular methodological importance is the identification and thematic development of four markers of normative commitment animating the orthodox view of substitute decision making (SDM) and current health law to a comprehensive critical analysis of the ethics of SDM. These four markers are: conceptions of personhood and personal identity; notions of personal autonomy and/or decisional authority in relation to personal well-being; difficulties associated with competence determinations, especially at the margins of autonomy; and the moral salience of personal, familial and community and family values in SDM in light of the claims others have to our assistance with their care. The heterodox view of SDM, incorporating insights from contextualist and constructionist modes of reasoning into the evaluation of the orthodox view and the implementation of health law concerning SDM, offers a basis for a critical ethics of SDM along the four markers of normative commitment. While clearly motivated by the efficacy of certain normative approaches and itself embodying one, this argumentative strategy calls on its audience to work through the moral and political/public policy value issues as they appear 49 XXVIe Congrès international de droit et de santé mentale within their particular professional and personal contexts. That is, the degree of persuasiveness and conclusiveness of the critical perspective argued for here is intimately connected to individual and group reflection on, engagement with, and ongoing contribution to articulating a critical ethics of substitute decision making in everyday life. The causal social construction of mental incompetence: A typology, case study, and proposal Barbara Secker University of Toronto This presentation provides a detailed theoretical and case-based analysis of our view (elaborated by Bill Harvey) that leading theories of competence (or decision-making capacity), together with medico-legal practices of competence assessment, fail to protect adequate conceptions of personal autonomy and well-being. I develop a typology of the causal social construction of mental incompetence involving five different forms (1) iatrogenic/critogenic construction; (2) psychosocial construction; (3) formative construction; (4) prejudicial construction; and (5) socioeconomic construction. This typology helps distinguish and clarify some of the main ways that a person’s condition and/or inaccurate label of (in)competence may be socially constructed. Within this typology I argue that when (in)competence is properly understood to be socially constructed in a causal sense, there are a number of indications that women–especially elderly women, women with disabilities and women in particular socioeconomic positions–may be more likely than men to be (a) assessed for competence and (b) judged to be incompetent. I illustrate my theoretical analysis with “real life” case examples, focusing on the recent case Koch (Re) (1997), heard in the Ontario Court General Division. I conclude that resisting the medico-legalization of decision-making is morally and politically necessary. To better protect persons’ autonomy, agency and well-being, we ought not to focus on labelling them “incompetent” and making their decisions for them (via substitute/surrogate decision-making), but rather on working to provide that which they need to make their decisions and direct their lives. I maintain that, toward demedicalizing decision-making, we ought to rethink informal capacity assessment in health contexts. Linking with Lorraine Landry‘s critical ethics of surrogate decision-making, I propose a model of supported decision-making and suggest we focus our attention on providing the resources and supports persons need for competent decision-making and the exercise of competently-made decisions. I provide objectives and recommendations for research, education, policy and practice. Assessing competence: Imagination or realism? Astrid Vellinga, Cees Jonker Free University of Amsterdam For decades the issues about competence and the capacity of medical decision making have kept us puzzled. The search for a general instrument to assess competence has been a central issue in practical and theoretical debates. Several options have been developed, however, each with its own problems. Two major critical points can be made, namely, that most methods have an exclusively cognitive character and that most of them have a hypothetical character. This hypothetical character is problematic: one can assume that making an hypothetical decision will probably have a different effect than making an actual decision. In this study the central question focuses on how competence is influenced by cognitive factors and other factors that have proved important in practice (i.e. emotive and motivational factors, personal values, etc). The effect of assessing competence under different circumstances is also evaluated. A clinical vignette was used to assess competence. This method is performed under two different circumstances: a realistic and a hypothetical situation. Several structured questionnaires were used to evaluate the factors described above. An age stratified sample (>65 years) of 150 elderly people was selected from geriatric day centers. They represent a range of cognitive states from moderate cognitive decline (MMSE >15) to normal cognitive function. The results of the study are discussed with respect to the effect of the above mentioned factors on competence and the effect of assessing competence in both hypothetical and realistic situations. Guardianship by centralized government agencies–The New South Wales experience John Bartlett, MP New South Wales Public Bodies Review Committee A Parliamentary Committee from NSW, Australia has been examining the State’s two institutions which manage financial and lifestyle decisions for persons who are unable to perform these functions themselves. While the Committee has found, that by world standards, the NSW system is extremely robust in terms of equitable coverage for all who require it, the move away from a system of appointment of individual guardians to government run agencies has also introduced a greater distance between the substitute decision maker and the protected person. It can be distressing for clients to deal with their guardians primarily by phone and with a seemingly ever changing array of case officers. Less direct regular contact with clients also means that there is a danger of the substitute decision maker acting less like an advocate and more like an arbitrary decision maker. Agencies also have their own internal policies which may override the wishes of an individual. 50 XXVIth International Congress on Law and Mental Health Ideally, there should be as much transparency concerning the reasons for decisions in such a system as possible. However, currently in NSW appeal is only available by way of the NSW Supreme Court, an expensive and difficult pathway. This has lead many clients and their families to perceive both government agencies as “secretive” and “unaccountable”. Such an appeal process also offers the agencies themselves little protection from such attack due to secrecy provisions which strictly bind them. Re-mixing ‘access’, ‘advocacy’, ‘empowerment’ and ‘protection’: A case for a specialised division of labour in guardianship, mental health and disability services adjudication? Terry Carney University of Sydney This paper reviews the multiple institutional players that comprise Victoria’s interlocked network of laws, institutions, advocacy and adjudicative bodies catering to vulnerable populations, such as the mentally ill, the intellectually disadvantaged and adults who have lost the power to manage their personal or property affairs. With a particular focus on the work of the Intellectual Disability Review Panel (IDRP), which hears appeals about denial of services or imposition of ‘restraint and seclusion’ penalties, this paper reviews the merits, or otherwise, of retaining such a specialist body. It is argued that access to a specialist merits review of both questions, despite arguments that this is a crude or inefficient way of handling such questions. The ‘division of labour’ rationale for retaining a variety of specialized tribunals and other bodies, each with its particular functions, is analyzed against the competing pressures to down-size government, adopt quality assurance management and market models of program regulation. It is concluded that the unique features of ‘open-grained’ flexible adjudication adopted by the IDRP–and the division of specialised functions of the mental health, guardianship and system of which it forms part–is a harbinger of the type of arbitral laws needed to accommodate the more complex, more heterogeneous and more flexible needs of ‘post-modern’ society. Offering a better reading of social plurality and diversity. Dilemmas and decisions: Working with mental health law Jill Peay London School of Economics This paper draws on work conducted with Nigel Eastman for the Department of Health, UK, as part of its programme of research examining the operation of the Mental Health Act 1983. The paper presents findings from a study of decision-making involving 108 consultant psychiatrists, approved social workers and second opinion appointed doctors. Participants were presented with one of three ‘everyday’ hypothetical cases (whether to admit a patient to hospital, to discharge a patient from hospital or to give treatment against the wishes of the patient) and asked to reach decisions both individually and as a professional pair. The information provided included extensive case notes and video material. The participants were subsequently questioned about their decision strategies and their understanding of the relevant applicable law. The study provides some insight into the limited applicability of law in the arena of ethical and clinical decision-making. SUICIDES IN CUSTODY I: INCREASING INCIDENCE AND CONCERN July 4 juillet 13:45 – 15:45 Room CMEL-102 Chair: Patrick Frottier, University Hospital of Psychiatry, Vienna A quarter century of suicides in Austrian jails and prisons Norbert Benda, Patrick Frottier, K. Ritter, Reinhard Eher, Stefan Frühwald University Hospital for Psychiatry, Vienna Suicide prevention among prisoners in custody is hampered by the lack of funds and professional staff. In order to evaluate the prison suicide phenomenon, a study was conducted evaluating all suicides that occurred in Austrian prisons between 1975 and 1999 (n=250). In addition to evaluating the number of male v. female suicides, the preferred suicide methods were studied. We also evaluated the suicide-risk of different circumstances of custody. Suicide rates of distinguishable, important subgroups of prisoners were calculated. The suicide rate for prisoners on remand was highest, followed by offenders classified as mentally ill. The rate was approximately eight times higher than the suicide rate in Austria’s general population (1975-1997: 24.6/100,000 individuals). The suicide rate for sentenced offenders was lowest, but still about twice the suicide rate in Austria’s general male population. The recommendations are that psychologists or psychiatrists concentrate on the suicide prevention of high risk offenders after screening the newly admitted offenders for their propensity to suicide. 51 XXVIe Congrès international de droit et de santé mentale Inmate suicides in the Correctional Service of Canada Jane Laishes Correctional Service of Canada This presentation conveys descriptive statistics on the 66 suicides that occurred in federal institutions in Canada over a four-year period. The research is based on investigation reports, psychological autopsy reports and other file information. Results show that criminological and institutional factors of those who committed suicide included lengthy involvement in the criminal justice system, a greater likelihood of being incarcerated for robbery or murder, and involvement in institutional incidents of a serious nature. In addition, 62% of the inmates who committed suicide had been transferred from other institutions within six months prior to their suicide, although 59% evidenced no indicators of suicidal intent and 44% were not considered to be depressed at the time of suicide. Family problems were the most commonly hypothesized motivating factor in the suicides; followed by denial of a request for appeal, parole, or transfer; fear of other inmate;, and substance abuse problems. Current and planned suicide prevention and intervention strategies of the Correctional Service of Canada are discussed in the context of these findings. Time distribution of custodial suicides–mere coincidence? Stefan Frühwald, Norbert Benda, S. Lehr, Reinhard Eher, K. Ritter, Patrick Frottier University Hospital for Psychiatry, Vienna The increase of suicides and suicide rates in custody has raised the concerns of professional staff and prison authorities. Among the questions asked is whether vulnerable times for suicides exist in custodial facilities. For example, does the time of the day, the day of the week, certain months or seasons, affect suicide rates? The results reported so far are contradictory, if we neglect consistent findings about an excess of suicides occurring during the night. Furthermore, it has been discussed whether clusters of suicides occur in jails and prisons, indicating modelling phenomenon. Using a large total survey of suicides that occurred in custody, we tried to determine whether vulnerable times for suicides exist in jails and prisons. Is it possible to identify certain hours, days, or months that could be useful in determining the suicidality of inmates? Could suicide prevention be improved by the knowledge of these vulnerable times? This study deals in detail with the timing of completed suicides, which has merely been a short remark in most pevious studies. US prison suicides: A case of American exceptionalism? J. Haycock Bedford Policy Insitute, Allston Studies of prison suicides indicate that in selected countries prison suicide rates exceed general population rates by a factor of 3 to 15. According to the most widely accepted figures in the literature, the one apparent exception to this pattern is the country with one of the world’s highest incarceration rates and largest prison populations, the United States. Although the most widely diffused studies on US prison suicides contend that the raw numbers show suicides in state and federal correctional institutions one and one–half times the suicide rate in the general US population, in fact sex, age and race adjustments to those raw numbers effectively eliminate the excess suicide mortality in US prisons. If such an exception exists, that fact has far reaching implications for suicide prevention in every country’s prison systems. If the US prison suicide rate is lower than that in other countries by comparison to general population findings, then either prison experience is very different in the US; US prisoners do not bring the same vulnerabilities to prison experience as prisoners do in other countries; US prison suicide prevention is considerably more sophisticated than that in other countries; or some combination of all three. In any case, there exist some relative immunities conferred by some factor or factors in the US experience, one or more co-efficients of preservation. The existence of such co-efficients would have extremely important theoretical and practical ramifications. This paper examines the methodological underpinnings of apparent American exceptionalism in prison suicide rates. The paper argues that these procedures are flawed even by comparison to the promiscuous use of official statistics in studies of suicides among the general population. The weaknesses in these methodological procedures compromise the most widely accepted conclusions about suicides among US prisoners. Presenting markedly divergent data from a study of suicides in one state’s prison system, the paper considers the possible implications that such differences might have for our understanding of US prison suicides. Murder suicides Patrick Frottier, Norbert Benda, K. Ritter, Reinhard Eher, and Stefan Frühwald University Hospital for Psychiatry, Vienna The association between violent behavior and suicide is a consistent assumption in the scientific literature. Several studies have found a hightened suicide risk in high violent offenders in custody. In an epidemiological study of jail and prison suicides in Austria between 1975 and 1999, we focused on all suicides of inmates accused or convicted of murder or manslaughter (n=39). The suicide records of all 29 Austrian penal institutions were investigated, as were statistical data concerning police crime reports, statistics of convictions, and statistical data of imprisonment. This presentation gives an overview of the information found in the personal records of the suicide victims. In addition to presenting the age, gender, education, marital status and 52 XXVIth International Congress on Law and Mental Health circumstances of custody of the suicide victims, we will present psychiatric diagnosis and criminological information. The results strengthen the hypotheses of an association between violent offenses and suicide. PROMOTING MENTAL HEALTH AND DECISION-MAKING IN CHILDREN AND ADOLESCENTS July 4 juillet 13:45 – 15:45 Room NCDH–201 Chair: Suzanne Lépine, Hôpital Ste Justine de Montréal The right of the child to participation Maria Grahn-Farley Golden Gate University This paper will connect the inherent rights of the child to life with the rights of the child to participation. The UN Convention on the Rights of the Child covers the rights of the child after birth. The right-to-life in this context is about the right of the born child. The purpose of this paper is to demonstrate in which ways the child’s right to participate is a key factor to the life, survival and development of the child. The inherent right of the child to life is a fundamental principle in International Child Rights as well as in Human Rights in general. What differentiates the child’s right to life from the general Human Right to life is that the child’s right goes beyond a mere right to not have its life taken. The child’s right-to-life includes the fact that a child is by its very definition an evolving and growing person. This means that the child also has a right to grow and develop. The UN convention on the Rights of the Child 1989 states that “State Parties shall ensure to the maximum extent possible the survival and development of the child.” One of the key factors to growing and developing is the right to participate. The right to participate is not only a civil and political right, it is also closely connected to the social, economic and cultural rights of the child. The ability of the child to participate in forming its environment, and the world that in return forms the growth and development of the child, is of interest to the individual child, children and the broader society in shaping the future. Building capacity for healthy child development in the family environment Jane Drummond, G.M. Kysela, L. McDonald University of Alberta Healthy human development has been declared an individual determinant of health. However, optimal early human development is contingent on successful early childhood experiences within the immediate environments of childhood. The role of the family in stimulating and sustaining healthy child development is the focus of this presentation. A synthesis of frameworks and published data will be used to outline some of the researcher’s important beliefs and values concerning the role of the family in early human development. The researcher and her colleagues have developed three approaches that contribute protective capacities in families. Each is based on The Family Adaptation Model. The model will be examined, as will the three approaches. The first is a family-centerd assessment and planning approach. The Natural Teaching Strategies approach is designed to enhance the contingent responsiveness and scaffolding techniques of parents. The Cooperative Family Learning approach was developed to enhance problem solving in families. Findings from a longitudinal control group investigation of these approaches will be presented. Implications for designing support to families at-risk and to families with children with special needs will be discussed. Special education needs: Institutional and family issues Jane Shadlen Northern Suburban Special Education District, Barrington Ms. Shadlen will speak to the issues facing an agency providing Special Education Programs for children birth to age twenty-one. She will discuss the dramatic changes that have occurred during her twenty years of providing services to children with special needs. She will specifically discuss how these changes affect families and special education children birth to five. The issues Ms. Shadlen will address include the many options available to families as they transition from one phase of a program to another, the multiple needs of children diagnosed with autism, the role of inclusion and the professional’s role in assisting families who are navigating this unfamiliar territory. The challenges for educators and institutional policy makers are all too familiar. The inconsistencies of educational programs are directly linked and depend on the economic strata of each community. However, children residing in these diverse communities have common needs. In today’s climate this incongruity poses questions that are not easily answered. However, what is clear, is our role in addressing these issues as the voice for these children. 53 XXVIe Congrès international de droit et de santé mentale What works and what doesn’t work in treating a child with a dual diagnosis B. Iskov, Ontario Poetry Society, Toronto This paper examines special education services from the perspective of families and the children needing assistance. It documents the case of Howard Iskov who had multiple diagnoses. The paper chronicles the family’s discovery of the child’s unusual condition and the traumatic process of accessing medical and education institutions on his behalf. Ms. Iskov describes the shocking treatment methodologies and strategies taken with Howie prescribed and inflicted by hospitals, schools and camps specifically designed to serve the needs of children with emotional challenges. Howie was labeled “emotionally disturbed”, “borderline autistic” and “mildly mentally retarded.” His parents were informed by specialists that he did not understand the concept of love, arguably suggesting that their affection for the child was a waste of time. He was seen or treated by some of the most reputable hospitals in Canada and the United States. The paper details how during Howie’s early years, every wrong therapy and wrong treatment was implemented to educate him. Every time the child urinated in his training pants, he underwent a cold shower. When he refused to complete a task put to him, he was ordered to stand up and sit down over and over again. After stay at a summer camp for children like Howie, he came home with massive bruises and many scars on his lower back. The parents were then informed that they used aversive conditioning to treat Howie and twisted his skin and bent his fingers back when he didn’t comply to their demands. This paper details one family’s struggle with institutional systems in an effort to seek and obtain appropriate and healthy services for a child who is special. It raises questions regarding aversive conditioning, appropriate treatment of children, and the right to adequate non-abusive services for families and children. Empowering adolescents to take control of their health care decisions Jennifer L. Rosato Brooklyn Law School Even though many agree that children acquire significant experience and maturity prior to adulthood, they still have little control over their health care decisions. The existing law is neither consistent nor comprehensive. Most importantly, it is not sufficiently respectful of the personhood of adolescents, who need opportunities to exercise their right to autonomy prior to adulthood. The general rule is that parents make decisions for their children. A few states make exceptions for minors who are mature, but most do not. Instead, mature minors are permitted to make health care decisions on an ad hoc basis, such as when they contract a venereal disease (and public policy prefers treatment to parental control). A minor does possess some constitutional rights, such as the right to an abortion, but such rights are not defined as expansively as those of the adult. Using sources from law, bioethics and psychology, the article proposes a comprehensive approach to health care decision making by adolescents. In particular, the article considers why children, particularly adolescents capable of adult decision making, should continue to be considered a vulnerable population in this context. It also considers how much power adolescents should possess to make decisions in areas such as abortion and contraception, life-sustaining treatment and participation in clinical trials. The law, in these and other areas, needs to protect children from harm but, just as importantly, needs to recognize that some children are capable of making many health care decisions on their own. These children must be given opportunities to practice making such important decisions so that they can shape their identities and become more effective adult decisionmakers. L’ÉCHELLE DE PSYCHOPATHIE DE HARE: ATELIER I QUESTIONS ET PERSPECTIVES July 4 juillet 13:45–16:45 Atelier – avec inscription seulement Salle IASL-106 Formateurs : Gilles Côté, Institut Philippe Pinel de Montréal Thierry Pham, Université Catholique de Louvain L’atelier s’adresse à des participants qui ont suivi une formation à l’utilisation de la CPCL-R. En groupe restreint, sur la base d’échange entre les participants, l’atelier a pour objectif d’aborder des problèmes de cotation et les problèmes de validation interculturelle. Les nouveaux développements de l’échelle, de même qu’une réflexion sur les tendances qui se dégagent, seront abordés. Finalement, des pistes de collaboration pour des projets de recherche conduits à l’aide la CPCL-R seront soulevées. 54 XXVIth International Congress on Law and Mental Health 16:00 – 17:45 RÉFLEXION SUR LA PSYCHIATIRE LÉGALE ET LE LEADERSHIP PSYCHIATRIQUE July 4 juillet 16:00–17:45 Salle MC Modérateur: Jocelyne Brault, Institut Philippe Pinel de Montréal Erreurs et expertises psychiatriques Gilles Chamberland, Paul-André Lafleur Institut Philippe Pinel de Montréal Au civil comme au criminel, le psychiatre expert n’est pas à l’abri des erreurs. Nous aborderons à ce sujet les trois volets suivants: 1. la catégorisation des différents types d’erreurs ; 2. leurs conséquences pour la personne expertisée ; 3. leurs conséquences pour l’expert. À l’aide d’exemples, nous répartirons les erreurs selon leur cause en quatre catégories: • la personne expertisée ; • le demandeur ; • l’expert ; • le processus d’expertise lui-même. Les conséquences pour la personne expertisée sont diverses. Elles peuvent concerner tout autant son statut socio-économique que sa santé mentale et physique. Pour ce qui est de l’expert, les conséquences de l’erreur vont de la poursuite judiciaire à un accroissement de sa clientèle. Ces diverses situations seront abordées en détail. Le travail clinique psychiatrique dans un cadre légal: avantages, difficultés et limites Renée Roy Institut Philippe Pinel de Montréal Certains patients qui souffrent de maladies mentales sont extrêmement difficiles à traiter autrement qu’à l’occasion de séjours en prison, au pénitencier, ou encore lorsqu’ils doivent se conformer à des conditions légales (suivi probatoire, suivi en libération conditionnelle, emprisonnement dans la communauté, ordonnance de la Commission d’examen suite à un verdict de non responsabilité légale pour troubles mentaux, …). Les principales difficultés d’un suivi volontaire tiennent souvent à la combinaison des éléments suivants: présence de pathologies comorbides, telles l’abus ou la dépendance aux drogues, ou encore d’un trouble sévère de la personnalité; antécédents de dangerosité envers l’entourage; difficultés marquées à établir une alliance thérapeutique, en partie à cause d’une pauvre reconnaissance de la maladie psychiatrique ainsi que d’une mauvaise observance au traitement. Le traitement administré dans un tel contexte a tout de même ses limites. Celles-ci seront examinées à la lumière de vignettes cliniques. Les avantages et les difficultés d’un traitement psychiatrique soutenu par un encadrement légal seront aussi révisés. Les vignettes cliniques seront tirées du suivi de patientes psychiatriques évaluées ou traitées en prison, au pénitencier ou en clinique externe. Ce suivi s’effectue en équipe interdisciplinaire et avec la collaboration d’intervenants de milieu, au Centre de psychiatrie légale de Montréal, clinique externe de l’Institut Philippe Pinel de Montréal. Leadership psychiatrique: essais et erreurs Jocelyn Aubut Centre hospitalier universitaire de Montréal Le travail psychiatrique s’effectue généralement en équipe. Les psychiatres sont souvent appelés à gérer les équipes soit de manière informelle ou formelle. Le type et la grosseur des équipes peuvent varier: petites équipes cliniques multidisciplinaires, gestion hospitalière, etc. La présente présentation a pour objectifs de faire ressortir les principaux défis et pièges mais aussi les solutions liées au leadership vu sous l’angle psychiatrique. Plusieurs concepts seront passés en revue dont: le sens du travail pour l’équipe, le sens du travail pour l’individu, la réconciliation des objectifs de travail individuels et collectifs, le leadership éclairé, 55 XXVIe Congrès international de droit et de santé mentale les processus décisionnels, la perversion de la gestion et l’analyse multidimensionnelle. Des exemples concrets associés à chacun de ces concepts seront également présentés. COMMUNICATIONS LIBRES III July 4 juillet 16:00–17:45 Salle NCDH–102 Modérateur: Linda Garceau, Institut Philippe Pinel de Montréal Les patients de l’IPPM orientés vers l’hébergement en psychiatrie-justice: sontils différents de ceux dirigés ailleurs ? Richard Lusignan Institut Philippe Pinel de Montréal Depuis septembre 2000, nous accumulons des informations concernant le processus de retour social des patients de l’IPPM ayant fait l’objet d’une présentation au Comité d’Accès Réseau Psychiatrie-justice de Montréal. Jusqu’à maintenant, plus de 55 patients font partie de cette étude. Quand un juriste rejoint une équipe pluridisciplinaire de prévention anténatale de la maltraitance E. Vanderstukken, S. Haeyere, M. Gerard Centre SOS Enfant - Centre Hospitalier Saint-Pierre, Belgique Avec le soutien de la Fondation Roi Baudouin et de la Loterie Nationale belge, le centre SOS Enfant - Université Libre de Bruxelles – Centre Hospitalier Saint-Pierre (Bruxelles) a mené un projet intitulé; Aide juridique aux familles monoparentales dans le cadre de la prévention périnatale; auprès d’une population de futures mères seules provenant d’un milieu socioéconomiquement défavorisé. Sur le terrain, l’équipe avait en effet constaté une demande d’aide juridique de la part de ces familles monoparentales, formulée au cours de la grossesse ou à la naissance. Afin de rencontrer ces interrogations, un juriste a été intégré dans notre équipe pluridisciplinaire de prévention anténatale des mauvais traitements, composée de médecins gynécologues, d’infirmières sociales, de psychologues et de pédopsychiatres. Les demandes d’aide furent transmises par l’équipe au juriste, qui a rencontré les patientes dans un second temps. L’expérience sur le terrain nous a appris que :a) peu de démarches juridiques avaient été engamées par cette population avant la rencontre avec le juriste, qui entraîne une (re)-mise en confiance dans une justice accessible à tous; b) la problématique majeure rencontrée par l’équipe est centrée sur les questions de filiation. Ces observations feront l’objet de développements lors de notre communication. Les délinquants suicidaires ou souffrant de troubles mentaux graves. Vers une approche communautaire. Marc Daigle Université du Québec à Trois-Rivières Gilles Côté Institut Philippe Pinel de Montréal L’évaluation de la problématique suicidaire et de trouble mental de 243 détenus a été réalisée dans deux villes du Québec. Les résultats indiquent que 28% avaient déjà tenté de s’enlever la vie. Cependant, seulement 14,7% des tentatives avaient eu lieu pendant une incarcération. Ce sont 8,2% des détenus qui présentaient une urgence suicidaire telle qu’elle nécessitait une prise en charge par le personnel. De la même façon, 14,1% des sujets avaient présenté un trouble mental grave pendant le dernier mois. Ce sont finalement 17,7% des détenus qui présentaient l’une ou l’autre des problématiques. La prise en charge de ces détenus, par le personnel des institutions carcérales, a été investiguée de diverses façons. Indépendamment de la valeur de cette prise en charge, il reste que la présence de détenus en difficulté était, au point de départ, significativement plus grande dans un établissement que dans l’autre. Or, cette différence pourrait s’expliquer par la quantité de services offerts dans leurs communautés respectives, notamment ceux qui évitent l’incarcération excessive des délinquants souffrant de troubles mentaux graves. 56 XXVIth International Congress on Law and Mental Health SUICIDES IN CUSTODY II: IS PREVENTION POSSIBLE? July 4 juillet 16:00 – 17:45 Room CMEL-102 Chair: Stefan Frühwald, University Hospital of Psychiatry, Vienna Differentiating between suicide and parasuicide in prisoners: Utilizing static and dynamic predictors Cherami Wichman, Ralph Serin, Larry Motiuk Correctional Service of Canada Offender populations have consistently been noted to be at high risk for suicidal behavior. Prevalence is high, as defined by prior histories (prior attempts) and incidents while incarcerated (attempts and completions). These are mental health and security concerns. To date, much of the empirical research has been retrospective in design and focussed on the identification of static predictors. The present study comprised an exploratory examination of the association between static and dynamic factors and suicidal behavior of offenders. Information was systematically retrieved at admission and proximal to the incident. Characteristics assessed included the lethality and intent of the act, mitigating factors and suspected precipitants, social competence, psychiatric and behavior problems, cognitive functioning, social support and substance abuse both, at admission and proximal to the suicidal behavior. These factors were investigated for 96 male federal offenders who had either attempted (n=48) or committed suicide (n=48). A matched (age, type of offense) comparison group of offenders (n=48) was also included. Key findings from this research are discussed with attention to differentiation of (1) Suicidal and Non-suicidal offenders; and (2) Completers and Attempters. Finally, the findings will be discussed in terms of theory and directions for future research. VISCI–The Viennese Instrument for Suicidality in Correctional Institutions Patrick Frottier, Stefan Frühwald University Hospital for Psychiatry, Vienna The assessment and estimation of suicidal risk constitute a serious and difficult task for any mental health professional. If we add to this the challenges that may be presented by a specific population at higher risk, the task appears even more complicated. Since the beginning of the nineties a research group investigated the phenomenon of prison and jail suicide in Austria. In a case control study all suicides in all Austrian jails and prisons between 1975 and 1999 were investigated: all records of all suicides (n=250) were evaluated, plus records of the controls (n=500). The Viennese Instrument for Suicidality in Correctional Institutions presented here is based on the results of this case-control study and on research on literature examining suicide prevention in general and prison population in particular. As suicide rates in custody are higher than in the general population, and there is evidence, that these rates are increasing within the last 20 years, the screening of offenders newly admitted to prison for their propensity to suicide are necessary to understand this phenomenon, to give a valid estimation of the suicide risk and hopefully to stop further increase of suicide rates in jails and prisons. Outside or in here: Importation and deprivation as dimensional variables in prisoner suicide J. Haycock Bedford Policy Insitute, Allston That prisoners are more likely to kill themselves than persons not held in confinement has been noted since the earliest 19th century students of suicide began utilizing and theorizing from official statistics. Well before Durkheim, observers of the phenomenon ascribed this increased suicide mortality and morbidity in prisons to both the special characteristics of places of confinement and to distinct characteristics of the persons put there. To explain the elevated rates of prisoner suicides and suicide attempts, some contemporary researchers have grouped the causes into two similarly inspired broad categories, and they have borrowed these categories from standard criminological texts on prisons: importation variables and deprivation variables. This paper briefly reviews the intellectual purchase of these transplanted categories for explaining the persistent problem of suicidal behaviors in jails and prisons. The paper argues that notwithstanding other virtues, standard criminological categories fail to capture what is uniquely suicidogenic in the correctional idea and correctional practice. Identifying suicide risk in penal institutions Eric Blaauw Free University of Amsterdam Accounting for nearly half of all deaths in penal institutions, suicide is the primary cause of death among prisoners. However, it is not easy to distinguish suicidal inmates from non-suicidal inmates. Many inmates are possess traits that in a normal population would be indicative of an increased suicide risk, including substance addiction, a psychiatric history and a history of broken relations. Therefore, it was necessary to examine the characteristics that distinguish inmates with a high suicide risk from 57 XXVIe Congrès international de droit et de santé mentale ‘normal’ inmates. This was done in a research project that consisted of a records study that focused on the characteristics, conditions of death and possible identifying signs occurring prior to death of the 95 suicides that had been committed in detention centers, prisons and TBS-institutions in the period 1987-1997. The research project also consisted of interviewing 221 randomly selected non-suicidal inmates from the regular population of inmates in all Dutch penal institutions. Comparison of the characteristics of these two groups showed that it was possible to construct a good screening device for suicide risk (consisting of eight questions). At a demarcation value of 24 points, around 18% of all inmates and as many as 95% of the suicide victims were placed in the high-risk of suicide group. The presentation addresses the method of the study, risk factors for suicide and the constructed screening instrument. Identification, communication and care procedures for suicidal inmates in Scottish prisons Kevin Power University of Stirling In 1994, the Scottish Prison Service (SPS), concerned at the rise in suicides in prison, commissioned a series of research studies that included, (a) a retrospective analysis of all suicides between 1976 and 1993; (b) an analysis, over a 12-month period, of 2841 inmates identified as at risk of suicidal behavior; and (c) and an assessment of the views of 200 inmates and 100 staff regarding the suicide prevention strategy as it then operated. On the basis of findings from the above, three main themes emerged that required attention. In particular: (a) Identification procedures regarding at risk inmates; (b) Communication procedures between staff regarding those inmates identified as at risk; and (c) the Care regime provided to those identified as at risk. In reply to these issues, the SPS introduced, in 1998, a revised suicide prevention strategy entitled Act to Care. The impact of this revised strategy is currently being assessed with regard to the number of prison suicides, number of inmates identified as at risk and the quality of care received. The proposed paper will provide a historical perspective in reviewing the impact of research on clinical practice and provide an update of the impact of the revised suicide prevention strategy Act to Care. Discussants: Julio Arboleda-Flórez, Queen’s University Brian Mishara, Université du Québec à Montréal OUTPATIENT COMMITMENT July 4 juillet 16:00 – 17:45 Room NCDH–101 Chair: Veena Garyali, Kirkby Forensic Psychiatric Center, New York Paradox and ambivalence in compulsory community care John Dawson University of Otago Many paradoxes arise in the use of compulsory community care (or outpatient commitment). For instance, its use may both support and undermine therapeutic relationships; it may only be appropriate for patients who do not meet its legal criteria; many patients treated under this form of compulsion are actually volunteers; family members may support its use in principle, but will not apply for its use on their relative; when the patient under this form of care avoids readmission to hospital for an extended period of time, this can be viewed either as an example of successful use of the order, justifying its continuation, or as an indicator that the patient should now be discharged. These and other paradoxes, it will be argued, are a prime reason for the ambivalence felt by so many participants concerning compulsory community treatment: e.g., the ambivalence of many patients, clinicians, family members, lawyers and judges. These thoughts arise from the early stages of qualitative work on the use of Community Treatment Orders in Otago, in the South Island of NZ, under New Zealand’s Mental Health Act, directed by Prof Dawson and funded by the Health Research Council of New Zealand. The coerciveness of involuntary outpatient commitment: Findings from an experimental study in the US Marvin Swartz Duke University Jeffrey Swanson, Virginia Aldigé Hiday North Carolina State University 58 XXVIth International Congress on Law and Mental Health H. Ryan Wagner, Barbara J. Burns Duke University This presentation examines the extent to which subjects in a 12-month experimental trial of involuntary outpatient commitment (OPC) felt coerced and what other demographic, clinical and study year factors predicted the subjects’ self-reports of coercion. In this study, severely mentally ill (SMI) subjects were randomly assigned to continue under or be released from court-ordered OPC following hospital discharge. Subjects with a history of serious violent behavior were not randomized to release and were followed in a nonrandomized comparison group. Appraisals of the coerciveness of treatment were examined using a modified version of the MacArthur Admission Experience Survey (MAES). Bivariate analyses indicated that significantly higher levels of coercion were reported by subjects under involuntary outpatient commitment, especially those who received longer periods of commitment. Multivariable analyses of predictors of coercion showed higher levels of coercion among subjects with longer periods of OPC, but also those subjects neither married or cohabiting, with ongoing co-morbid substance abuse problems, psychiatric hospitalizations during the study year, or lower intensity of outpatient treatment. Subsequent analyses of case manager reports of reminders and warnings given to subjects about the consequences of treatment nonadherence partially accounts for higher subject reports of the coerciveness of OPC. Previous reports from this study have found that OPC, if sustained and combined with relatively intensive services, can improve a number of outcomes. The current analyses demonstrate a clear cost of OPC in increased subject reports of coercion. An unintended consequence of outpatient commitment: Reduced victimization Virginia Aldigé Hiday North Carolina State University Jeffrey Swanson, Marvin Swartz, Randy Borum, H. Ryan Wagner Duke University This study reports results from a randomized controlled trial of outpatient commitment on a sample of severely mentally ill persons. Subjects in the control groups were almost twice as likely to be criminally victimized during one year as were the outpatient committed subjects despite both groups’ having case management and individualized treatment plans. Duration of outpatient commitment also impacted criminal victimization, with decreasing odds of victimization associated with increased days on outpatient commitment. These relationships remained statistically significant when other theoretical and empirical predictors of victimization were controlled. We found that outpatient commitment had its effect through improving medication adherence and reducing substance use/abuse. Discussant: Susan Ridgely, Rand Corporation, Santa Monica, California DIAGNOSIS AND TREATMENT OF SEQUELS OF TORTURE July 4 juillet 16:00 – 17:45 Room NCDH–201 Chair: Pierre Deschamps, Canadian Human Rights Tribunal, Ottawa Building community support for survivors of torture Teresa Dremetsikas, Mohamed Ahmed Canadian Center for Victims of Torture, Toronto This paper will give an outline of the experience of the Canadian Center for Victims of Torture (CCVT) in rebuilding support networks for torture survivors trying to resettle in Canada. It will make reference to the programs at CCVT with emphasis on the volunteer program as a core program. It will describe the methodology and findings of a four-year research project conducted in partnership with the Faculty of Social Work at the University of Toronto. Changes to broad social structures can disrupt human relationships and the reconstruction of human relationships contributes to social change. The initial research project qualitatively evaluated the “Befriending” component of the Volunteer Program at CCVT. The importance of reconnecting with the surroundings is paramount to the process of heeling from trauma, but this “reconnection” presents challenges such as, forming relationships among individuals, forming relationships in the context of trauma,·cross-cultural communication, the need for safety and protection and connecting with the wider picture. During the presentation, these five aspects will be explored in depth. Audience participation in the discussion will be encouraged. One of the outcomes of this project was a training workshop (two-days long) that included a manual for volunteers, staff and clients. The materials displayed in this presentation will relate to the images chosen in the Manual “Befriending Survivors of Torture” in an effort to accurately communicate the issues encountered during the data gathering portion of the project. The images also address the preferences in learning styles suggested by the researchers and other participants of the project. The CCVT has always been aware of the need for going beyond tolerance and arriving at respect for human rights in order to attain 59 XXVIe Congrès international de droit et de santé mentale harmony. Therefore, the presentation will aim at sharing our findings on the importance of community support for the mental health of survivors of torture and to achieve social change. Treatment implications of acute v. chronic PTSD: A comparative study of three groups of rebel traumatised college students in Uganda Eugene Kinyanda Butabika National Psychiatric Referral Hospital, Kampala Seggane Musisi Makerere University J. Rozermeijer University Hospital for Psychiatry, Vienna This is a retrospective comparative study of three groups of students following a rebel terrorist attack on their school. During the night attack, the rebels set fire to the school dormitories in which about 80 students died, 50 suffered burns and 80 were abducted for recruitment into the rebel ranks. The rest (250) escaped with no physical injuries. The severely burnt victims were rescued and transferred to Mulago Teaching Hospital where they received immediate and intensive physical and psychiatric treatment. Months later, some of the abducted students escaped and five presented for psychiatric treatment. Attempts to organize treatment for the non-physically injured students failed. This study compares profiles, treatments and prognostic outcome of the three groups of survivors (1) the burnt but immediately treated; (2) the abducted who received delayed treatment; (3) the escaped, never injured and never treated. A modified Arcle’s IRCT standardized questionnaire comprising symptoms of depression, anxiety, somatization, trauma events as well as a DSM IV PTSD was used. Results showed that the burnt but immediately treated group recovered completely with no residual PTSD symptoms despite significant physical injury (burns); those who were abducted and tortured, but eventually escaped and later received treatment developed chronic and often complex PTSD symptoms; and the escaped uninjured group had minimal symptoms, although one subsequently became severely depressed and killed himself. These findings underscore the need for immediate psychiatric intervention for all traumatized victims and call for the establishment of a crisis response team to handle the victims of mass traumatization due to rebel attacks or bomb blasts. Lastly, we found that supportive social networks and economic empowerment enhanced the victims’ confidence and recovery. We, therefore, recommend this intervention in all rehabilitative programs for traumatized victims. The psychological consequences of prisoner labour–The Kanungu case Seggane Musisi Makerere University Eugene Kinyanda Butabika National Psychiatric Referral Hospital, Kampala Introduction: On March 17th, 2000, the world woke up to the horror of what came to be the largest cult instigated mass death– 1000 dead at Kanungu in Southwestern Uganda. Prisoners from a nearby prison were used to excavate and rebury these bodies without concern about their psychological traumatization. Objective: To investigate the psychological trauma suffered by the prisoners who were forced to excavate mass graves of decomposing dead bodies at Kanungu. Methods: A previously tested research instrument was administered to all the prison inmates of Rukungiri Prison in Southwestern Uganda. This research instrument identified socio-demographics, physical and psychological trauma, charges, sentence and legal status and psychological assessment batteries. Results: For purposes of analysis, the prisoners were divided into two groups: the “Exposed group”, 30 (28.3%) who participated in the mass grave excavations and reburials and the “Non Exposed” group 76 (71.7%) who did not participate in this exercise. The Excavation Group had significantly higher GHQ scores (p=0.0011) and significantly more patients who met the criteria for Post Traumatic Stress disorder (PTSD) 23 (76.7%) compared to 4 (5%) in the Non Excavation Group (p=0.000). Conclusions and Recommendations: Prisoners who participated in the excavation of mass graves suffered significant psychological traumatization. There is therefore a need to improve prisoner conditions in Uganda including the observance of the Human Rights. References: 1. Beebe G.W. (1975) Follow-up studies of World War II and Korean War Prisoners. Part II Morbidity, Disability and Maladjustments. American Journal of Epidemiology 101:400-422. 