Montreal 2001 Program

Transcription

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
Room / Salle 102
Room / Salle 200
NCDH–
201
IASL106
CMEL102
CPCL101
This file last updated on 24/07/01 10:15.
ii
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
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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
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
Co-Chair/Co- Président
Paul-André Lafleur
Co-Chair/Co- Président
International Scientific Committee
Comité scientifique international
David N. Weisstub
Chair/Président
Wendy Austin
University of Alberta
Peter Bartlett
University of Nottingham
Terry Carney
Volker Dittmann
University of Basel
Michele Goodwin
DePaul University
Thomas Gutheil
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
George B. Palermo
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
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
Comité scientifique local
Gilles Chamberland
Gilles Côté
Jean Hébert
Association des médecins psychiatres
du Québec
André McKibben
Sylvain Palardy
Jean Proulx
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
Comité organisateur
Martine Côté
vi
Danielle Séguin-Marois
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
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Program at a glance / Coup d’œil sur le programme
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
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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.
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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?
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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
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
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
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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
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.
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Sessions of the Academy
Sessions de l’Académie
Tuesday, July 3, 2001
mardi 3 juillet, 2001
14
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
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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
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
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
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.
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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
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
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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
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
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.
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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
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
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.
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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
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
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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.
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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
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
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Lars Kjellin
Matti Joukamaa
Oulu University
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
Georg Høyer
Marianne Engberg
Aarhus University
Rittakerttu Kaltiala-Heino
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.
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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
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
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
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
The psychodynamics of sexual offending
George B. Palermo
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
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
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
Wednesday, July 4, 2001
mercredi 4 juillet, 2001
29
Program at a glance
Coup d’œil sur le programme
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
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
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
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
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
(extended session)
Room NCDH–200
Chair: Thomas Wenzel, Université de Montréal
T 4 and the ethics of medicine
Thomas Wenzel
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
Legitimacy, decency and the state: Historical aspects of the application of
torture
Ingrid Sibitz, Monika Krautgartner, Wolfgang Prause, Thomas Wenzel
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
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
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
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
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
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
(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
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’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
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
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
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
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
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
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
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
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
Johanne Boivin
Hôpital Ste-Justine, Montréal
39
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
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
Psychopathie et justice réparatrice
Hubert Van Gijseghem
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
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
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
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.
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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
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
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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
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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
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.
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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
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
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
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
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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
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.
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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
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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
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
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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
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
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.
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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
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
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.
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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
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
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
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
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.
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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
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.
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16:00 – 17:45
RÉFLEXION SUR LA PSYCHIATIRE LÉGALE ET LE LEADERSHIP PSYCHIATRIQUE
Salle MC
Modérateur: Jocelyne Brault, Institut Philippe Pinel de Montréal
Erreurs et expertises psychiatriques
Gilles Chamberland, Paul-André Lafleur
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
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
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
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
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
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
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
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
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
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
‘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
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
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
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
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
61
Thursday, July 5, 2001
jeudi 5 juillet, 2001
62
Program at a glance
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
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
8:30 – 10:00
HOW TO REGARD CRIMINAL ADOLESCENTS ?
COMMENT CONSIDÉRER LES ADOLESCENTS CRIMINELS ?
July 5 juillet 2001 8:30–10:00
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
(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
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
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
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
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
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
Hy Bloom, David Nussbaum
65
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
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
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
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
(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
Ruth Stoddart
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.
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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
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
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.
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Deinstitutionalization or trans-institutionalization? A comprehensive research
program in south-western Ontario
Evelyn Vingilis
Ted Schrecker
McGill University
Kathleen Hartford, Young-Ho Cheong
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.
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RACIAL PROFILING
(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.
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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
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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?
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INDIGENOUS PEOPLES: SOCIAL AND LEGAL CONCERNS
Room NCDH–200
Chair: Sylvain Lussier, Avocat, Montréal
Aboriginal children raised in non-aboriginal families: From dis-membering to
remembering
Simon Nuttgens
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
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.
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Gambling: A new social hazard for Maori
Lorna Dyall
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
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
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
Bilingual session / Session Bilingue
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