2. El Sarraj, Punamaki R.L., Summerfield D, et al (1993). Experiences of Torture and ill treatment and Post Traumatic Stress Disorder symptoms among Palestinian Political Prisoners. Journal of Traumatic Stress Disorder 9: 595-606. Discussant: Thomas Wenzel, University Hospital for Psychiatry, Vienna 60 XXVIth International Congress on Law and Mental Health 61 XXVIe Congrès international de droit et de santé mentale Sessions of the Academy Sessions de l’Académie Thursday, July 5, 2001 jeudi 5 juillet, 2001 62 XXVIth International Congress on Law and Mental Health Program at a glance Coup d’œil sur le programme July 5 juillet, 2001 Parallel sessions / sessions parallèles 8:30 10:00 10:15 12:15 13:45 15:45 16:00 17:45 Bilingual Forum / Forum bilingue: How to Regard Criminal Adolescents? Comment considérer les adolescents criminels? (64) ................................................ MC Adjudicating Mental Illness: Dilemmas in the Courtroom and in Practice (until 12:15) (64) ......................................................................... NCDH–201 Community Mental Health in a New Era (until 12:15) (67).......................... NCDH–101 Racial Profiling (until 12:15) ( 70) ................................................................. CMEL-102 Indigenous Peoples: Social and Legal Concerns (p.73)................................. NCDH–200 Addiction (74).................................................................................................. CPCL-101 Break / pause Bilingual session / Session: Mental Health In Native Communities : Problems and Stakes I Santé mentale en milieu autochtone: problématiques et enjeux I (75) ....................... MC Expertise au civil (77)........................................................................................ IASL-106 Communications libres IV (78)...................................................................... NCDH–102 Adjudicating Mental Illness: Dilemmas in the Courtroom and in Practice (cont’d) ( 64).................................................................................................. NCDH–201 Community Mental Health in a New Era (cont’d) (67) ................................. NCDH–101 Racial Profiling (cont’d) (70) ......................................................................... CMEL-102 Socio-Legal Facets of Womens’ Mental Health (79) .................................... NCDH–200 Mentally Disordered Offenders: The Netherlands’ Experience (81) ............... CPCL-101 Break / pause Bilingual session / Session bilingue: Mental Health In Native Communities : Problems and Stakes II Santé mentale en milieu autochtone: problématiques et enjeux II (82) ...................... MC Poursuites médicales (84).............................................................................. NCDH–102 Admissibility and Ethics of Expert Evidence in Criminal Cases (84) ............ CMEL-102 Ethics and the Professional Self (until 17:45) (86)........................................ NCDH–101 Current Issues in Womens’ Corrections (88)................................................. NCDH–201 Mental Health and the Workplace (90)............................................................ CPCL-101 Abuse and Neglect of Children I (92)............................................................ NCDH–200 Atelier II: Valeur, place et limite de l’examen cognitif face à l’évaluation clinique (tests neuropsychologiques) (se termine à 16:45) (94) ....................... IASL–106 Break / pause Bilingual session / Session bilingue: Mental Health In Native Communities : Problems and Stakes III Santé mentale en milieu autochtone: problématiques et enjeux III (95)..................... MC Regard multidisciplinaire sur les expertises (96) .......................................... NCDH–102 Ethics and the Professional Self (cont’d) (86) ............................................... NCDH–101 Governance of Madness (98).......................................................................... CMEL-102 New Perspectives on the Sexually Violent Offender (99) ............................. NCDH–201 Social Responses to Mental Illness (100) ...................................................... NCDH–200 End / fin 63 XXVIe Congrès international de droit et de santé mentale Abstracts for July 5, 2001 Résumés pour le 5 juillet 2001 8:30 – 10:00 BILINGUAL FORUM /FORUM BILINGUE HOW TO REGARD CRIMINAL ADOLESCENTS ? COMMENT CONSIDÉRER LES ADOLESCENTS CRIMINELS ? July 5 juillet 2001 8:30–10:00 Bilingual forum / Forum bilingue Simultaneous translation / Traduction simultanée Room / Salle MC Modérateur/Chair: Jean Trépanier, Université de Montréal Discutante/Discussant: Catherine Latimer, Ministère de la Justice Canada Restorative justice and its emotional and socio-psychological potentials in dealing with the aftermath of a crime Lode Walgrave, Nathan Harris Katholieke Universiteit Leuven, Belgium All over the world, restorative justice is increasingly used as another method of dealing with crime, and is distinct from both the punitive and rehabilitative models of dealing with offenders. Mediation and conferencing are used in restorative justice, and have gained credibility as constructive models with deep and constructive impact on both the offenders and victims. It is important to disentangle the types of (moral) emotions and socio-psychological dynamics at work, and the conditions under which they can provoke these mainly positive influences. Research has advanced shame, guilt, remorse, sympathy, compassion and other feelings. This paper will outline the essentials of restorative justice and of the impact research, and will explore the psychological processes it may provoke. ADJUDICATING MENTAL ILLNESS: DILEMMAS IN THE COURTROOM AND IN PRACTICE July 5 juillet 8:30 – 12:15 (extended session) Room NCDH–201 Chair: Richard Cooper, Federal Court of Australia On matters of causation–Issues in forensic examination of injury claimants Robert Ferrari University of Alberta Oliver Kwan Forensic Psychologist, Edmonton Expert examiners are often called upon to examine an injured person and answer the question of What is causing their symptoms? We will explore here the specific issues of causation, such as cause-in-fact, proximate cause and remoteness, convenient focus, and thin (eggshell) skull or thin (eggshell) psyche rules from the point of view of the information that may be brought forward by the examiner. We shall do so by looking at examples of chronic pain e.g., the late whiplash syndrome and post-traumatic stress disorder following accidents. Although the legal concepts and rules are relatively straightforward, such cases are often complex or lead to apparently opposite judgements because, too often, diagnostic labels are applied without an explicit statement of the probable illness mechanism. 64 XXVIth International Congress on Law and Mental Health Discourse of the law in psychiatric illness: “To be or not to be” Yega Muthu Macquarie University The purpose of this paper is to critically describe the way in which the courts have analyzed claims for psychiatric illness. In this paper, I will draw attention to the problems that exist in determining the causation of psychiatric disorders for the purposes of deciding issues of compensation. What is at issue is the different standards of causation that operate in law and medical psychiatry. In the former, it is necessary to show only that on the balance of probabilities, a chain of causation exists, showing that the defendant’s conduct “caused the plaintiff’s psychiatric illness”. Whereas in the latter, issues of causation present even greater problem as they are confined to issues of diagnosis of mental disorders, multifactorial etiologies, and the degree of psychiatric impairment. In addition, the discussion will turn to the revised interpretation of Post Traumatic Stress Disorder encapsulated in the Diagnostic Statistical Manual for Mental Disorders (DSM-IV-TR) and the International Classification of Diseases (ICD-10). The purpose of this examination is to question the method adopted by practitioners and judges in interpreting the manual. This is seen from a methodological assessment of diagnostic concordance in the light of inherent problems of psychiatric classifications and malingering. This assessment will ultimately relate to psychiatric classification of individual patients who are subjected to an intense trauma, fear and helplessness , unable to relate to what had taken place, not able to realize that the psyche is muddled or reorganised. In the absence of an actual physical lesion, the courts have become skeptical and wary of extending the defendant’s liability to cover alleged damage, such as psychiatric illness. The inherent fears are that evidence can be confabulated and based on false premise, i.e. repressed and false memory. Hence, the courts make a linguistic interpretation in view of the struggle between the law and psychiatric illness. Assessing susceptibility to influence in the mentally imparied Michel Silberfeld University of Toronto The legal theories of undue influence are reviewed to highlight the unavoidable relevance of the susceptibility theory. The susceptibility theory is discussed with a view to the creation of indicia of susceptibility to influence in the mentally impaired. These indicia are compared to the common law indicia of undue influence in order to show that they are distinct, although related. A reported case from the Ontario courts is used as an illustration of the complexities that susceptibility to undue influence poses for the legal system. Fitness to stand trial: Obligation of the court to inquire? Richard Schneider Ontario Court of Justice Recently, the Ontario Court of Appeal quashed a conviction for attempted murder and proceeded to find that the accused/appellant was unfit to stand trial. At trial, the accused was unrepresented. Throughout the proceeding the accused displayed substantial signs of mental illness. While the Crown observed that this situation was one that the court “may wish to consider”, the Judge simply asked the accused whether or not he was fit to stand trial and, with an affirmative answer, proceeded with the trial. The Court of Appeal indicated that the trial judge should have directed a trial of the issue. The Criminal Code of Canada makes such an inquiry discretionary. What should the trial court do? Comparison of mental health courts in Canada and the United States Edward F. Ormston Ontario Court of Justice Mental Health Courts in North America have taken somewhat different approaches to solving the problem of the criminalization of the mentally ill. This paper will describe the origins of the Mental Health Court approach, the common features and differences among various courts and the issues that arise from the Mental Health Court models. It will discuss various judicial approaches and the tension created within the criminal justice system when the judge “enters the arena”. The status and usefulness of psychiatric reports in court Mini Mamak Correctional Service of Canada Hy Bloom, David Nussbaum University of Toronto 65 XXVIe Congrès international de droit et de santé mentale Forensic psychiatric reports are the essential vehicle for conveying an expert psychiatrist’s findings following the assessment of an accused in a criminal matter, and are by far, the most basic work product or outcome of a forensic psychiatric evaluation. The role of mental health experts is expanding in the criminal courts, and this is so notwithstanding the ongoing debate about the usefulness or appropriateness of psychiatric participation in criminal proceedings. Judges vary in their knowledge of and familiarity with mental health issues and in their attitude about the usefulness of mental health experts in the courts. These attitudinal differences could influence the way they see and manage mental health issues as they arise relatively frequently in criminal proceedings. No systematic study has yet been carried out in Canada to determine precisely what features of psychiatric reports and psychiatric expert participation judges find useful. The current presentation will first review the current literature dealing with the subject of judge’s attitudes towards psychiatric participation in legal proceedings. The presenter will then report on the first study of its kind in Canada; the study examines the effectiveness and value of psychiatric input and testimony at various stages of criminal proceedings. The study involved the development of a questionnaire that addressed the circumstances in which psychiatric reports were considered helpful. The questionnaire further canvassed judge’s attitudes towards psychiatric evidence for the purposes described and the role of psychiatry within the overall legal framework. One hundred and ninety-one questionnaires were forwarded to Provincial Criminal Court Judges; sixty-three responded. The results indicated that a significant number of judges found psychiatric reports to be helpful at all stages of criminal proceedings. Recommendations designed to enhance the quality and usefulness of psychiatric participation in court will also be discussed. Treatment delayed, justice denied: delays in initiating treatment caused by court review of incapacity Richard L. O’Reilly, Michelle Kelly, Sandra Dunbar, John E. Gray University of Western Ontario Part I: In Ontario, a physician determines if a patient is capable of consenting to psychiatric treatment. The patient can apply to a board for a review of this finding and decisions of the review board can be appealed to the courts. Once an application for review is initiated, treatment cannot begin until the matter is resolved. We studied delays in initiating treatment associated with 334 applications made by 237 patients at two psychiatric hospitals between 1990 and 1999. Forty-nine patients applied more than once, with one patient making 11 separate applications. The diagnostic breakdown was schizophrenia, 45%; bipolar disorder, 24%; schizoaffective disorder, 18%; and other psychotic disorders, 13%. Patients withdrew 22.7% of the applications prior to a hearing, 3.6% were reassessed by the physician to be capable of consenting to treatment and 2.7% of applications were dismissed without a hearing. Thus, 70.9% of the original 334 applications resulted in a hearing. The review board overturned the physician’s finding of incapacity in 5 (2.1%) of these 237 hearings. The average time between an application and the review board hearing was 7.5 days (range 1 to 59). In the absence of an appeal of the review board’s finding to the courts, the average delay in initiating treatment was 25 days. Whereas, of the 15 patients who appealed to the courts the average delay in initiating treatment was 253 days (330 days for the 7 patients who eventually had a court hearing). The court did not find any patient capable. Part II: The effects of these delays in initiating treatment include prolonged individual suffering, increased self harm, increased use of seclusion and restraint, worsening of the long-term prognosis, deterioration of the therapeutic alliance, increased frequency of assaults, creation of a non-therapeutic ward milieu, demoralization of health professionals, blocking of scarce inpatient beds, redirection of limited financial and clinical resources to non-treatment activities and, paradoxically, the deprivation of liberty rights by withholding standard clinical treatment necessary to effect release from involuntary detention in hospital. Can withholding treatment be justified in the face of these detrimental consequences? We suggest that delay cannot be justified in the absence of evidence to show that stays of treatment during legal reviews of incapacity prevent the administration of inappropriate treatment to substantial numbers of individuals. This evidence does not exist. Review panels and courts seldom overturn a finding of incapacity and almost never do so when a first level of judicial or quasi-judicial review has confirmed incapacity. We thus recommend that non-urgent treatment begin immediately after the first level of review which should take place within a clinically appropriate period, i.e. within a week of a patient challenging a finding of incapacity. Forensic psychiatry: The double agent and the criminal law Gordon DuVal University of Toronto The recent case of R. v. MacDonald highlights the conflicting obligations of psychiatrists acting on behalf of courts or crown attorneys in assessing accused persons for fitness to stand trial and for criminal responsibility. Under section 672.11 of the Criminal Code, accused persons may be assessed by a physician, commonly a psychiatrist, for this purpose. However, the psychiatrist has significant ethical and legal obligations to the accused as a patient, which sometimes conflict with their courtordered responsibilities. In particular cases, this dual-agency problem raises significant ethical difficulties. Clearly, the psychiatrist cannot simply abandon either set of responsibilities, so such conflicts must be managed rather than definitively resolved in favour of one or the other obligation. 66 XXVIth International Congress on Law and Mental Health Accused persons, particularly those for whom mental capacity is an issue, may not appreciate the ramifications of divulging certain information to the forensic psychiatrist. The subsequent use of that information may be unfairly prejudicial to the accused. Issues surrounding consent to treatment, as distinct from the psychiatric assessment, are complex. Treatment itself may be controversial, since many lawyers believe that some clients, for whom the defense of not criminally responsible is to be advanced, are better served by not having psychiatric treatment prior to their trial. Cases drawn from the Canadian criminal courts are presented and discussed to highlight some of the conflicts inherent in forensic psychiatric practice. Discussant: Hy Bloom, University of Toronto COMMUNITY MENTAL HEALTH IN A NEW ERA July 5 juillet 8:30 – 12:15 (extended session) Room NCDH–101 Chair: Heather Stuart, Queen’s University Appraising community psychiatry in a new era: Pressing ethical, clinical and social issues Wilson Lit, Steve Abdool, Edgardo Pérez Homewood Health Centre, Guelph In an age of extensive deinstitutionalization in Canada, patients with severe and persistent mental illness are being discharged earlier and earlier for reintegration into societies that are ill-prepared to deal with them, where they suffer from stigmatisation and prejudice. Community psychiatry’s primary objectives are to establish and promote authentic autonomy and well-being through continuing support and treatment, crisis intervention in a timely manner and to facilitate further independence and purpose through adequate living arrangements, education, occupation and the recovery of other social roles. However, actualizing these goals poses difficult challenges due to limited resources and other impediments, such as patients’ refusal to collaborate with their clinicians, sometimes due to a lack of insight and awareness into their illness. This occasionally results in disastrous consequences for the individual, family and innocent bystanders, and often serves to perpetuate stereotyping and other prejudices directed at the mentally ill. Forensic mental health services policy: From whence the crisis? Howard E. Barbaree Centre for Addiction and Mental Health, Toronto Ruth Stoddart Ontario Ministry of Health and Long-Term Care It seems universally agreed among experts the world over that there is a crisis in forensic mental health services. However, every expert has his or her own explanation of the reasons for the perceived crisis, and equally personal solutions to the problems. This presentation will review the literature and research to present evidence of the crisis; examine the varied explanations of many forensic experts for the crisis and present a plan for a research study to systematically document the trends in forensic mental health services and some of the possible antecedents/correlates of those trends. Coercion justified?–Evaluating the Training In Community Living model and its replications (programs of assertive community treatment)–A conceptual and empirical xritique Tomi Gomory Florida State University This presentation examines the research and theory offered for Programs of Assertive Community Treatment (PACT), the model that is supported by Institutional Psychiatry as the most well validated and best model of intervention for the Severely Mentally Ill. This program has been researched for over 25 years, and the extensive literature on this model claims to have established its efficacy on both the systems and patient level. My critical review disputes these claims. I reviewed the empirical evidence of the randomized controlled trials of PACT as well conducted a conceptual analysis of the theoretical framework and a situational analysis of the problem situation of the PACT inventors. 67 XXVIe Congrès international de droit et de santé mentale I found that no superior efficacy could be attributed to PACT methodology when compared to no treatment or standard treatment control groups. Any statistically significant impact putatively favoring PACT is a tautological outcome based on administrative rules differentially applied to PACT and CONTROL groups, or are misattributions of worker activity as client outcome, or are based only on data supporting various outcomes and the ignoring or minimizing of negative results which contradict such claims, or are based on manipulation of data to indicate significance for variables which are not supported by the data (ie, collapsing various outcome variables some of which are statistically significant, but are tautological, like number of hospital stays, and some which are not statistically significant but empirically important, like less homelessness or less time spent incarcerated, and suggesting that the significance found (derived from the tautological components) indicates treatment effectiveness for the non tautological components). Finally, the conceptual analysis of this model demonstrates that this model is coercive and may lead to harm (ie, excessive suicide among its treatment population). Measuring therapeutic gains: Walking a fine line Steve Abdool, Wilson Lit, Edgardo Pérez Homewood Health Centre, Guelph In an age of increased concerns about limited health care resources and heightened emphasis on individual rights and freedoms, there is sometimes a tendency in psychiatric practice to hold patients responsible for their therapeutic stagnation or deterioration. When a patient’s condition appears to be at a standstill or worsening (albeit not dangerously), it is sometimes argued that the patient may be ‘resistant’ or not ‘treatment ready’. Therapy should therefore be discontinued and the patient discharged (perhaps until such time when he or she is more ‘ready’ for therapy, which sometimes means waiting for lengthy periods of time for reentry into a program, decline in the patient’s condition and increased distress experienced by caring families). Patient accountability for ‘relapse’ or lack of progress, for example, assumes that the patient has volitional governance over his or her illness, able to control therapeutic gains at the rate that clinicians desire. The primary problem is created when responsibility is shifted onto the shoulders of an already deeply troubled patient, who legitimizes the clinician’s perception by reverting to unhealthy coping skills and other negative behaviors. In this paper, the authors critically explore this phenomenon, critique key concepts, and provide guidelines to enhance clinical outcomes using ethically justifiable means. Who’s in those beds? Effects of psychiatric deinstitutionalization on acute care hospitals Kathleen Hartford, Evelyn Vingilis, Jeff Hoch University of Western Ontario Southwestern Ontario (SWO), a geographical region with 10 counties, has a population of 1.4 million. This region is experiencing fundamental changes in the structure of mental health care provision. A transfer of governance from two provincial psychiatric hospitals to one tertiary care facility in London is planned for 2001, along with reduction and re-distribution of tertiary acute care beds in London, relocation of beds to other communities and enhanced community-based services. Reform is focussed on those with severe mental illness (SMI) as defined in policy papers. To study the effect of de-institutionalization on acute care hospitals, a retrospective observational design was used. Hospital discharge abstract data from three tertiary acute care hospitals in London in 1997/98 were analyzed and will be updated annually. In the baseline year, 1841 discharges with mental illness as the most responsible diagnosis represented 1431 persons admitted once. Multiple readmissions occurred with 1.3% admitted more than six times; 90% of first admissions had a length of stay (LOS) <30 days, 7.6% between 31 and 60 days, and 2.4% >61 days. Affective psychoses represented the majority of first admissions with LOS <30days. Significant differences in diagnoses, age, gender, method of admission, LOS, readmission and transfers among the three hospitals revealed variation in practice patterns. Indeed 29.7% of admissions did not meet SMI criteria. The majority of admissions (72%) were through Emergency: the issue of planned admission and monitored care is of concern. Predictors of LOS and readmission.were examined. Future data will assess the impact of mental health reform in SWO. Towards community mental health: Use of New Zealand’s 1992 Mental Health (Compulsory Assessment and Treatment) Act Therese Egan, David Chaplow New Zealand Ministry of Health Alexander Simpson University of Auckland In late 1992, new mental health legislation came into effect in New Zealand, introducing community-based compulsory assessment and treatment orders as an alternative to hospital involuntary treatment. Use of the various provisions of this Act is reviewed for the eight years since its introduction. The effects of the legislation on clinical practice and on delivery of mental health services will also be reviewed. 68 XXVIth International Congress on Law and Mental Health Deinstitutionalization or trans-institutionalization? A comprehensive research program in south-western Ontario Evelyn Vingilis University of Western Ontario Ted Schrecker McGill University Kathleen Hartford, Young-Ho Cheong University of Western Ontario Southwestern Ontario serves as a ‘natural laboratory’ for the study of deinstitutionalization because of the downsizing of two provincial psychiatric hospitals in the region. We provide a history of restructuring efforts, and report preliminary findings from a multidisciplinary research project on this topic that incorporates both quantitative and qualitative methods. Among our findings: The population with ‘severe mental illnesses’ (SMI) is highly heterogeneous–a fact not reflected in official definitions used for purposes of health planning. Because of the inadequacy of existing tools, a comprehensive, client-centered model had to be developed for purposes of outcome assessment. Although comparisons must be made cautiously, Canada apparently spends far less than the United States in caring for patients with schizophrenia. Data on the indirect costs of mental illness are extremely difficult to obtain, as are cost data from other areas of service provision. Trans-institutionalization–the provision of ‘care’ within another sector without the transfer of funds–is an especially important phenomenon. (1) We find that the lack of systematic assessment of people in provincial jails leads to substantial under-reporting of the prevalence of SMI among inmates. (2) Tracking interactions between police and people with SMI will also allow examination of trans-institutionalization. (3) Substantial changes are evident in patterns of acute care hospital admission, as are substantial differences among hospitals in patterns of psychiatric treatment. Much conventional wisdom about deinstitutionalization and ‘care in the community’ is probably wrong, and certainly is not evidence-based. The model we have developed should be widely used in health system planning in other jurisdictions as a way of addressing this problem. We also need to consider the proposition that cost savings from deinstitutionalization may be achieved only at the expense of service quality in the community, thus requiring normative choices about society’s level of obligation toward people with SMI. Queensland Hostel Industry Development Unit proposed residential service sector legislation Lynda Crowley-Cyr James Cook University In 1992, a National Mental Health Policy was released in Australia aimed at improving the quality of life of people with mental illness by returning long term residents of psychiatric institutions to community life. This process involves the downsizing of state run public hospitals and the mainstreaming of mental health services into the general health care system. The deinstitutionalisation movement was given a significant boost with much optimism, yet numerous problems associated with the change have since been identified. One in particular, is the lack of adequate community-based accommodation and commensurate mental health services for people who are disabled by their mental illness. A substantial number of people are found to be living in boarding houses and hostels. Boarding houses have been identified by various State and National reports and discussion papers as posing the greatest risk to the safety, well-being and protection of human rights of vulnerable residents such as people disabled with mental illness. As such, most of the discussion will focus on the establishment of the Hostel Industry Development Unit in Queensland and proposed legislation that will directly impact on residential services such as boarding houses. In view of the likelihood of a continued increase in the demand for boarding house and hostel type accommodation, and the growth of privately run rather than public funded facilities in Australia, coupled with the globalisation trend, urgent consideration must be given to this issues. Queensland Governments have consistently raised the need for legislation to regulate residential services. 69 XXVIe Congrès international de droit et de santé mentale RACIAL PROFILING July 5 juillet 8:30 – 12:15 (extended session) Room CMEL-102 Chair: Juanita Westmoreland Taoré, Cour du Québec A personal encounter with racial profiling: The mythical reasonable person and the documentary aftermath of profile stops John A. Walton Northern Illinois University Much has been written about the race-based, temporary detention of minorities. Indeed, in his book, “No Equal Justice”, David Cole recently noted that stories and incidents of black men being stopped because of skin color are so commonplace, they are no longer news. This presentation highlights two remedial problems of Racial Profiling. First, the victim of such a stop may have no legal recourse against the police due to the fact that courts have created a myth that some detentions are voluntary in the mind of the person detained. According to these cases, a reasonable person who voluntarily stops to talk to the police has no constitutional remedy because a voluntary detention has no constitutional implications. The second remedial problem is related to the fact that permanent police reports are frequently generated as a result of these stops of innocent people. Many jurisdictions have no procedure for expunging these police records, which are increasingly becoming part of regional electronic databases. Mr. Walton will discuss, from a research and personal encounter perspective, the judicial myth that blacks voluntarily stop and talk to police. He will also discuss the prospects of tainting non-arrested minorities with the stigma of a documented police encounter history. ‘What’s Love Got to Do With It’: Black women, American medicine, and power Fon Louise Gordon University of Central Florida The subject of my paper is an examination of Ruby Jackson McCollum as a metaphor for the historical complexity of black women’s medical narrative. In August 1952, in Live Oak, Suwannee county, Florida, Mrs. McCollum, married, pregnant, and the mother of four children, shot and killed her physician of seven years in his office. Allegedly, Dr. C. Leroy Adams, a graduate of the University of Arkansas Medical School at Little Rock: unethically exposed McCollum to drug abuse and sexual assault in his professional treatment, dating from the birth of her second daughter in 1945; was the father of her youngest daughter born in 1951; and the father of her unborn child as well. In the aftermath of the shooting and during the first of two trials, McCollum testified that she loved Dr. Adams. I suggest that the relationship between McCollum and Adams was one of power rather than love; and reifies Michel Foucault’s analysis of the investiture of physicians as a “therapeutic clergy.” Emotional warfare: Legalized assaults on the black mind Michele Goodwin DePaul University Professor Michele Goodwin will explore the psychological trauma associated with racial profiling in the context of the United States’ civil rights era and movement. In her talk she will refer to works written by James Baldwin and other prolific black authors of the mid 20th century who captured, in literature, the crippling and often deadly effects of racism on the American cultural psyche. Professor Goodwin draws upon one of Baldwin’s more obscure, yet incredibly profound, essays on Black American life, “Just Above My Head.” She highlights the moral conundrums, paradoxes and hypocrisy in American laws that often led to the physical and emotional trauma inflicted upon massive numbers of Black Americans. Goodwin provides a historical context to America’s racism and describes how racism became institutionalized through political structures. Government agencies, emboldened by ambivalent courts, then waged what was not only a physical war against African Americans, but to also engaged in emotional warfare. This warfare has had the effect of hearing a voice crying fire in a dark theatre with unknown exits. One knows that she must run, and does so, never knowing whether a fire really exists or not, but also not wanting to be burned alive. In this dance of legitimate fear and possible paranoia (though one never knows for sure), one realizes that in the end she might be dead before exiting the hysteria or fire is possible. Racism is the roller coaster ride with an attendant asleep at the wheel. Goodwin suggests that racial warfare has resulted in traceable physical and psychological conditions manifesting disproportionately in communities of color. 70 XXVIth International Congress on Law and Mental Health Racial profiling in medicine Rene Bowser University of Illinois This paper examines the issue of racial bias in the treatment of patients of color. The central argument is that a subtle form of racial profiling exists within medicine that governs the decision of whether or how to treat a patient of color. Cultural stereotypes and unscientific understandings about the efficacy of medical treatments, I argue, are institutionalized and lead to different and inferior medical care. Differential treatment, in turn, leads to countless excess deaths, growing health disparities between minority and majority populations, and a distrust of the health care system. The remedy, I suggest, is to require each health care entity that receives federal funds to collect and report data on racial disparities in the use of services and the choices of diagnostic and therapeutic alternatives. Existing “report cards” offer an existing system for data collection; all that is needed is to stratify the reporting by race. This proposal has the obvious advantage of withholding federal funds from institutions that have statistically significant racial disparities. Equally important, it would force institutions to think about race and medical treatment. The white superiority complex–A work-in-progress Rhonda Magee Andrews University of San Francisco As one part of the study of inhumanity, racial oppression deserves continuing scholarly attention. Racial profiling has emerged as one manifestation of the continuing problem of racial oppression in the U.S. This article starts with the premise that a comprehensive approach to the study of the social-psychological effects of the institutionalized notions of white superiority on whites is critical to the management of race bias and oppression both within and through American law. Accordingly, this paper analyzes the problem of racial profiling through the lens of a broader objective: that of identifying the social-psychological effects of centuries-old practices and ideologies of white superiority, not on the minority population, but on members of the majority. This article will discuss recent legal scholarship on race and color consciousness, and on the related concepts of white transparency and white privilege. These concepts will then be considered together as part of the larger, complicated issue of whites’ social-psychological responses to the persistence of white superiority in America. I suggest that white transparency, white privilege and other aspects of white race consciousness (such as, perhaps, “white race denial,” “white race weariness,” and the “fear of Blackness”) should be considered elements of what might be called “White Superiority Complex.” Indeed, “White Superiority Complex” may be understood as a particular social-psychological phenomenon, the invisibility of which may act as a latent barrier to the amelioration of continuing racial oppression. Terry’s “Yo-yo” Effect: Reasonable Suspicion Doctrine, the Puerto Rican Day Parade and Critical Cultural Theory Frank Rudy Cooper Villanova University At last summer’s New York City Puerto Rican Day Parade (Parade), groups of men sexually assaulted at least 57 women while police officers refused to intervene. This article concludes that police inaction resulted from the confluence of (1) inherent flaws in the Terry doctrine—its “yo-yo” effect—and (2) the politics of identity then prevailing in New York City. Terry’s “yo-yo” effect is its inherent tendency to lead, first, to over-policing of racial minorities, and, then, to under-policing of racial minorities. That occurs because judicial review of police Terry stops is so limited, it provides no basis for moderating police action in individual cases. The Terry doctrine lends itself to racial profiling for the following reasons: (1) its “reasonable articuable suspicion” test has become increasingly easy to satisfy; (2) it defers substantially to officer interpretation of seemingly innocent conduct; and (3) it does not punish officers for racially motivated stops. In turn, racial profiling lends itself to controversy over policing of racial minority communities. As a result, police “yo-yo” between over-utilization and underutilization of the Terry doctrine in order to suggest overall moderation in policing of racial minority communities. The politics of identity in New York City at the time of the Parade had a great deal to do with the Terry doctrine’s yo-yo effect. For six years prior to the Parade, the Giuliani administration had conducted an experiment in full utilization of the Terry doctrine. Just prior to the Parade, the administration had come under intense criticism for police harassment of racial minority men. After the Parade, officers explained their inaction as required to refute claims of racial bias. The officers chose a racialized reading of the event—requiring inaction—over a gendered reading—requiring action—because they wanted to protect the reputation of the Giuliani administration. Racism-related mental disorders and assumption of risk Camille A. Nelson Saint Louis University 71 XXVIe Congrès international de droit et de santé mentale Query the validity of racism-related mental illnesses. Is it a legitimate hypothesis that mental illness may be exacerbated, or caused, by racism? There is increasing evidence to support the existence of racism-related mental disorders. If a supportable response to one or both of these investigations reveals the existence of racism-related mental disorders, should the law recognize and incorporate such vulnerability into existing legal doctrine? Specifically, the Tort law doctrines of Thin-skulled plaintiffs, Egg-Shell Personalities and Assumption of Risk as potentially responsive conceptual frameworks might be instructive points of departure for such an exploration. Taking the “Thin Skull” problem first, it has been held that the reasonable foreseeability test instructs that a tortfeasor “takes his victim as he finds him.”(Smith v. Leech Brain & Co. [1961] 3 All. E.R. at 1161) The reasonable forseeability test requires only that there be foreseeability of the type of injury and not its extent or the manner of its occurrence. Thus, if one were to apply this principle to a scenario with an injury inflicted by a white tortfeasor upon a racialized person, who is particularly vulnerable due to the ravages of racism, the fact that the effect of the tort is more serious than one would have expected ought to be of no particular consequence in the formulation of an appropriate remedy. “The test is not whether these defendants could reasonably have foreseen that a burn would cause cancer and that Mr. Smith would die. The question is whether these defendants could reasonably foresee the type of injury he suffered, namely, the burn. What, in the particular case, is the amount of damage which he suffers as a result of that burn, depends on the characteristics and constitution of the victim. “(ibid. at 1162) Hence, a defendant tortfeasor will be held liable for the full extent of the plaintiff’s injuries, notwithstanding that they were more serious due to a pre-existing condition, or the increased vulnerability of the plaintiff, as long as the initial injuries were of a kind that was reasonably foreseeable. Thus, there may be possibilities for compensating racialized defendants, who are “thin skulled” due to racism, for the tortuous wrongdoings they have suffered. Utilization of this doctrine together with “Egg Shell Personality” and Assumption of Risk principles may prove useful tools in more accurately defining and shaping the proper remedy for racialized persons who are particularly vulnerable or susceptible to injuries due to micro- and macro-racial aggression. How “White teachers’” perceptions of racism lead to the over-representation of Black students in special education Julie Kailin University of Wisconsin-Milwaukee This presentation will discuss a study which examined white teachers’ perceptions of racial issues in their schools. White teachers’ conceptions of race and racism reveal how their traditional ways of “knowing” often lead to the phenomenon of labeling, tracking and “blaming the victim,” threatening the mental health of African American children who are overrepresented in the problematic categories of special education. The study also considers the affects of these racial disparities on the mental health of white students and teachers. I will examine how individual or subjective racism is manifested in teacherstudent interactions and in the general culture of the school. This presentation places this problem in historical context examining the historical precedents from slavery. When permanence and indifference collide: Neglected children and neglected families Gerald Shadlen DePaul University Racial bias in the juvenile justice system attracts comparatively little public attention, although a growing number of studies appearing in the literature explicitly consider the race of adoptive children as one potentially relevant variable. Mr. Shadlen frames the debate about racial injustice in the Adoption and Safe Families Act of 1997 (ASFA), by surveying several examples of potential abuse. By using his experience in the office of the guardian ad litem, he connects these examples to existing practices and suggests changes to ASFA to reduce the potential for racial discrimination. In a society that remains marked by little hopefulness about race relations, the equitable provisions of the four major permanency options in the juvenile system reunification, adoption, guardianship, and independence - represent an important area that demands prompt and serious attention. Indifference to the plight of those families who have little access to political power is intolerable; indifference is participation. Mr. Shadlen asks a fundamental question to those who claim to be sensitive to the plight of such families in need of services to reunify them with their children. Is ASFA simply a natural progression in the drive to reduce the number of children in foster care and the length of their stay, or is it, by design, another in the long string of decisions that reduce constitutional protections for those who are powerless to protect themselves? 72 XXVIth International Congress on Law and Mental Health INDIGENOUS PEOPLES: SOCIAL AND LEGAL CONCERNS July 5 juillet 8:30 – 10:00 Room NCDH–200 Chair: Sylvain Lussier, Avocat, Montréal Aboriginal children raised in non-aboriginal families: From dis-membering to remembering Simon Nuttgens University of Alberta Despite the significant number of transracial Aboriginal adoptions that took place in Canada, especially through the 1960’s and 1970’s, little of the available research addresses the psychological and psychosocial ramifications for the children involved. The scant literature that does exist raises concerns about the psychological impact of this type of adoption, and thus indicates a clear need for additional research. This presentation aims to promote an understanding of the experience of Aboriginal children raised outside of their traditional family and community in a white-adoptive home. Specific attention is paid to issues of racial identity, cultural dislocation and cross-cultural social competencies, all of which have been identified in the literature as important areas of concern in transracial adoption. This presentation is based on the author’s doctoral research, which employed a narrative qualitative methodology to gather the storied accounts of Aboriginal adult participants. The terms “dis-membering” and “remembering” are used to highlight exclusionary versus inclusionary practices in the raising of Aboriginal children in nonaboriginal families and how, in some respects, this replicates similar practices at a societal level. It is suggested that exclusionary practices lead to experiences of disconnection, not belonging, confused identity, and loss of hope. In contrast, it is suggested that inclusionary practices are hope–inspiring, in that they serve to re-establish knowing oneself through a sense of connection with, and belonging to, a family and community. Developing citizens: Children, their rights and other psycholegal issues Sue Olsen Métis Nation of Alberta Association, Edmonton The Canadian Constitution has been described as one of the highest laws of the land and the one all other forms of law flows from. Métis people, in general, and, therefore, Métis children are acknowledged through the Canadian Constitution since 1982. This legislation recognizes Métis people as a distinct Aboriginal group within Canada which has rights to life, liberty and justice under the Charter of Rights. According to Section 35.2, the Act presents an opportunity for Métis people to prove that there is benefit to them under the law. In the province of Alberta, a precedent was set for legislative recognition of Métis rights through the Métis Betterment Act of 1938. Since then, agreements, policies, legislation and standards have been enacted solidifying Provincial rights of Métis children. British Columbia’s Ministry for Children and Families has a Strategy Plan, or policy, which supports a Memorandum of Understanding (MOU) with the Métis Provincial Council of BC. This MOU facilitates the delegation of authority for child and family services. Manitoba has also adopted a Memorandum of Understanding, which facilitates planning for the governance of Métis child welfare in that province. Federally, Métis Children continue to be unable to access resources particular to Aboriginal children in Canada. This continued lack of recognition of the distinctiveness of Métis children’s ability to access Federal resources has led to inequity, confusion and even shame of being a Métis child in Canada. The recognition of Métis child Federally has yet to adequately affect the Métis child in their communities. Challenges, choices and chance: The impact of gaming on American Indian communities Omie Baldwin University of Wisconsin-Madison The remarkable growth of the gaming industry on Indian reservations over the past decade offers unprecedented opportunities to Indian people all over the United States, but it also presents many new choices and challenges. Gaming can be a gold mine for an Indian nation in a good location, yielding jobs, training, political clout, as well dollars. People with education and training are returning to their homelands from cities, where they had previously relocated, in search of work and other opportunities. Once poverty-stricken reservations can now afford to develop new educational, health and welfare systems and services that can truly help their people. The funds support increasing independence of leadership and governance of these nations, and are producing political leaders with the experience and economic backing to deal with the outside authorities from a position of strength. 73 XXVIe Congrès international de droit et de santé mentale Gambling: A new social hazard for Maori Lorna Dyall University of Auckland Abbott and Volberg’s 1991 and 2000 research on the prevalence of problem gambling in New Zealand, identifies that Maori are more risk than non-Maori for problems relating to gambling and, subsequent, mental health and social problems. Maori are a unique indigenous people, who havebeen subjected to gambling as part of the process of colonalisation. Many Maori social institutions and services, which support and maintain Maori cultural values and beliefs, are now dependent on gambling for their financial survival. The expansion of gambling is becoming increasingly normalized, which requires mental health and legal practitioners to become involved in the debate in their countries and internationally about the size and role gambling should play. The New Zealand experience of the expansion of gambling will be discussed from an indigenous perspective. ADDICTION July 5 juillet 8:30 – 10:00 Room CPCL-101 Chair: Gregory Baum, McGill University Addiction is a choice (NOT a “Public Health Problem”) – Some implications for the contemporary drug prohibition, harm reduction and anti-tobacco crusades Jeffrey A. Schaler American University Gone are the days when public health was concerned solely with physical–that is literal–disease. Today, public health means behavioral–that is metaphorical–disease. In this sense, the public health movement is one of the greatest threats to liberty and responsibility that we face today: It is a moralistic crusade masquerading as medicine, implemented by government–the “therapeutic state” Thomas Szasz accurately warned us of this about 40 years ago. The logic of the positions taken up by this extension of “public health” concerns leads its proponents into areas which are not strictly matters of public or private health, but rather of personal morality and political control. They tend to find themselves drawn into imposing, by political means, a particular morality on others–a “duty to be healthy”–and depriving those others of the liberty to engage in certain behaviors. For example, the war-on-people called the “war on drugs” is waged by government in the name of public health: Drugs are pronounced “dangerous.” The drug-legalization movement called “harm reduction” is waged by the private sector in the name of public health. Drugs are pronounced “addictive” and addiction is pronounced “treatable.” The “anti-tobacco crusade” is waged by government and the private sector in the name of public health. The tobacco industry and its products are pronounced dangerous; both are said to cause addiction and addiction is said to be a disease. In this presentation, the contradictions and false premises on which these three public health crusades are based are outlined and discussed. A pilot project: Acupuncture treatment for drug addiction in pregnant women and young mothers Debra Friedman Bioenergy Clinic Inc., Madison A pilot project began in August 2000 in association with the local maternal substance abuse program. Originally, the pilot was to last one month, but due to its success, the program continued an additional four months. The women are referred from the W2 program, the jail diversion program and the criminal justice system. The women are drug users who are usually pregnant or young mothers, or jailed or recently convicted female users. The women voluntarily choose acupuncture to treatfor cocaine, marijuana and alcohol abuse. Treatment occurs while the women participate in various daytime group-counseling sessions. The procedure is the official treatment protocol endorsed by the National Acupuncture Detoxification Association (N.A.D.A.) that was pioneered 25 years ago in Hong Kong and at Lincoln Memorial Hospital in New York City. Yale Medical School has confirmed the effectiveness of this protocol. The official program consists of daily acupuncture treatments, urinalysis tests and counseling sessions. The counseling staff report the women receiving acupuncture are less hostile, more cooperative and improved in multiple withdrawal symptoms and cravings. With 40% of inmates affected by alcohol and drug addictions, it is possible that the jail population could be decreased if acupuncture treatment were offered. The local sheriff has expressed a willingness to try incorporating acupuncture in the local jails. Acupuncture could also help prevent the pain and cost of crack babies. 74 XXVIth International Congress on Law and Mental Health Opiate addiction and viral hepatits B and C among youth and teenagers Tatiana Korolenko Institute of Physiology, Russian Academy of Medical Sciences, Novosibirsk L.I. Anterjkina, T.V. Uchkina Municipal Drug Addiction Center for Treatment of Children and Adolescents, Novosibirsk O.N. Poteryaeva RAMS Institute of Physiology, Novosibirsk I.A. Goncharova Municipal Hospital for Treatment of Infectious Diseases, Novosibirsk E.A. Sakharova, Tsezar P. Korolenko Novosibirsk Medical Academy In Novosibirsk, drug addictive disorders (DAD) are a serious and steadily–growing problem, especially among young persons and teenagers. In 1999 and 2000, the number of heroin users was greater than it was between 1995 and 1998. Today, approximately 90% of Novosibirsk’s chemical addicts are using heroin or home-made opiates. The sex ratio of addicts has also changed: female youths and adolescents now constitute 30% of those hospitalized at the Drug Addiction Center. A higher incidence of viral hepatitis B and C was observed among these heroin addicts, as indicated by abnormal liver functional tests (ALT, AST in 80 patients). In addition, four cases of AIDS were diagnosed. Serum acute phase proteins (APP), including Creactive protein (CRP), alpha-1-proteinase inhibitor (PI) and albumin l (negative reactant of APP), were studied in group of 142 users of home-made opiates who tested negative for viral hepatitis infection using polymerase chain reaction (PCR), and who had normal ALT, AST values. The results show serum CRP increased several times during the early withdrawal period in this group of teenagers. Decreased albumin levels and PI activity were also noted. The duration of hospitalization was 21 days. Following treatment, albumin levels remained low, whereas CRP and PI activity had a tendency to approach normal values. The APPs studied have been suggested as possible biological markers of DAD. As such, restoring of APP levels may change the biological mechanisms of dependence, and advance the treatment of DAD. Discussants: Linda Garceau, Institut Philippe Pinel de Montréal George B. Palermo, Medical College of Wisconsin J. Dennis Thornton, Attorney-at-Law, Wauwatosa, Wisconsin 10:15 – 12:15 BILINGUAL SESSION / SESSION BILINGUE MENTAL HEALTH IN NATIVE COMMUNITIES: PROBLEMS AND STAKES I SANTÉ MENTALE EN MILIEU AUTOCHTONE: PROBLÉMATIQUES ET ENJEUX I July 5 juillet 10:15–12:15 Bilingual session / Session Bilingue Simultaneous translation / Traduction simultanée Room / Salle MC Modérateur / Chair: Raymond Sioui, Psychologue, Consultant en matière autochtone, Québec L’intervention auprès des enfants autochtones manifestant des comportements sexuels problématiques et de leurs parents: une approche clinique et communautaire Intervention with native children manifesting problem sexual behaviours and their parents: a clinical and community approach Judith Morency Université Laval 75 XXVIe Congrès international de droit et de santé mentale L’exploration mutuelle et les jeux sexuels entre enfants sont des comportements qui font partie d’un développement psychosexuel normal. Cependant, il arrive que les comportements sexuels deviennent problématiques et envahissent les interactions de l’enfant avec son entourage, ce qui nécessite que des interventions correctrices soient mises en place pour favoriser la reprise d’un développement normal. Les causes possibles des comportements sexuels problématiques entre enfants sont nombreuses: répétitions post-traumatiques d’abus sexuels subis, exposition à du matériel pornographique ou à des interactions sexuelles entre adultes, vécu de violence, négligence, etc. En milieu autochtone, l’intervention auprès d’enfants présentant des comportements sexuels problématiques doit tenir compte de certaines caractéristiques de la vie communautaire. Par exemple, la proximité physique des familles vivant sur réserve et les interrelations familiales étroites (liens de parenté nombreux et étendus) nécessitent que les interventions s’inspirent d’une approche familiale et qu’elles s’inscrivent dans une démarche communautaire de guérison. Dans le cadre de cette présentation, les participants pourront se familiariser avec une grille d’évaluation clinique de la situation de l’enfant et de sa famille. Les éléments clés d’un modèle d’intervention clinique et communautaire maximisant la contribution de toutes les ressources dans le milieu seront également présentés. Le syndrome d’alcoolisme fœtal / Fetal Alcohol Syndrome Lise Bastien Conseil en Éducation des Premières Nations, Québec L’éducation spéciale est un programme qui offre aux étudiants des Premières Nations, des services adaptés en milieu scolaire qui répondent à leurs besoins particuliers (les troubles de comportement et de communication, difficultés d’apprentissage, handicaps physiques, etc.) Conséquemment, et surtout parce que les représentants des communautés ont informé le Conseil en Éducation des Premières Nations que les enseignants ont, dans leurs classes, des enfants affectés par le syndrome d’alcoolisme et qu’ils ne savent pas comment agir avec ces enfants, le CEPN a dû s’intéresser particulièrement à cette situation. Le syndrome d’alcoolisme fœtal constitue un type de malformations congénitales associées à la consommation d’alcool durant la grossesse. Le résultat de cette consommation peut être la cause préjudiciable et résulter en des difficultés d’apprentissage, une déficience mentale, une coordination médiocre et des anomalies physiques. Malheureusement, ces effets ne décroissent pas ni ne disparaissent, et demandent des stratégies d’interventions appropriées tout au long de la vie des enfants affectés. Le taux d’incidence est très élevé, par rapport à la moyenne canadienne. Compte tenu de l’ampleur du problème, le Conseil en Éducation des Premières Nations a décidé d’intervenir. Depuis quelques années déjà, le CEPN a entrepris des démarches afin d’informer ses communautés membres au sujet du syndrome d’alcoolisme fœtal. Les activités tenues et les informations distribuées à cette fin sont: Dépliant de sensibilisation destiné aux communautés, vidéocassette sur le syndrome alcoolique fœtal, entente avec la «Alberta Alcohol and Drug Commission» pour la traduction d’un manuel sur le SAF, cliniques d’évaluation avec les hôpitaux, affiches bilingues «Pas d’alcool pour un bébé en santé», entente avec le centre d’amitié autochtone de Vancouver pour la traduction française d’un cahier d’activités et d’un document d’informations sur le SAF. Enfin, un projet pour clinique d’évaluation pour contrer aux problèmes d’identification et de dépistage du SAF (découlant du fait qu’il n’y a pas de spécialistes dans les communautés); grâce à ce projet, une vingtaine d’enfants ont pu être évalués. Le CEPN a récemment formulé une demande de financement pour mettre en œuvre les quatre projets suivants : 1 Projet clinique: Ce service formule «guichet unique» développé en collaboration avec l’Hôpital Sainte-Justine de Montréal offrira aux communautés la possibilité de faire évaluer des enfants soupçonnés d’avoir les effets du SAF. À cause de la demande incessante d’évaluations des communautés, le CEPN envisage de mette sur pied une clinique permanente, à guichet unique, afin de redresser les faiblesses, de s’évaluer périodiquement, d’établir un même mode de fonctionnement. Le CEPN désire agir à titre d’agent de première ligne, et adopter une approche globale en menant des évaluations, et en déterminant non seulement les troubles d’apprentissage, mais également les troubles neurologiques. Cette approche est préconisée afin de mieux régler le problème dans son ensemble, et non pas seulement les problèmes d’apprentissage. 2 Programme de prévention pour les jeunes Au niveau des écoles secondaires, des jeunes filles et des jeunes mères à risques, effectuer un travail de sensibilisation au SAF et de prévention. 3 Sensibilisation des communautés Le CEPN compte faire imprimer des brochures, des affiches, des dépliants et des autocollants, qui seront par la suite distribués dans les communautés. 4 Formation aux intervenants Le CEPN offrira à la demande des communautés membres une formation d’une durée de deux jours sur le SAF, qui consiste à donner des méthodes et outils pratiques pour travailler efficacement avec les enfants atteints du SAF. 76 XXVIth International Congress on Law and Mental Health Mental Health Problems in Inuit populations: Community initiatives Problèmes en santé mentale dans les populations inuit : initiatives communautaires Aani Tulugak Youth Protection Agency, Nunavik Not more than 40 years ago, Inuit people were living as nomads. They started to live in communities after the government decided that it would be easier to administer Inuit Affairs from communities. Life seemed to get easier and people did not have to work so hard to survive. The government also proposed new ways to deal with mental health problems. The conference will focus on problems of mental health in Inuit communities, traditional responses to these responses and new methods “imported” from the South, the impact of these ways to provide services and which methods the communities would keep if they were absolutely free to choose. EXPERTISE AU CIVIL July 5 juillet 10:15–12:15 Salle IASL-106 Modérateur: Jacques Lesage, Institut Philippe Pinel de Montréal La quérulence processive Louis Bérard Institut Philippe Pinel de Montréal «Le droit est l’art du bien et du juste» disaient les Anciens. La possibilité pour tout citoyen qui s’estime lésé d’obtenir juste réparation en s’adressant aux tribunaux est un fondement de la démocratie. Des procédures judiciaires peuvent être entreprises par des gens souffrant de troubles mentaux ou utilisées pour des motifs ayant bien peu à voir avec l’enjeu manifeste du litige. Elles risquent alors de devenir de véritables outils d’agression d’autant plus redoutables qu’elles sont drapées d’une forte présomption de légitimité. Le but de cet exposé est de présenter brièvement «deux cas auxquels le présentateur à été exposé, de réviser les rares écrits récents sur le sujet et surtout de discuter avec l’auditoire des moyens de réconcilier ou de rapprocher les considérations a priori diamétralement opposées que les univers judiciaires et médicaux ont de ce problème. Le médecin expert et le médecin traitant face à l’invalidité: deux faces de la médecine ? Denis Lepage Clinique médico-légale, Sherbrooke Il arrive souvent que les conclusions du médecin expert s’opposent à celles du médecin traitant lorsqu’il s’agit de déterminer l’existence, l’importance ou la durée de l’invalidité d’un individu. Cette situation peut susciter des interrogations chez les intervenants (par exemple: assureurs, employeurs, avocats ) qui doivent orienter leur action selon l’opinion et les décisions du médecin. Dans certains cas, on assiste à une mise en question de l’objectivité du médecin traitant, dont on exige de plus en plus qu’il justifie, documents officiels et notes de travail à l’appui, son diagnostic, son traitement et ses décisions; tout en lui demandant de commenter le résultat des expertises auxquelles a été soumis son patient. L’auteur souhaite clarifier cette situation, en confrontant notamment les modèles médicaux et psychologiques et les rôles de diagnosticien et d’aidant que doit assumer le médecin. «Mémoire d’outre tombe» de feu Monsieur Moore Yvan Gauthier Centre hospitalier Robert-Giffard, Québec Dans le cadre de cette conférence, le participant sera confronté aux différents obstacles auxquels l’expert est exposé lors d’un recours civil. Nous reverrons les dispositions légales pertinentes en regard de l’aptitude du majeur. Au terme de cette rencontre, l’auditeur pourra peut-être répondre à cette question «Gasper était-il apte?» 77 XXVIe Congrès international de droit et de santé mentale COMMUNICATIONS LIBRES IV July 5 juillet 10:15–12:15 Salle NCDH–102 Modérateur: Bernadette Lamoureux, Institut Philippe Pinel de Montréal Intégration des victimes dans le traitement des abuseurs sexuels intra familiaux: 10 ans de collaboration Marielle Mailloux et Paul-Robert Laporte Programme VISA, Québec Visa est un programme de traitement offert à l’Établissement Montée St-François (un pénitencier fédéral canadien) à tous les détenus ayant sexuellement abusé d’enfants ou d’adolescents auprès desquels ils exerçaient une relation d’autorité dans un cadre familial. Le programme thérapeutique a été modelé et adapté de l’approche Giarretto, il s’agit d’un modèle intégré qui allie le judiciaire et le psychosocial. Le programme thérapeutique présente des objectifs spécifiques pour permettre aux abuseurs de travailler les facteurs internes et externes de leur problématique pour les aider à réorganiser leur vie sainement tout en évitant les situations à risque. Le programme Visa inclut les victimes dans le travail de conscientisation et de sensibilisation par: • Des témoignages de victimes afin de confronter les participants au vécu de celles-ci; • Des échanges entre victimes et participants afin de confronter les perceptions et les distorsions de ces derniers; • L’utilisation de documents vidéo portant sur le vécu des victimes afin de permettre aux participants d’identifier des séquelles possibles causées par les abus; • La recherche par les participants des conséquences réelles des abus pour leurs victimes; • L’identification et l’application par les participants de moyens de réparation afin de les responsabiliser face à leurs actions et de leur montrer le rôle possible à jouer face aux victimes; • Des contacts familiaux afin de permettre au sujet de faire face à ses victimes et aux conséquences de ses actes. Cette communication libre vise à mettre en évidence le bien-fondé, l’utilité et l’apport de l’intégration d’une place pour les victimes à l’intérieur d’un programme de traitement pour abuseurs. L’imagerie mentale chez les psychopathes Adèle Claix Hôpital Sécuritaire Les Marronniers, Tournai Thierry Pham Université Catholique de Louvain La littérature clinique décrit les psychopathes comme des individus vivant dans le temps présent, s’attachant à l’environnement immédiat et concret (cf. Lippert & Senter, 1966; Gibello, 1978, 1983; Debray, 1984). Ces sujets seraient peu aptes à imaginer avec vivacité des événements futurs (Schalling, 1978). Ce déficit en imagerie mentale observé cliniquement chez les psychopathes n’a été démontré que très partiellement sur le plan empirique (Patrick, Cuthbert, & Lang, 1994; Pham, 1995). C’est dans le but de déterminer s’il s’agit d’un déficit cognitif ou d’une mauvaise (voire d’une non) utilisation de l’imagerie mentale par ce type de sujets que nous avons développé la présente étude en 3 phases: (1) une première expérience teste l’hypothèse selon laquelle les psychopathes présenteraient un déficit global (quelle que soit la modalité sensorielle à laquelle appartient l’image) de vivacité de l’imagerie mentale à l’aide du QMI qui est une échelle autorapportée; (2) une seconde expérience, dans laquelle nous présentons aux sujets des stimuli sur un écran d’ordinateur, sonde les capacités purement cognitives d’imagerie mentale chez les psychopathes et (3) une troisième expérience visant à examiner le déficit en imagerie des psychopathes lors de l’évocation de mots émotionnels. Les sujets (N = 25), incarcérés dans une prison belge de haute sécurité, de sexe masculin et d’expression francophone, ont été assignés dans 2 groupes: (a) «les psychopathes» (N = 13; score moyen à l’échelle de Hare = 26,93) et (b) «les contrôles» (N = 12; score moyen à l’échelle de Hare = 7,18). L’ensemble de ces sujets a réalisé les 3 expériences d’imagerie mentale. Nous n’avons obtenu aucune différence significative entre les 2 groupes pour les 3 expériences. Ces résultats remettent en question l’image traditionnelle qu’ont les cliniciens sur le déficit en imagerie mentale des psychopathes. Les inconduites sexuelles en entreprise: Le harcèlement sexuel en milieu professionnel Jean-Pierre Vouche Antenne de psychiatrie légale de La Garenne Colombes, Paris 78 XXVIth International Congress on Law and Mental Health Cette intervention permet de jeter un regard singulier sur les inconduites sexuelles en entreprise, sur le harcèlement sexuel au travail, un pas de plus dans le harcèlement moral en entreprise. Ainsi que les agressions sexuelles agies par un ou plusieurs sujets. L’Institut d’Accompagnement Psychologique Post-traumatique, de Prévention et de Recherche que j’ai co-créé avec la RATP (Société des Transports Urbains de la région parisienne) s’occupe de prévention et d’accompagnement thérapeutique pour des salariés victimes ou potentiellement victimes dans des sociétés ou organisations de secteurs d’activités très différents. La consultation “Souffrance, Stress, Violence au travail” de la Ligue Française pour la Santé Mentale ouvre en 2001 ses portes à Paris. Elle est destinée à des salariés victimes de violence au travail dont le harcèlement sexuel. L’ONG Aide Psychologique Sans Frontières France s’associe à ces prises en charge grâce à son réseau national qui peut intervenir en proximité des victimes. Sur les 147 millions de travailleurs de l’Union Européenne, 12 millions se disent victimes d’intimidation et de violence physique et 3 millions de harcèlement sexuel. tels sont les chiffres qui ressortent de le seconde enquête européenne sur les conditions de travail réalisées à partir d’entretiens individuels à travers l’Europe. Les conseils de la Commission Européenne pour la prévention de la violence au travail dont le harcèlement fait partie, sont de clarifier les responsabilités des différentes instances – internes et externes à l’entreprise – qui ont un rôle légitime à jouer dans la réaction globale face aux différentes formes de violence au travail. Mais aussi la nécessité d’organiser une campagne de sensibilisation à destination des petites entreprises. Message: la violence, le harcèlement moral et sexuel sont des graves problèmes occultés qui surviennent dans un nombre croissant de professions; ces violences peuvent être gérées et évitées de façon efficace. Il s’agit d’imposer le respect de l’individu sur le lieu de travail. C’est aux chefs d’entreprise de réintroduire le respect dans leurs structures. SOCIO-LEGAL FACETS OF WOMENS’ MENTAL HEALTH July 5 juillet 10:15 – 12:15 Room NCDH–200 Chair: Hélène Tessier, Commission des droits de la personne et de la jeunesse du Québec Depression and PTSD in women: Differences and important similarities Kathy Hegadoren University of Alberta Ruth Gallop, Nick Coupland University of Toronto Jean-Michel Lemelledo, Jessica Myrholm University of Alberta Depression is a serious health problem in women, with prevalence rates twice that of men. A significant number of women who seek treatment for depression will not demonstrate a positive treatment response to antidepressant drug therapies. Predicators of response to specific types of antidepressants remain elusive. Research in the treatment of depression is hampered by the recognition that depression represents a heterogeneous spectrum of disorders. Previous attempts to subtype depression have been based on symptom clustering or in relation to a specific event, as in the case of postpartum depression. These attempts fail to adequately acknowledge the role of traumatic life events, either in the vulnerability towards developing depression or their impact on treatment response. This is the case despite strong evidence of the close relationship between serious stressors and depression in women. Indeed, the most common response to a serious stressor in women is depression. Combined psychological and neuroendocrine data will be presented to illustrate the need for mental health professionals to include historical questions related to traumatic life events and an assessment of whether those events have impacted on a woman’s health. In the face of new drug development based on neuroendocrine abnormalities associated with depression, it becomes even more important for clinicians to understand the impact of life events on a woman’s health. Evidence is accumulating that if the depression is part of a larger health issue related to posttraumatic syndromes, there is an increase in the complexity of symptoms beyond classical depressive symptoms and higher risk of antidepressant drug treatment failure in women. Being able to identify this subgroup of depressed women would improve our ability to combine highly targeted psychotherapies with drug therapies, thus avoiding adding to their often-overwhelming feelings of despair. Anorexia nervosa Terry Carney University of Sydney Severe anorexia nervosa is life threatening, raising various dilemmas about the place of coercion in therapy. Treatment regimes adopt different stances about its place with a program. Australia’s federal system of government offers a matching variety of regulatory agencies from which authority for involuntary treatment may be obtained, including from family and ordinary courts, 79 XXVIe Congrès international de droit et de santé mentale mental health tribunals, and adult guardianship boards. This paper explores differences in the policy and reasoning adopted by these bodies (such as the weight given to the patient’s choice, best-interest protection from self-harm and principles of habilitation) and in their ‘style’ of discourse (including deference to clinicians and parents). It will explore possible paradigms for establishing an optimal approach to the resolution of these difficult dilemmas. ‘No matter how deep the craving’: An exploration of the treatment of Munchausen’s Syndrome By Proxy by Australian courts Arlie Loughnan University of Sydney ‘No matter how deep the craving’, the law expects and implies certain standards for defendants. How does the law read disabled women’s bodies? What does this mean for women ‘diagnosed’ with Munchausen’s Syndrome By Proxy and charged with child abuse? What does this suggest about the legal concept of the Self, created in and through legal discourses? This paper explores the interface between medical and legal discourses about Munchausen’s Syndrome By Proxy. Through an examination of recent case law, both criminal and civil, I consider the ways in which judicial treatment of the syndrome ‘fits’ into dominant legal paradigms of voluntariness and contrition. I will consider the gendered assumptions and implications of the legal discourse on Munchausen’s. Drawing on recent feminist commentary on this subject, this paper critically examines the concept of the legal Self through a problematisation of the categorisation and legal treatment of Munchausen’s ‘syndrome’. Pharmaceutical drug liability and uncertainty Patricia Peppin Queen’s University Pharmaceutical manufacturers owe a duty of care to patients to warn of product risks as well as benefits. For prescription drugs, the company discharges this duty by warning the physician, who is the “learned intermediary” between the drug company and the patient/consumer. Uncertainty in the science underlying innovative drug therapies creates difficult legal problems and these have a differential impact on women, certain racial groups and elderly persons. For example, lack of information about the long-term effects of a product undermines the duty to disclose risks by pharmaceutical manufacturers and health professionals. Where clinical trials have been conducted on samples unrepresentative of the population for whom the drug will be prescribed or where small sample sizes have precluded sub-sample analysis, data on differential adverse effects and efficacy will be lacking. Causation is difficult to prove in these cases. Particular drugs prescribed for psychiatric conditions are subject to these problems. The silicone gel breast implant litigation illustrates the difficulties of proof for plaintiffs who are unable, because of scientific uncertainty, to prove a causal link between their health problems and the medical device. The regulation of women’s sexuality in institutional health settings Mary-Jane Dykeman Health Law Forum, Toronto In many institutional health settings, patients, staff, and administrators grapple with the question of patient sexuality. Health facilities must create and maintain safe environments that meet the requisite standard of care. They must also acknowledge that in many settings (particularly where individuals experience extended stays of months or years), sexual expression may be inevitable, and must be addressed in a respectful and dignified manner. This paper will look at the historical regulation of women’s sexuality in mental health and related settings, from a Canadian perspective. It will explore the notion of a ‘right’ to sexual expression, and will also examine the capacity of certain categories of disabled persons (e.g. those suffering from acute mental disorder, the developmentally disabled, and the dually diagnosed) to consent to sexual activity. Finally, it will evaluate the development of comprehensive sexuality policies as an institutional response to the regulation of women’s sexuality. Health promotion in women’s lives Sandi Harmer Amethyst Women’s Addiction Center, Ottawa Health promotion seems to be the buzz word of today, but what does it mean in the context of women’s lives? Working in health promotion with women means understanding the complexity of women’s lives. Issues such as violence, poverty, mental health and multiple roles are all experiences that place women at high risk for using substances as a way of coping. The Ottawa Charter for Health Promotion (World Health Organization 1986) defines health promotion as “the process of enabling people to increase control over, and improve their health.” The criterions to health are no longer only disease prevention, but also must reflect the standard of living or lifestyle of the individual. Many women are living in socioenvironmental risk conditions such as poverty, low-paying jobs or unemployment and lack of education or the inability to obtain one. A commitment to providing health promotion/prevention services in the community stems from the resolve to help women take control of the factors affecting their health and well-being, preferably before substance misuse/abuse occurs. It also reflects the belief that social change is necessary too, if women are to be able, well and whole. The Health Promotion program at Amethyst Womens Addiction Centre has been 80 XXVIth International Congress on Law and Mental Health developed for a woman’s individual healing, addressing such areas as self-esteem, anger, assertiveness, stress and wellness. The work being done by the women in their communities is change-oriented. Change means opportunity, the opportunity to have a healthier lifestyle. The paper will address the programs currently provided by the Health Promotion program that mitigate against those conditions in women’s lives that put them at risk. Participants feedback provides further insight into the need and effectiveness of health promotion programming. MENTALLY DISORDERED OFFENDERS: THE NETHERLANDS’ EXPERIENCE July 5 juillet 10:15 – 12:15 Room CPCL-101 Chair: Eric Blaauw, Free University of Amsterdam Systems of dealing with mentally disordered offenders in several countries Machteld Hoeve Free University of Amsterdam The Dutch government is reevaluating the current method of managing mentally disordered offenders. In order to design sound policy, the Ministry of Justice commissioned the Department of Clinical Psychology of the Vrije Universiteit Amsterdam to study the management of mentally disordered offenders in several countries. The main objective of the research project was to compare the foreign systems with the Dutch so-called TBS system. The countries involved were Canada (British Columbia), the UK, Sweden, Germany (Hessen), Belgium, France and The Netherlands. Information was gathered about legislation regarding the assessment, placement, furlough, release and after care of inmates that are found to have a mental disorder during the committing of a crime. In addition, data about how these countries handle inmates in practice (e.g. procedures, type of institution) were studied. The interesting results from the study are discussed. Treatment of a high risk child sex offender in forensic psychiatric hospital ‘De Kijvelanden’, the Netherlands S. de Reuver De Kijvelanden Forensic Psychiatric Hospital, Rhoon In this case presentation, the treatment of a high risk child sex offender will be discussed. The patient has been in the clinic for the past two years. His offences and diagnosis (accountability) will be outlined. Moreover, the treatment program, obstacles encountered during his treatment, and the long run prognosis of this young male will be disscussed. The Dutch TBS Experience: a summer holiday on ice Hjalmar van Marle University of Nijmegen The Dutch entrustment Act, the Terbeschikkingstelling (TBS), has existed since 1925 because the penal courts sought different laws to apply to personality disordered offenders (PDO’s) and the mentally disabled. Though the TBS is still appreciated, offering full possibilities for treatment, disadvantages have been noticed with regard to the connections between general psychiatry and the financing of the provisions. This is not startling because since its inception, the TBS was a measure of the security of society, providing intensive care for the PDO’s and the possibility for treatment. The facilities’ quality and low recidivism rate made it popular with the courts. Thus, in the 1990’s, a waiting list arose without the ability to control the system’s efficacy. Since then, changes in the penal law have lead to many conditional variations of the TBS: TBS with conditions and the conditional release from TBS. The routing of the patients within the system has been differentiated: long stay provisions have been erected so an undetermined treatment is no longer granted. Also, rehabilitation (‘transmuralisation’) was integrated at an earlier stage of treatment, but with intense supervision and surveillance. These changes made the next problem visible: how can the most dangerous disordered offenders be differentiated from the less dangerous within these different treatment modalities? The proposed Dutch solutions to these forensic psychiatric problems will be discussed with regard to existing law, ethics and state of the art psychiatry. Treatment of mentally disordered patients in forensic psychiatric hospital ‘De Kijvelanden’ the Netherlands Ch. van Nieuwenhuizen De Kijvelanden Forensic Psychiatric Hospital, Rhoon 81 XXVIe Congrès international de droit et de santé mentale In this presentation, the treatment, diagnostic procedures and research in “de Kijvelanden”–a forensic psychiatric hospital in the Netherlands–will be discussed. First of all, an outline is given of the number of patients and their psychopathology (axis I, axis II and co-morbidity). Moreover, the various disciplines working in the hospital and the different kind of units will be discussed. Finally, the five ‘special care programs (SCP)’ for specific groups of disorders and/or psychiatric problems will be presented, i.e. the SCP for psychotic patients, SCP for mentally retarded patients, SCP for patients with substance-related disorders, SCP patients from different cultures, and SCP for patients convicted of sexual offences. Prevalence of mental disorders in prison systems and forensic psychiatric institutions Eric Blaauw Free University of Amsterdam Most prison systems hardly pay attention to the needs and capabilities of remand prisoners. Usually, prisons for sentenced prisoners have drug treatment programs, programs for successful reintegration into society, special care programs for mentally disordered prisoners, maximum security programs for prisoners with a high risk of violence, and several other programs. Assessment for the placement of prisoners in such programs usually takes place once a prisoner has been sentenced. A study in The Netherlands investigated whether it is also possible to decide about future placements in special programs while prisoners are still in their pre-trial phase. For the study 160 adult prisoners, 80 young adult prisoners (18 to 24 years of age) and 20 juveniles were interviewed (at different points in time) about many aspects that could be important for the placement of prisoners in special regimes in prisons. The study showed that it is possible to identify the most suitable programs for prisoners at a very early stage. The study also showed that the programs required by some less mature18 to 24 year olds differ from other 18 to 24 year olds. The presentation will address many findings of the study. Discussant: Gian Carlo Nivoli, Cagliari University 13:45 – 15:45 BILINGUAL SESSION /SESSION BILINGUE MENTAL HEALTH IN NATIVE COMMUNITIES : PROBLEMS AND STAKES II SANTÉ MENTALE EN MILIEU AUTOCHTONE: PROBLÉMATIQUES ET ENJEUX II July 5 juillet 13:45–15:45 Bilingual session / Session bilingue Simultaneous translation / Traduction simultanée Room / Salle MC Modérateur/Chair: Pierre Picard, Sexologue clinicien, Québec Meanings of mental health / Le sens de la santé mentale Naomi Adelson York University As a medical anthropologist, my contribution to the study and dissemination of knowledge about mental health amongst First Nations peoples centers on the social, political and cultural realms of health and illness. Thus, I focus on the qualitative aspects of stress and mental health, examining in particular local, community-based knowledge systems and practices. In the recent past, for example, I examined meanings of “mental health” as described by the elders of a small, remote Québec Cree community. Preliminary findings indicate that mental health is not simply an individuated phenomenon, but highly social and contextualized within the general well-being of families and the community at large. This has tremendous implications in terms of modalities of understanding and treating individuals both within and outside of their social or cultural context. Further, I will be conducting research with the young adult women of the same Cree community, assessing their concept of “stress”. Simply put, on cannot make sense of what it means to be healthy – in all senses of the term – for First Nations women without seeing the larger social. Cultural political and economic contexts which bear upon women’s experiences of well-being. Madeleine Dion Stout directly and cogently addresses the relationship between the cultural, political, legal, social and economic dimensions of health for Aboriginal women and specifically points to “income and social status, social support networks, education, physical surroundings, biological and genetic makeup, child development and health services” (1995:3) that are all vital components of health for First Nations women. Mental heal this inextricably tied to all these other aspects of health and well-being. Thus, psychological stressors will, by this definition, impinge on all other aspects of women’s lives. The majority of Aboriginal women’s mental health research focuses on the effects of social traumas such as domestic violence and alcohol/drug 82 XXVIth International Congress on Law and Mental Health dependence or addresses psychiatric disorders, suicide or suicidal ideation, or more broadly, the availability of mental health services. There are relatively few qualitative or anthropological studies that look either at conceptualizations of stress or examine stressors defined by women, and in particular First Nations women. In my presentation, I will offer these case studies as examples of the ways in which medical anthropology can substantively contribute to a fuller understanding of the meanings of “mental health” for First Nations communities. La santé mentale c’est l’harmonie du corps et de l’esprit Mental health is the harmony of the body and the spirit Raymond Sioui Consultant en matière autochtone, Québec «La santé mentale c’est l’harmonie du corps et de l’esprit. La santé mentale repose sur l’estime de soi et la dignité personnelle qui découlent d’une harmonie et d’un bien-être sur les plans physique, émotif, mental et spirituel et d’une identité culturelle bien définie.» Cette définition permet de mettre l’accent sur les facteurs les plus susceptibles de favoriser l’estime de soi, la dignité personnelle et une identité culturelle bien définie, 3 conditions considérées primordiales à une bonne santé mentale. L’hypothèse de base devient fort simple, c’est-à-dire que tout ce qui stimule et contribue à un développement harmonieux de la personne sur les 4 plans mentionnés ci-dessus, va forcément contribuer à sa santé mentale, et en contrepartie, le manque de stimulations va jouer à l’encontre. Ce que je propose alors dans un premier temps, c’est de rappeler brièvement ce qui a contribué à déstructurer le tissu social des Premières Nations en développant quelques thématiques appropriées, dont à titre d’exemples: • Ce processus (avec composante légale) ayant conduit à une perte d’autonomie (auto-suffisance) des Premières Nations et qui a résulté en un manque de vision pour l’individu en quête de visions, c’est-à-dire en un manque d’opportunités de trouver une raison d’être ou rôle social qui s’insère dans sa communauté culturelle et stimule son développement; • Une tendance qui a la vie passablement dure et qui consiste en une identification autochtone c’est pas si ou pas ça et à ne proposer que des modèles stéréotypés, sclérosants et forts difficiles à concrétiser dans la réalité d’aujourd’hui, et ce, au risque d’être catalogué de faux autochtone, qui pire est, parfois de l’intérieur ou encore de bien pensants qui nous veulent vraiment du bien; • Les 5 stades identifiés dans le modèle de l’identité minoritaire et qui expliquent certaines réactions de groupes dominés qui vont de l’infériorisation totale par rapport au groupe dominant, en passant par le rejet total de tout ce qui vient de ce groupe sans discrimination, pour aboutir éventuellement en une plus grande confiance en soi n’impliquant pas un rejet global de l’autre mais l’exercice d’une meilleure discrimination à son égard. Dans un second temps et c’est là que l’emphase doit être mise, je propose d’illustrer des exemples de ce que font les Premières Nations aujourd’hui pour sortir d’une situation difficile et redonner à leurs membres des opportunités de se réaliser, dont à titre d’exemples: • Les projets en milieu éducatif pour que l’identité culturelle soit abordée de façon positive et comme pouvant s’intégrer dans la réalité d’aujourd’hui; • L’intervention précoce auprès des enfants au niveau des services communautaires et en milieu scolaire pour leur faire vivre des expériences de réussite axées sur le développement d’une bonne estime de soi (note: relation circulaire de causes à effet); • Les initiatives dans le secteur de l’économie qui véhiculent une image différente et plus contemporaine et ouvrent sur de nouvelles possibilités ou visions favorables au développement des individus; • L’importance attachée au droit à l’autonomie des Premières Nations en vue de donner un cadre et une dignité à toutes ces initiatives. En conclusion, la définition de la santé mentale implique l’importance d’un milieu riche en stimulations pour un développement harmonieux de l’individu sur les 4 plans mentionnés à la définition et c’est ce que la présentation fera ressortir. Problématique sociale dans la communauté autochtone Social problems in native communities Bernard Roy Université Laval Dans la société autochtone contemporaine, le «système de surveillance populaire» est un lieu d’exercice d’un pouvoir endogène contre ce qui est interprété comme étant des incursions d’un pouvoir exogène associé au monde des Blancs. Cette surveillance reflète les forces multiples qui émanent des différents groupes d’intérêts qui composent la mosaïque communautaire. Elle relève de l’exercice du pouvoir d’un ou de groupes d’intérêts de la communauté. Ce «système» vise, entre autres, à assurer la cohésion du groupe face à ce qui est identifié comme relavant de «l’autorité blanche». Dans ces communautés, l’émergence de comportements individuels distinctifs peut avoir pour effet de soulever des phénomènes de réprobation sociale. Cette réprobation 83 XXVIe Congrès international de droit et de santé mentale s’avère parfois si puissante qu’elle peut engendrer l’isolement voire même l’exclusion d’individus qui risquent d’être accusés de ne pas agir comme de «vrais autochtones», d’agir comme des «Blancs». Ces individus sont dès lors considérés comme des «pommes» à l’intérieur de la communauté et comme des «sauvages», des «lâches», des «paresseux» et quoi encore dans la société non-autochtone. POURSUITES MÉDICALES July 5 juillet 13:45–15:45 Salle NCHD-102 Modérateur: Lionel Béliveau, Psychiatre, Montréal La responsabilité civile du psychiatre: Quelles sont les conditions d’une poursuite victorieuse? Jean-Pierre Ménard Avocat, Montréal L’exposé comprendra une description des conditions de la responsabilité civile, suivie d’une description des situations qui donnent lieu le plus fréquemment à des poursuites contre les psychiatres, soit la prévention du suicide et de l’agression, les erreurs de médication, les erreurs de diagnostic, les rapports sexuels, le secret professionnel et le défaut d’avertir les tiers, etc. Nous traiterons finalement de l’importance du dossier médical. Ça n’arrive pas qu’aux autres… Albert Plante Université de Montréal Seront présentées dans un ordre chronologique, les grandes lignes d’un événement affligeant, soit le suicide d’un adolescent de 16 ans survenu quelques minutes après qu’il eut reçu son congé médical de l’urgence d’un centre hospitalier universitaire. Seront partagées avec l’auditoire les étapes du processus déclenché par le dépôt d’une plainte et d’une poursuite par un apparenté, par l’enquête menée par le Collège des médecins et chirurgiens du Québec jusqu’au règlement hors Cour de cette poursuite. Sera décrite la réaction psychosomatique grave éprouvée par l’auteur dans les jours qui ont suivi. Sera énoncée une suggestion d’accès facilité à de l’aide psychosociale à titre préventif pour les médecins, psychiatres et autres, ayant à vivre une situation semblable. La responsabilité professionnelle des psychiatres au Canada Martine Gagnon L’Association canadienne de protection médicale Julie Chenette McCarthy – Tétrault, Montréal er Cette présentation passera en revue 305 actions en justice terminées entre le 1 janvier 1990 et le 31 décembre 1999. Les conclusions légales, les coûts, les événements significatifs, les conclusions légales en rapport avec les événements significatifs de même que les problèmes cliniques les plus fréquemment à l’origine d’actions en justice seront discutés. Certaines mesures visant à réduire le risque de poursuite seront proposées. Au niveau strictement légal, il sera discuté des principes sur lesquels les tribunaux se sont appuyés dans le passé pour rejeter des poursuites en responsabilité médicale à l’encontre de psychiatres. Certains des problèmes particuliers à ce genre de poursuite civile seront également abordés de même que le rôle particulier de l’avocat représentant le médecin psychiatre défendeur. ADMISSIBILITY AND ETHICS OF EXPERT EVIDENCE IN CRIMINAL CASES July 5 juillet 13:45 – 15:45 Room CMEL-102 Chair: Derek Jones, McGill University Information-excluding privileges and the adversarial trial system Ronald Sklar McGill University 84 XXVIth International Congress on Law and Mental Health “In a Court of justice every person and every fact must be available to the execution of its supreme functions,” wrote Rand J. in R. v. Snider, a 1954 decision of the Supreme Court. It is against this philosophy that privileges designed to keep persons and facts from adversarial trial scrutiny must be measured. The traditional approach where information of alleged probative value, which, at the same time, protects important confidential relationships, is sought by a party in a trial has been to submit that information for inspection by the trial court. The court is then charged with determining the relevance if any of the information and with balancing any probative value found to exist against damage to the protected relationship. That approach is seen, for example, when information potentially damaging to national defence and security is sought by a party to the trial. In the case of psychotherapeutic relationships protected by ss. 278.1 ff. of the Criminal Code, that traditional approach has been altered to the extent that the Ontario Court of Appeal in the 2000 case of R. v. Batte stated that therapeutic records admitted concerning material relating to the alleged sexual assault incident on trial and containing “some exact quotes” should not have been produced to the Court for its inspection (even though the judge in the case had upon inspection refused disclosure to the defence). Admitting that such therapeutic records will normally be of dubious probative value, it will be argued that the restrictions imposed by the legislation and decisions like Batte are inconsistent with the basic approach to privileged information and the fundamental values of the adversarial trial system. The questionable contribution of psychotherapeutic records to the truth-seeking process Allannah Furlong Canadian Psychoanalytic Society, Montréal Evidence based on material drawn from psychotherapeutic treatment situations has a high potential for leading astray the court’s search for truth and justice. The common motives for production requests will be critically examined in the light of the inevitable distortion which occurs when clinical material is taken out of context. Moreover, it can be argued that witness credibility will be enhanced by the protection of the psychotherapeutic relationship. The impact of disclosure on the psychoanalytic relationship Charles Levin McGill University Under the pressure of threats of disclosures, professional orders have issued a number of guidelines to members regarding record keeping and informed consent. Not only are these adjustments of dubious value, they fail to articulate a more vigorous analysis of the impact on the integrity of the psychotherapeutic/psychoanalytic relationship of court disclosures. Secrecy, privacy and confidentiality issues need to be teased apart and the inappropriate psychologisation of legal thinking in these matters questioned. The role of expert evidence in prosecutions for offences of child sexual abuse in Australia Penny A. Cooper Queensland Law Reform Commission Children who have been sexually abused may delay disclosing the occurrence of the abuse or may retract a previously made allegation. In a subsequent prosecution, cross-examination about such behaviors is likely to be used to undermine the child’s credibility. Expert evidence about the psychological effects of childhood sexual abuse on the behavior of the victim is therefore likely to be of considerable assistance to a court in understanding and evaluating the evidence of a complainant. However, courts in common law countries have traditionally regarded expert evidence with suspicion and have significantly limited the extent to which it can be used. This suspicion stems from a concern that to allow a witness to express an opinion or to draw an inference from a set of facts would be to usurp the fact-finding role of the court. There are two rules in particular which impact on the admissibility of expert evidence about children who have been abused. The “bolster” rule prevents a party calling evidence purely for the purpose of re-inforcing the credibility of one of its own witnesses. The “common knowledge” rule will permit expert evidence to be admitted only if the evidence is beyond the range of ordinary human knowledge and experience. The paper will examine the use of expert evidence in Australian jurisdictions to explain why the behavior of a child witness who has allegedly been abused might not reflect adversely on the child’s credibility. The withering role of the psychiatric report in the Canadian youth justice system Brian Weagant Ontario Court of Justice Canada is currently in the process of revamping its criminal legislation for 12- to 18-year-old offenders. This revamping is but one more manoeuvre in Canada’s endless struggle for a political solution to the problem of a widely held public fear of teenagers and the media-driven sentiment that the law itself is somehow responsible for criminal acts by teenagers. The new tougher 85 XXVIe Congrès international de droit et de santé mentale approach finds as its context a period of declining crime statistics and the fact of Canada’s world leading incarceration rates of children. The Canadian constitution gives the federal government the power to pass criminal law for children and young persons, but leaves administration of the juvenile justice system in control of the provinces. This divide injects yet another layer of government that seeks political solutions to the problem of public insecurity around justice issues. The divide also means that the federal justice minister may feel compelled to compromise and bargain with provincial counterparts in an attempt to make law that is palatable across the land, or as is more accurate in the Canadian context, to divide the discontent with the law equally among the provinces. The presenter will argue that the described legislative process has resulted in a discourse on juvenile justice that focuses on punishment at the expense of rehabilitation. One obvious casualty of a system focused on incarceration is the multidisciplinary approach that many believe should be the cornerstone of any youth court intervention. The presenter will draw on his youth court history, both as practitioner and judge, to demonstrate that the current issues surrounding psychiatry’s input into the juvenile justice process – accessibility, cost, utility–are symptoms of a system on a political ride backwards. ETHICS AND THE PROFESSIONAL SELF July 5 juillet 13:45 – 17:45 (extended session) Room NCDH–101 Chair: Melvin L. Rothman, Cour d’appel du Québec Medical ethics in the era of managed care: An oxymoron? Aleen Grabow Mental Health Resources, Madison, Wisconsin While the economics of health care have become a concern worldwide, the institution of managed care has taken on a life of its own in the United States. Managed care originated as a cost containment strategy and has evolved into a convoluted system that maximizes profits by limiting physician autonomy and decision-making. As market forces, pre-selected provider panels and various levels of gatekeepers insert themselves, (actively or passively, consciously or unconsciously) into the doctor-patient relationship–the challenge of maintaining a consistently ethical medical practice increases. For complicated reasons of selfpreservation, identity and perhaps a sense of duty to patients, the field of psychiatry in the United States has attempted to adapt to these constraints. As a result, the entity of “medication back-up” has come into being. Non-medically trained therapists may refer to psychiatrists without ever consulting with the physician before or during treatment. Theoretical and philosophical orientations, training and experience are less relevant than the ability of the physician to see several more patients exclusively for “medication management” than would have been possible in the previous role as physician-psychotherapist. The presentation will discuss the ethical conflicts inherent in a system that often relegates physicians to the position of observer and hand-maiden to the therapist. The physician, paradoxically, remains liable for treatment outcomes and consequences. We will consider the case of a young woman with chronic, life-threatening Anorexia Nervosa and her efforts to access treatment in a small Midwestern university town. It is within this context, and from the vantage point of the medication back-up, that the presentation will examine the pitfalls of attempting to maintain an ethical practice. Clash of disciplines: A review and application of the clinical evaluation of dangerousness to the legal standards for involuntary admission Imat Amidjaya Douglas H. Singer Mental Health and Development Center, Rockford, Illinois Teresa L. Berge Illinois Guardianship and Advocacy Commission Lawyers and clinicians and their competing interests often meet in the arena of proceedings over involuntary admission. The wishes of the client often differ from the best interests or beliefs of the clinician. The presenters of this session will review the purpose and effect of involuntary admission, the public policy and legal justification for confinement with review of US and Illinois case law. The presenters will then review the clinical rationale for confinement and the Illinois standards for involuntary commitment as a general standard for commitment. Both the Illinois Code and case law will be reviewed. The distinctions between the legal description of mental illness and commitment and the clinical descriptions will be emphasized. Clinical and legal aspects of “imminence”, “nexis”, “dangerousness”, “psychiatric iatrogenics” as well as other issues, will be discussed. The dynamics of these clinical and legal principles–when applied to actual cases in which both presenters were involved–will be highlighted. A workshop format will be used and participation encouraged. 