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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.
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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
Salle IASL-106
Modérateur: Jacques Lesage, Institut Philippe Pinel de Montréal
La quérulence processive
Louis Bérard
«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?»
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COMMUNICATIONS LIBRES IV
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
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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
Ruth Gallop, Nick Coupland
Jean-Michel Lemelledo, Jessica Myrholm
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
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,
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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
‘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
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
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
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
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
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
Bilingual session / Session bilingue
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
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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
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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
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
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
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“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
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
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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.
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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
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.
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Ethics at the boundaries of professional relationships
Wendy Austin
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.
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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.
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Female sex offenders: A comparative study based on clinical and criminological
data from a Belgian prison sample
Julie Snyders
Thierry Pham
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
Resa S. Eisen
Mediator, Toronto
Christopher Webster, Nathan Pollock
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
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
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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
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.
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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
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
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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
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
Wolfgang Prause, Thomas Wenzel, Gerhard Lenz
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.
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ATELIER II
VALEUR, PLACE ET LIMITE DE L’EXAMEN COGNITIF FACE À
L’ÉVALUATION CLINIQUE (TESTS NEUROPSYCHOLOGIQUES)
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.
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16:00 – 17:45
MENTAL HEALTH IN NATIVE COMMUNITIES: PROBLEMS AND STAKES III
SANTÉ MENTALE EN MILIEU AUTOCHTONE: PROBLÉMATIQUES ET ENJEUX III
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.
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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
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.
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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.
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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
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.
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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
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
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
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
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.
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Friday, July 6, 2001
vendredi 6 juillet, 2001
102
Program at a glance
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
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
8:30 – 10:00
SEXUAL MISCONDUCT OF PROFESSIONALS
L’INCONDUITE SEXUELLE PROFESSIONNELLE
Room / Salle MC
Modérateur/Chair: Louis Morissette, Institut Philippe Pinel de Montréal
Boundary issues in clinical practice
Thomas Gutheil
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
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
EUROPEAN PERSPECTIVES ON SEXUAL OFFENDING
(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
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
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
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
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
(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
Jean-Paul Brodeur
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
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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
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
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Phillippe Cortèse, Thierry Pham
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
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
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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
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
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.
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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
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10:15 – 12:15
FITNESS TO STAND TRIAL AND CRIMINAL RESPONSIBILITY
APTITUDE À COMPARAÎTRE ET RESPONSABILITÉ CRIMINELLE
July 6 juillet 2001 10:15–12:15
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
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.
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VICTIMISATION SEXUELLE
Salle NCDH–102
Modérateur: Benoit Dassylva, Institut Philippe Pinel de Montréal
Les victimes: les voies de la réparation
Hubert van Gijseghem
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
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
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).
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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
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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
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
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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
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
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
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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.
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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
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
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
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
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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
Salle MC
Modérateur: Jean Proulx, Université de Montréal
Du viol au meurtre sexuel: cadre théorique et empirique
Éric Beauregard, Jean Proulx et Maurice Cusson
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.
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
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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
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
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
Salle NCDH–102
Modérateur: Frédéric Millaud, Institut Philippe Pinel de Montréal
Avitolicide
Jacques D. Marleau, Frédéric Millaud et Nathalie Auclair
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
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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
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
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.
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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
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
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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.
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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
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
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
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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
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
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
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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
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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
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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
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
C. Delecluse, Adèle Claix, S. Remy
Hôpital Sécuritaire “Les Marronniers”, Tournai, Belgique
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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:
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.
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16:00 – 17:45
FEMMES ET ADOLESCENTES AGRESSEURES OU VICTIMES?
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
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
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.
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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
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
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
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
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
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
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
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
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
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
Calvin M. Langton, Howard E. Barbaree
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
Clarifying the role of moderating variables in risk assessment
Calvin M. Langton, Howard E. Barbaree
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
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
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
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
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
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
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
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
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
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
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
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
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,
101 – 3644 Peel,
102 – 3644 Peel,
200 – 3644 Peel,
201 – 3644 Peel,
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:
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

Montreal 2001 Program

Transcription

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