86 XXVIth International Congress on Law and Mental Health Medical/legal aspect of presentence assessment Yuri Metelitsa, Lisa Buys Forensic Assessment and Community Services, Edmonton Forensic psychiatrists and psychologists are often asked to conduct presentence assessments. However, our experience suggests a lack of clarity in the nature and goals of these assessments, both by the experts who conduct them and by the legal authorities who request them. It is our opinion that the psychiatric/psychological issues discussed should be directly linked with relevant legal issues. Both the experts and the referral agents need to share a clear understanding of all of the medical/psychiatric issues that could be addressed in these assessments. In addition, the presentence assessment should explicitly guide the legal system with regard to rehabilitation and risk reduction strategies for the mentally ill offender. The authors outline a framework for the presentence assessment that clarifies and structures the issues that should be addressed regarding individuals who suffer psychiatric illnesses. Public mental health roles: Roles of the psychiatrist Rosemary Meier, J. Glaister University of Toronto The privilege and responsibility of serving as a member of the Consent and Capacity Board raises certain ethical issues. As the medical member at the Hearing, the Psychiatrist can contribute knowledge of mental illness, including the epidemiology of the condition in question, providing a context to the natural history of the patient’s experience. As a member appointed to an administrative tribunal, the Psychiatrist is required to observe policies and procedures in the same manner as the Lawyer and Community members. At times, the dual roles are divergent. Concern for the individual and concern for society must be considered in the formulation of the issue that is brought to the attention of the Board. This divergence reflects other dimensions of psychiatric care in the community, now highlighted by the option of Community Treatment Orders. The possibility of offering treatment that requires an agreement and can be enforced if not continued, adds another dimension to the consideration of capacity. The capacity to continue to consent and the continued appropriateness of the agreed treatment have to be factored into the presentation brought to the Board. This situation may be compared to the challenges posed by conditions regarded as medical, such as AIDS and tuberculosis, where public health regulations apply. The incidence and prevalence of non-communicable disease is recognised to provide a burden to the healthcare system, in addition to the individual, the family and society. The inclusion of Community Treatment Orders brings the reality of the burden of community mental health to the table, and further challenges the roles of the Psychiatrist on the Review Board. Treating clinicians v. forensic clinicians: The illusions of objectivity, the realities of enactment. Rodney J.S. Deaton Indiana University Almost all forensic clinicians agree that it is unwise, if not unethical, for a treating clinician to serve as an expert witness for a patient who is involved in litigation. Proponents of this stance usually justify their position by reference to the supposed increased “objectivity” of the third-party forensic clinician, who is supposedly more free to examine all the available evidence without the “subjective” pull that is often experienced by the treating clinician. In this presentation, I too argue for the wisdom of separating the clinician and forensic roles, but I argue that it is not because the forensic clinician offers the legal process “objectivity.” Instead, the forensic clinician offers a different type of subjectivity, one that then interacts with the subjectivity of the examinee to create a localized and temporary, but quite real, relationship. Drawing on current research and writing on the neurobiology and psychodynamics of intersubjective experience, I argue that all forensic encounters, like all clinical encounters, have to carry within them the seeds of a mutual enactment: a mutual, if only temporary, living out of both the examinee’s and, far too often, the examiner’s interpersonal relationship patterns. I argue that by conceptualizing forensic encounters as a special subclass of mutual, intersubjective enactments, forensic clinicians may both more accurately assess the complexities of an examinee’s psychology and then more effectively foresee and perhaps forestall potential ethical dilemmas in a particular forensic encounter. The varied faces of forensic psychiatry: Some aspects of challenges and problems Gerald J. Sarwer-Foner Wayne State University Forensic Psychiatry represents many interactions of Social, Psychiatric, Criminal Behavior, Legal, Political, and the Sociology of Political; within its definitions, assignments, ideologies and practices. The contact points, and the manifestations, implications, as well as both problems and solutions; of some of these aspects are discussed in the paper. 87 XXVIe Congrès international de droit et de santé mentale Ethics at the boundaries of professional relationships Wendy Austin University of Alberta Particularly difficult and complicated ethical concerns are to be found in the boundaries of professional helping relationships. It is in the boundaries that we find the “slippery slope,” the slope where professionals slide from small personal acts not strictly in the therapeutic realm (like sharing a cup of coffee with a client) to more serious relationship violations (like a sexual encounter). Professionals are cautioned to protect their clients from harm by careful avoidance of the slippery slope and by the strict maintenance of relational boundaries. Yet it can be argued that rigid boundaries diminish therapeutic effectiveness. Clients may experience fixed boundaries and role assignments as a barrier between them and those who seek to help them. There can seem a diminishment in the humanity of the encounter. This paper explores the concept of “boundries”, as based on the findings of an interdisciplinary study in relational ethics. The implications of the “boundary” metaphor will be discussed and alternate metaphors addressed. Disciplining the professions Robin Henry Woellner University of Western Sydney There is a suspicion among many in the community that professional groups, particularly those that are self-regulating, discipline members who breach the standards of conduct differently than the community would discipline its members who commit analogous ‘wrongs’. This paper examines the Australian data to determine whether professions do take a different approach to disciplining their members, and whether there are ‘internal’ differences in approach between various professions. Burn out: A metaphor of suffering Ginette Pagé Université du Québec à Rimouski Freudenberger (1980) is considered to have coined the metaphor burn out (named in French, épuisement professionel) as a jobrelated stressful process that affects many of the helping professionals. In 1982, Maslach introduced a scale to measure the level of burn out of workers. The Maslach burn out inventory> (MBI) is conceptually framed by emotional exhaustion, personal accomplishment and depersonalisation. Nursing professionals are highly exposed to burn out. It is even considered as being the nurse’s greatest professional hazard. The purpose of this paper is to present the metaphors used by nurses to express their experiences of burn out and to initiate discussion about the language they use. This study is a secondary analysis of transcripts from a previously conducted study on the incidences revealing how nurses practice nursing. The understanding of metaphors, as an interpretative process, is congruent with a Heideggerian hermeneutic method. As such, it pertains to the exposure of hidden meanings. (Kiesel, 1985), such as suffering. Discussants: Frédéric Grunberg, Université de Montréal Gordon Kugler, Attorney, Montréal CURRENT ISSUES IN WOMENS’ CORRECTIONS July 5 juillet 13:45 – 15:45 Room NCDH–201 Chair: Donna McDonagh, Correctional Service of Canada Development of a secure women’s ward from a group of mixed gender secure services Timothy Lambert West London Mental Health NHS Trust, United Kingdom In the past decade, descriptive research into the nature of secure psychiatric services, in the UK and elsewhere, for women patients, has consistently revealed a number of relevant clinical factors some of which distinguish this population from its male counterpart and many of which may be important in planning services. In addition, it is well recognized that the security requirements for women offenders (and those with similar clinical needs) are not yet matched by available services and that gender sensitive therapeutic models are, as yet, poorly developed. 88 XXVIth International Congress on Law and Mental Health This paper reviews the relevant research concerning mentally disordered women offenders and describes the creation of a women only secure ward within a wider group of forensic and secure services in a mental health (National Health Service) Trust. The clinical profile of the patient group, drawn from a series of mixed services, is described with reference to established work concerning detained offender and non-offender women. A service model will be proposed. The model is designed to allow for a broad spectrum of women patients requiring secure care to be effectively and safely treated within a gender sensitive and flexible service, whilst retaining appropriate linkage with mixed, specialist (including forensic) and generic psychiatric services. Psychological interventions with women within a secure psychiatric service Maja Turcan West London Mental Health Trust, United Kingdom This paper describes the various psychological interventions used with female patients in a secure psychiatric service, part of a large National Health Service Trust in West London (UK) comprising General and Forensic Services. The female patient population, representing a wide spectrum of diagnosis, offending and behavioural profiles, nevertheless comprises a small proportion of the patients catered for by the Forensic Directorates (In total: 33 women, 169 men). Seventeen of the women are cared for in a dedicated women’s ward, the remainder are distributed amongst five, predominantly male, mixed wards. The use of Individual Psychotherapy, Group Psychotherapy, Cognitive Behaviour Therapy, (CBT), Dialectic Behaviour Therapy (DBT) and psychosocial interventions is discussed, with reference to the advantages and pit-falls of working in this setting and of using several approaches, as opposed to a single psychological model. Issues of staffing, training and resourcing, and evidence of the impact of the work will be presented. Experience of a women psychiatric secure ward in London Silvia Bercu West London Healthcare NHS Trust Our 17 bed women’s ward was created in the Local Secure Directorate (in theory less Secure than Medium Secure Units and more secure than open wards, in practice most of the patients fulfilled criteria for Medium Security but were regarded in need of female-only environment due to vulnerability) as an interim measure (one year) until the completion of a 36 bed unit, which was to be divided into different areas of treatment and levels of security to accommodate different rehabilitation stages. This has not happened. Three years later the business plan for the new unit has been “put on hold” by the London Regional Office to await the development of a London Wide strategy for women in need of Secure Services. The factors that have affected the ward environment with regards to disturbance, violence and therapeutic milieu, (including patients’ diagnosis, interactions, staff training, supervision, Trust’s policies and political decisions regarding the development of services) are discussed. We note that adequate services have cost implications that most health authorities are reluctant to meet, but this has led to overuse of private facilities (the only ones that have actually moved ahead to provide these services), which are much more expensive and are draining the public purse, while they do not provide the integrated inpatient/community service necessary for this population. Pattern of substance use in violent female offenders Lynn Lightfoot Attorney-at-Law, Oakville Substance abuse has consistently been related to violence in male offenders, however, little empirical research has addressed this relationship in female offenders. This paper will describe the nature and extent of substance abuse in a sample of 98 female Federal Offenders, convicted of a violent offence. All women in the sample were convicted of a Schedule 1 offence, and were referred for a psychological risk assessment. Subjects participated in a semi-structured interview, and completed a battery of psychological tests. Tests included the Minnesota Multiphasic Personality Inventory-2, the General Health Questionnaire, the Interpersonal Behaviour Survey, the Criminal Sentiments Scale, the State Trait Anger Inventory, the Beck Depression Inventory and the Shipley Institute of Living Scale. Substance abuse was assessed through administration of the Alcohol Dependence Scale, Problems Related to Drinking Scale and the Drug Abuse Screening Test. The MacAndrew Alcoholism Scale of the MMPI-2 was also scored. Risk of re-offence was assessed using the Level of Supervision–Revised and the HCR-20 scales. A comprehensive review of files was also conducted yielding the following information: psycho-social history, prior criminal history, education, institutional adjustment, prior psychiatric and psychological assessment and treatment, institutional adjustment and medical status. Descriptive demographic data will be presented as well as correlational analysis in which substance abuse severity and degree of violence in the current (index) and past offences will be analyzed. These data will be related to the treatment needs of violent female offenders. Directions for future research will also be explored. 89 XXVIe Congrès international de droit et de santé mentale Female sex offenders: A comparative study based on clinical and criminological data from a Belgian prison sample Julie Snyders Université de Montréal Thierry Pham Université Catholique de Louvain Although acts of sexual abuse are mostly committed by males, the phenomenon of sexual abuse by women has been taken into consideration by researchers and clinicians these last few years. Indeed, recent research tends to demonstrate that the number of reported sex offences committed by females is increasing. Firstly, we will present a critical review of clinical and empirical literature on female sex offenders. This review will discuss the prevalence, the clinical characteristics (Axe I and Axe II symptoms) and criminological characteristics (type of abuse, sex and age of the victim) of these women in order to observe constants in the description of the profile proposed in the literature, and to compare between female sex offending and male sex offending process. The methodological limits which are specific to this literature (the definition of abuse, selection sample, clinical heterogeneity and research design) will also be discussed. Secondly, we will address preliminary empirical data collected in a female sample who are incarcerated in a francophone Belgian prison. A group of female (N=15) convicted for sexual offences will be compared to a group of female (N=15) convicted for non-sexual offences. These two groups will be matched in terms of age, socio-economical status and length of detention. Perspectives for future research will be proposed. MENTAL HEALTH AND THE WORKPLACE July 5 juillet 13:45 – 15:45 Room CPCL-101 Chair: Katherine Lippel, Université du Québec à Montréal The various roles of mental health experts in preventing and managing workplace violence Hy Bloom University of Toronto Resa S. Eisen Mediator, Toronto Christopher Webster, Nathan Pollock University of Toronto Workplace violence has become an increasing public health concern in recent years. It is presently unclear whether the rise in inappropriate and aggressive conduct in the workplace represents an actual increase in the incidence of the phenomenon, or greater awareness and reporting of the problem of aggression in the workplace. What is clear, however, is that mental health consultants have a unique and important role to play in workplace violence prevention and management. Experts in the behavioural sciences can assist organizations in a number of ways. They can firstly identify, and to some extent quantify, the level of risk a prospective workplace violence perpetrator represents. Mental health experts familiar with the potential contribution of situational risk factors for violence may further play a role in identifying the systemic risk intrinsic to a particular work setting. In either case, defining the risk allows for meaningful recommendations to be made and interventions to be put in place that will not only ultimately reduce the risk, but may have the longer lasting effect of reducing the risk of a future outbreak of violence. This talk will examine the numerous roles a mental health consultant can serve in assisting organizations in their efforts to both prevent and manage a violent incident in the workplace. Employment issues for young people with a dual diagnosis Damian Mitchell, Andy Betts, Michael Epling University of Nottingham Employment plays a pivotal role in helping young people successfully negotiate the transition period between childhood and adulthood, as it is a key factor in healthy identity development (Erikson 1968). This adult identity is often linked with greater autonomy, self-expression, self-determination and self-sufficiency, which is generally associated with finding independent occupation outside the home (Gurney 1980, Donovan and Oddy 1982, Hannan et al 1997). Winefield (1997) suggests that high youth unemployment rates should be viewed as an area of major social concern for four reasons. Firstly, because unemployment among young people is much higher than in the adult population. Secondly, that psychosocial development can be severely 90 XXVIth International Congress on Law and Mental Health affected by unemployment. Thirdly, that unemployment may lead to widespread social alienation and a subsequent rise in criminal and/or other anti-social activity, and lastly, that it could lead to a higher incidence of suicide within this group. Social alienation has also been closely associated with substance misuse, which itself is identified with initiation into criminal activity (Tackling drugs to build a better Britain 2000). The problems of unemployment are compounded for young people with a mental health and substance misuse problem. As studies have shown substance dependence and mental illness are the most notable barriers to gaining and maintaining employment (Social Security Independence and Program Improvements Act 1994, Claussen 1999) Violence in the workplace and incapacity to work Margui Vieira Gomes Federal Univesrity of Rio de Janeiro Valéria Queiroz Universidade Gama Filho, Rio de Janeiro This study examined municipal workers in Rio de Janeiro who were temporarily unable to work due to violence in workplace, during the period between April 1999 and September 2000. Among 1531 reports by medical experts, we identified 45 cases of medical incapacity caused by violence against workers (2.9%). We examined not only sociodemographic features of the victims of violence, but also activity, localization of work, time that the violent event occured, and type of labour. Results: Teachers were found to be at highest risk, especially women between the ages of 40 and 50 years. The highest rates of violence were detected in places where poorer populations were identified. Depression and anxiety were the most frequent causes of incapacity. An increased number of violent episodes were reported in the last year. Conclusion: Posttraumatic reactions may occur in injured individuals, causing high costs, particulary in lost work days. The increase in workplace violence should be discussed by mental health professionals (forencic experts) to provide limits and determine possible interventions by experts. New researchis necessary to discuss the effects of compensation and litigation in posttraumatic reaction, as well as to prevent violence in workplace. Workers’ Compensation and mental health: The process and outcomes of an injured workers’ participatory research project Bonnie Kirsh University of Toronto The relationship of legal and systemic issues to the mental health of injured workers has been discussed in a preliminary way through examination of variables affecting the injured worker’s return to work. However, holistic approaches to understanding the experiences of injured workers have not been documented. An increasing number of workers reporting occupational injuries and health problems with nonspecific diagnoses have met with challenges in the compensation, medical and legal systems and, in turn, have experienced significant effects on their mental health. Some research has shown that problems of legitimacy are a central feature of workers’ experiences and may contribute to psychological distress and chronic disability. Indeed, much of the literature regards people with such non-specific injuries as chronic pain and soft tissue injuries as powerless and passive in their relationships with the compensation system, the employer and the medical legal system. This paper presents the process and findings of a participatory research project designed to enhance the capacity of injured workers to collectively identify, understand, analyze and address their experienced concerns. The project brings to light the current crisis in the relationship between “the system” and injured workers, and proposes directions for social change. It presents results of a mixed method (qualitative and quantitative) approach to investigating the needs and experiences of injured workers. Findings in the area of mental health and psychosocial outcomes will be highlighted. The paper will also describe the process of participatory research as an alternative, non-dominant method of creating knowledge, as well as its impact on engagement in critical reflection to bring about effective social analysis and action. Development of validated screening and assessment tools for family caregivers D. Nahmiash, N. Guberman, J. Keefe, P. Fancey, L. Vézina, M. Knox, L. Barylak Université Laval This paper will present a screening tool to be used by multidisciplinary professionals that has been developed and tested to systematically screen high-risk family caregivers. The project was funded by the Health Transition Fund of Canada and administered by CLSC René-Cassin in Montreal in collaboration with three universities in Montreal, Quebec and Nova Scotia. The Caregiver Risk Screen was developed to establish a more comprehensive method of determining the level at which a caregiver’s physical and/or mental well-being is at risk and whether the care being provided is adequate. A level of risk is determined to establish the urgency of intervention and potential outcomes which may result from delayed intervention could be abuse or neglect of the care receiver, family breakdown or a change in the situation. The screening tool was constructed following an intensive review of validated screening measures, a survey of home care agencies to identify non-validated tools and focus groups with caregivers and professionals. 91 XXVIe Congrès international de droit et de santé mentale The tool was administered by telephone by intake workers from home care agencies to family caregivers. The study, based on a sample of English and French caregivers, presents results of the validation of the screening tool for internal and external consistency using Alpha Chronbach measures. The choice of instrument to validate the tool is the eleven item instrument used by Rankin, Hunt, Keefover and Franzon (1994) Caregiver Burden Screen. Results conclude that the Caregiver Risk Screen is a valid instrument which can predict caregivers at risk on a broader level than other instruments which usually are very long or measure only one or two specific dimensions of risk, such as depression. ABUSE AND NEGLECT OF CHILDREN I July 5 juillet 13:45 – 15:45 Room NCDH–200 Chair: Jean-Paul Braun, Cour du Québec The impact of serious neglect on children Dirk Huyer Toronto Hospital for Sick Children Neglect is a serious problem in childhood reportedly accounting for over half of the child maltreatment related deaths in the United States. Many different attempts have been made to develop a definition of neglect that is accepted by the various disciplines involved in child maltreatment. Defining neglect from the child’s perspective seems logical. Neglect can be defined as when a child’s basic needs are not met adequately. Basic needs include food, nurturing, shelter, clothing, safety, education, and medical care. By focusing on the issue from the child’s eyes, we can work together to develop strategies to ensure improvement. Neglect is a shared responsibility with many important contributors. In the ecological model important factors include the parents, i.e. parental ability, cognitive ability, interpersonal problems; families, i.e. extent of family support; the community, ie, social isolation, extent of support networks; and society, i.e. poverty. Operationalizing the definition is problematic. Personal values attitudes and judgements play a large role in establishing if the issue is neglect. Case examples will be presented that will challenge the definition. Dependency and family reunification in California Donna Toulmin University of Southern California In recent years, attitudes toward family reunification have dramatically changed, notably in California. When the state “detains” a child based upon abuse/neglect and places the child in foster care, it needs to make one of two decisions. It can either (1) provide reunification services to the family for a specified time; or (2) treat the case as one where the prospects of a safe reunification are so tenuous that an alternative permanent plan should be promptly determined. A trend has developed around the first decision; namely, to provide very little time for the parent(s) to “make substantive progress” and so enable their child’s return. For example, if a child is aged three or under, only six months of services are legally required to enable a parent to change. This abbreviated service period belies the time it takes to effect behavioral change in dealing with addiction or family violence. Are similar trends developing elsewhere? I have noticed two responses to this trend: (1) California is experimenting with the New Zealand model of the family conference that permits the family to devise a plan that avoids placing the child in foster care with a stranger; and (2) Alternatively, if the family can recognize the problem before the state does, a relative can apply for legal guardianship in probate court with the parent’s consent and so avoid dependency jurisdiction when the parent is incapable of caring for the child. Are abbreviated services evoking similar responses in other jurisdictions? Judicial perceptions of the dynamics of child sexual abuse Rita Shackel University of Western Sydney Child sexual abuse is not a new phenomenon. Although child sexual abuse today is largely recognized as a complex and serious issue, many aspects of the problem still remain poorly understood. This paper argues that the underlying dynamics of child sexual abuse continue to be poorly misunderstood in a criminal justice setting. The specific focus of this paper is the level of understanding among judicial members of the behavior of children who have been sexually abused. An analysis of relevant case law in Australia, Canada and the United States highlights that judicial perceptions of the way children respond to sexual abuse are grounded in misunderstandings and misconceptions about the underlying dynamics and nature of child sexual abuse. Specifically, many judgements demonstrate a poor understanding of the disclosure process. Expert testimony relating to the behavior of children who have been sexually abused represents an important forensic tool. Expert evidence of this kind can assist 92 XXVIth International Congress on Law and Mental Health judges and other courtroom players in a criminal context to better understand the underlying dynamics of child sexual abuse and accordingly better evaluate the testimony of child-victims. Admissibility of this kind of evidence can help ensure that decisionmaking in the courtroom and the criminal justice system more broadly, is better informed, more objective and is ultimately fair and just. Reporting by professionals of sexual abuse–yes, but are we equiped to avoid some potential damage to the victims Jean-Yves Frappier Université de Montréal When considering reporting of sexual abuse by professionals, we should distinguish intrafamilial versus extrafamilial abuse. In intrafamilial abuse, one obstacle would be “Am I going to destroy the family”. In extrafamilial sexual abuse, one question would be: “is it worth the trouble”. To overcome the obstacles in reporting by professionals, we have to address these questions and others. Reporting of sexual abuse by professionnals is in itself desirable. However, it is not without potential problems to the victims and their families. For example, in the case of an adolescent who would not prefer not to report with parents who would like to report; the professional could additionally burden this victim and her family. Reporting by professionals can only effective if we avoid increasing the suffering of the victim and the family. This means specific intervention with necessary resources and time are required. Reporting by professionals also means education and information are required before imposing it by law. Sexual abuse and trauma in childhood: Late effects in retrospectivelongitudinal perspective as measured by the CAPS Denis Kensin Novosibirsk Medical Academy, Novosibirsk Wolfgang Prause, Thomas Wenzel, Gerhard Lenz University Hospital for Psychiatry, Vienna In Western countries, sexual abuse is probably the most important trigger in the subsequent development of posttraumatic stress disorder (PTSD). Structured clinical interviews are frequently regarded as the best instrument to reliably evaluate the presence of clinical disorders, with the added benefit of frequently (as in the case of SCID and CAPS) offering retrospective longitudinal data that are more conclusive than single-point time-limited measurements. CAPS data from 14 patients treated because of borderline personality disorder at the behavior therapy unit of the University Hospital Department of Psychiatry are presented and document the developmental onset of PTSD symptomatology as remembered by the patient, which was marked by a usually early onset of PTSD symptoms with a reduction over adult development, but fulfilling criteria at the time of presentation years after the trauma. Comprehensive protection for children Rachelle Boivin Ministère de la justice du Québec Child victims of sexual and/or physical abuse are often imprisoned in a code of silence as to the various forms of abuse they suffer at the hands of others, whether they are parents, brothers, sisters, friends of the family, or strangers. They endure, being ill equipped to deal with these difficult situations. This code of silence is often imposed by the abusive person or by external circumstances. The child victim does not wish to shatter the family or expose beloved friends of the family. In cases of abuse by strangers, the shame felt is oftentimes so overpowering that the child keeps the secret locked inside. But when the abusive situation does come to light, through disclosure by the victim or outside observers, it is imperative that the various agencies, governmental or other, act swiftly and together to ensure that the child victim is offered the adequate protection and help required by the situation. To do so, information must be shared. Otherwise, the abusive situation may be but halfway remedied or badly remedied. On March 1ST 2001, the Québec government made public two policies: Orientations gouvernementales en matière d’agression sexuelle, which addresses all crimes of a sexual nature; l’Entente multisectoriellle relative aux enfants victimes d’abus sexuels, de mauvais traitements physiques ou d’une absence de soins menaçant leur santé physique, which specifically addresses the problem of sexual assaults, physical assaults, or lack of care endangering the health of child victims. These governmental policies call for the collaboration of all interested parties to bring swift, adequate and comprehensive action to all cases of child victims. It is imperative that the information detained by children’s aid societies, police forces, crown attorneys and any other implicated organisation be shared with the other partners involved. Such collaboration is essential to ensure that the actions taken by the respective parties be coherent and ensure, overall, the desired aid and protection to the child victim. When deciding the actions to be taken, the primary concern must always be that of the interest and well being of the child victim. 93 XXVIe Congrès international de droit et de santé mentale ATELIER II VALEUR, PLACE ET LIMITE DE L’EXAMEN COGNITIF FACE À L’ÉVALUATION CLINIQUE (TESTS NEUROPSYCHOLOGIQUES) July 5 juillet 13:45–16:45 Atelier – avec inscription seulement Salle IASL–106 Formateur : Gilbert Desmarais, Université de Montréal Discutants : Gilles Chamberland, Institut Philippe Pinel de Montréal Christine Truesdell, Tribunal administratif du Québec La neuropsychologie, une discipline de la psychologie, est une science qui permet de documenter les séquelles d’atteintes cérébrales par l’observation rigoureuse de la relation cerveau-comportement. Plus particulièrement, la neuropsychologie vise l’étude des fonctions cognitives et mnésiques. À l’observation qualitative, s’ajoute l’administration d’épreuves, ou tests neuropsychologiques valides et fidèles, permettant de mettre en évidence les déficits de la personne cérébrolésée ainsi que les ressources à sa disposition pour la réadaptation. L’exactitude des propos allégués par la clientèle, peut être vérifiée par le type de dysfonction manifesté aux épreuves administrées et par une analyse des stratégies de résolution de problèmes habituellement retrouvées chez les personnes cérébrolésées. Parmi les analyses effectuées, nous retrouvons les mécanismes attentionnels dont la complexité implique une observation systématique des capacités du client à être non seulement attentif dans un rapport un à un mais également à effectuer une gestion d’informations complexes. De plus, les dysfonctions mnésiques sont au cœur de moult complaintes et à cet égard, il est impérieux de comprendre et intégrer les derniers développements de la neuropsychologie cognitive eu égard aux processus mnésiques conscients et inconscients. La mémoire consciente fait appel à information verbale ou visuelle difficilement accessible à la conscience ou à des apprentissages moteurs. Les fonctions attentionnelles et mnésiques sont les préludes de la cognition, et cette cognition implique les mécanismes exécutifs. Les mécanismes exécutifs sont le reflet de l’adaptation d’un individu à la société et aux exigences de la vie quotidienne. Elles découlent des stratégies adoptées par la personne cérébrolésée afin d’outrepasser ses difficultés. La neuropsychologie ne permet pas d’établir de preuves, mais bien d’effectuer des démonstrations. La multiplicité des tests permet plutôt de documenter un déficit si la dysfonction est présente fréquemment. Il y a donc un danger aux examens agrégés. Un simple pointage à une épreuve n’est certes pas une indication des processus en cause lors d’atteinte cognitives. À la cour, le neuropsychologue doit donc élaborer sur les faits observés mais aussi procéder à un enseignement permettant aux membres de l’auditoire de mieux intégrer et comprendre les dysfonctions du cérébrolésé. Il aura également pour mission de prédire, autant que faire se peut, les capacités de réintégration sociale, familiale et professionnelle de la personne atteinte. Si l’équipe des médecins examinateurs voit notamment à une description de l’étiologie des atteintes cérébrales, le neuropsychologue met davantage l’accent sur les aspects fonctionnels de l’individu en termes d’atteintes et de ressources sur le plan du fonctionnement intellectuel, attentionnel et mnésique. Aussi la neuropsychologie est une science en pleine évolution et il demeure important qu’elle soit pratiquée par les professionnels qui ont une solide expertise dans le domaine. Ces professionnels doivent être membres de l’Ordre des psychologues du Québec et être reconnus comme experts par la communauté scientifique. 94 XXVIth International Congress on Law and Mental Health 16:00 – 17:45 BILINGUAL SESSION /SESSION BILINGUE MENTAL HEALTH IN NATIVE COMMUNITIES: PROBLEMS AND STAKES III SANTÉ MENTALE EN MILIEU AUTOCHTONE: PROBLÉMATIQUES ET ENJEUX III July 5 juillet 16:00–17:45 Bilingual session / Session bilingue Simultaneous translation / Traduction simultanée Room / Salle MC Modérateur/Chair: André McKibben, Institut Philippe Pinel de Montréal Problèmes sociaux et santé mentale chez les amérindiens du Québec Social problems and mental health among Amerindians in Quebec Pierre Picard Sexologue clinicien, Québec Quand on examine les études portant sur les Amérindiens et leurs conditions de vie, les résultats maintes fois rapportés ne sont guère encourageants. Comparativement à la moyenne canadienne, on dénombre généralement trois fois plus de morts violentes, deux fois plus de suicides, dix fois plus d’alcooliques, deux fois plus de femmes violentées et quatre fois plus d’enfants intoxiqués aux solvants chez les Autochtones. Les facteurs historiques sont importants à considérer pour mieux comprendre l’émergence et le maintien des nombreuses problématiques sociales rencontrées en milieu autochtone. L’incidence sur la santé mentale de la détérioration du milieu de vie, issue principalement des tentatives d’assimilation et d’acculturation de la société dominante, est considérable. En dépit de la capacité de plus en plus grande des Amérindiens à nommer le problème pour lequel ils consultent, peu demeurent enclins actuellement à regarder leur détresse psychologique sous l’œil de la santé mentale. Un travail de sensibilisation auprès des populations amérindiennes et des intervenants qui y travaillent serait une piste intéressante à regarder. La représentation sociale que l’on se fait des maladies mentales chez les Autochtones est trop souvent associée à la folie, freinant du même coup l’apport de soins spécialisés et le refus pour plusieurs d’obtenir une aide plus appropriée à leur état mental.Jeudi le 5 juillet 2001 Le projet pilote en éducation spéciale Pilot project in special education Lise Bastien Conseil en Éducation des Premières Nations, Québec Depuis l’avènement de la maîtrise indienne de l’éducation indienne dans les communautés autochtones du Québec, l’éducation relève de la communauté. L’éducation spéciale quant à elle concerne les services adaptés pour les enfants ayant des besoins spéciaux en matière d’éducation. Ces services sont nécessaires dans la mesure où l’on constate que plus de 52% des enfants des communautés des Premières Nations du Québec éprouvent des difficultés d’apprentissage et/ou de comportement. Malheureusement, le gouvernement fédéral n’a pas inclus les services en éducation spéciale dans son financement. Ce manque de financement a créé un grand tort à certains enfants autochtones qui se sont vus forcés d’être exilés de leur communauté, perdant contact avec leur famille, leur culture et leur peuple et, pour plusieurs d’entre eux, vivant un rejet qui les marquera à jamais, et qui, faute de soins et de services appropriés, ont vu leur avenir compromis. Au début des années ‘90, exaspérées par la douleur des enfants en exil et la souffrance des enfants qui sont ignorés dans leurs besoins éducatifs spéciaux, les Premières Nations membres du Conseil en Éducation des Premières Nations faisaient une priorité de cette importante question, et décidaient de déployer tous les efforts possibles afin de mettre fin à cette situation inacceptable. Après 7 années de revendications et d’efforts incessants, un budget annuel spécial de 4,4 millions de dollars fut débloqué pour une durée de 3 ans, afin de conduire un projet pilote visant à mesurer si la mise en place de services éducatifs adaptés à nos enfants ayant des besoins spéciaux donnerait des résultats probants et augmenterait leurs chances de réussite scolaire et améliorerait leurs habiletés sociales. Quinze des 21 communautés membres ayant des écoles ont été impliquées dans le projet pilote alors que les 6 autres communautés n’ayant pas d’école ont participé au projet de façon différente et moins approfondie. Le projet fut mené avec rigueur et professionnalisme. En matière de formation et de surveillance, le CEPN s’est associé avec le Bureau de recherche sur les politiques scolaires de l’Université McGill (Montréal), apportant ainsi toute la crédibilité nécessaire au projet. C’est ce même bureau qui fut chargé d’analyser les données recueillies au cours des 3 années du projet et de rédiger le rapport final. 95 XXVIe Congrès international de droit et de santé mentale Au cours des 3 années du projet pilote, plusieurs projets ont été développés et mis en œuvre par les communautés. D’une grande diversité, ces projets ont en commun les objectifs du programme ainsi que la clientèle constituée d’enfants ayant des besoins spéciaux. De plus, au cours de la dernière année du projet, la moitié des enfants (2.167 sur 4.494, soit 48%) recevaient des soins éducatifs spéciaux par l’entremise du projet. Le projet pilote aura aussi permis de développer des stratégies d’intervention et l’application de mesures appropriées. De plus, après 3 années de rigueur méthodologique, les communautés (parents, enseignants, et intervenants) ont acquis des compétences. Lors du congrès, l’on désire faire état de la mise en œuvre du projet pilote en éducation spéciale, des résultats et des problématiques rencontrés. Par exemple, une étude de cas portant sur 79 jeunes, âgés entre 7 et 18 ans, qui présentaient les difficultés suivantes: • Difficultés d’apprentissage; • Troubles de comportement; • Troubles d’apprentissage et troubles de comportement; • Dans 71% des cas, les interventions menées auprès des élèves en difficulté constituant l’échantillon de l’étude de cas ont conduit à des améliorations notables tandis qu’un autre 20% présentait des améliorations moindres mais positives; • Pour 34% des étudiants, l’amélioration des problèmes ciblés au départ a permis une modification de la catégorie d’appartenance, et pour quelques-uns, la fin des services préalablement requis; • Les changements de catégories, au terme de l’intervention, confirment une forte proportion d’améliorations supplémentaires dans 70% des cas; • De nombreux cas d’étudiants ont mené à une réinsertion complète en classe régulière avant même la fin du projet triennal. En plus des résultats du projet pilote en éducation spéciale, l’on démontrera aussi comment l’école est une voie par laquelle il est possible d’intervenir directement. Violence familiale dans les familles autochtones signalées à la protection de la jeunesse: Nature et caractéristiques Family violence in native families brought to the attention of Youth Protection Authorities : Nature and characteristics Patricia Cham et Marc Tourigny Université du Québec à Hull Les objectifs de la communication sont de: (1) décrire le cheminement des situations d’enfants autochtones signalées à la Direction de la protection de la jeunesse du Québec; (2) décrire les diverses formes de violences vécues par les enfants autochtones et leurs parents; (3) dégager la spécificité des situations autochtones par rapport aux situations non autochtones. Ces signalements ont été documentés dans le cadre d’une vaste enquête québécoise réalisée à l’automne 98 (du 1er octobre au 31 décembre 98) auprès de 16 Centres jeunesse du Québec et ayant documenté près de 10 000 signalements dont plus de 3% concernait des signalements d’enfants autochtones. Dans un premier temps, une brève présentation de la méthodologie sera faite. Dans le cadre du premier objectif, nous décrirons l’évolution des signalements à travers les différentes étapes décisionnelles des services de protection à savoir, le placement ou non de l’enfant, la judiciarisation ou non de la situation, la présence de poursuites criminelles, etc. Pour le second objectif, nous décrirons les caractéristiques des victimes, de leurs parents et leurs familles de même que les caractéristiques des mauvais traitements vécus par les enfants (en termes de nature, durée, séquelles et lien avec l’agresseur), la présence de violence conjugale et l’existence de mauvais traitements dans l’enfance du parent. Finalement, nous présenterons les résultats des analyses statistiques comparant les situations des enfants autochtones à des caractéristiques touchant les victimes, les formes de violence et les principales étapes décisionnelles. Finalement, quelques implications cliniques seront identifiées. REGARD MULTIDISCIPLINAIRE SUR LES EXPERTISES July 5 juillet 16:00–17:45 Salle NCDH–102 Modérateur: Paul-André Lafleur, Institut Philippe Pinel de Montréal Les attentes du juge administratif envers le psychiatre, témoin-expert Anne Leydet Tribunal administratif du Québec Le psychiatre qui témoigne à titre d’expert dans une affaire instruite par un tribunal administratif doit tenir compte de la nature spécialisée du tribunal et du caractère souvent multidisciplinaire de la formation qui entendra l’affaire. 96 XXVIth International Congress on Law and Mental Health Le témoin psychiatre s’assure que le tribunal sera satisfait de sa qualité d’expert. Il aura, en prévision de l’audience, bien cerné le mandat d’expertise qui lui a été confié et aura obtenu de son mandant des précisions quant à la nature du litige devant le tribunal. Ces préparatifs permettront à l’expert de rendre un témoignage véritablement pertinent. L’expert démontrera d’abord la qualité de sa méthode de travail. Pour ce faire, il résumera au tribunal les étapes de la méthodologie qu’il a adoptées pour en arriver à une conclusion particulière: dossiers et documents consultés, faits constatés, examens cliniques et para-cliniques effectués, autant d’éléments qui, si bien colligés, ne pourront que contribuer à la force probante de son opinion. L’expert s’assurera que les faits qui sous-tendent son opinion constituent des prémisses sûres, en ce que conformes à la preuve factuelle. Il attachera une attention particulière aux éléments contemporains à l’événement déclencheur ou à la situation d’où origine du litige. Il se satisfera, dans la mesure du possible, de l’exactitude de l’histoire des antécédents. Ceci implique une revue méticuleuse du dossier. L’examen clinique sera poussé et conforme aux règles de l’art. L’opinion sera supportée par une discussion très étayée. Les opinions émises par d’autres experts seront commentées. Le cas échéant, référence sera faite à la doctrine médicale récente. L’expert, par son rapport d’expertise et son témoignage doit démontrer au tribunal la rigueur de son raisonnement, sa conformité aux règles de l’art et de la science médicale, et par là, faire reconnaître la force probante de son opinion. La relation entre l’avocat, l’expert et le tribunal Laurent Roy Trudel, Nadeau S.E.N.C., Montréal 1 La relation entre l’avocat, l’expert et le tribunal (l’aspect théorique): Contrairement à la règle généralement applicable à tout témoin, l’expert est là pour donner une opinion et aussi éclairer les parties et le tribunal sur des sujets d’ordre technique ou scientifique habituellement hors la compréhension du profane. Comme l’expert donne une opinion, la qualité de celle-ci et la valeur de l’expertise sont déterminantes. L’avocat doit donc offrir au tribunal un expert dont les qualités, y compris celles reliées à la crédibilité, rencontrent les critères habituellement reconnus. Ces critères seront donc examinés. 2 Les difficultés inhérentes à l’exercice (l’aspect pratique): En pratique, la présentation d’un expert soulève plusieurs problèmes. Nous aurons l’occasion d’en examiner un certain nombre d’entre eux notamment ceux qui sont reliés: a) au nombre d’experts appelés à témoigner en faveur d’une partie dans le cadre d’une affaire; b) aux coûts associés à l’expertise; c) à la recherche des experts, en particulier ceux qui sont connus comme appartenant à l’industrie de l’expertise. Assesseur psychiatrique dans un tribunal spécialisé: expérience de 3 ans et demi Yves Quenneville Centre hospitalier universitaire de Montréal La Commission des Lésions Professionnelles est un tribunal spécialisé qui étudie les contestations portant sur certaines décisions de la CSST. Le tribunal prend sa décision sur prépondérance de preuve, ce qui inclut la preuve médicale. Il étudie les expertises portées au dossier médical et présentées par les parties intéressées. Le tribunal attend des experts un éclairage qui lui permet de prendre sa décision et peut aussi se prévaloir de l’aide d’un assesseur médical. Celui-ci, au cours de l’audition de la cause, peut, comme les autres membres du tribunal, interroger les témoins et les experts. Lors du délibéré, il donne son opinion sur les aspects médicaux mais la décision est celle du juge-commissaire seul. Des remarques générales seront présentées, concernant les qualités et les défauts des expertises notées au cours de près de quatre années passées à la CLP à titre d’assesseur psychiatrique. De plus, quelques suggestions seront offertes visant à parfaire la qualité des expertises psychiatriques. 97 XXVIe Congrès international de droit et de santé mentale GOVERNANCE OF MADNESS July 5 juillet 16:00 – 17:45 Room CMEL-102 Chair: Claes-Göran Westrin, University of Uppsala A psycholinguistic approach to mental health legislation Lawrence Solan Brooklyn Law School Many mental health statutes are designed to take into account competing values. Guardianship law, for example, weighs the autonomy of the individual for whom a guardian is sought against the needs of the individual to receive appropriate care. Similar tensions characterize the law governing the refusal to accept mental health treatment, and various statutes concerning the rights of children. The challenge in writing statutes is to achieve the desired balance between these goals. Courts that must interpret these laws face problems. In this paper, I present an approach to writing mental health legislation that takes into account the perspective of the decision maker in advance. Using advances in linguistics and the psychology of conceptualization, (work by P.N. Johnson-Laird, among others), I propose that those drafting legislation self-consciously use four methods of legislating, depending on the goals. The methods are legislation by rule (“you have 30 days to appeal”), legislation by prototype (“unless the court determines that it would not be in the individual’s best interest, a guardian ad litem shall be appointed”), legislation by standard (“a person who is declared incompetent shall not have the right to refuse treatment”) and legislation by enhanced mental model (using a partially-inclusive list of factors to consider). I will illustrate how these different approaches to legislation work with respect to a number of mental health laws, relating their use to particular policy choices in different circumstances. Deinstitutionalization in Canada of the chronically mentally ill: Women as primary family caregivers and the governance of madness Lisa Hanna Carleton University Women in Canada are increasingly expected by the state to take on the additional caring work of family members with chronic mental illness given the ongoing deinstitutionalization process, growing fiscal crisis of the state and ensuing cutbacks in health and mental health care. This paper is based on a qualitative, in-depth and semi-structured interview study that uses a feminist political economy framework and Foucault’s notion of ‘governance’ to examine (1) the deinstitutionalization process in Canada; (2) problems, issues and tensions created for 15 women as primary caregivers of 17 chronically mentally ill family members; and (3) resistance of their family members. The subjects reported that caregiving was fraught with crises and uncertainties. Caregivers exercise skill and governance of family members through monitoring and controlling: manic and depressive episodes and hospitalization with reported resistance by family members. The study concludes with recommendations for reforms, innovations and suggestions for further research. Governance of the criminally insane Michael Gulayets University of Alberta Few members of our society garner more misunderstanding and engender more fear in the general population than those individuals who, after having committed a crime, are found not guilty for reasons of insanity. Historically, individuals deemed criminally insane have faced a wide range of responses from banishment, to segregation, to hospitalization. In Canada, both historically and currently, a person found ‘Not Criminally Responsible on Account of Mental Disorder’ (NCR) will most commonly spend a period of time as an inpatient in a forensic psychiatric facility. However, more recently, most persons, at some point in their tenure as NCR, will also find themselves discharged from an inpatient setting to live in the community under the charge of a community psychiatric clinic. I argue that this shift in the care and control of the criminally insane, from the exclusively inpatient settings of the past to one that includes both inpatient and outpatient settings, demonstrates a shift in powerknowledge relations exercised with the criminally insane. Specifically, this shift denotes the emergence of governmental forms of power relations. This presentation relates the current approaches to, and the care and control of, the criminally insane in community forensic psychiatric settings to power-knowledge relations based in the notion of governance (Foucault, 1991). The objective of the presentation is to explore the relevant governmental rationalities and techniques in the responses to, and the treatment and management of, the criminally insane. Ultimately, this presentation works toward new considerations and theories with respect to the concept of criminal insanity in light of models of power based in governance. 98 XXVIth International Congress on Law and Mental Health NEW PERSPECTIVES ON THE SEXUALLY VIOLENT OFFENDER July 5 juillet 16:00 – 17:45 Room NCDH–201 Chair: Robert Cormier, Department of the Solicitor General, Canada Overview of sexual homicide literature Leonard I. Morganbesser State University of New York The criminological literature has episocially focused on the crime of sexual homicide (or rape-homicide), with the leading intial study by Ressler, Burgess and Douglas (1988). Further work followed by others associated with criminal profilng studies, for example, Hazelwood and Burgess (1995). Other contributions include those of Langevin on sex killers and Meloy’s (2000) Rohrshach-based studies. A newer line of studies have addressed juvenile and adolescent perpetrators, such as Hunter et al (2000) in The FBI (Federal Bureau of Investigation) Law Enforcement Journal, by Myers (1994) and Myers, Burgess and Nelson (1998). A useful perspective for the law enforcement, correction and mental health systems may be to study the extent or absence of prior criminal record,–for sex crimes as well as for non-sex crimes–of offenders incarcerated for sexual homicide, as well as prior mental health system involvement. Suggestions are offered for further research studies of such offenders. In cold blood: Motivation and sexual dynamics of Canadian homicides as function of psychopathy Steve Porter, Michael Woodworth Dalhousie University Although many studies have investigated the relationship between psychopathy and criminal behavior, little is known about the relationship between psychopathy and homicide, and in partciular, sexual homicide (a homicide that includes sexual activity before, during or after the commission of the offense). The purpose of the present study was to examine the characteristics of a large sample of Canadian homicides as a function of psychopathy. One hundred and twenty-five offenders who had perpetrated a murder were investigated for several characteristics regarding the nature of, and possible motivations behind, the offense. Results indicated that homicides committed by psychopathic offenders (N=34, as catergorized by a score of 30 on The Psychopathy Checklist-Revised, Hare 1991) were significantly more instrumental (planned, goal-oriented) or “cold-blooded” than those committed by non-psychopathic offenders (N=91) whose homicides were more often spontaneous “crimes of passion”. In addition, psychopathic offenders were found to exhibit more gratuitous, sadistic and sexual violence in general (54.5%), in the context of their homicides than non-psychopathic offenders (22.5%). Weapon choice and other variables relating to the modus operandi of the homicide offenders will also be discussed Sexual sadism among sexual offenders William Marshall Queen’s University Recent findings concerning sexual sadism among sexual offenders will be presented. The first focus will be on a review of the literature on this emerging topic. Subsequently, the findings of a study of sexual offenders who were defined as sadists or nonsadists by clinicians will be discussed. The non-sadists scored worse on aspects that are supposed to define sadism, and discussion will be offered on such findings. Finally, data will be presented on a study of inter-diagnostician (N=24 psychiatrists) agreement (or inter-rater reliability) of the sadism diagnosis of 12 sexual offenders. The findings of the literature review and the two aforementioned studies will be integrated in order to offer suggestions for further needed research. The sex killer Ronald Langevin University of Toronto This paper examines the sex killer from a sexological, psychological and biological perspective. Little is known of this group of dangerous offenders. A model, which compares this group to sexually aggressive offenders, in general, and to violent non-sex offenders, will be discussed.. Data on a small sample of cases will be presented. Discussant: Bernard Grenier, Cour du Québec 99 XXVIe Congrès international de droit et de santé mentale SOCIAL RESPONSES TO MENTAL ILLNESS July 5 juillet 16:00 – 17:45 Room NCDH–200 Chair: Mary Kay O’Neil, Psychoanalyst, Montréal The benefits of voluntary inpatient psychiatric hospitalization: Myth or reality Donald H. Stone University of Baltimore Throughout the United States, individuals with mental illness are confined against their will in psychiatric hospitals as a result of allegations of dangerous behavior. Some are committed involuntarily by a judge after an administrative hearing is conducted where the mentally ill person is afforded legal representation, a right to be present and important due process protections including the right to cross-examine witnesses and present one’s own witnesses. However, a significant number of individuals who are initially confined in psychiatric institutions on the basis of assertions that the individual presents a danger to life or safety never see the light of an impartial judge, lawyer, or family member. These mentally ill individuals are not retained as an involuntary patient at the facility, but rather as voluntary patients without the benefit of due process protections. The legal and medical implications of being a voluntary patient in a psychiatric hospital will be discussed. This presentation will make specific recommendations as to when a psychiatric hospital will be permitted to accept and treat a mentally ill person as a voluntary patient. Interpretation of health insurance coverage for children for non medical or social care John Jacobi Seton Hall University Severely chronically ill children’s health care needs are both more expensive than and different in kind from that for non-disabled children. In addition to the preventive care, and the occasional acute care provided to non-disabled children, children with disabilities require “chronic care.” For children with chronic psychological and cognitive impairments, care can include longterm psychological, social work and occupational therapy. These services exist on the border between “medical” and “social” care. This distinction was unimportant prior to the era in which medical managed care organizations came to dominate both public and private American medical insurance. Recently, parents with chronically ill children have found that essential care is neither fish nor foul: medical MCOs reject coverage because it is not “medially necessary” or “curative.” Government services are less available, as care for children is privatized into systems unaccustomed to treating the chronically ill. This presentation will describe the current state of this shifting situation, and examine the legal framework within which the disjointed coverage must be brought together. An obligation to consult with the relatives of the hospitalized mentally ill: A comparison of Ontario and New Zealand Legislation John Grigor Consulting Psychiatrist, Wellington In Ontario, the Personal Health Information Privacy Act 2000 has been drafted in order to provide consistent and comprehensive rules that had been lacking with regard to those responsible for collecting health information. In addition to protecting the privacy, confidentiality and security of personal health information, a secondary aim is to facilitate the use of personal health information to improve quality of care for patients. In New Zealand, the Mental Health [Compulsory Assessment and Treatment] Amendment Act 1999 came into force in April 2000. This amendment was designed to facilitate family involvement in the care, assessment and treatment of the mentally ill. It arose from a concern that New Zealand Privacy Act legislation was being used by mental health professionals to avoid communicating with the family. The World Schizophrenia Fellowship noted in 1998 that research had conclusively shown that there were significant clinical, social and economic advantages to providing mental health services in a family-inclusive way. In contrast, clinical experience suggests that the family may have been instrumental in developing the patient as a representative of family pathology. On the other hand, in many cases the family is the reconstituting unit for the fractured individual. This paper compares and contrasts two very different legislative approaches to this dilemma in Commonwealth communities with otherwise very similar approaches to mental health legislation and the treatment of the mentally ill. Psychiatric mystification, bio-psy triumphalism and advocacy impotence Ken Barney Psychiatrist, Cambridge 100 XXVIth International Congress on Law and Mental Health Several decades of rights work has produced no substantial change in the pattern of psychiatric oppression. Defense work, occasionally successful for individuals, does not address bio-psy triumphalism. Psy-ideology and pseudoscience mystify severe distress and breakdown, and grossly exaggerate efficacy of psy-medication. We have neurotransmitter disturbances and broken brains–not unmet needs, powerlessness, hopelessness, or broken identities. The framework represses out the larger social context–unrestrained competitive individualism, pervasive insecurity, oppressive work, erosion of community, the triumph of the Market–creating and aggravating powerlessness, especially for those who are more vulnerable because of specific histories. Courtroom psychiatric testimony–crude and selective–continues to employ the “entity” paradigm. Despite several decades of withering criticism and thorough debunking, the concept of “diagnosis” persists. A steady bombardment from Academic Psy-Big Pharma sustains debunked concepts, especially “Schizophrenia.” The DSM continues to serve as textbook and Bible in the courtroom. “Competency” and “dangerousness” hearings are generally charades, rationalizing the hegemonic “need for treatment” (medication, hospitalization). The need is for bold strategies to contest psy-ideology, judicial deference to psypseudoscience and authority, and the scandalous paucity of critical resources–real employment, adequate housing alternatives and income and a range of small supportive asylum locations. Tribunals would require cadres of advocates (including lawyers) armed with critical perspective, plus special judges committed to affording equal consideration to alternative critical-position philosophy and testimony. 101 XXVIe Congrès international de droit et de santé mentale Sessions of the Academy Sessions de l’Académie Friday, July 6, 2001 vendredi 6 juillet, 2001 102 XXVIth International Congress on Law and Mental Health Program at a glance Coup d’œil sur le programme July 6 juillet, 2001 Parallel sessions / sessions parallèles 8:30 10:00 10:15 12:15 13:45 15:45 16:00 17:45 18:00 Bilingual forum / Forum bilingue: Sexual Misconduct of Professionals L’inconduite sexuelle professionnelle (104) ............................................................... MC European Perspectives on Sexual Offending (until 12:15) (105) .................. NCDH–201 Sentencing and the Welfare and Mental Health Needs of Youths (until 12:15) (107) ......................................................................................... NCDH–101 Violence Among the Severely Mentally Ill (109).......................................... NCDH–200 Chidren at the Intersection of Health and Justice (110)..................................CMEL–102 Break / pause Bilingual session / Session bilingue: Fitness To Stand Trial And Criminal Responsibility Aptitude à comparaître et responsabilité criminelle (112) ......................................... MC Victimisation sexuelle (113)........................................................................... NCDH–102 Communications libres V (114) ......................................................................... IASL-106 European Perspectives on Sexual Offending (cont’d) ( 105)......................... NCDH–201 Sentencing and the Welfare and Mental Health Needs of Youths (cont’d) ( 107) ................................................................................... NCDH–101 Families: Social and Legal Intervention (115)............................................... NCDH–200 Confidentiality and Sharing of Health Information (117)............................... CMEL-102 Break / pause Du viol au meurtre sexuel (119) ................................................................................. MC Violence et famille (120)................................................................................ NCDH–102 Psychological Jurisprudence: Mapping Social Boundaries (121)................... CMEL-102 The Right to Refuse Medications (until 15:45) (123).................................... NCDH–201 Trans-National Changes in Mental Health Systems (until 15:45) (126) ....... NCDH–101 Violence in Correctional Settings (127) ........................................................ NCDH–200 AtelierIII: Les gangs à Montréal: un phénomène qui semble prendre un nouveau tournant depuis les deux dernières décennies (se termine à16:45) (129).......... IASL-106 Break / pause Femmes et adolescentes agresseures ou victimes? (130) ........................................... MC Communications libres VI (131).................................................................... NCDH–102 The Right to Refuse Medications (cont’d) ( 123) .......................................... NCDH–201 Trans-National Changes in Mental Health Systems (cont’d) ( 126).............. NCDH–101 The Forensic Practitioner as Consultant: Varying Roles (132)....................... CMEL-102 Developing a Conceptual Model for Risk Management of Sex Offenders (133)....................................................................................... NCDH–200 End / fin Annual Business Meeting of the International Academy of Law and Mental Health Assemblée générale annuelle de l’Académie internationale de droit et de santé mentale 103 XXVIe Congrès international de droit et de santé mentale Abstracts for July 6, 2001 Résumés pour le 6 juillet 2001 8:30 – 10:00 BILINGUAL FORUM /FORUM BILINGUE SEXUAL MISCONDUCT OF PROFESSIONALS L’INCONDUITE SEXUELLE PROFESSIONNELLE July 6 juillet 8:30–10:00 Bilingual forum / Forum bilingue Simultaneous translation / Traduction simultanée Room / Salle MC Modérateur/Chair: Louis Morissette, Institut Philippe Pinel de Montréal Boundary issues in clinical practice Thomas Gutheil Harvard Medical School The presentation will review the concept of boundary crossings and their relationship to sexual misconduct in clinical practice. Risk management principles and techniques for clinical approaches will be outlined. Objectives: Participants will learn: • how to avoid both the appearance and reality of boundary violations; • how to respond to boundary violations observed in practice; • how to understand legal and clinical aspects of sexual misconduct. Inconduites sexuelles professionnelles / Professional sexual misconduct Christian Mormont Université de Liège La règle générale est claire et sans équivoque: pour le psychologue et le psychiatre, tout contact érotique est prohibé dans le cadre de leurs relations professionnelles. Sur le plan concret, les choses sont pourtant moins simples car: 1. l’attribution d’une qualité érotique à un comportement résulte d’une appréciation subjective influencée par la société, la culture, le style et les problèmes personnels, la psychopathologie; 2. la délimitation de ce qu’est une relation professionnelle est variable, notamment dans une perspective temporelle (à partir de quand est-on dans une telle relation? À partir de quand en est-on sorti?…), dès lors, jusqu’où et jusqu’à quand porte la prohibition ?; 3. l’administration de la preuve est malaisée, dès lors, comment faire la part de ce qui est réel, imaginaire, inventé ? Qu’en estil du vécu subjectif de l’un par rapport au comportement conscient de l’autre ? 4. les mesures répressives à l’encontre du «délinquant» sont de nature, de gravité et de durée diverses. Elles peuvent n’être que morales ou demeurer au niveau de l’exercice de la profession ou relever du pénal. Elles peuvent être temporaires ou définitives. Sans pouvoir affirmer qu’il existe une position unique en Europe, il semble néanmoins que les transgressions font l’objet d’une réprobation unanime mais ne suscitent pas nécessairement des réactions très passionnées. Deux éléments interviennent, au moins de façon intuitive, dans l’appréciation de la transgression: • il existe une gradation dans les transgressions et dans les conduites érotiques; • la relation concerne deux adultes Jusqu’à ce jour, le problème n’a pas mobilisé l’opinion publique de façon très marquée. La réaction vis-à-vis de la transgression de l’interdit est davantage liée à la personne du client (de quoi se plaint-il? Quels abus a-t-il subis? Quelles ont été ses attitudes avant, pendant et après la transgression?) qu’à l’idée même de la violation d’un principe. 104 XXVIth International Congress on Law and Mental Health EUROPEAN PERSPECTIVES ON SEXUAL OFFENDING July 6 juillet 8:30 – 12:15 (extended session) Room NCDH–201 Chair: Volker Dittmann, University of Basel Psychosis and sexual offending Anneliese Ermer, University of Basel, M. Graf, Volker Dittmann University of Basel The evaluation of 78 expert reports on sexual delinquents that were made since 1991 in the forensic psychiatric department of the Psychiatric University Hospital of Basel show that in 10 cases schizophrenic or schizoaffective disorders were diagnosed. In another case no expert report made since the diagnosis of schizophrenia occurred during hospitalisation. Another patient with a schizoaffective disorder showed sexually deviant thoughts and behavior during treatment. In our investigation we considered, in particular, the possibility of the presence of a disorder regarding sexual preference in addition to the psychotic disorder. First results will be presented. Classification of sexual offenders, HCR 20, SVR 20 and prognosis M. Graf, Anneliese Ermer, Volker Dittmann University of Basel According to current opinion, the classification of sexual offenders is crucial to risk assessment. In a retrospective study of 73 reports on sexual offenders, we examined whether, in addition to criteria-based assessment, the application of the HCR/SVR and a taxonomic classification could provide further relevant prognostic information. The study involved 73 reports from the past 10 years from the forensic department of the psychiatric university hospital: 37 cases were accused of aggressive sexual assault, 34 of pedosexuality and 3 of exhibition. The diagnostic categories (ICD-10) included seven cases of substance dependence, eight cases of schizophrenia, one case of affective disorder, one case of reactive disorder, one case of behavior disturbance, 42 cases of personality disorders, 15 cases of altered sexual preference and two cases of mental retardation. Surgical castration can be effective Josef Sachs Psychiatric Services of Aargau Canton, Switzerland A 50-year old man accused of sexual acts involving two boys was referred to us for forensic-psychiatric assessment. Coming from a disharmonious family background the offender had shown marked behavioral problems and persistent delinquency and had been placed, at age five, in various educational and correctional facilities, in one of which he was reportedly physically mistreated and sexually abused. From the age of 18, he repeatedly committed sexual acts involving boys, in some cases also resorting to force. He frequented homosexual circles and committed larceny. Several treatment attempts with Cyproteron failed due to poor compliance. At 28 year of age, after a renewed bout of delinquency involving sexual acts with boys, he abruptly decided to submit to surgical castration. From then on he embarked on a successful professional career, quickly working his way up to sales manager of a large company and starting a successful travel agency. At 43, he convinced a doctor under some pretext to prescribe androgens which, were regularly administered only seven years later. A few months after androgen administration, a relapse occurred. Comment: The castration of this man occurred in 1976, and was one of the last performed in Switzerland on forensic-psychiatric grounds. In this case, it is remarkable castration resolved not only the sexual delinquenc,y but also the antisocial behavior. We discuss the import of castration of sexual offenders in Switzerland and its effect on the case at presented. Evaluation of sexual offences among juveniles in the Canton of Zurich: A retrospective analysis from 1995 to 1999 Cornelia Bessler Department of Justice, Canton of Zurich The discussion about the appropriate legal and practical dealings with sexual offenders has been brought to the public eye since the early 90’s through several spectacular cases in this and also in other European countries. Extensive reports by the mass media concerning the offenders, the court cases that followed and the diverse political discussions gave the public the opinion that sexual offenders, especially child molesters, are basically violent offenders who are driven by instinct and have a high risk of relapse. In contrast, the discussion about juvenile sex offenders is rather controversial. Some classify sex offences among juveniles as careless, awkward lapses that occur within normal sexual development. Others, however, regard sexual crimes during adolescence as the first sign of a highly deviant, dangerous criminal potential. Consequently there are considerable differences in dealing with such aberrant behavior among adolescents. Taking these views into consideration, we are interested in both the extent of the offenceand in the biographical and criminal development of the juvenile. Our study investigated the 105 XXVIe Congrès international de droit et de santé mentale forensic histories and the types of sexual offences committed by juveniles who received orders to appear in front of the juvenile court between 1995 to 1999, in the Canton of Zürich. Based on the offenders’ records, we examined their family and educational background, the presence of any specific life events, as well as any outstanding family or personal developments. Our study further highlighted the offenders’ psychopathological problems, the demographic markers, the characteristics concerning the victims, the type and extent of the legal and therapeutic interventions and the characteristics of their social network. Diaper-fetishism: Two case reports and some theoretical aspects Thomas A. Knecht Munsterlingen Psychiatric Clinic, Switzerland The lecturer presents two case reports: Firstly a young man with Klinefelter-Syndrome who showed behavioral problems since his early childhood. In his adolescence, he placed newspaper advertisements to get jobs as a babysitter. He had sexual intercourse with two of these children (ie, mutual fellatio), and played games while using diapers. The second case is a twenty-eight year old computer specialist who almost became addicted to the internet, searching for web sites under the keyword “diaper”. In addition to these activities, he formed a bondage-like relationship with an elderly aunt, who was expected to wrap him in diapers. He was eventually convicted of having played such games with her two children. In the theoretical part, the author presents several types of deviant sexual behaviors in the context of paedophilia. He finally outlines a hypothesis concerning the genesis of these disorders, although the entire neurobiological basis of psychosexual infantilism is not yet clarified. The Zurich Model - A modern and guiding conception for a better cooperation of justice and psychiatry Frank Urbaniok Department of Justice, Canton of Zurich The Psychiatric and Psychological Service of the Department of Justice in Zurich is a specialized forensic center, providing a lot of outpatient services in the area of justice: The wide range of therapeutic treatments allows us to offer, for example, specialized prevention programs or, as a basic coverage, psychiatric services in the prisons. Making risk-assessments available to the prosecutors and the system of correctional services, organizing trainings for interested colleagues, and contributing to scientific questions that are relevant to the practice , are some of the additional professional activities undertaken by the service. To understand the potential of the Zurich-Model it is necessary to note that service representatives are responsible for the management functions of the justice system. This means that psychiatrists take responsibility for the development of the whole justice system, permiting a close cooperative relationship between psychiatry professionals and the justice system. The primary goal of the entire legal concept is to prevent relapse by focusing on many organizational levels. This includes differentiation (special arrangements for specific kinds of offenders, or problems inside and outside the penitentiary), systematic interdisciplinary cooperation, specialization (e.g., risk assessment and preventive therapy programs).These working conditions create an intensive interdisciplinary culture of working together, making practical solutions to problems possible, that in other situations could not be attained. The Zurich-Model will be presented in the lecture, the philosophy of treatment programs will be described and a new approach for risk-assessment will be introduced. AIP–a highly intensive, specialized, long-term program for high-risk sexual and violent offenders Stefan Schmalbach Department of Justice, Canton of Zurich One of the Zurich projects comprises a highly intensive specialized program for sexual and violent offenders at canton Zurich’s largest penitentiary. Prison staff here work closely with therapy personnel. The author, one of the therapists, will present the program results to date and pay special attention to therapy aspects with regard to offenders with personalitiy disorders. This presentation will show the possibilities that were opened up through close interdisciplinary teamwork, which is structurally anchored in the overall justice organization. The Effect of psychotherapy on relapse prevention of sex offenders Isolde Morawitz Forensic Outpatient Service, Vienna Patrick Frottier University Hospital of Psychiatry, Vienna 106 XXVIth International Congress on Law and Mental Health Guntram Knecht Forensic Department, Ochsenzoll, Hamburg This presentation deals with 88 sex-offenders who were sentenced by the court to compulsory outpatient treatment and sent to our forensic outpatient service during the period of April 1992 to March 1998. 66 of these sex offenders had been released from prison, 22 from high security hospitals for mentally ill offenders. The committed offences ranged from sexually motivated homicide to paedophilic violence. The majority of the offenders had a psychiatric diagnosis (e.g. personality disorder, schizophrenia, paedophile sexual identity). 68 offenders received psychiatric and/or psychotherapeutic treatment, as established by our treatment unit. 20 offenders required no therapeutic offer. We investigated relapse rates, using the criminal records of March 1999, with a mean follow-up time period of 4.2 years after the index assessment at out unit. We will present our concept and costs for treatment of our service. We compared treatment costs of 66 sex-offenders kept in prison, and of 22 offenders kept in high security hospitals, to the treatment cost of the same risk set of our unit. We contrasted the treatment costs and the costs following relapse. The results show, that our outpatient treatment is more effective and economic in relation to no treatment after release. Discussant: Gerard J. Werckle, California Department of Corrections SENTENCING AND THE SOCIAL WELFARE AND MENTAL HEALTH NEEDS OF YOUTH July 6 juillet 8:30 – 12:15 (extended session) Room NCDH–101 Chair: Rose Gabrielle Birba, Department of Justice Canada Sentencing reform: Canada’s Youth Criminal Justice Act Richard Barnhorst Department of Justice Canada Canada’s House of Commons has recently passed new youth justice legislation, the Youth Criminal Justice Act. After passage in the Senate, the new legislation is expected to come into force in 2002. It will replace the Young Offenders Act, which has been in place for seventeen years. A significant reform contained in the new legislation is a distinct sentencing code that includes a statement of the purpose of youth sentencing and a set of specific principles to guide the determination of an appropriate sentence. A fundamental issue in the development of the new sentencing provisions has been how should youth justice legislation take account of the social welfare and mental health needs of the young person while ensuring that the sentence is fair and reflects restraint in the use of the criminal law. The paper explains the new youth sentencing provisions and how they address specific problems that exist under the current legislation. These problems include: sentences being imposed on young people that are more severe than would otherwise be warranted in order to address their social welfare needs; the over-use of custody; and the significant number of first offenders found guilty of minor offences who are sentenced to custody. The paper also includes a discussion of a new mental health treatment sentence for young people who commit serious violent offences and are suffering from a mental or psychological disorder or an emotional disturbance. Locking up youth for their own good Anthony Doob University of Toronto Jean-Paul Brodeur Université de Montréal In the course of the deliberations concerning the recently enacted Youth Criminal Justice Act, some critics suggested that it should be permissible to place a youth in custody even if the offense the youth committed did not justify the use of this sanction. Custodial facilities were often said to provide the kind of environment that could be beneficial for youths in distress. In other words, the suggestion was made that under certain circumstances it should be permissible to incarcerate youths for their own good. A related argument is that the judge can sometimes "protect society" and help the young person by imposing a custody 107 XXVIe Congrès international de droit et de santé mentale sentence for rehabilitative purposes even when the offense itself could not justify a custodial sentence. Our paper argues that these closely related views are misguided, even when they are based on the best of intentions and on the wish to provide the best possible care for youths in need of help. These views exemplify a tendency to misconstrue punishment as a benevolent measure to make the infliction of harm upon a youth more palatable to the sentencer's self-awareness. Therapeutic interventions for seriously violent youth Carla Cesaroni University of Toronto Though there are no “ silver bullets” in the form of interventions that work for all serious and violent young offenders, there is still enough available evidence about serious and violent behavior that policy makers can develop and evaluate appropriate programming. This paper will suggest that any intervention for violent youth must have clarity regarding which youth such programming would hope to target. It will suggest that effective interventions must be multimodal to address multiple problems and that aftercare should be an integral part of any coordinated strategy. It will argue that the development of any therapeutic sentence for violent youth should work in tandem with larger, long-term efforts that are reliable in their ability to reduce the number of young people who are likely to commit any type of crime. Juvenile homicide offenders Patricia White California Youth Authority A retrospective case study of a group of 76 homicide offenders (convicted of First or Second Degree Murder, Voluntary or Involuntary Manslaughter; aged 14 to 17 years at the time of the offense, and aged 18 to 25 years at the time of release from incarceration). The analysis yields information as to background history, antecedent risk factors for criminal behavior, ethnicity of offender, characteristics of the victims, nature of the crime, type of psychopathology, psychiatric diagnosis, response to treatment and risk factors for re-offending following release. Juvenile killing sprees John K. Cornwell Seton Hall University The United States has witnessed various high-profile killing sprees carried out by juveniles in or around school yards over the past several years. As a result of these events, parents are growing more fearful of troubled adolescents and are less willing to dismiss offhanded, threatening remarks. When, for example, Wisconsin teenager Daniel Shipley told his father that he would imitate teenager Kip Kinkel, who had murdered his parents and classmates, if Mr. Shipley did not let him sleep in on a Saturday morning, the Shipleys had their son arrested in an effort to obtain court-ordered psychiatric hospitalization. In this talk, I will discuss the legal alternatives available to the Shipleys and others like them who seek mental health intervention for their children. While I will address both the civil and the criminal law, my focus will be on civil commitment, specifically the propriety of broadening parental authority to commit children “voluntarily” to state hospitals, the place, if any, of incorrigibility proceedings, and the role that outpatient commitment may play in this process. Time, difference and the ethics of children’s criminal responsibility Ben Mathews Queensland University of Technology Laws ascribing criminal responsibility to children in Australia are largely based on the child’s age and their knowledge of the wrongness of their criminal act. This discussion questions the ethics of imputing criminal responsibility to young children. In questioning Australian legal positions, two factors are considered: difference and time. Law tries to essentialise children by assuming that all children of a certain age have similar understandings of right and wrong, and have similar capacities to control their actions (although this capacity is not investigated). However, depending on social, familial and personal characteristics, an individual child may have ‘different’ understandings of right and wrong, and may have different capacities of self-control. Given these variables, and given that young children have not had much time to overcome what might be described as a less than ideal environment in which to grow up, under what circumstances is it ethically justifiable to hold them (and them alone) criminally responsible, and to sentence young criminal offenders to custodial sentences? Are there alternatives that are more justifiable when these differences are considered, that also produce greater benefits for the individual, for the family and for society? Assessment of the static variables in belgian juvenile sex offenders Bernard Pihet Unité de psychopathologie légale, Tournai 108 XXVIth International Congress on Law and Mental Health Phillippe Cortèse, Thierry Pham Université Catholique de Louvain There is an obvious interest in juvenile sex offenders in Belgium. However, to our knowledge, this population has never been systematically assessed using static variables. The present study included 34 juvenile male sex offenders who were referred as outpatients by the juvenile justice authorities to the “Unité de Psychopathologie Légale” (UPPL). The static variables were extracted from the registration file which cover the domains of (a) sociodemography; (b) sexual behavior; (c) psychopathology; and (d) emotional development. The 34 subjects were assigned to different groups according to (a) intra- (N= 19) versus extrafamily relation (N= 15) between victim and agressor and (b) female (N=15) v. male (N=14) sex of the victim. The statistical analysis included either continuous (means comparisons) or discrete variables (frequency comparisons). The results are discussed with reference to the data described in the international literature. VIOLENCE AMONG THE SEVERELY MENTALLY ILL July 6 juillet 8:30 – 10:00 Room NCDH–200 Chair: Peter G.J. Greeven, Ministry of Justice, The Netherlands Studying violent incidents: Methodological issues Charles Lidz University of Massachusetts Research suggests that the amount of low level violence is very high among people with mental illness, at least in the US. Whether it is greater among people who are similarly situated but not mentally ill is still uncertain, but it is clear that this is a serious problem, both for people with mental illness living in the community and for those with whom they live. If we are to find ways of reducing this sort of violence, we must learn how it comes about. The paper describes a study of violent incidents based on intensive interviews with both parties of the incident. Gathering reliable data on the events involved, and the integration of the two different accounts present substantial methodological problems which, however, are manageable if adequate resources are committed to the task. The paper describes some solutions to these problems and discusses future work that needs to be done. The social-environmental context of violent behaviour in persons with severe mental illness Jeffrey Swanson, Marvin Swartz Duke University Recent studies suggest that the causal determinants of violent behavior in persons with mental disorder are varied and complex. The large majority of persons with severe mental illness (SMI) do not commit violent acts. Psychopathology plays some role in explaining violent behavior when it does occur in this population, but other variables are perhaps equally important. Using multivariable analysis of a large, pooled sample of individuals with SMI (N=802), this study examined a range of potential risk factors for violence. Three salient variables–history of violent victimization, exposure to violence in the surrounding environment and co-occurring substance abuse–were found to exert a cumulative effect on violence risk. Subjects with none of these three risk factors had less that a 1% predicted probability of violent behavior in a year–i.e. less than the rate that other studies have reported for the general population without mental illness. However, subjects with all three risk factors combined had a 30% predicted probability of acting violently. These analyses support the view that violent actions by adults with SMI may result from multiple variables with compounded effects over the lifespan, with an important role attributable to developmental experience and the social environment, as well as clinical status. Effective community-based interventions to manage risk in such individuals must be comprehensive and broadly focused, addressing multiple problems including underlying psychopathology, addiction, trauma sequelae, and need for community support. Dangerous and incompetent: Employers’ perceptions of mental illness Teresa L. Scheid University of North Carolina at Charlotte This research examined the effect of the Americans with Disabilities Act on the employment of individuals with mental disabilities. We surveyed a random sample of 117 employers in a large metropolitan community in the Southeast US and asked questions about their employment practices as well as their attitudes towards those with various types of mental illnesses or disabilities. Previous research has found that employers held stigmatized and ignorant attitudes toward those with mental illnesses, and were reluctant to hire these individuals. Employers were also found to hold false assumptions about job-related abilities and the costs of accommodations. Our data confirm these findings, and also demonstrate that employers continue to hold stigmatizing attitudes, and are particularly concerned with the potential dangerousness of those with mental illnesses. Employers 109 XXVIe Congrès international de droit et de santé mentale also tended to associate mental illness with incompetence. Such attitudes reflect public misconceptions and common stereotypes and consequently limit the employment opportunities of millions of individuals. Filicide George B. Palermo Medical College of Wisconsin Family violence has been present since the beginnings of humankind. This presentation offers observations regarding some of its major manifestations - neonaticide, infanticide and filicide from an historical perspective. Observations are drawn from mythological tales and early cultures, the Middle Ages, the Renaissance, and the present. The dyadic relationship between parent-child, and especially mother-child attachment and bonding are touched upon. Nature/nurture and biological/environmental assumptions are discussed. A brief typology of murdering mothers or fathers seen in forensic psychiatric practice, supported by six case studies (1 neonaticide, 2 infanticides, and 3 filicides) is presented. Recent literature is noted and a psychodynamic formulation is proposed. CHILDREN AT THE INTERSECTION OF HEALTH AND JUSTICE July 6 juillet 8:30 – 10:00 Room CMEL–102 Chair: Bernard Starkman, Department of Justice Canada The Competency of Children to Give Evidence in Criminal Proceedings Barbara Esam National Society for the Prevention of Cruelty to Children, United Kingdom The purpose of this paper will be to outline the competency provisions relating to young witnesses in the criminal jurisdiction in England and Wales. The paper will deal with the following points: Introduction outlining information about the National Society for the Prevention of Cruelty to Children (NSPCC) and the role the organisation plays in influencing and developing legislation and policy which affects children in the civil and criminal jurisdictions Background to the development of the competency provisions in criminal proceedings The current legal position, including new legislation in the ‘Youth Justice and Criminal Evidence Act 1989’ (not implemented yet) The rules on sworn and unsworn testimony The vulnerable status of child witnesses Special measures to assist child witnesses Advice given to judges on competency by the Judicial Studies Board for cases involving children and young people as witnesses The impact of the competency rules on the criminal justice system The views of the Criminal Bar Association, Crown Prosecution Service, judges, and young witness support workers The impact on child witnesses and trial outcomes Working together to safeguard children Jenny Gray Department of Health of England Purpose: To describe how the child welfare and criminal justice systems in England relate to each other, and how professionals share information between the two systems. In addition, how policy and guidance have been developed in these areas with a focus on the welfare of the child. Scope: The paper will set out the key legislation, regulations and guidance which underpin the child welfare and criminal justice system as it relates to child protection. It will describe how these documents relate to each other and how they are expected to be implemented in practice. Specific documents will be drawn upon to illustrate the tensions which had to be resolved during their development and the process by which they were finalised for approval by the government. A key issue for discussion will be the differences between the family and criminal justice systems. In the former, the welfare of the child is paramount and in the latter the court has a duty to ensure the defendant has a fair trial. 110 XXVIth International Congress on Law and Mental Health Finally the paper will discuss the legislation and guidance on consent and confidentiality when a child is considered to be likely to, or has suffered significant harm, and the issues around the disclosure of information about the child in criminal court proceedings. Alcohol and substance use in pregnancy - Motherisk’s clinical perspective and research agenda Susan Santiago Friends of Motherisk Alcohol: It has been estimated that between 0.5 to 2 in 1000 babies born are the victims of Fetal Alcohol Syndrome (FAS) - the most severe alcohol-related abnormality found in the children of women who drink heavily during pregnancy. Rates of Alcohol Related Neurodevelopmental Defects (ARND) are less well understood, but thought to be higher. At the present time, very little is available to help prevent, diagnose and manage FAS and ARND even though we know that these preventable outcomes are associated with cognitive delays and neurobehavioural problems that can lead to delinquent or illegal activities in adolescence. Other substances: An estimated 10 to 45 percent of women cared for at urban teaching hospitals in large US cities use cocaine in pregnancy. In the Metropolitan Toronto area, there has been a steady increase in the number of newborns affected by maternal drug use. The damaging effects include intrauterine prematurity, growth retardation and developmental delay. Appropriate diagnosis, treatment and perinatal care, depend on accurate and timely classification of “exposed” infants. For over a decade, Motherisk has worked to understand, quantify and address the effects of prenatal exposure to alcohol and substances of abuse. Today, Motherisk operates the Alcohol and Substance Use Helpline -- the only national, toll-free counselling service of its kind in Canada. It offers FAS/ARND diagnosis for children up to the age of 16, and is actively engaged in experimental research to develop sensitive neonatal screening tools to help identify children at risk. This presentation will describe: Motherisk’s search for objective biomarkers in newborn hair and meconium to identify babies who have been exposed in utero to alcohol and cocaine; Motherisk’s FAS/ARND diagnostic checklist; Motherisk’s national Helpline for women who have engaged in high risk behaviour in pregnancy and/or prior to learning that they were pregnant. Dealing with people who suffer from Fetal Alcohol Syndrome / Alcohol-related birth defects Anna Marie Mallard Royal Canadian Mounted Police, Yellowknife, Northwest Territories There are many great people in Canada’s North and many great challenges. Many of our communities are accessible by air only. Police officers rotate in every two years. We learn the culture and deal with day-to-day police work. Often, young offenders are afflicted with Fetal Alcohol Syndrome and as police officers; we may not look past the offense. A charge is laid and the court process begins. Many communities have community justice committees to deal with young offenders. Dealing with youth affected by Fetal Alcohol Syndrome requires all social agencies to work together – including social services, public health, police, and teachers. Often, the youth are not diagnosed, however, and may possess characteristics of Fetal Alcohol Syndrome or a learning disability. This paper will discuss issues such as the need for community awareness of Fetal Alcohol Syndrome and the need for communities to address the need. Police officers require awareness training in detecting/identifying the characteristics of Fetal Alcohol Syndrome and best approaches when dealing with the behavior of the offenders. FAS is a community problem and must be dealt with in a community setting. Discussant: Carol Cumming Speirs, McGill University 111 XXVIe Congrès international de droit et de santé mentale 10:15 – 12:15 BILINGUAL SESSION /SESSION BILINGUE FITNESS TO STAND TRIAL AND CRIMINAL RESPONSIBILITY APTITUDE À COMPARAÎTRE ET RESPONSABILITÉ CRIMINELLE July 6 juillet 2001 10:15–12:15 Bilingual session / Session bilingue Simultaneous translation / Traduction simultanée Room / Salle MC Modérateur/Chair: Jacques Talbot, Institut Philippe Pinel de Montréal Scientific evidence in forensic expert assessments Preuves scientifiques sur les expertise psycho-légales Julio Arboleda-Flórez Queen’s University One of the major developments in Justice systems of the United States and Commonwealth countries over the past one hundred years has been the growth of the use of expert evidence in Courts of Law. Rules about the admissibility of their evidence and what constitutes the need to accept such evidence, known as the Frey Test, were enacted in the United States at the beginning of the 20th century, but they were overturned in the mid 1990s, when the Bendectine cases gave rise to much controversy about the quality of the expert evidence proffered by the parts. The new rules, known as the Daubert test, have not helped to clarify the issues pertaining to the quality that should be expected from scientific experts. Similar rules in Canada have not helped to clarify these issues in this country either. In this presentation the author will review the scientific evidence rules and will seek to elucidate the elements of what should constitute good scientific expertise. Une analyse du processus et des facteurs associés aux évaluations de l’aptitude à subir son procès Process analysis and factors related to the fitness to stand trial Anne Crocker New Hampshire-Dartmouth Psychiatric Research Center L’évaluation de l’aptitude à subir son procès (ASP) constitue un volet important de l’interface entre le système de santé mentale et le système de justice criminelle. Les demandes d’évaluation psychiatrique le plus souvent requises par les Cours criminelles auprès des professionnels en santé mentale concernent l’ASP. Étant donné: (1) l’intérêt d’évaluer l’application de la Partie XX.1 du Code criminel canadien suite à son entrée en vigueur en 1992; (2) la variabilité interjuridiction observée dans les pratiques d’évaluation de l’ASP; (3) l’absence quasi totale de femmes dans les échantillons généralement décrits dans la documentation scientifique et; (4) le peu de données actuellement disponibles au Québec, nous avons entrepris un programme de recherche sur l’ASP au Québec. Les objectifs généraux poursuivis étaient les suivants: (1) décrire la population sous ordonnance d’ASP; (2) identifier les facteurs associés à la recommandation d’inaptitude chez les hommes et les femmes; (3) décrire la mise en application des dispositions concernant l’ASP de la Partie XX.1 du Code criminel canadien; (4) recenser les méthodes d’évaluation de l’ASP actuellement disponibles par le biais d’une analyse de leur utilité et de leurs propriétés psychométriques. Les résultats et les interprétations de ce programme de recherche seront présentés à la lumière de l’ensemble de la documentation scientifique se rapportant à l’ASP et dans une perspective de recherches futures. L’expertise psychiatrique: la perspective du juge Expert assessments in criminal court: the judge’s perspective Claire Barrette-Joncas Cour supérieure du Québec Qu’il s’agisse de déterminer l’aptitude à subir son procès ou la responsabilité criminelle d’un accusé ou d’établir si l’auteur d’un crime violent doit être considéré criminel dangereux, la Cour requiert l’opinion de psychiatres-experts. Mais comment peut-on déterminer si l’expert est crédible et son opinion fondée ? Comment peut-on trancher entre les opinions divergentes de deux experts ? Ce sont là quelques-unes des difficiles questions que doit résoudre le juge. Dans le cadre de cette présentation, Madame la juge Barrette-Joncas nous fera bénéficier de ses connaissances approfondies et de sa riche expérience sur ces sujets. 112 XXVIth International Congress on Law and Mental Health VICTIMISATION SEXUELLE July 6 juillet 10:15–12:15 Salle NCDH–102 Modérateur: Benoit Dassylva, Institut Philippe Pinel de Montréal Les victimes: les voies de la réparation Hubert van Gijseghem Université de Montréal Trop facilement croit-on qu’à pareil trauma, pareil remède. Ainsi a-t-on vu se développer des thérapies spécialisées dans le cas de victimes d’agressions ou d’abus sexuels et on a pris pour acquis qu’il s’agissait là de la voie royale eu égard à la “réparation” ou au rétablissement de cette personne, jeune ou moins jeune. Des données venant de la recherche évaluative de tels programmes sont venues jeter un doute sur la tranquille certitude des traitants. Ceci n’est pas si surprenant si on tient compte de ce qu’une déjà ancienne expérience clinique nous a appris: les voies de la guérison en matière de la psyché humaine sont imprévisibles et souvent inédites. Une foule de variables contextuelles, familiales, sociales, culturelles et personnelles font que les séquelles ne seront pas les mêmes chez différentes personnes suite à un trauma et à fortiori, les stratégies réparatrices ne le seront pas plus. Il y aurait plutôt lieu de regarder les victimes cas par cas dans le but de déterminer les ressources déjà présentes dans elles et dans leur monde et ensuite de personnaliser les mesures proposées, si celles-ci s’avéraient nécessaires. Les réponses à la violence sexuelle: entre le discours et la mise en œuvre Arlène Gaudreault Université de Montréal Les années ‘70 ont marqué un tournant important dans la reconnaissance des besoins et des droits des victimes d’agression sexuelle au Canada et dans de nombreux pays. La non dénonciation des infractions à caractère sexuel, le manque de considération à l’endroit des victimes au sein du système pénal, le laxisme des mesures sentencielles, l’absence de services pour répondre aux besoins psychosociaux des victimes: voilà autant de problèmes et de réalités qui exigeaient des changements majeurs. Emboîtant le pas, à partir du début des années ‘80, le gouvernement canadien adoptait d’importantes réformes législatives visant à humaniser le système de justice et à rétablir un meilleur équilibre entre les droits des victimes et ceux des agresseurs. Parallèlement, de nombreux programmes et initiatives se développaient dans la communauté et dans les réseaux institutionnels afin de contrer et de prévenir la violence sexuelle. Trois décennies plus tard, où en sommes-nous ? Les changements législatifs ont-ils modifié sensiblement les façons de faire du système de justice? Ont-ils instauré de meilleures garanties pour la reconnaissance des droits des victimes ? Les programmes d’aide permettent-ils de répondre aux demandes exprimées par les victimes ? Ces questions seront examinées dans une perspective critique de façon à mettre en lumière les progrès réalisés et à dégager les principaux enjeux pour l’avenir. Approche multidimensionnelle de l’impact de l’abus sexuel sur des hommes Elham Forouzan Institut Philippe Pinel de Montréal Le but de la présente étude consistait à évaluer l’adaptation psychosociale et la psychopathologie d’hommes ayant connu des contacts sexuels précoces avec un adulte. Au total, soixante-quatre sujets ont participé à une entrevue et ont rempli huit questionnaires portant sur les différents aspects de leur enfance et de leur vie à l’âge adulte. Les résultats de notre recherche suggèrent l’existence de trois types de scénario de contacts sexuels. Les sujets de chacun des trois groupes présentent une adaptation spécifique à l’âge adulte. En effet, les sujets ayant connu leur premier contact sexuel avec un homme connu non coercitif ne rapportent aucun problème majeur à l’âge adulte et présentent une perception positive de ces contacts. En revanche, les hommes ayant connu leur premier contact sexuel avec un homme inconnu coercitif rapportent des difficultés d’ordre sexuel (paraphilie, troubles sexuels, délits sexuels), relationnel (caractéristiques des troubles des personnalités évitantes, passiveagressive et état-limite) et émotionnel (symptômes d’anxiété, d’anxiété phobique et d’idéation paranoïde) à l’âge adulte. Quant aux sujets ayant connu leur premier contact sexuel avec une femme connue, ils rapportent essentiellement des problèmes relationnels et divers symptômes actifs et intenses (symptômes obsessifs-compulsifs, dépressifs, et psychotiques). De façon générale, les problèmes présentés par les sujets de cette étude sont fréquemment évoqués dans la littérature, comme des «conséquences» observables d’abus sexuels subis en bas âge. Toutefois, la méthodologie et les analyses multivariées de notre étude ont permis de préciser que tous ces problèmes ne sont pas associés uniquement à ces contacts, mais également aux autres expériences infantiles et aux ressources cognitives, affectives et psychologiques du sujet (style d’attachement). 113 XXVIe Congrès international de droit et de santé mentale COMMUNICATIONS LIBRES V July 6 juillet 10:15– 12:15 Salle IASL-106 Modérateur: Jocelyn Aubut, Centre hospitalier universitaire de Montréal Réforme et révision des règles régissant le caractère contradictoire de l’expertise psychologique en droit belge: une révolution de palais à l’exclusion du parlement Claude Philippart de Foy et Jean-Louis Gilissen Avocats, Belgique En droit belge, l’expertise judiciaire est régie par la loi (soit les articles 962 à 991 du Code judiciaire). La procédure légale assure une parfaite contradiction et transparence de l’ensemble des opérations d’expertise. Pourtant, dans la pratique, cette exigence légale mérite de nombreux commentaires dans la mesure où on est en droit de s’interroger quant à savoir si elle s’applique à l’expertise dite « psychologique », d’une part, et, d’autre part, à l’expertise ordonnée par une juridiction pénale. Sur le plan civil, le caractère contradictoire de l’expertise se limite le plus souvent à: 1 • Une première réunion au cours de laquelle les parties et leurs avocats sont entendus par l’expert; • L’envoi par l’expert des préliminaires de son rapport afin de permettre aux parties de faire valoir leurs observations; • Les conclusions de l’expert qui seront soumises au Tribunal et donneront lieu à un débat contradictoire. Dans de telles conditions, il apparaît légitime de se poser la question de savoir si on peut imaginer d’imposer à l’expert d’entendre chaque partie en présence de l’autre, celles-ci éventuellement assistées de leurs avocats. 2 Au pénal Depuis l’entrée en application du Code Judiciaire, la Cour de Cassation de Belgique a pourtant et sans aucune base textuelle, invariablement affirmé que et à quelque stade de la procédure que ce soit, l’expertise en matière répressive devait se dérouler de manière non contradictoire. La réaction à l’enseignement de la Cour de Cassation est venue de la Cour d’Arbitrage, nouvelle juridiction à compétence constitutionnelle créée du fait d’une complexe réforme institutionnelle de l’État. Par deux décisions distinctes, la Cour d’Arbitrage a introduit, mais partiellement, un aspect contradictoire dans les expertises confiées dans le cadre de la procédure pénale. Réagissant à cette décision, la Cour de Cassation introduisit à son tour, également par deux décisions distinctes, une forme de contradiction au sein des expertises ordonnées au pénal. Toutefois, les décisions de la Cour d’Arbitrage et de la Cour de Cassation restent divergentes et ne permettraient pas une unicité de Jurisprudence. En pratique, les juridictions de fond se sont dès lors trouvées dans l’impossibilité de prononcer des décisions conformes à la jurisprudence des deux Cours. L’expert judiciaire pouvait légitimement, à l’occasion des missions qui lui étaient confiées, se trouver pris en otage. Dès lors, le débat reste toutefois ouvert et la latitude laissée au Juge n’est guère de nature à assurer ni une contradiction, ni sa qualité. L’émoi et les réactions propres à «l’affaire DUTROUX» ne sont pas sans avoir relancé un débat particulier concernant la contradiction des expertises psychologiques. La contradiction est-elle, et invariablement, garante de la qualité d’une expertise? L’échange d’informations entre toutes les parties au litige, la communication de préliminaires par l’expert et la possibilité d’envoi de notes de faits directoires sont-ils toujours et invariablement compatibles avec les principes du droit répressif? L’évaluation de la jurisprudence belge en la matière est de nature à générer une réflexion profonde sur le rôle et la place de l’expertise en matière judiciaire. Incrimination internationale d’une criminalité spécifique: violence sexuelle et viol: de la reconnaissance du viol en tant que crime contre l’humanité, de crime de guerre ou d’acte de génocide Jean-Louis Gilissen Avocat, Belgique 114 XXVIth International Congress on Law and Mental Health Les violences sexuelles, sous leurs diverses formes, sont appréhendées par les législations pénales nationales via le recours à des techniques d’incrimination particulièrement différentes et multiples. L’étude de la diversité des législations nationales en la matière permet de mettre en exergue les difficultés probatoires propres aux législations de certains pays. Les violences sexuelles commises en temps de conflit armé ont toutefois fait longtemps l’objet d’une forme de tolérance propre et inhérente aux fatalités. Aujourd’hui pourtant, les violences sexuelles et plus particulièrement le viol, sont considérés comme des crimes de droit international. Les conventions de Genève de 1949 permettent en effet d’intégrer ces formes spécifiques de violence via les notions génériques de «atteinte à l’honneur et au concept de «torture» ou de «traitement cruel et inhumain» constitutifs de violation grave des Conventions de Genève. L’actualité, via les conflits qui ont ensanglanté la Yougoslavie et le Rwanda, a toutefois attiré l’attention sur la spécificité d’une certaine criminalité sexuelle empruntant une forme systémique et massive et servant, dans le cadre de conflits internationaux ou internes, de véritables moyens, qu’ils soient de purification ethnique ou de terreur vis-à-vis d’une population déterminée. Lors de la création du Tribunal Pénal International pour l’ex-Yougoslavie et du Tribunal Pénal International pour le Rwanda, le Conseil de Sécurité de l’O.N.U. a dès lors érigé le crime de viol au rang de crime contre l’humanité et de crime de guerre. Par un jugement rendu le 2 septembre 1998 en l’affaire AKAYESU C/ Le Procureur, le Tribunal Pénal International pour le Rwanda a livré la première définition du viol en droit international. De plus, et pour la première fois, le Tribunal Pénal International pour le Rwanda a affirmé que le crime de viol et les violences sexuelles, commis dans certaines conditions, étaient constitutifs d’actes de génocide. Depuis lors, l’adoption en juillet 1998 du statut de la Cour Pénale Internationale a élargi la liste des crimes de nature sexuelle et des violences à motivation sexiste considérés comme pouvant constituer des crimes de guerre, des crimes contre l’humanité ou un crime de génocide. Une nouvelle fois la mécanique des laboratoires juridiques mis en œuvre dans la tentative de l’organisation d’une justice internationale par l’O.N.U. a permis un apport nouveau et original constitutif d’un véritable progrès dans la lutte contre l’impunité des criminels contre l’humanité. Délinquants dangereux ou à contrôler: Législation canadienne et Expérience québécoise Louis Morissette Institut Philippe Pinel de Montréal L’auteur révisera, de façon historique, les lois canadiennes qui ont traité et traitent des délinquants que le code criminel canadien a qualifié de différentes façons depuis plus de cinquante ans : criminels d’habitude, délinquants sexuels dangereux, délinquants dangereux et délinquants à contrôler. Pour la très grande majorité des délinquants ainsi qualifiés, il s’agissait d’une délinquance d’ordre sexuel. La législation actuelle sera discutée et de façon particulière, l’auteur présentera l’expérience québécoise depuis l’été 1998 (environ 25 cas). Tous ces hommes (aucune femme) ont été évalués par des professionnels de l’Institut Philippe Pinel de Montréal (par suite d’un contrat de service avec le système judiciaire de la province de Québec). L’auteur discutera des disparités régionales au Canada (selon les régions, plus ou moins de délinquants sont considérés dangereux ou à contrôler). Pour conclure, l’auteur discutera des services spécialisés externes qui devront être offerts par les Services correctionnels lorsque ces individus seront remis en liberté. Aussi, l’auteur discutera de la pertinence et de l’éthique d’une telle législation qui identifie, catégorise, regroupe des individus à risque sans nécessairement offrir des services et, en particulier, du rôle de l’expert dans ce processus judiciaire (utilisation de concepts cliniques pour justifier une décision judiciaire, punitive et contraignante). FAMILIES: SOCIAL AND LEGAL INTERVENTION July 6 juillet 10:15 – 12:15 Room NCDH–200 Chair: John Wilson, Ontario Consent and Capacity Board Domestic Violence Courts: Changing the way we prosecute Margo A. MacKinnon Barrister and Solicitor, Toronto 115 XXVIe Congrès international de droit et de santé mentale Domestic violence is a prevalent social problem with devastating effects on families and society as a whole. It is also a crime. As we enter this millennium, several government agencies involved in the criminal justice system have been working together to develop an integrated approach in an effort to break the cycle of violence and promote healthy and safe homes and families. The Ministry of the Attorney General for Ontario is expanding a program of dedicated Domestic Assault Courts across the province. Specialized teams of assistant Crown Attorneys coordinate the prosecution of domestic violence offences with police services, staff from Victim Witness Assistance Programs, court services staff, and staff from probation services and Partner Assault Response and counseling programs. This integrated approach is designed to (1) provide information and support to victims and witnesses throughout the court process; (2) increase the quality of prosecutions; and (3) provide effective sentencing options upon guilty plea or conviction. The expansion of Domestic Violence Courts requires that Crown Attorneys understand not only the legal issues involved in prosecuting crimes of domestic violence, but also the complex social and psychological factors. This presentation will address why Domestic Violence Courts were created in Ontario, what we are striving to achieve and how we hope to accomplish our goals. Clinical assessment in contested child custody disputes: Opportunities for alternative dispute resolution John Leverette, Trish Crowe, Rose Wenglensky, Christopher Cooper Queen’s University Much has been written about the role of the child custody evaluator and the nature of the custody assessment, although at present, there are no universally accepted content criteria for the latter. There is, however, little in the literature concerning the role or function of the custody assessment itself in relation to the course of resolution of the custody dispute. While clinical testimony has long been recognized as a source of evidence to be considered at trial, this represents an overly restrictive view, particularly in a legal climate that promotes mediation and settlement. This paper will discuss the functions of the custody and access assessment as a form of alternative dispute resolution. It will emphasize the interdisciplinary context and practices between the legal and mental health professions that are necessary for this to occur. The authors draw on their own study of 72 judicial referrals conducted using a format which integrated the clinical custody assessment with the work of counsel and judicial case management procedures and compare this to other findings in the American literature. In a judicial climate that emphasizes dispute resolution, combining legal and mental health efforts can result in more efficient use of resources and a substantial diversion of cases from continuing litigation. While altering the process of clinical assessments enhances such findings, further work is required to assure appropriate selection criteria for various intervention formats. The application of systemic principles to forensic psychiatry: Review of a family intervention programme Sergio Santana University of Alberta Myrna Gower Surrey Oaklands NHS Trust, England Family therapy is an increasingly influential therapeutic model, which has rapidly been integrated into practice by child psychiatrists. Incorporating this model into the adult population, however, seems to have been slower and more difficult. Cottrell and Foster (1988 & 1992) found that systemic models of care had not influenced general psychiatrists. Santana & Evans (1996) concurred with them, although they studied populations that remained in contact with the psychiatric services for far longer than the population studied by their predecessors. Clinical observation suggested to Santana and Evans, a number of reasons that seemed to prevent the application of family interventions to the long term mentally ill treated by either the rehabilitation or the forensic services. Therefore, they proposed a number of strategies that aimed to enhance the influence of systemic practice in psychiatry in general and the long term mentally ill, in particular. In order to explore the validity of these ideas, Santana and Gower devised a program aiming to incorporate family therapy as part of the treatment package offered to the long term mentally ill (1998). In1999, this package of treatment was applied to families of long term patients with enduring maladaptive behaviors requiring management in conditions of minimum security. The Burnham Family Intervention Model was the result of this work. The Psychiatric siagnosis v the psychological study in mental health in the Brazilian family court - Assessment since of a case of child custody Júlio César Fontana-Rosa University of São Paulo 116 XXVIth International Congress on Law and Mental Health In the analysis of psychiatric development we observed that until recent decades, the psychiatric diagnosis could provide the judicial decision in cases where suspected mental upset. Decisions in mental health instituations are no longer made by the psychiatrist in an isolated manner, but by an integrated team of mental health professionals (psychologists, social workers, etc). This form of decision-making is also used in the justice system. However, the judge can request individual expertise in each area (psychiatry, psychology, social service, etc). When the judge requests psychiatric expertise, the professional can request that other specialties elaborate upon the diagnosis. The author understands that the definition of psychiatric diagnosis using the international codes CID 10 and DSM 4 is fundamental to the judicial needs. The paper will discuss a case of a psychological study where a mother was determined to have psychiatric problems. As a result of this study, but without a psychiatric diagnosis, the mother lost custody of her child. The “psychological diagnosis” used in the study referred to isolated symptoms, but did not define the clinical picture. The author questions the validity of this judicial conclusion since basic evaluation was not performed, including specific diagnosis, development of a corresponding clinical picture, etiology, and possible treatments, prognosis, etc. Characteristics and experiences of domestic violence offenders E. Gilchrist, E. Bowen, M. Kebbell and A.Beech University of Birmingham Rates of domestic violence are increasing. This may be due to increasing sensitivity from agencies such as the police, or to women being more able and more willing to report these offences. Also, the incidence of Domestic Violence could be increasing. Social structures and expectations have greatly changed over the past few decades. Fewer families would be considered intact and gender roles are also less clearly, or rigidly, defined. This crisis in family life and in masculine identity has coincided with an increase in maladaptive coping such as drug use, mental health issues and violence. Previous work would suggest that these issues are linked. Men from families where violence has been used are more likely to abuse women, and men who experience early family breakdown and other problems within their family of are more likely to become offenders and suffer similar problems with alcohol, mental health issues and so on, in later life. Men who are unduly dependent within their adult relationships and who have unrealistic expectations are also more likely to offend against their partners. This paper uses data from 95 domestic violence offenders to explore these issues. The men did display some predictive characteristics, for example, employment and educational histories, but there was little evidence of exposure to family violence in family of origin and fewer mental health problems were identified. Implications of these preliminary findings are discussed. The implications for the various theoretical perspectives on Domestic Violence are discussed. Denial of responsibility among male batterers: Anecdotal evidence from a group facilitator Lee Ross University of Wisconsin-Parkside Batterers’ Anonymous, a program designed to address the issues of men who batter, has been in existence for nearly three decades. Evaluations of its success and failures are often mixed-whether the foci are recidivism, attitudinal assessments, or group dynamics. While reasons for mixed results vary, one reason deserving of further consideration is the unwillingness of batterers to take responsibility for their actions. As such, the purpose of this presentation is the explore issues relevant to a batterer’s denial of responsibility from a group facilitators perspective. In doing so, a critical overview of Batterers’ Anonymous programs is provided while exploring alternative treatment options. CONFIDENTIALITY AND SHARING HEALTH INFORMATION July 6 juillet 10:15 – 12:15 Room CMEL-102 Chair: Michael Bay, Ontario Consent and Capacity Board Confidentiality and the release of information to families of adults with mental illness: Overcoming communication barriers Tina Marshall American Psychiatric Association Sara-Ann Steber University of Pennsylvania Best practice guidelines for the treatment of mental illness recommend sharing information and involving families in the treatment process. However, research indicates that provider-consumer-family collaboration is not currently a part of routine clinical practice. One barrier that is frequently cited by providers and families is unclear confidentiality policies. 117 XXVIe Congrès international de droit et de santé mentale Many mental health systems do not have clear procedures and consent forms for releasing information to families. Without formalized procedures, mental health providers base their decisions regarding releasing confidential information on their own individual interpretation of their legal and ethical obligations to their client. These decisions may have serious implications for both the individual practitioner and the mental health agency. The proposed workshop presents a model, including policy guidelines and consent form, that mental health providers may use to clarify confidentiality regarding the release of information to families. The model places a high priority on the protection of client’s rights and clearly states that the release of information from the client’s clinical record to family members requires client consent. The release form includes categories for the types of information that may be released. Workshop participants will learn strategies to adapt and integrate these procedures into their agency. Participants will also acquire skills and techniques for discussing the release of information with persons with mental illness and their families. Presenters will draw from their experience in implementing the model in two county mental health systems in Pennsylvania. “Never say never again”–A troubled look at privacy protection in mental health services research Ted Schrecker McGill University Kathleen Hartford University of Western Ontario Lisa Heslop London Police Service, Ontario As part of a comprehensive research program on psychiatric deinstitutionalization in Southwestern Ontario, we sought to determine whether the frequency of contact between people with severe mental illness (SMI) and police in the city of London was increasing. The London police maintain a database of all contacts, in which individuals thought to have mental health problems are identified, based primarily on the reporting officer’s opinion. Having developed an algorithm to define those with “definite”, “probable” and “possible” SMI, we proposed to check the “probable” and “possible” against the first-hand knowledge of psychiatrists and other health professionals, and against hospital records in order to confirm or delete the SMI code from the database. However, legal opinions provided by counsel to the London police and a university law professor indicated that such verification was not permissible under the confidentiality provisions of the Mental Health Act without the consent of the individuals in question. It is hard to oppose prohibitions on the disclosure of mental health records, yet this case indicates potential ethical drawbacks to a policy of blanket non-disclosure. Among these drawbacks is the possible inhibition of research that could demonstrate a costly and unjust shift of responsibility for the ‘care’ of people with SMI from care providers and social service agencies to the police: the phenomenon known as trans-institutionalization, which has become a major concern in our overall research program. We outline the benefits of the proposed research–emphasizing the combination of minimal risk and potential benefit to a vulnerable population–and invite comments, critiques, and suggestions for an alternate methodology. Access to medical records Robin Henry Woellner University of Western Sydney There are numerous files, documents and other written material related to a patient’s medical health, social history, diagnosis, or treatment created or maintained by health care providers, hospitals, or other health facilities. These records may include doctors’ notes on the patient’s background, history, or condition, notes of medical observation obtained from examination of the patient, speculative diagnosis and the like. In various circumstances, a patient may wish to access these records, to check, for example, for inaccuracies, or even to seek support for an action against the health care provider. In these circumstances, important questions arise as to the circumstance in which a patient can insist upon obtaining access to their records. This paper examines Australian legislative case law, which has in some cases clarified and in others obscured the patient’s right to access. Privacy and confidentiality of health information: Issues for mental health stakeholders in Canada’s and Ontario’s new laws Gail Czukar Centre for Addiction and Mental Health, Toronto The federal Personal Information and Privacy of Electronic Documents Act (PIPEDA), and the proposed Ontario Personal Health Information and Privacy Act (PHIPA) have significant implications for several groups of stakeholders in the mental health system: consumers, professional groups, other service providers, researchers, institutional ethics review boards, and health records/information managers in health care facilities. This session will explore the policy dilemmas that are inherent in legislation that attempts to protect individual privacy at the same time as it facilitates communication among various actors in the health care system to ensure high quality patient care. Additional policy issues arise as governments and others responsible for the health system seek to make the best use of health 118 XXVIth International Congress on Law and Mental Health information that is becoming more available in electronic form to analyze, evaluate and plan the system. The particular sensitivities of stakeholders in the mental health and addictions fields about use and disclosure of personal health information will be highlighted in this presentation. Philosophical underpinnings of privacy in the protection of health information Mary Marshall Alberta Mental Health Board Privacy of personal information is protected through constitutional guarantees, international legal instruments and statutes addressing different aspects of personal information, such as health information. This paper will discuss the philosophical underpinnings of the right to privacy, and the reasons why privacy protection is important in democratic societies. Specifically, this paper will examine why privacy protection is essential to enhance autonomy and dignity for each individual. Effective oversight is an integral part of any legislative scheme, and this paper will review possible models for a privacy commissioner or ombudsman. 13:45 – 15:45 DU VIOL AU MEURTRE SEXUEL July 6 juillet 13:45–15:45 Salle MC Modérateur: Jean Proulx, Université de Montréal Du viol au meurtre sexuel: cadre théorique et empirique Éric Beauregard, Jean Proulx et Maurice Cusson Université de Montréal Firestone et coll. (1998) ont comparé des pédophiles meurtriers et des pédophiles non-meurtriers. Les deux groupes se révèlent très semblables sur l’âge, le Q.I., l’histoire familiale et la plupart des tests psychologiques. En revanche, les pédophiles qui ont tué ont commis plus de crimes violents dans le passé et ont des scores de psychopathie plus élevés que les pédophiles nonmeurtriers. De plus, leurs préférences sexuelles vont plus nettement dans le sens de la violence envers les enfants. Malheureusement, aucune étude de ce type ne fut réalisée avec des agresseurs sexuels de femmes. En conséquence, l’objectif principal de ce programme de recherche est de comparer des agresseurs sexuels de femmes à des meurtriers sexuels et ce, afin de tenter de comprendre la logique interne du délit qui favorise son aggravation. Les facteurs explicatifs privilégiés sont de trois ordres: (1) les facteurs développementaux; (2) les facteurs psychologiques et (3) les facteurs situationnels. Au cours de cette étude, 246 agresseurs sexuels de femmes et 43 meurtriers sexuels de femmes furent évalués. Les sujets furent évalués par les membres d’une équipe multidisciplinaire composée de criminologues, de sexologues, de psychologues, de conseillers en formation professionnelle et d’agents correctionnels. Chacun des sujets a été soumis à une batterie d’instruments psychométriques (ex. MCMI, MMPI). De plus, au cours d’entretiens semi-structurés, des données relatives au développement du sujet et au modus operandi de ces crimes furent aussi colligées. L’ensemble de ces données furent à la base des diverses études qui constituent notre programme de recherche sur les processus d’aggravation du viol au meurtre sexuel. Du viol au meurtre sexuel: appréhension du développement personnel et de la trajectoire criminelle Alexandre Nicole, Jean Proulx et Maurice Cusson. Université de Montréal Selon plusieurs auteurs (Ressler, 1986-1988, Marshall et Barbaree, 1990, Hall et Hirschman, 1991, Malamuth et coll. 1993, Le Blanc, 1986, Loeber et LeBlanc, 1990, Blumstein et al., 1986-1988, etc.), le développement personnel d’un individu est relié aux premiers balbutiements de la délinquance en bas âge et de la délinquance juvénile, celles-là mêmes qui mèneront plus tard à une délinquance adulte. Le modèle présenté dans le cadre de la présente étude stipule que le profil développemental est un élément prédicteur des caractéristiques de la trajectoire criminelle et que le meurtre sexuel représente une étape dans la chaîne de progression de l’agir criminel sexuel coercitif. L’analyse des résultats a permis de regrouper les sujets de l’échantillon selon trois profils développementaux distincts. De ces profils, on observe une gradation en ce qui a trait à la «perturbation» du développement personnel parmi l’échantillon d’agresseurs sexuels (de femmes adultes (n-178) et de meurtriers sexuels de femmes adultes (n-42)). Les résultats ont permis de démontrer que le profil développemental personnel est un indicateur d’une progression dans la gravité du passage à l’acte sexuel 119 XXVIe Congrès international de droit et de santé mentale coercitif et serait donc un élément séquence temporelle du premier au dernier délit. En effet, le profil de développement le plus affligeant est associé principalement aux meurtriers sexuels alors que le profil développemental le moins problématique est associé aux violeurs. Du viol au meurtre sexuel: intentions de l’agresseur et données situationnelles Sabine Chené Université de Montréal Le viol est un des crimes les plus réprouvés par l’opinion (Ouimet, Guay et Proulx, 2000), mais il suscite aussi une certaine curiosité si on en juge la nombreuse presse qui relate ce type de crime. Certains viols ont une issue fatale pour la victime car ils se terminent en homicides sexuels. Comment un agresseur arrive-t-il à cette extrémité? Quelle était son idée première ? Le meurtre était-il d’emblée envisagé? Un meurtre sexuel est-il le résultat d’un violeur qui tue ou d’un tueur qui viole? Voici plusieurs questions auxquelles nous allons essayer de répondre au cours de cette présentation. Notre objectif principal est donc de saisir ce qui amène un agresseur à tuer sa victime. Notre étude a la particularité de mettre l’accent sur la situation. Cette approche s’inspire des travaux de Felson et Steadman (1983) et de Cusson (1998a et 1998b). Afin de poursuivre une approche situationnelle, nous avons été amenés à contextualiser l’homicide sexuel et à le rendre intelligible. Car si l’homicide sexuel paraît absurde de par son extrême gravité, cette absurdité n’implique nullement que nous ne puissions le rendre intelligible. De quelle façon pouvons-nous le rendre intelligible? Est-ce qu’il y a quelque chose dans la situation même du crime qui a poussé l’agresseur à tuer sa victime? L’agresseur s’adapte-t-il aux différentes circonstances du crime et aux comportements de sa victime? Expliquer l’homicide sexuel, le rendre compréhensible, c’est aussi considérer le déroulement du crime comme le fruit d’une dynamique, d’un affrontement entre deux volontés opposées (celle de l’agresseur et celle de la victime). Un phénomène d’escalade est peut-être déclenché au cours du crime. L’agresseur est pris dans une situation, il ne voit plus comment s’en sortir, la seule issue peut être de tuer sa victime. Ainsi, nous nous sommes intéressés à des variables intentionnelles (liées à l’agresseur) et situationnelles (liées au contexte de l’agression) pour expliquer le processus d’aggravation du viol au meurtre sexuel. Des analyses bivariées, nous retenons qu’une agression sexuelle est plus favorable à une aggravation pouvant aller jusqu’au meurtre si elle comprend une des caractéristiques suivantes : un agresseur en colère (avant et pendant le crime), avec des sentiments de vengeance, non excité sexuellement (pendant le crime), qui a consommé de l’alcool ou de la drogue, qui humilie physiquement ou verbalement sa victime, un agresseur et une victime qui n’ont pas de lien familial ou intime, une victime qui résiste verbalement et physiquement, l’utilisation d’une arme blanche ou d’objet contondant, un crime d’une durée de plus d’une heure. Les analyses multivariées soulignent plus particulièrement que la consommation de l’alcool, l’absence de lien familial ou intime et l’utilisation d’objet contondant sont responsables du processus d’aggravation du viol au meurtre sexuel (issue et niveau de gravité de l’agression). Du viol au meurtre sexuel: le rôle des facteurs de personnalité Nadège Sauvêtre, Jean Proulx et Maurice Cusson Université de Montréal Les résultats de plusieurs études concernant la personnalité des agresseurs sexuels de femmes indiquent l’existence d’une hétérogénéité dans les profils qu’ils présentent (Proulx, St-Yves, Guay et Ouimet, 1999). De plus, ces agresseurs sexuels se distinguent les uns des autres en fonction du niveau de violence physique utilisé lors du délit (Kalichman, 1990, Panton, 1978). Ainsi, le but de la présente étude est de comparer des agresseurs sexuels de femmes et des meurtriers sexuels de femmes quant à leur profil de personnalité. Les meurtriers sexuels présentent un profil de personnalité caractérisé par des traits propres à l’état limite alors que les agresseurs sexuels présentent des traits de personnalité antisociale. Ces résultats concordent avec ceux obtenus par Proulx et al. (1999) et qui indiquent que les agresseurs sexuels présentant un trouble de la personnalité état-limite ont recours à une violence expressive. Le scénario délictuel propre à ce type d’agresseur est non planifié, découle d’une rage intense contre les femmes et est associé à un état de désinhibition découlant de la consommation de substances psychoactives. VIOLENCE ET FAMILLE July 6 juillet 13:45–15:45 Salle NCDH–102 Modérateur: Frédéric Millaud, Institut Philippe Pinel de Montréal Avitolicide Jacques D. Marleau, Frédéric Millaud et Nathalie Auclair Institut Philippe Pinel de Montréal L’avitolicide (meurtre des grands-parents) est très rare. Il est habituellement considéré comme un parricide. Objectifs: Isoler les caractéristiques des avitolicides et évaluer s’il s’agit d’une entité clinique distincte des parricides. Méthodologie: Revue de littérature et examen sur dossier de quatre cas cliniques de l’Institut Philippe Pinel de Montréal. Résultats: 36 cas d’avitolicides 120 XXVIth International Congress on Law and Mental Health et de tentatives d’avitolicides sont répertoriés dans les écrits scientifiques. Il s’agit d’un crime majoritairement commis par les hommes jeunes. Les caractéristiques sont très diverses, de même que les raisons du passage à l’acte. Les principales hypothèses explicatives seront discutées. Conclusion: La rareté des cas d’avitolicides rend leur étude difficile. Ils méritent cependant une attention particulière et ne semblent pas simplement assimilables aux parricides. De plus grands échantillons cliniques devront être recueillis en vue d’études plus systématiques. À l’aide…j’ai tué mon enfant… Bernard Poulin et Line Laporte Institut Philippe Pinel de Montréal Le filicide maternel est un passage à l’acte rare qui, lorsqu’il survient, nous interpelle chacun, tant sur le plan humain que professionnel. En tant que clinicien et chercheur nous souhaitons contribuer à une meilleure connaissance de ces gestes filicides. Existe-il un profil type de ces mères? Peut-on noter des distinctions entre les mères orientées vers le système carcéral ou thérapeutique? Comment le système de justice au Québec réagit-il à l’égard de ces mères? Ces questions, ainsi que celles qui en découlent, seront abordées de manière détaillée à partir d’un échantillon québécois recensant onze années de situations filicides. Lien entre les caractéristiques de l’homicide d’enfants par leur-s parent-s (filicide) et les caractéristiques de la violence conjugale Myriam Dubé Université de Montréal Suzanne Léveillée Université du Québec à Trois-Rivières Plusieurs auteurs qui ont étudié le filicide constatent une relation entre cette problématique et la violence conjugale (Korbin, 1986, 1987, 1989; Marleau, 1995; Wilczynski, 1997), incluant l’homicide conjugal (D’Orban, 1979; Somander and Rammer, 1991; Wilson, Daly et Danièle, 1995). Le meurtre du ou de la conjoint-e et des enfants par un parent se nomme familicide et est presque toujours perpétré par un homme. Cette présentation traite du lien entre le filicide et la violence conjugale et est tirée d’une récente étude qui concerne les caractéristiques de tous les parents qui ont tué leur-s enfant-s entre janvier 1986 et mars 1994 dans la province de Québec. Cette étude a été réalisée en recueillant les informations aux dossiers du Coroner, dans les enquêtes préliminaires du système pénal de justice et dans les journaux rapportant les événements entourant les filicides. Subséquemment, les informations ont été classifiées à l’aide d’une grille d’analyse multifactorielle du filicide (Dubé et Hodgins, 1998). Parmi les 75 agresseur-es (39 mères et 36 pères) qui ont tué leur-s 105 enfant-s (45 filles et 60 garçons), 20 hommes ont été violents envers leur conjointe avant le filicide et neuf femmes ont été abusées par leur conjoint avant le filicide. Les résultats présentent certaines caractéristiques de ces parents et seront discutés, dans un premier temps, à la lumière de la théorie de Dutton (1996) sur les profils de conjoints violents et dans un second temps, en regard d’un questionnement sur l’existence d’un lien entre la violence conjugale et l’homicide conjugal, voire la familicide. PSYCHOLOGICAL JURISPRUDENCE: MAPPING SOCIAL BOUNDARIES July 6 juillet 13:45 – 15:45 Room CMEL-102 Chair: Leonard V. Kaplan, University of Wisconsin-Madison Evaluating the mental health hazards of jury duty in death penalty cases Regina M. Cusack Our Lady of the Lake University Capital punishment and the responsibility placed upon jurors selected to serve in capital murder trials may be creating mental health risks for some citizens serving the criminal justice system. Therapeutic jurisprudence research has suggested that jury duty may be hazardous duty for some individuals serving the American judicial system. A number of studies have reported observing symptoms in jurors after their jury service consistent with posttraumatic stress disorder (PTSD) and depression. Previous research has identified several contributing factors to stress reactions including gruesome and graphic evidence, media attention, fear of retribution by the defendant, sequestration, the length of the trial, the personalities and relationship of jurors to each other, community responsibility, courtroom rules and procedures and whether jurors must consider the death penalty. This researcher, based on 15 capital murder trials in Texas, compared the stress levels of capital murder jurors tasked to make a sentencing determination with those jurors who had no sentencing authority, and between groups based on sentence outcomes. Results indicate that some jurors experienced PTSD symptoms and may have been exposed to a significant mental health stressor. Debriefing and post-trial counseling may be an appropriate psychological recompense to jurors for performance of their civic duty in capital cases. 121 XXVIe Congrès international de droit et de santé mentale The effects of private discrimination: Boy Scouts of America v. Dale David Friedman University of Wisconsin-Whitewater The “Boy Scout case” is an excellent example of the clash between two basic values–The right to associate with whom you please and the right of society to prohibit discrimination. The Boy Scouts of America prohibit homosexuals from serving as adult leaders. An Assistant Scoutmaster’s membership was revoked because he was an acknowledged homosexual. He then sued claiming discrimination. The Boy Scouts claimed the right as a private not- for- profit organization to determine their own membership. The US Supreme Court ruled in favor of the Boy Scouts. The United States Constitution has been interpreted to recognize the right of groups of people to engage in “expressive association.” At the same time, both state and federal laws protect people against discrimination, on various grounds including sexual orientation, and also protect the opportunity for all persons to obtain the advantages and privileges of any place of “public accommodation.” The Boy Scout case attempts to define the boundaries where these two concepts collide. Having won its case, the Boy Scouts are now facing a severe reaction. Institutions, such as schools, that sponsored troops and agencies, such as United Way chapter and other funding sources, have threatened to, or have withdrawn their support for the Boy Scouts. In reaction, the Boy Scouts are suing claiming, among other things, their right to free speech is now impinged. Internet dating, social isolation and self-esteem Robert J. Brym University of Toronto Rhonda L. Lenton McMaster University One of the enduring myths about avid computer users is that they are social isolates, locked in their basements alone for hours on end, windows tightly sealed and shuttered. Similarly, people who use online dating services are often characterized as “losers” or “lonely hearts,” people who are unable to form normal social ties and enjoy normal social interaction. In this view, they suffer from low self-esteem and pursue online dating out of desperation. This paper challenges the conventional wisdom. Based on a telephone survey of a representative sample of Canadians (n=1200) and an online survey of people who use online dating services (n=5681), both conducted at the end of 2000, we show that online daters are not social isolates and do not suffer low self-esteem. Instead, they are ordinary people who use online dating as a means of overcoming constraints on their ability to establish intimate relations with others. Online dating is not a symptom of poor mental health. Instead, it has emerged as an adaptation to postindustrial society–a society in which the popularity of marriage is declining, work schedules are becoming more demanding, geographical mobility is increasing, and work settings are becoming less acceptable as dating markets. The reintegration difficulties of long-term offenders in relation to their experience of prison culture Tom Gorman Alberta Hospital, Edmonton Not surprisingly those offenders who are most in need of treatment while incarcerated are frequently the most resistant to genuinely participating in treatment. Upon their return to the community they respond poorly to the multiple issues, problems and situations that they face and are at risk of re-offending. The author will examine how these reintegration difficulties relate to the offender’s experience of prison culture. He will describe working with and forming a therapeutic alliance with men who have entrenched criminal values. He will identify interventions that can be useful in addressing their maladaptive and sometimes destructive responses to the stress of returning to “the street.” He will address such issues as the “con code”, anger, trust, victim to victimizer, dependency, manipulation, blaming “the system” and machismo. Who are the victims of death sentences? Alan D. Eisenberg Attorney-at-Law, Milwaukee The death penalty is a hotly debated topic in America and around the globe. While countless scholarly debates involve questions of whether capital punishment is ethical, constitutional, moral, racially biased, adequate, accurate, or simply wrong, it is a rare discussion which examines a more closely-held tragedy of the death penalty: the living survivors of the condemned. Every individual on death row has a story: a mother, a father, grandparents, perhaps a wife or a husband, or children. The family, often already impoverished, bankrupts itself trying to save their loved one. Like the condemned, they too are imprisoned by the impending date of execution. Occasionally, a false ray of hope stalls the process and the family is forced to wait again, sometimes for decades, for the execution. When an individual is executed at the hands of the state, in the name of “justice,” the family suffers; the innocent are imprisoned by the process. Their anguish escalates until the execution, and the aftereffects endure long after that. Parents lose a child, children lose a parent. A family forever loses a provider, a pillar of emotional, if not always financial, support. Society may forget the executed, but the family is forever changed. The death penalty leaves its mark on the 122 XXVIth International Congress on Law and Mental Health innocent in a way that imprisonment never could. Capital punishment brands a stigma onto the survivors which endures for generations. With more and more innocent death row inmates narrowly escaping their fate by advances in DNA testing and other forensic sciences, the time to rethink the death penalty is nigh. Indeed, most death penalty cases that are appealed are reversed or modified on appeal. In a society obsessed with what is “just,” how can we let the innocent continue to be punished? Mental health intervention after terrorist events Jonathan Call Forensic Psychologist, Oklahoma City A recent United States government report warns of an increase in terrorist events in America and elsewhere. If this prediction proves accurate, a knowledgeable community mental health response following terrorist events will be crucial. On April 19, 1995, a terrorist bombing in Oklahoma City killed 168 people and injured 853 others. The Oklahoma City bombing was a human-made, centripetal disaster in which the victims lived and worked in the affected areas and the entire community shared in the assault. Such disasters tax local resources, but can also unite residents in the recovery process. The Oklahoma Department of Mental Health and Substance Abuse Services was the lead agency in crafting a community mental health response to reduce impairment of those affected. The Project Heartland program, which opened on May 15, 1995 and closed in the fall of 2000, was the first community mental health program in the US designed to intervene in the short to medium term with survivors of a major terrorist event. The goal of Project Heartland was to provide crisis counseling, support groups, outreach, and education. In 1998, Project Heartland was given a Special Award by US Attorney General Janet Reno at the annual Crime Victim Service Award ceremony held at the US Department of Justice in Washington, D.C. Dr. Call represented the Board of Directors of the ODMHSAS at this presentation. The present program is designed to describe the lessons learned in the areas of planning and service delivery as well as the types and extent of services provided in the project’s existence. The program will also describe the disaster model used. THE RIGHT TO REFUSE MEDICATIONS July 6 juillet 13:45 – 17:45 (extended session) Room NCDH–201 Chair: Jagannathan Srinivasaraghavan, Southern Illinois University Social activist or double agent? The perils of Prozac and Ritalin Jeffrey Spike University of Rochester There has been much discussion of the many ways doctors are asked to be agents for social causes, such as testing pregnant women for drug abuse to protect the fetus, or drivers in accidents to help those injured in the crash (or their insurance companies). These are sometimes called being a dual or double agent. This is often criticized, saying the traditional role of the physician as an advocate for the patient is compromised. Social activists, in contrast, are usually seen as working to correct the inequities in society, and carry a positive connotation. But there is also a political agenda to which each group is considered in a positive light. For people concerned about law and order, or the rights of innocent victims, the first group, double agents, are refusing to let their patients harm others, and so it is akin to the second group. In psychiatry, there are controversies about two drugs, Prozac and Ritalin, which might be beneficially analyzed in these categories. The controversies around Prozac are well known. I will review them briefly, focusing especially on the role of social change. Over the past century, the expectations of work have increased dramatically, with productivity measures becoming almost an obsession in business and management circles. School teachers commonly work a 50-hour week, and doctors 60-90 hours, depending upon their specialty. Could it be these external pressures are making otherwise normal people feel inadequate? Further, the pressure to be productive may mean less tolerance for people with an existential or poetic nature. Aptly named, many have decided that it is better to be prosaic. Similarly, the rise of ADHD has occurred over the century of urbanization. One hundred years ago most ADHD children would have had a future working on the family farm, while only the most academically talented child from a family of five or ten children would go to college. In contrast, now 1 or 2% of the population in economically developed nations work on farms, over 50% go to college, and are considered a failure if you don’t at least graduate from high school. The ability to sit in class and memorize (whether in a textbook or on the board) are essential, rather than optional skills. Indeed, it is often the school’s that ask for the child to be evaluated (and medicated), not the parents. Whether these psychopharmacological interventions are seen as helpful and patient friendly, or overused and done primarily for the good of others, will be the topic of my presentation, and of the discussion afterwards. Together we can decide whether psychiatrists are being used as double agents, and whether it is a justifiable role for them to assume. 123 XXVIe Congrès international de droit et de santé mentale Right to refuse medications: Evolution and models Jagannathan Srinivasaraghavan Southern Illinois University Paul Appelbaum University of Massachusetts In the 1960’s, the criteria for civil commitment shifted from need for treatment to need for confinement based on dangerousness. With increasing acceptance of the doctrine of informed consent, the decision making power shifted from physicians to patients. Along with these changes, a civilly committed person’s right to decision making, including the right to refuse medications, came to be recognized. The right of refusal is adjudicated either judicially or administratively. Giving patients’ autonomy and rights greater significance than treatment considerations are models fashioned like Rogers v. Commissioner of Mental Health (Mass 1983), using judicial review mechanisms. Models that emphasize treatment, not just confinement, and that rely on the principles of Rennie v. Klein (Third Circuit Court 1983), are models that utilize administrative review panels. This lecture will highlight these two models and variants of these models currently in operation in the United States. Non-judicial “forced medication panel” in the State of Maryland Geetha Jayaram Johns Hopkins University Psychiatric care in Maryland is provided both voluntarily and involuntarily in general medical and psychiatric hospitals. Severely mentally ill patients often refuse treatment. Such patients may present a danger to themselves or others if released without appropriate care. The law in the State of Maryland–HG 10-708–provides for a “forced medication panel” to prescribe treatment under these circumstances. This lecture will outline the procedures involved in administration of medication over patients’ objection by a clinical review panel. There will be case examples to demonstrate the working of this panel emphasizing how it is possible to safely and successfully treat involuntary patients with forced medications in a responsible and humane manner. A performance improvement project to improve utilization of court-ordered treatment in a state hospital Malini Patel Finch University of Health Sciences Daniel Hardy Loyola University of Chicago The overturning of Right to Refuse Psychotropic Medications is a function of the judicial system in the State of Illinois. There is wide discrepancy among hospitals and psychiatrists how this statute is utilized for the benefit of the patients. This presentation focuses on methods that encourage the use of court-ordered treatment in a 500-bed State hospital. Literature and clinical practice confirm that denial or delay in treatment can result in an increase in morbidity and adverse events for patients. A performance improvement project aimed at encouraging staff psychiatrists to actively pursue the option of court-ordered treatment for appropriate patients was designed. The major theme of the project was education and feedback to address the court avoidance attitude of psychiatrists. Results: In four years the number of petitions seeking court-ordered medications doubled. This project also led to a hospital wide effort to foster the theme of assertive treatment extending to other disciplines. The heightened awareness of the benefits of assertive treatment contributed to a decrease in average length of stay as well as reduced restraint usage and patient-to-patient injuries during the same period. Conclusion: Severely mentally ill patients derive benefit by early medication intervention, even if it is court-ordered. Education, support, and feedback can positively influence clinician attitudes and behaviors. Correlation between peer review of professional performance and outcome in judicially enforced medication trials Jagannathan Srinivasaraghavan, Alan Felthous, Wenona Whitfield Southern Illinois University Sarah Andrew, Nancy Watkins Choate Mental Health Center, Anna, Illinois Objective: To test whether the combined ratings of the quality of testimony of the psychiatrist, the performance of the State Attorney and Public Defender can differentiate between two groups of cases where the petition for medication of psychotropic medications was granted or denied. Subjects: From 1991 to 1999, in Southern Illinois, there were 17 denials and 109 grants of petition for administration of psychotropic medications in Union County Court. Preliminary study involves transcripts of randomly selected six denials and eight granted petitions. Method: From the court transcripts, any reference to the court decisions is deleted. An academic forensic psychiatrist and an academic lawyer rate the content and process of psychiatric 124 XXVIth International Congress on Law and Mental Health testimony, and the performance of legal professionals on a scale of one to four (poor, fair, good, and excellent). Results: Mean rating of the performance of the Psychiatrist, State’s Attorney and Defense Attorney for granted and denied petitions are noted. There were six psychiatrists, four State Attorneys, two Defense Attorneys, and one judge involved. Conclusion: Co-efficient of the Linear Discriminant Function suggests that the most important variable for discrimination between the two groups is the rating of overall performance of the psychiatrist. The study provides opportunity to improve psychiatric testimony by education and regular feedback. Administrative review model in a maximum security hospital in Louisiana Alan W. Newman Tulane University The East Louisiana Mental Health System, Forensic Division, is the maximum security inpatient forensic hospital for Louisiana. The population comprises of patients who are unfit to stand trial, not guilty by reason of insanity, permanently incompetent defendants and patients too dangerous to be in state civil hospitals. Although judicial review is not required to force medications, the facility has adopted procedures to ensure that the patient receives appropriate due process when refusing medications. When a patient refuses medications, the treating physician requests an Administrative Review to assess the appropriateness of enforced medications. The Medical Director reviews the patient’s hospital record, including staff reports of the patient’s behavior and the treating physician’s recommendations. The Director interviews the patient with a patient advocate to determine if the patient is competent to make an informed decision regarding medications. In order to force medication, the Director must determine that the patient is mentally ill or suffering from substance abuse and is dangerous to self or others, or gravely disabled without the medication, and that the recommended medication is the most appropriate treatment. The presenter will discuss the data collected over the past three years concerning outcomes of this process and factors which contribute to the decision whether to force medications involuntarily. Implications of the right to refuse treatment in defendants found unfit to stand trial Angeline Stanislaus Southern Illinois University In the criminal setting, psychiatrists are frequently confronted with the issue of the right to refuse treatment. In Illinois, after a defendant is found Unfit to Stand Trial, he is committed to a Department of Human Services forensic inpatient facility for treatment and restoration to Fitness. But the defendant has the right to refuse treatment. The statutes outlining the criteria for court-ordered enforced medication also apply to the mentally ill criminal defendants. But the issues arising from treatment refusal by these inpatients are different to those committed for civil reasons. In Riggins v. Nevada, the issue of enforcing treatment with psychotropic medications in order to restore Fitness to Stand Trial was raised. Even if the defendant is medicated for restoration of Fitness to Stand Trial, whether the medications would affect the ability of the individual to effectively take part in the trial has been questioned. There is a tug-of-war between the liberty interest of the defendant and the State’s interest to expedite the trial. The case laws addressing these issues will be reviewed. The clinical, legal and ethical dilemmas faced by psychiatrists who work in the forensic inpatient facilities will also be addressed. Legal v. ethical issues related to enforcing medications for restoration of competency to be executed Stephen Robinson Southern Illinois University The Supreme Court determined in the case of Ford v. Wainwright that an incompetent defendant cannot be executed. This led to competency-to-be-executed evaluations on death row inmates. One of the most controversial issues in psychiatry is the participation of psychiatrist in capital punishment. Once found incompetent to be executed, the question of the prisoner’s right to refuse treatment comes into play. In Perry v. Louisiana, the Supreme Court was faced with the issue of determining whether forcibly medicating a death row inmate in order to restore competency-to-be-executed is unconstitutional. Often the prison psychiatrist is called upon to treat the death row inmate for restoration of competency. Our ethical values are greatly questioned under these circumstances, when our goals depart from treatment to relieve suffering to treatment to allow execution. What are the clinical and ethical problems, when the prisoner refuses treatment? The case laws addressing this issue will be reviewed, along with a discussion of the ethical dilemmas. Discussant: Maggie Tweddle, University of Alberta 125 XXVIe Congrès international de droit et de santé mentale TRANS-NATIONAL CHANGES IN MENTAL HEALTH SYSTEMS July 6 juillet 13:45 – 17:45 (extended session) Room NCDH–101 Chair: Allan Young, McGill University Aftermath of the Caracas Declaration: The development of mental health policies and legislation in Latin America and the English-speaking Caribbean during the last ten years Monica Bolis Pan American Health Organization/World Health Organization In November 1990, the Latin American countries signed the Caracas Declaration, aimed–among other objectives–at promoting the respect for the human and civil rights of the mentally ill and the organization of community mental health services that guarantee the fulfillment of those rights. Since then, many developments have taken place in the countries of the region from the economic and political to the social standpoints (health sector reform, stabilization of democratic forms of government, political and social participation, and economic downfalls) with impact on the formulation of health policies and legislation, in general, and mental health, in particular. The objective of this presentation is to review the status of mental health policies and legislation in Latin America and the English-speaking Caribbean, in order to determine the degree of accomplishment of health legislation reform on the terms of the Caracas Declaration. Considerations will be made to the special circumstances characterizing the last decade. The reform of the protection of incompetent persons in Japan Yoji Nakatani University of Tsukuba The author will give an outline of the legal provisions regarding mental incompetence and describe the reform that is now in progress. Japanese Civil Law provided legal protection for individuals who have a diminished mental capacity, including financial matters, such as managing properties or making will. The family court declares a person incompetent, if he or she was constantly incapable of decision-making. However, the problem of incompetence was rarely discussed, probably due to a scarcity of cases. The circumstances have drastically changed since around 1985. The number of persons declared incompetent by the family courts has tripled over the past 15 years. The main reason for this change is the aging of Japanese population, which resulted in an increase in the number of elderly people suffering from dementia. In addition, during the period of the ‘bubble economy’ in the mid-1980’s, it became a priority to protect the elderly with dementia from losing their properties through careless transactions. Under these circumstances, various flaws in the old system became evident. After discussion by jurists and others concerned with the legal rights of the elderly, the new Guardianship Law for Adults came into effect in April 2000. The principle of the Law is to protect a person with impaired capacity while respecting his or her autonomy, aiming at the ‘normalization’ of mentally disabled people, and helping them to maximize intact abilities. The provisions of the Law will be presented. Mental health law in the UK: The question of treatment provision Nicola Glover-Thomas University of Liverpool At the current time, mental health law in the UK is undergoing a process of reform. The government’s legislative program is expected to include three policy initiatives regarding the Mental Health Act 1983, a new Incapacity Act for the mentally impaired and vulnerable and reform to the law relating to dangerous severely personality disordered individuals. The question of treatment inevitably arises in relation to each of these reform issues and provides an interface between the above initiatives. This paper will focus on treatment and will consider the scope of the concept and how it is perceived in medical, legal and social terms. Should treatment be viewed as a means to cure and/or prevent deterioration of the mental condition or can treatment be a justifiable method of control? The mentally ill, mentally impaired and severely personality disordered all have different treatment needs. These needs will be examined and the current methods of satisfying them will be evaluated. The mentally ill have, in recent years, had to face a gradually changing approach to mental health care provision. The days of protracted periods of institutional care are long gone and have been replaced by short inpatient hospital stays and community care. Difficulties, which have hampered community, care in England and Wales have highlighted the question of how treatment in this care environment should be regarded. Suggestions of Community Treatment Orders and the use of drug depots have further led to the emergence of a conflict between the provision of care and coercion in a less restrictive environment. Likewise, incapacity whether through mental impairment or some other form of vulnerability raise a number of legal and ethical dilemmas associated with treatment provision. As the population ages, the vulnerable, as a group, are growing and the question of how the provision of treatment for those who are incapable of consenting to treatment becomes increasingly important. Furthermore, consideration must be given to 126 XXVIth International Congress on Law and Mental Health some forms of treatment that, in the past, have been considered necessary and desirable especially to those who are not considered capable. The most notable example of which is the use of sterilization as a therapeutic technique. Treatment associated with those who are personality disordered raises further dilemmas. The most obvious being whether personality disorders can actually be treated. If such treatment methods are available what role does the patient play–is it necessary for him to co-operate in the treatment process, and if he will not, what impact does this have on the operation and applicability of the legislation? Finally, consideration will be given to the impact of the Human Rights Act 1998. Under the European Convention of Human Rights and Fundamental Freedoms, Article 3 provides that no one shall be subjected to torture or to inhuman or degrading treatment or punishment. Now that the Human Rights Act is in force in England and Wales it seems inevitable that the question of treatment for mental disorder; treatment for those who are not capable of consenting; and, treatment for personality disorders will provide plenty of scope for possible litigation in the future. Improvement of Ireland’s Criminal Insanity Law: A consideration of overdue judicial and legislative reform Darius Whelan Institute of Technology, Tallaght, Dublin, Ireland While Ireland’s Parliament is currently in the final stages of debating a Bill which will reform civil mental health law, its law on criminal insanity is still based on the Trial of Lunatics Act 1883. A general consensus, confirmed by Government statements, that there is a need for reform of the insanity defence, has not yet led to the production of a Bill. This paper will examine the deficiencies in Ireland’s criminal insanity law, particularly in the light of the Irish constitution and the European Convention on Human Rights. Consideration of court decisions will show that the judiciary have dealt with this area in an incoherent and unconvincing manner, and have failed to develop the rights of mental patients detained under criminal statutes, in spite of numerous opportunities which have been presented to them. Possible reasons for the lack of legislative response will also be examined. The paper will finally consider whether the imminent enactment of new legislation on civil mental health law will serve to further highlight the shortcomings of the Irish criminal mental health system. Protecting the handicapped in Austria Gerda Ressl Organisation for the Protection of the Rights of Handicapped Persons, Vienna Handicapped people are in Austria protected by laws that are effective on paper, but neglect to provide adequate access to the legal institutions for these people to sue for and realize this necessary form of support. An organisation has been set up to integrate lawyers, physicians and social workers in an active team to run law suits and further legal action to realize and protect the basic laws and needs of the handicapped. The structure of legal institutions and laws is contrasted with the specific need so different handicapped, especially those with mental handicap. Guardianship in the new millennium Sabry Attia Professional Counsellor, Grosse Point Farms, Michigan The elderly population is growing rapidly. The session will present demographics of the elderly from 1800 to 2050, their familial attitudes and their.mental and physical status. Sometimes the elderly’s needs necessitate the appointment of a guardian and/or conservator. The presentation will explain how the guardian is appointed, the guardian’s role as required by Law and how the guardian can act as an innovative explorer and utilize the available community resources to enhance the elderly individual’s quality of life. VIOLENCE IN CORRECTIONAL SETTINGS July 6 juillet 13:45 – 15:45 Room NCDH–200 Chair: José G.V. Taborda, Federal Faculty of Medical Sciences of Porto Alegre Three different ways criminal law deals with mental patients in Portugal Fernando Vieira, S. Brissos Miguel Bombarda Hospital, Queluz-Barcarena, Portugal After a brief introduction, the authors approach the three different methods of psychiatric admission in accordance with the law in the Portuguese Penal Legislation, namely, (1) the Admission of Inimputable (N.G.R.I./N.C.R.) patients by reason of “Psychic Anomaly” (Penal Code’s article 20), judged with dangerousness (Penal Code’s Article 91) and convicted with Security Measures by penal sanction decreed by a competent Court; (2) compulsive admission of patients with “Psychic Anomaly”, due to the law 127 XXVIe Congrès international de droit et de santé mentale 36/98 (Mental Health Law); and (3) preventive admission to a psychiatric hospital of the criminal is subject to constraint measures (preventive emprisonment) with presumed mental disorder, which is determined by the magistratein accordance with Article 202 of the Penal Process Code. The authors comment on these three ways of admission, on a critical point of view, with respect to the rehabilitation process of Inimputable Patients, and the flaws in the legislation leading to some confusion between Penalties and Security Measures. The Mental Health Law’s evolution is discussed, and some problems which may occur in the future concerning the admission of drug abusers and those with personality disorders, which are difficult to strictly consider as “Psychic Anomaly”. Anatomy of violent incidents in Canadian corrections W. Loza Correctional Service of Canada This presentation will focus on violent incidents against others (assaults) and against self (suicide) in Canadian federal penitentiaries. Some statistics demonstrating the incidents of violence at the national, regional (Ontario) and a Maximum-security penitentiary will be reviewed along with the characteristics of offenders who commit violence against others and self. Explanations for the causes for these incidents, preventive measures and treatments available for these offenders will also be discussed. Rebellions among penitentiary prisoners in Brazil Kátia Mecler, Sander Fridman, Mauro V. Mendlowicz, Pedro Coscarelli, Talvane Marins de Moraes Federal Univesrity of Rio de Janeiro The author describes the common elements of a series of rebellions which occured in the Brazilian Pententiary System in the period of 1996 to 2000, as recorded in the Brazilian press. Most rebellions involved male inmates and were frequently very violent, with the kidnapping of guards, interns, volunteer workers or other prisoners, and often resulted in the killing of some of the hostages. The author analyzes data on the prisoner population, vacancies and alleged reasons for the rebellions, in an attempt to establish directives for understanding and preventing these social tragedies. The growth of the Brazilian incarcerated population is far greater than the general population growth. According to the government’s National Penitentiary Department, in July 2000 there were 216,780 prisoners under the System’s care, which represents a 45.7% increase on 1995 figures. As a result, current facilities show a deficit of 66,400 vacancies to meet the demand, and forcing a large number of convicts to serve their sentences in precinct jails. In this situation, prisoners who have committed crimes of very different natures are placed together, causing the violation of the weaker prisoners’ rights by the more dangerous inmates. Security breaches are common, and prisoners have easy access to firearms and illegal dugs. The combination of the above with the similarity observed in the sadistic code of values of prisoners and guards alike, and the delays in the legal system–resulting in prisoners not being released after serving their sentences or not having their applications for parole analyzed–are a social timebomb. Violence in a Brazilian forensic psychiatric facility Lorena Caleffi, Luiz C.I. Coronel, Rogério Göttert Cardoso, Vivian Day, Ruben de Souza Menezes, Pedro Zoratto, L.E. Telles, Paolo Blank. Forensic Psychiatric Institute, Porto Alegre The authors describe the various aspects of violence inside and outside the Forensic Psychiatric Insitute and discuss the solution that is being used. Violence is defined as: (1) Violence against patients: social, governmental and family abandonment are crucial sources of violence, leading to a worse prognosis; (2) suicide as the innermost form of violence; (3) the social exclusion itself as a form of violence; (4) a judicially indefinite period for inpatient treatment is viewed as a potential source of violence; (5) staff’s violent behavior, denial, and silence, which makes the pyschiatrists’ work more difficult; (6). patients’ violent behavior within the institution: sexual and psychological abuse, burglary and homicides; (7) violence against the psychiatrist’s work: the psychiatrist evaluates his or her own patient for legal purposes (dangerouness evaluation, as an annual report for the judiciary). In conclusion, the authors discuss what is being done to minimize the problem of violence inside the insitution. Psychiatrists, with a broad vision of the patient’s treatment from the begining through the time of discharge, with access to the various legal reports that are required during treatment, may diminish social violence against patients. This can be attained through a legal authorization to continue patient’s treatment in an outpatient basis as soon as possible, called progressive discharge. The progressive discharge is a judicial and a psychiatric authorization for the patient to be outside the institution. Psychopathy and major mental disorders in two Belgian criminal populations Thierry Pham Université Catholique de Louvain C. Delecluse, Adèle Claix, S. Remy Hôpital Sécuritaire “Les Marronniers”, Tournai, Belgique 128 XXVIth International Congress on Law and Mental Health The study examines the relationship between psychopathy and mental major disorders in two criminal populations. Subjects were assessed on the basis of the Psychopathy Checklist (CPCL-R; Hare, 1991) and the screening version of the Diagnostic Interview Schedule (DISSI, Robins & Marcus, 1987). The subjects (N=120) were french-speaking male adult offenders confined to either (a) high security prison (N=60), or (b) security hospital (N=60). Comorbidity of psychopathy will be assessed by factor analysis procedures. The hypothesis of a distinct entity of psychopathy will be discussed with reference of the classical trait-state debate. Managing the violent patient in a forensic setting Aubrey Levin University of Calgary Violent behavior represents one of the greatest potential challenges in a forensic and correctional setting. It is far more frequently encountered than in general psychiatry. The greater propensity for violence in this population is briefly addressed, noting the more frequently encountered causes and environmental factors. The need for history, assessment and diagnosis should, ideally, be undertaken prior to management. The risk for violence in the short term, should be assessed as part of the initial assessment of any person in this setting. The medical and legal implications of failure to anticipate and treat potentially violent patients are in particular, of great importance. Attention will be given to the basic techniques, which should be used in order to prevent the use of involuntary methods of treatment. The first need will be to “talk down” a potentially violent patient, depending on the etiology. This will include attention to the setting and the need to establish rapport. Violence can often be prevented by appropriate action at critical times when violent incidents are more likely to occur. Where ever possible, involuntary treatment should be avoided. In order to fully comply with the Charter for Human Rights and Mental Health Legislation, a medical certificate should be completed whenever involuntary detention and/or treatment is required, dependent on the Province concerned. Minimal force should be used but adequate show of force may be required in some instances. Psychotropics are not always appropriate in all conditions, however, where required, the indications are specific. Advantages and disadvantages of currently available compounds and delivery forms and new delivery forms will be discussed. There is a preference for rapidly dissolving Olanzapine (Zydis) and for Zuclopenthixol (Clopixol) Acuphase by intra-muscular injection. A benzodiazepine may be utilized to facilitate the onset of action. Overall, however, second generation neuroleptics are preferred. The indications for seclusion and, even in extreme instances, restraint, will be reviewed. Violent behavior should be carefully monitored and reviewed subsequently, to prevent or reduce future incidents. ATELIER III UN PHÉNOMÈNE QUI SEMBLE PRENDRE UN NOUVEAU TOURNANT DEPUIS LES DEUX DERNIÈRES DÉCENNIES LES GANGS À MONTRÉAL: July 6 juillet 13:45–16:45 Atelier – avec inscription seulement Salle IASL–106 Formateurs: Sylvie Hamel, Institut de recherche pour développement social des jeunes Chantal Fredette, Centre Jeunesse de Montréal Marie-Marthe Cousineau, Université de Montréal Le phénomène des gangs n’est pas nouveau mais l’intérêt qui lui est porté paraît avoir gagné en popularité au cours des deux dernières décennies. En grande partie, cette recrudescence dépend de l’inquiétude que cause le phénomène des gangs par son intensification qui se manifeste de deux façons: (1) il se propage désormais dans les villes, les banlieues et les écoles et (2) les gestes de violence auxquels s’adonnent les jeunes appartenant à ces groupes paraissent de plus en plus sévères. En d’autres termes, il semble que le phénomène des gangs ait pris un nouveau tournant, en élargissant son territoire et en touchant plus durement des villes comme Montréal. Toutefois, cette attention tournée vers l’intensification du phénomène des gangs ne sert pas nécessairement les jeunes qui en font partie. Elle contribue plutôt à éveiller un sentiment d’urgence, accompagné du désir d’éliminer rapidement le phénomène. Cette option visant essentiellement à nous protéger des gangs, sans égard aux individus qui en font partie, n’aurait pas donné lieu jusqu’à maintenant à des résultats probants. Dans le courant des dernières années, l’étude du phénomène des gangs aurait elle aussi connu des transformations. En adoptant une approche qualitative et phénoménologique, différente de celle habituellement utilisée pour analyser le phénomène, certaines recherches éclairent brillamment les processus de l’entrée et de la sortie des gangs, de même que les motivations et les besoins des jeunes justifiant leur participation à ces groupes. Elles ouvrent sur de nouvelles stratégies d’intervention, prometteuses et novatrices, pour faire face au phénomène des gangs. 129 XXVIe Congrès international de droit et de santé mentale 16:00 – 17:45 FEMMES ET ADOLESCENTES AGRESSEURES OU VICTIMES? July 6 juillet 16:00–17:45 Salle MC Modérateur: Martine Côté, Centre de Psychiatrie Légale de Montréal Des femmes agresseures sexuelles; l’ultime tabou de la perversion du rôle maternel Monique Tardif Université du Québec à Montréal La question des abus sexuels perpétrés par des femmes comporte des difficultés à différents niveaux. Notre propos vise à les aborder au cours de cet exposé. En premier lieu, il convient de saisir les difficultés associées à l’établissement des taux d’incidence et de prévalence. Par la suite, nous discutons de la reconnaissance même de l’existence du phénomène en raison des mythes et des distorsions cognitives qui entourent cette question. Quelques classifications qui permettent de structurer et de catégoriser les caractéristiques de ces femmes sont présentées et font ressortir en quoi ces typologies diffèrent de celles de leurs congénères masculins. Les données cliniques et évaluatives recueillies auprès d’un échantillon de 9 femmes qui ont abusé sexuellement d’un enfant ou d’un adolescent sont rapportées. Finalement, nous élaborons une proposition théorique à l’effet que le clivage de l’identité sexuelle chez la femme serait un élément déterminant à l’abus sexuel d’un enfant ou d’un adolescent. Une étude descriptive d’une cohorte d’adolescentes responsables d’abus sexuels Martine Jacob Institut Philippe Pinel de Montréal La problématique de l’agression sexuelle commise par les adolescentes est un sujet méconnu et encore peu exploré dans les écrits scientifiques. Pourtant, les statistiques canadiennes et américaines suggèrent que 3 à 10% des adolescents agresseurs sexuels seraient en fait des adolescentes. La reconnaissance de cette problématique se heurte à de nombreuses résistances tant au niveau du dévoilement par la victime qu’à celui de la prise de décisions relative à l’encadrement de l’adolescente. Cela fait en sorte qu’on retrouve peu d’adolescentes dans les services spécialisés. Depuis le début du programme pour les adolescents agresseurs sexuels affilié à l’IPPM, en milieu externe, 15 adolescentes ont été évaluées. Les données recueillies auprès de cette cohorte d’adolescentes font non seulement ressortir leurs caractéristiques personnelles, familiales, sociales et délictuelles mais offrent un éclairage différent de la problématique de ces jeunes adolescentes comparativement de celles dégagées des jeunes adolescents. Des considérations inhérentes au parcours légal et thérapeutique seront aussi abordées. Femmes reconnues coupables d’agression sexuelle: agresseures ou victimes Johanne-Lucine Rouleau Université de Montréal Les données du Home Criminal Justice montrent que sur une durée de 10 années 95% des crimes sexuels sont commis par des femmes. Plus près de nous Badley rapporte que 1.1% de 727 délinquants sexuels incarcérés au Canada en début des années 80 ont affirmé avoir été abusés par une femme. Plusieurs auteurs ont identifié des facteurs pour expliquer que les abus sexuels perpétrés par les femmes auraient sous-rapportés. Lors de cette présentation, la nature et les caractéristiques des abus sexuels commis par des femmes seront présentés ainsi que les caractéristiques psychologiques de ces femmes. Enfin les stratégies de traitement utilisés seront revues et des recommandations seront effectuées suite aux nouvelles méthodes d’évaluation utilisées auprès de ces femmes. 130 XXVIth International Congress on Law and Mental Health COMMUNICATIONS LIBRES VI July 6 juillet 16:00 –17:45 Salle 102 Modérateur: Louis Bérard, Institut Philippe Pinel de Montréal Violence et santé mentale au travail Nathalie Jauvin Université de Montréal Michel Vézina et Renée Bourbonnais Université de Laval Romaine Malenfant et Martin April CLSC Haute-Ville-des-Rivières, Québec Objectifs: • dresser un portrait de l’exposition à la violence au travail chez un groupe de travailleurs; • faire état des principales caractéristiques de la santé mentale de ces travailleurs; • explorer l’interrelation entre l’exposition à la violence vécue au travail et l’état de santé mentale altéré retrouvé chez de nombreux individus. L’intérêt pour le phénomène de la violence au travail est de plus en plus marqué. Plusieurs documents ont été publiés sur ce sujet au cours des dernières années. Cependant, parmi ces publications, peu ont porté spécifiquement sur la violence exercée entre les membres d’une même organisation (violence organisationnelle), les travaux publiés à ce jour ayant essentiellement traité de la violence exercée par des personnes étrangères à l’organisation (clientèle, étrangers). De plus, peu d’études empiriques ont, jusqu’à aujourd’hui, permis d’établir des liens entre l’exposition à la violence au travail et l’état de santé mentale des travailleurs. Dans le cadre de cette communication, nous présenterons des données qui porteront sur l’exposition à la violence au travail chez des travailleurs québécois et européens de même que sur leur état de santé mentale. Ces données proviennent essentiellement de la dernière enquête effectuée par Santé Québec ainsi que de l’Enquête européenne sur les conditions de travail. Nous tenterons ensuite de démontrer l’interrelation possible entre la violence à laquelle les travailleurs sont exposés dans le cadre de leur travail et leur état de santé mentale (détresse psychologique, épuisement professionnel, tension au travail, etc.). Expertise pour invalidité chez des italo-canadiens: préjugés et facteurs culturels Tiziana Costi Institut Philippe Pinel de Montréal Analyse de dossiers d’expertise pour invalidité chez des Italo-canadiens. Des personnes qui ont toujours travaillé et eu une vie fonctionnelle, suite à un accident de travail et à des limitations qui s’ensuivent, n’arrivent plus à s’adapter à leur situation et deviennent non fonctionnelles. Objectivement, elles ne répondent pas aux critères d’invalidité mais en fait ne sont plus fonctionnelles. Des facteurs culturels et directement reliés à l’immigration peuvent être à la base de cet état. La présentation, qui touche autant au domaine de l’expertise au civil qu’à l’ethnopsychiatrie, résumera les données sociodémographiques, psychologiques et les hypothèses relevées dans l’étude d’une trentaine de dossiers et discutera des implications pour l’expertise, l’intervention et le traitement. Psychose, toxicomanie et responsabilité criminelle Élise St-André et Marie Fédérique Allard CH Centre de la Mauricie, Québec Renée Fugère Institut Allan Memoria, Montréal Monsieur B. est un jeune homme qui a été reconnu responsable, en Cour Criminelle, d’homicide involontaire coupable. Pour prendre sa décision, le jury a bénéficié du témoignage de trois psychiatres experts, l’un témoignant pour la Couronne, les deux autres pour la Défense. De plus, un quatrième psychiatre est venu témoigner de sa rencontre avec le sujet, à titre de médecin traitant. Les quatre médecins psychiatres ont fait état de symptômes de maladie mentale chez le sujet. Leurs opinions étaient basées sur une ou des rencontres de durée variable avec Monsieur B., et sur des documents médico-légaux en quantités variables. Les rencontres avec les experts ont été effectuées à des moments variables, soit peu de temps après les faits, au début et pendant son 131 XXVIe Congrès international de droit et de santé mentale hospitalisation, et dans certain cas, dans les semaines précédant le procès donc après un traitement psychopharmacologique de plusieurs mois reçu par l’individu. Nous nous proposons, lors de cet exposé, outre de rappeler la définition légale de la responsabilité criminelle, de comparer des cas similaires et leurs conclusions légales (jurisprudence), de décrire le parcours du patient (donc d’un individu reconnu comme souffrant de problème de santé mentale), qui sera bien différent s’il est ou non reconnu responsable de ses actes. Ce constat pourra faire place à une critique de l’interaction entre le système médical et légal dans le cadre du processus judiciaire. Découlant du partage de nos expériences, des propositions seront énoncées comme critères de qualité incluant les aspects éthiques des expertises psychiatriques en général, mais aussi plus spécifiquement des expertises concernant la responsabilité criminelle. THE FORENSIC PRACTITIONER AS CONSULTANT: VARYING ROLES July 6 juillet 16:00 – 17:45 Room CMEL-102 Chair: Thomas Gutheil, Harvard Medical School Variables affecting police procedures when dealing with the mentally ill Bernice Kelly, Marilyn Price, Thomas Gutheil, Michael Commons Harvard Medical School With the closure of state hospitals in favor of community based treatment, law enforcement officers have increasingly been responding to situations involving the mentally ill. Little research has addressed whether police officers adapt police procedure when dealing with mentally ill individuals. A survey of police officers, including patrolmen, detectives and supervisors, from 44 towns and cities south of Boston was conducted. The majority of these officers handled fewer than five calls per month in which they suspected that they were dealing with a mentally ill individual. The officers were presented with one of two scenarios involving a situation with a mentally ill individual in the community. One involved a situation which occurred in the home, and the other in a restaurant. Options for response included mental health team assistance, transport for psychiatric evaluation, and filing charges. Officers were asked to rank the importance of several factors affecting their decision on how to respond to the situation, including the availability of mental health emergency services, safety concerns, victim preference, community supports, and the perceived need to use a criminal charge to get the individual into treatment. The use of a consultation versus an adversarial model in dealing with issues at the intersection of mental retardation and the law Mark Hauser Harvard Medical School In dealing with issues at the intersection of psychiatry, mental retardation and the law, it is usually more productive to have a consultative model rather than an adversarial model. This paper details how such models work in two situations: one in which the parties are seeking a settlement and other one in which a settlement has been reached but treatment decisions remain to be made. In contradistinction to the role played by many expert witnesses, in these situations, the task is to reach a solution that is satisfactory to everyone. In such cases, it is usually preferable to work for the court rather than one side or the other. One can render an opinion as to their diagnoses, treatment and prognosis. One can also render an opinion as to what the organizational system that has been serving them may benefit from doing to better meet their client’s needs. Such diagnoses of both entities can lead to improvements in the system that the mentally retarded individual is part of, and this in turn improves the lot of the client. In other cases, in which settlements have already been reached, I recommend strategies for the staff so they can come up with an effective treatment plan. Other examples of the use of these models at different points in the process will be presented, with practical implications for expert witnesses working in a variety of areas. The anorexic’s choice to die: Assessing competence Margery Gans Harvard Medical School William Gunn Dartmouth Medical Center, Concord, New Hampshire Some severe anorexics, after going through years of treatment, choose to die. This decision on the part of the anorexic creates agonizing ethical dilemmas and a situation in which the anorexic’s competence to make this choice must be assessed. The anorexic falls somewhere in between the dying person for whom the choice of death might be respected and of the clearly schizophrenic (for instance) whose requests for death would be overruled. Some health professionals would argue that the diagnosis of anorexia itself renders the patient incompetent to make this choice. Others argue that there needs to be standards of 132 XXVIth International Congress on Law and Mental Health competence–identifiable tasks–that could be applied so that the anorexic could be evaluated and deemed competent or incompetent to choose to die. This presentation will explore both points of view and offer a preliminary effort to identify the tasks that might comprise such a competency evaluation. The psychology behind the psychology in law Michael Commons Harvard Medical School This paper is on the psychology of the law. Basically, the psychology embodied in the law is based on Aristotle’s and Aquinas’s notions of free will and competence to choose. It is surely pre-Kantian in that it violates the basic tenets of fairness and pre-Mill in that it is totally unutilitarian. Particularly, all of these aspects may be seen in the corporal punishment of infants and young children in the nineteenth century and before and the continuance of corporal punishment in the schools and home in the twentieth century. The only new notion in this century is that now it is felt that true children “can” be rehabilitated rather than punished, but we continue to believe that adults cannot. Retribution and punishment comes from all cultures’ religions and is widely espoused in the old testament and is not supported by psychology. Discussant: Julio Arboleda-Flórez, Queen’s University DEVELOPING A CONCEPTUAL MODEL FOR RISK MANAGEMENT OF SEX OFFENDERS July 6 juillet 16:00 – 17:45 Room NCDH–200 Chair: Howard E. Barbaree, Centre for Addiction and Mental Health, Toronto Actuarial assessment of risk for reoffense: A comparison of five current instruments Michael C. Seto, Calvin M. Langton, Howard E. Barbaree Centre for Addiction and Mental Health, Toronto Research has identified a number of static variables that predict risk for recidivism among sex offenders. Reflecting this work, a number of actuarial risk instruments have been introduced in recent years for use with adult sex offenders. Five well-known instruments are the Violence Risk Appraisal Guide (VRAG), Sex Offender Risk Appraisal Guide (SORAG), Rapid Risk Assessment for Sexual Offense Recidivism (RRASOR), Static-99, and the MnSOST-R. The Static-99 combines the four RRASOR items with additional items from Thornton’s Structured Anchored Clinical Judgement, while the SORAG is a modification of the VRAG, to be used specifically with sex offenders (Hanson & Thornton, 1999; Quinsey, Harris, Rice, & Cormier, 1998). This study compared the accuracy of these five risk instruments in predicting violent and sexual recidivism in a sample of 224 sex offenders assessed at the Warkworth Sexual Behaviour Clinic, a treatment program located within a Canadian medium security penitentiary, and subsequently released on parole or at the end of their sentences. The results are discussed in terms of selecting risk assessment instruments and using actuarial predictions in risk management decisions. Sex offender risk assessment: Integration of treatment performance with actuarial risk Edward J. Peacock Correctional Service of Canada Calvin M. Langton, Howard E. Barbaree Centre for Addiction and Mental Health, Toronto Sex offender treatment programs are intended to promote cognitive and behavioral changes that result in decreased recidivism. Consequently, it is often assumed that participants who perform well in such programs have made important changes that decrease their risk for reoffense. This presentation examines the issue of whether information about treatment performance contributes to the prediction of recidivism beyond that provided by actuarial risk scores. Findings are reported for a sample of 153 male sex offenders who participated in treatment while incarcerated, were subsequently released and then followed in the community. Treatment performance, as measured by clinician ratings and treatment-related variables such as attendance, and actuarial risk scores are examined as predictors of recidivism. The findings indicate that integrating treatment performance with actuarial scores did not improve the prediction of recidivism. The implications for clinical practice and subsequent research will be discussed. 133 XXVIe Congrès international de droit et de santé mentale Clarifying the role of moderating variables in risk assessment Calvin M. Langton, Howard E. Barbaree Centre for Addiction and Mental Health, Toronto Despite the growing body of research that supports the predictive validity of actuarial assessments of risk for reoffense with sex offenders, concerns remain about the clinical utility of actuarial tools. One primary objection to their use is their reliance on static (historical) factors and the general absence of dynamic factors in their composition, which renders the assessment insensitive to interventions and affords the clinician little guidance about how best to manage an offender in the short term. The provision of treatment and community supervision practices are two dynamic factors that would be expected to lower the probability that an offender will recidivate. An important question for risk assessors is how best to integrate information pertaining to these two factors into an assessment of risk, and this is the subject of the final presentation in this symposium. However, an important first step in addressing the question includes clarification of the conceptual differences between static and dynamic factors. In this presentation, the role of moderating and mediating variables in research is considered in reference to the static-dynamic factor distinction. Theoretical and clinical implications are then discussed. A matrix model of risk classification and management Howard E. Barbaree, Calvin M. Langton Centre for Addiction and Mental Health, Toronto The presentations in this symposium illustrate two important points: (1) Accurate prediction of reoffense amongst sex offenders is possible using actuarial assessment, and (2) Questions remain about how best to integrate information from interventions in assessments of risk. Some authors have proposed that actuarial assessment establishes a benchmark of static risk which can then be modified according to treatment-related information. As an alternative, we are proposing a matrix model in which actuarial assessment is used to classify offenders into risk categories. Risk classification is then combined with risk management strategy in a two-dimensional matrix. A different set of rules for risk management are applied according to risk category: In low risk categories, management involves less intensive monitoring and supervision; at higher levels of risk, more intensive supervision or more restrictive management options are applied. In this system of risk management, offenders are not moved from one risk category to another based on treatment-related information. Once their risk category is established through actuarial assessment, they remain in that category. However, within each category, offenders who complete treatment and are compliant with other requirements can progress towards community release or other objectives. Once an offender is released to the community, the intensity by which he is supervised is determined by his risk classification. 134 XXVIth International Congress on Law and Mental Health List of Sessions / Liste des sessions Bilingual forums – Forums bilingues How to Regard Criminal Adolescents? Comment considérer les adolescents criminels? ..................................................................... 64 Sexual Misconduct of Professionals L’inconduite sexuelle professionnelle.................................................................................... 104 Will we criminalize pedophiliac sexual behaviours on the internet? Criminalisation des comportements sexuels pédophiles sur Internet ...................................... 31 Bilingual sessions – Sessions bilingues Fitness to Stand Trial and Criminal Responsibility Aptitude à comparaître et responsabilité criminelle ............................................................. 112 Mental Health in Native Communities : Problems And Stakes I Santé mentale en milieu autochtone: Problématiques et enjeux I ........................................... 75 Mental Health in Native Communities : Problems And Stakes II Santé mentale en milieu autochtone: Problématiques et enjeux II.......................................... 82 Mental Health in Native Communities : Problems And Stakes III Santé mentale en milieu autochtone: Problématiques et enjeux III......................................... 95 Sessions françaises Communications libres I.......................................................................................................... 40 Communications libres II ........................................................................................................ 46 Communications libres III....................................................................................................... 56 Communications libres IV ....................................................................................................... 78 Communications libres V ...................................................................................................... 114 Communications libres VI .................................................................................................... 131 Du viol au meurtre sexuel...................................................................................................... 119 Expertise au civil ..................................................................................................................... 77 Femmes et adolescentes agresseures ou victimes?................................................................ 130 Itinérance ................................................................................................................................ 38 Pédopsychiatrie I..................................................................................................................... 39 Pédopsychiatrie II ................................................................................................................... 45 Poursuites médicales ............................................................................................................... 84 Réflexion sur la psychiatrie légale et le leadership psychiatrique .......................................... 55 Regard multidisciplinaire sur les expertises............................................................................ 96 Victimisation Sexuelle ........................................................................................................... 113 Violence et famille ................................................................................................................. 120 Ateliers I. L’échelle de psychopathie de Hare: questions et perspectives .......................................... 54 II. Valeur, place et limite de l’examen cognitif face à l’évaluation clinique (tests neuropsychologiques)............................................................................................... 94 III. Les gangs à Montréal: un phénomène qui semble prendre un nouveau tournant depuis les deux dernières décennies............................................................................................ 129 135 XXVIe Congrès international de droit et de santé mentale English Sessions Abuse and Neglect of Children I ............................................................................................. 92 Addiction................................................................................................................................. 74 Adjudicating Mental Illness: Dilemmas in the Courtroom and in Practice ............................. 64 Admissibility and Ethics of Expert Evidence in Criminal Cases............................................. 84 Advocacy Under Ontario’s Mental Health Act ....................................................................... 25 Children at the Intersection of Health and Justice ................................................................. 110 Coercion .................................................................................................................................. 47 Community Mental Health in a New Era ................................................................................ 67 Competence Assessment and Guardianship: Retrospective and Prospective .......................... 49 Confidentiality of Health Information ................................................................................... 117 Current Issues in Womens Corrections ................................................................................... 88 Developing a Conceptual Model for Risk Management of Sex Offenders .......................... 133 Diagnosis and Treatment of Sequels to Torture ...................................................................... 59 Ethics and the Professional Self .............................................................................................. 86 European Perspectives on Sexual Offending......................................................................... 105 Families: Social and Legal Intervention ................................................................................ 115 Governance of Madness .......................................................................................................... 98 Indigenous Peoples: Social and Legal Concerns ..................................................................... 73 Innovations in Mental Health Systems .................................................................................... 43 Law, Justice and Genetics ....................................................................................................... 41 Making it Happen: Mental Health Reform – The Ontario Context......................................... 16 Mental Health and the Workplace ........................................................................................... 90 Mental Illness, Violence and Social Protection ....................................................................... 18 Mentally Disordered Offenders: The Netherlands’ Experience ............................................. 81 New Perspectives on the Sexually Violent Offender............................................................... 99 Ontario’s Community Treatment Order Legislation: From Legislative Policy Development to Constitutional Change................................................................................... 36 Outpatient Commitment .......................................................................................................... 58 Paternalism and Autonomy: A Nordic Study .......................................................................... 23 Promoting Mental Health and Decision-Making in Children and Adolescents....................... 53 Psychological Jurisprudence: Mapping Social Boundaries ................................................... 121 Psychology, History, Literature and the Law .......................................................................... 21 Racial Profiling........................................................................................................................ 70 Sentencing and the Welfare and Mental Health Needs of Youths......................................... 107 Sex Offenders: Public Policy Dilemmas ................................................................................. 32 Sex Offenders: Theory, Research and Treatment.................................................................... 26 Social and Historical Dimensions of Torture .......................................................................... 33 Social Responses to Mental Illness ....................................................................................... 100 Socio-Legal Facets of Womens’ Mental Health...................................................................... 79 Suicides in Custody I: Increasing Incidence and Concern....................................................... 51 Suicides in Custody II: Is Prevention Possible? ...................................................................... 57 The Forensic Practitioner as Consultant: Varying Roles....................................................... 132 The Mental Health Care System in Spain: Chronicle of a Friendly Reform ........................... 27 The Right to Refuse Medications .......................................................................................... 123 Transcultural Aspects of Law and Mental Health ................................................................... 19 Trans-National Changes in Mental Health Systems .............................................................. 126 Violence Among the Severely Mentally Ill ........................................................................... 109 Violence in Correctional Settings.......................................................................................... 127 136 XXVIth International Congress on Law and Mental Health List of Chairs, Speakers and Discussants Liste des modérateurs, conférenciers et discutants Blank, Paolo ..........................................................128 Bloom, Hy ...................................................65, 67, 90 Boivin, Johanne .......................................................39 Boivin, Rachelle ......................................................93 Bolis, Monica ........................................................126 Boothroyd, Lucy J. ..................................................41 Borum, Randy..........................................................59 Bourbonnais, Renée...............................................131 Bouthiller, Geneviève..............................................38 Boutin, Sandra .........................................................46 Bowen, E. ..............................................................117 Bowser, Rene...........................................................71 Brault, Jocelyne .......................................................55 Braun, Jean-Paul......................................................92 Bravo, Marifé ....................................................27, 28 Brissenden, R. Bernadette........................................19 Brissos, S. ..............................................................127 Brodeur, Jean-Paul.................................................107 Brown, Gregory P....................................................18 Brym, Robert J.......................................................122 Burbidge, Nancy........................................................9 Burns, Barbara J. .....................................................59 Bütter, Hendrik J. ....................................................40 Buys, Lisa ................................................................87 A Abdool, Steve ....................................................67, 68 Adelson, Naomi .......................................................82 Ahmed, Mohamed .............................................35, 59 Allard, Marie Fédérique ........................................131 Allodi, Federico .................................................27, 35 Amidjaya, Imat ........................................................86 Andrew, Sarah .......................................................124 Andrews, Rhonda Magee ........................................71 Anechiarico, Barry...................................................26 Anterjkina, L.I. ........................................................75 Appelbaum, Paul ...................................................124 April, Martin..........................................................131 Arboleda-Flórez, Julio .........................8, 58, 112, 133 Attia, Sabry............................................................127 Attia-Galland, Samia ...............................................40 Aubut, Jocelyn...........................................33, 55, 114 Auclair, Nathalie....................................................120 Austin, Lisa..............................................................42 Austin, Wendy.....................................................8, 88 B Baldwin, Omie.........................................................73 Baptista, João P. ......................................................48 Barbaree, Howard E. ...............................67, 133, 134 Barney, Ken...........................................................100 Barnhorst, Richard.................................................107 Barrette-Joncas, Claire...........................................112 Bartlett, John............................................................50 Bartlett, Peter.....................................................21, 43 Barylak, L. ...............................................................91 Bastien, Lise ......................................................76, 95 Baudouin, Jean-Louis ..............................................15 Baum, Gregory ........................................................74 Bay, Michael....................................................16, 117 Beauregard, Éric ....................................................119 Beech, A ................................................................117 Béliveau, Lionel.......................................................84 Benda, Norbert ............................................35, 51, 52 Bérard, Louis ...................................................77, 131 Bercu, Silvia ............................................................89 Berge, Teresa L........................................................86 Bessler, Cornelia....................................................105 Betts, Andy ..............................................................90 Birba, Rose Gabrielle ............................................107 Birnie, Peter.............................................................16 Bisko, Susanne ........................................................33 Blaauw, Eric ................................................57, 81, 82 Blackburn, Janice.....................................................36 Blacksher, Erika.......................................................12 Bland, Roger C. .......................................................41 C Caleffi, Lorena.......................................................128 Call, Jonathan ........................................................123 Campbell, Mary .......................................................32 Cardoso, Rogério Göttert.......................................128 Carey, Linda ............................................................25 Carne, Jonathan .......................................................45 Carney, Terry...............................................38, 51, 79 Cesaroni, Carla ......................................................108 Cham, Patricia .........................................................96 Chamberland, Gilles ..........................................55, 94 Chan, Michael..........................................................18 Chanut, Florence......................................................39 Chaplow, David .......................................................68 Chaves, Márcia L. F. ...............................................48 Chené, Sabine ........................................................120 Chenette, Julie .........................................................84 Cheong, Young-Ho..................................................69 Chowdhury, Akram H. ............................................34 Chowdhury, Mahfuza Akram ..................................20 Claix, Adèle.....................................................78, 128 Commons, Michael........................................132, 133 Cooper, Christopher...............................................116 Cooper, Frank Rudy ................................................71 Cooper, Gerry ..........................................................17 Cooper, Penny A. ....................................................85 137 XXVIe Congrès international de droit et de santé mentale Cooper, Richard.......................................................64 Cormier, Hugues......................................................12 Cormier, Robert.......................................................99 Cornwell, John K...................................................108 Coronel, Luiz C.I. ..................................................128 Cortèse, Phillippe ..................................................109 Coscarelli, Pedro....................................................128 Costi, Tiziana.........................................................131 Côté, Gilles ..................................................40, 54, 56 Côté, Martine.........................................................130 Cotton, Dorothy .......................................................18 Coupland, Nick........................................................79 Cousineau, Marie-Marthe ......................................129 Cox, Beverlee Ann ..................................................41 Crocker, Anne........................................................112 Crowe, Trish ..........................................................116 Crowley-Cyr, Lynda................................................69 Cusack, Regina M..................................................121 Cusson, Maurice ............................................119, 120 Czukar, Gail...........................................................118 Esam, Barbara........................................................110 Escudero-Nafs, Antonio ....................................27, 28 F Fancey, P. ................................................................91 Felthous, Alan........................................................124 Fernández-Liria, Alberto .........................................28 Ferrari, Robert .........................................................64 Fontana-Rosa, Júlio César .....................................116 Forouzan, Elham....................................................113 Fortin, Gilles............................................................45 Frappier, Jean-Yves .................................................93 Fraser, Suzan E. .......................................................19 Fredette, Chantal....................................................129 Fridman, Sander.....................................................128 Friedman, David ....................................................122 Friedman, Debra ......................................................74 Frottier, Patrick..............................35, 51, 52, 57, 106 Frühwald, Stefan....................................35, 51, 52, 57 Fugère, Renée ........................................................131 Furlong, Allannah....................................................85 D G Daigle, Marc ............................................................56 Dalphond, Pierre......................................................36 Dassylva, Benoit..............................................46, 113 Davidson, Laura.......................................................44 Dawson, John ..........................................................58 Day, Vivian............................................................128 de Foy, Claude Philippart ......................................114 de Moraes, Talvane Marins ...................................128 de Reuver, S.............................................................81 de Sierra, Lucia Fernandez ......................................39 de Souza Menezes, Ruben .....................................128 Deaton, Rodney J.S. ................................................87 Delecluse, C...........................................................128 Deschamps, Pierre ...................................................59 Desmarais, Gilbert ...................................................94 Dittmann, Volker ...................................................105 Doob, Anthony ......................................................107 Dremetsikas, Teresa...........................................35, 59 Drummond, Jane......................................................53 du Fort, Guillaume Galbaud ....................................41 Dubé, Myriam........................................................121 Dufour, Natasha.......................................................38 Dunbar, Sandra ........................................................66 DuVal, Gordon ........................................................66 Dyall, Lorna.............................................................74 Dykeman, Mary-Jane...............................................80 Gagnon, Martine......................................................84 Gallop, Ruth ............................................................79 Gans, Margery .......................................................132 Garceau, Linda ..................................................56, 75 Garfinkel, Paul.........................................................17 Garyali, Veena.........................................................58 Gaudreault, Arlène.................................................113 Gauthier, Yvan ........................................................77 Gauthier, Yvon ........................................................45 Gendron, Pierre........................................................38 Gerard, M. ...............................................................56 Gilchrist, E.............................................................117 Gilissen, Jean-Louis...............................................114 Glaister, J.................................................................87 Glover-Thomas, Nicola .........................................126 Gomes, Denise A. R. ...............................................48 Gomes, Margui Vieira .............................................91 Gomory, Tomi .........................................................67 Goncharova, I.A. .....................................................75 Goodman, Lenn .......................................................10 Goodwin, Michele ...................................................70 Gordon, Fon Louise.................................................70 Gorman, Tom ........................................................122 Gower, Myrna........................................................116 Grabow, Aleen.........................................................86 Graf, M. .................................................................105 Grahn-Farley, Maria ................................................53 Gray, Jenny......................................................35, 110 Gray, John E. ...........................................................66 Greeven, Peter G.J. ................................................109 Grenier, Bernard ......................................................99 Grey, Julius H..........................................................31 Griengl, Hemma ......................................................34 Grigor, John...........................................................100 E Egan, Therese ..........................................................68 Eher, Reinhard.............................................35, 51, 52 Eisen, Resa S. ..........................................................90 Eisenberg, Alan D............................................33, 122 Engberg, Marianne ............................................23, 24 Epling, Michael .......................................................90 Ermer, Anneliese ...................................................105 138 XXVIth International Congress on Law and Mental Health Grunberg, Frédéric...................................................88 Guberman, N. ..........................................................91 Gulayets, Michael....................................................98 Gunn, William .......................................................132 Gutheil, Thomas ............................................104, 132 Kissell, Judith Lee .....................................................9 Kjellin, Lars.......................................................23, 24 Knecht, Guntram ...................................................107 Knecht, Thomas A.................................................106 Knox, M...................................................................91 Koenig, F. ................................................................35 Korkeila, Jyrki .........................................................47 Korolenko, Tatiana ..................................................75 Korolenko, Tsezar P. ...................................19, 20, 75 Krautgartner, Monika ..............................................34 Kriegman, Daniel.....................................................26 Kugler, Gordon........................................................88 Kwan, Oliver ...........................................................64 Kysela, G.M.............................................................53 H Hadley, Trevor.........................................................43 Haeyere, S................................................................56 Hamel, Sylvie ........................................................129 Hanna, Lisa..............................................................98 Hardy, Daniel ........................................................124 Harmer, Sandi..........................................................80 Harris, Nathan..........................................................64 Hartford, Kathleen .....................................68, 69, 118 Harvey, William ......................................................49 Harvey-Blankenship, Michele .................................42 Hashman, Kenneth...................................................44 Hauser, Mark .........................................................132 Haycock, J. ........................................................52, 57 Hegadoren, Kathy....................................................79 Helm, Dennis...........................................................36 Henderson, Jeannette ...............................................43 Hernández-Monsalve, Mariano ...............................27 Heslop, Lisa.....................................................26, 118 Hiday, Virginia Aldigé ................................47, 58, 59 Hillen, James ...........................................................18 Hoch, Jeff ................................................................68 Hocking, Barbara Ann.............................................42 Hoeve, Machteld......................................................81 Høyer, Georg .....................................................23, 24 Huyer, Dirk..............................................................92 L La Fond, John Q. .....................................................47 Lafleur, Paul-André .....................................15, 55, 96 Laishes, Jane............................................................52 Lambert, Timothy....................................................88 Lamoureux, Bernadette ...........................................78 Landry, Lorraine................................................49, 50 Langevin, Ronald ....................................................99 Langton, Calvin M.........................................133, 134 Lapointe, Stéphane ..................................................31 Laporte, Line .........................................................121 Laporte, Paul-Robert ...............................................78 Latham, Craig ..........................................................26 Latimer, Catherine ...................................................64 Lehr, S. ....................................................................52 Lehtinen, Ville .........................................................47 Lemelledo, Jean-Michel ..........................................79 Lemmens, Trudo......................................................42 Lenton, Rhonda L. .................................................122 Lenz, Gerhard ..........................................................93 Lepage, Denis ..........................................................77 Lépine, Suzanne.......................................................53 Lesage, Jacques .......................................................77 Léveillée, Suzanne.................................................121 Leverette, John ......................................................116 Levin, Aubrey........................................................129 Levin, Charles..........................................................85 Leydet, Anne ...........................................................96 Lidz, Charles....................................................23, 109 Lightfoot, Lynn........................................................89 Lippel, Katherine .....................................................90 Lit, Wilson.........................................................67, 68 Loewy, Erich ...........................................................13 Loughnan, Arlie.......................................................80 Loza, W. ................................................................128 Lusignan, Richard....................................................56 Lussier, Patrick ........................................................46 Lussier, Sylvain .......................................................73 I Iskov, B. ..................................................................54 J Jacob, Martine .......................................................130 Jacobi, John ...........................................................100 Jauvin, Nathalie .....................................................131 Jayaram, Geetha.....................................................124 Jélius, Gloria............................................................45 Jones, Derek ......................................................22, 84 Jonker, Cees.............................................................50 Joukamaa, Matti ................................................24, 47 K Kailin, Julie..............................................................72 Kaltiala-Heino, Riittakerttu ...............................23, 47 Kaplan, Leonard V. ...................................15, 21, 121 Kebbell, M.............................................................117 Keefe, J. ...................................................................91 Kelly, Bernice........................................................132 Kelly, Michelle ........................................................66 Kensin, Denis ..........................................................93 Khushf, George........................................................10 King, Mary-Claire ...................................................42 Kinyanda, Eugene....................................................60 Kirsh, Bonnie...........................................................91 M MacFarlane, Diane...................................................17 MacKinnon, Margo A............................................115 139 XXVIe Congrès international de droit et de santé mentale Mailloux, Marielle ...................................................78 Malenfant, Romaine ..............................................131 Mallard, Anna Marie .............................................111 Mamak, Mini ...........................................................65 Manners, Steven ......................................................22 Marin-Lira, Angelica ...............................................34 Marleau, Jacques D................................................120 Marshall, Mary ......................................................119 Marshall, Tina........................................................117 Marshall, William....................................................99 Mathews, Ben ........................................................108 Maywood, Scott A...................................................18 McCallum, Hamish..................................................41 McDonagh, Donna...................................................88 McDonald, L............................................................53 McKibben, André ..............................................31, 95 Mecler, Kátia .........................................................128 Meier, Rosemary .....................................................87 Ménard, Jean-Pierre.................................................84 Mendel, James .........................................................25 Mendlowicz, Mauro V...........................................128 Metelitsa, Yuri.........................................................87 Millaud, Frédéric .............................................39, 120 Mishara, Brian .........................................................58 Mitchell, Damian .....................................................90 Morawitz, Isolde....................................................106 Morency, Judith .......................................................75 Morganbesser, Leonard I. ........................................99 Morissette, Louis ...........................................104, 115 Mormont, Christian .........................................15, 104 Morrison, Denis .......................................................44 Motiuk, Larry ..........................................................57 Muhomedzanov, H.M..............................................20 Musisi, Seggane.......................................................60 Muthu, Yega ............................................................65 Myrholm, Jessica .....................................................79 Ovchinnikov, R........................................................20 P Pagé, Ginette............................................................88 Palardy, Sylvain.......................................................45 Palermo, George B. .............................11, 27, 75, 110 Patel, Malini ..........................................................124 Patton, Lora .............................................................25 Pautler, Kate ............................................................16 Peacock, Edward J.................................................133 Peay, Jill ..................................................................51 Peppin, Patricia........................................................80 Pérez, Edgardo...................................................67, 68 Petrunik, Michael.....................................................32 Pham, Thierry ..............................54, 78, 90, 109, 128 Pharand, Ginette ......................................................40 Picard, Pierre .....................................................82, 95 Pihet, Bernard ........................................................108 Plante, Albert...........................................................84 Plante, Marie Carmen ..............................................38 Plaus, Xavier............................................................18 Pochieser, H.............................................................33 Pogodin, D.A. ..........................................................19 Pollock, Nathan .......................................................90 Porter, Steve ............................................................99 Poteryaeva, O.N.......................................................75 Poulin, Bernard......................................................121 Power, Kevin ...........................................................58 Prause, Wolfgang...............................................34, 93 Price, Marilyn ........................................................132 Proulx, France..........................................................46 Proulx, Jean .............................................46, 119, 120 Prowse, Allen ..........................................................36 Q Queiroz, Valéria.......................................................91 Quenneville, Yves ...................................................97 R N Ralston, Richard ......................................................20 Remy, S. ................................................................128 Ressl, Gerda...........................................................127 Ricci, Gabriel R. ......................................................22 Ridgely, Susan.........................................................59 Ritter, K. ......................................................35, 51, 52 Robinson, Stephen .................................................125 Rodríguez González, Abelardo................................28 Roed, Ole Tom ........................................................48 Rosato, Jennifer L....................................................54 Ross, Lee ...............................................................117 Rothman, Melvin L..................................................86 Rouleau, Johanne-Lucine ......................................130 Rousseau, Cécile......................................................34 Roy, Bernard............................................................83 Roy, Laurent ............................................................97 Roy, Renée ..............................................................55 Rozermeijer, J..........................................................60 Nahmiash, D. ...........................................................91 Nakatani, Yoji........................................................126 Nelson, Camille A. ..................................................71 Newman, Alan W. .................................................125 Newman, Stephen C. ...............................................41 Nicole, Alexandre..................................................119 Nivoli, Gian Carlo ...................................................82 Nogueira, Luciano ...................................................48 Novak, David.............................................................9 Nuss, Joseph ............................................................49 Nussbaum, David.....................................................65 Nuttgens, Simon ......................................................73 O O’Neil, Mary Kay..................................................100 O’Reilly, Richard L. ..........................................37, 66 Olsen, Sue................................................................73 Ormston, Edward F..................................................65 Ouimet, Marc...........................................................46 140 XXVIth International Congress on Law and Mental Health Talbot, Jacques ......................................................112 Tardif, Monique...............................................46, 130 Telles, L.E. ............................................................128 Termblay, Mario......................................................31 Tessier, Hélène ........................................................79 Thomasma, David C. .......................................13, 124 Thornton, J. Dennis .................................................75 Tjosvold, Ken ..........................................................44 Toulmin, Donna.......................................................92 Toulmin, Stephen ..............................................11, 15 Tourigny, Marc........................................................96 Trépanier, Jean ........................................................64 Trimnell, Jean ..........................................................17 Trudel, Rémy...........................................................15 Truesdell, Christine .................................................94 Tulugak, Aani ..........................................................77 Tuohimäki, Carita..............................................23, 47 Turcan, Maja............................................................89 Turner, Tyrone.........................................................16 Tweddle, Maggie ...................................................125 S Sachs, Josef............................................................105 Sakharova, E.A. .......................................................75 Samy, Mounir ..........................................................19 Santana, Sergio ......................................................116 Santiago, Susan......................................................111 Sarwer-Foner, Gerald J............................................87 Sauvêtre, Nadège ...................................................120 Schaler, Jeffrey A. ...................................................74 Scheid, Teresa L. ...................................................109 Schell, Diana............................................................36 Schmalbach, Stefan ...............................................106 Schneider, Richard...................................................65 Schrecker, Ted.................................................69, 118 Scott, Liam ..............................................................37 Secker, Barbara........................................................50 Serin, Ralph .............................................................57 Seto, Michael C. ....................................................133 Sévigny, Pierette......................................................18 Shackel, Rita............................................................92 Shadlen, Gerald .......................................................72 Shadlen, Jane ...........................................................53 Sharpe, Gilbert.........................................................16 Sheehan, Ken...........................................................45 Sibitz, Ingrid ............................................................34 Sigurdjonsdottir, Maria......................................23, 24 Silberfeld, Michel ....................................................65 Simalchik, Joan........................................................35 Simpson, Alexander.................................................68 Simpson, David .......................................................25 Sioui, Raymond .................................................75, 83 Sklar, Ronald ...........................................................84 Smith, Joanna ..........................................................46 Snyders, Julie...........................................................90 Solan, Lawrence ......................................................98 Speirs, Carol Cumming .........................................111 Spike, Jeffrey.........................................................123 Srebnik, Debra.........................................................47 Srinivasaraghavan, Jagannathan ....................123, 124 St-André, Élise ......................................................131 Stanislaus, Angeline ..............................................125 Starkman, Bernard .................................................110 Steber, Sara-Ann....................................................117 Stoddart, Ruth..........................................................67 Stone, Donald H. ...................................................100 Stuart, Heather.........................................................67 Studer, Lea H...........................................................32 Sulmasy, Daniel P....................................................12 Swanson, Jeffrey........................................58, 59, 109 Swartz, Marvin ..........................................58, 59, 109 Syse, Aslak ..............................................................48 Szigeti, Anita ...........................................................38 U Uchkina, T.V. ..........................................................75 Urbaniok, Frank.....................................................106 V van Gijseghem, Hubert ....................................41, 113 van Leeuwen, Evert .................................................10 van Marle, Hjalmar..................................................81 Van Nieuwenhuizen, Ch..........................................81 Vanderstukken, E.....................................................56 Vellinga, Astrid .................................................10, 50 Vézina, L. ................................................................91 Vézina, Michel ......................................................131 Vieira, Fernando ....................................................127 Vingilis, Evelyn .................................................68, 69 Vouche, Jean-Pierre...........................................39, 78 W Wagner, H. Ryan .....................................................59 Walgrave, Lode .......................................................64 Wallrap, Albert ........................................................43 Walton, John A. .......................................................70 Ward, Tony..............................................................21 Watkins, Nancy .....................................................124 Weagant, Brian ........................................................85 Webster, Christopher ...............................................90 Weisstub, David N...................................................11 Wenglensky, Rose .................................................116 Wenzel, Thomas ....................................33, 34, 60, 93 Werckle, Gerard J. .................................................107 Westmoreland Taoré, Juanita ..................................70 Westrin, Claes-Göran ..............................................98 Whelan, Darius ......................................................127 White, Patricia .......................................................108 Whitfield, Wenona.................................................124 Wichman, Cherami..................................................57 Wilson, John ..........................................................115 T Taborda, José G.V. ................................................127 Taillon-Wasmund, Peggy ........................................16 141 XXVIe Congrès international de droit et de santé mentale Woellner, Robin Henry....................................88, 118 Woodworth, Michael ...............................................99 Z Zagoruyko, E.N. ......................................................19 Zinger, Ivan .............................................................32 Zoratto, Pedro ........................................................128 Y Young, Allan .........................................................126 Young, John L. ........................................................18 142 XXVIth International Congress on Law and Mental Health th XXVI International Congress on Law and Mental Health e XXVI Congrès international de droit et de santé mentale FOUNDATIONS OF HEALTH CARE July 1–2 juillet 2001 Faculty of Law, McGill University 3644, rue Peel Moot Court, New Chancellor Day Hall (Metro: Peel & Stanley) Registration / Inscription: 8:00 – 18:00 SESSIONS OF THE ACADEMY / SESSIONS DE L’ACADÉMIE July 3-6 juillet 2001 Plenary Morning/ Matinée plénière July 3 juillet 9:30 – 12:00 Moot Court – 3644 Peel, New Chancellor Day Hall MC Parallel Sessions / Sessions parallèles July 3 juillet 13:45 – 17:45 July 4,5,6 juillet 8:30 – 17:45 MC NCDH-101 NCDH-102 NCDH-200 NCDH-201 IASL-106 CMEL-102 CPCL-101 Moot Court – 3644 Peel, New Chancellor Day Hall 101 – 3644 Peel, New Chancellor Day Hall 102 – 3644 Peel, New Chancellor Day Hall 200 – 3644 Peel, New Chancellor Day Hall 201 – 3644 Peel, New Chancellor Day Hall 106 – 3661 Peel, Institute and Centre of Air and Space Law 102 – 3690 Peel, Centre for Medicine, Ethics and Law 101 – 3647 Peel, Centre of Private and Comparative Law (Metro: Peel & Stanley) Registration / Inscription: 8:00 – 18:00 Registration / Inscription Pre-Conference: Foundations of Health Care July 1-2 juillet, 2001………………... CDN$150 XXVIth Congress / XXVIe Congrès July 3-6 juillet, 2001 Members of the Academy Membres de l'Académie……………… CDN$250 Non-Members / Non-membres………. CDN$350 Students / Étudiants…………………… CDN$75 Single day / Journée seule……………. CDN$125 Combined Registration / Inscription combinée Members of the Academy Membres de l'Académie……………… CDN$350 Non-Members / Non-membres………. CDN$450 Academy Membership / Abonnement à l'Académie…………... US$100 (Includes annual subscription to the International Journal of Law and Psychiatry / Comprend l'abonnement à l'International Journal of Law and Psychiatry ) Information / Renseignements: International Academy of Law and Mental Health Académie internationale de droit et de santé mentale a/s Chaire de psychiatrie légale et d'éthique biomédicale Philippe Pinel Faculté de médecine, Université de Montréal C.P. 6128, Succ. Centre-Ville Montréal, Québec, H3C 3J7, Canada Tel.: (1) 514-343-5938 Fax: (1) 514-343-2452 E-mail: [email protected] Visit the Academy at / Visitez l'Académie au: http://www.ialmh.org 143