Abstracts of the XXXIInd InternationalCongress on Law and Mental HealthRésumés du XXXIIe Congrès Internationalde droit et de santé mentaleDavid N. WeisstubChair/PrésidentUniversité de Montréal,Institut Philippe-Pinel,Montréal, CanadaChristoph PaulusCo-ChairHumboldt UniversityBerlin, GermanyHumboldt UniversityBerlin, GermanyJuly 17 - July 23, 2011Under the auspices of:International Academy of Law and Mental Health1

International Scientific CommitteeDavid N. WeisstubChairUniversité de Montréal/Institut Philippe-PinelNorbert KonradCo-ChairFree University of Berlin (Charié)Henrik AnckarsäterCo-ChairUniversity of GothenburgSteve AbdoolAurea AlcaldeJulio Arboleda-FlorezJocelyn AubutVirginia Aldige HidayMadelon BaranoskiAstrid BirgdenStefan BogaertsHarold BursztajnDuncan ChappellJeri Beth CohenJohn DouardClara Hellner GumpertThomas GutheilTrevor HadleyRuud H.J. HornsveldLeonard V. KaplanRaija KontioDanielle LaudyOtto M. LeschWilliam MarshallVincenzo MastronardiYega MuthuThomas NilssonKarel OeiMichael OsterheiderGuillermo Diaz PintosSusanna RadovicJagannathan SrinivasaraghavanJosé TabordaClaudio TamburriniDavid WexlerGeorge WoodsSuzanne YangNóra Kerekes2

Organizing CommitteeWerner PlatzVivantes Outpatient Psychiatric Clinic, BerlinRoman M. SkobloInstitute for Laboratory Medicine, BerlinHermann SimonCentrum Judaicum, BerlinAndreas SchmittVivantes International Medicine, Berlin3

1. Strengthening the Case: Mental Health Examinations of TortureSurvivors According to the Istanbul ProtocolIstanbul Protocol Examinations for Court Proceedings: The Experience of theForensic Expert GroupÖnder Özkalipci, The International Rehabilitation Council for Victims of Torture, Copenhagen,Denmark([email protected])International humanitarian law obliges States to investigate alleged crimes of torture and tobring perpetrators to justice. However, many cases of torture still go unpunished, partlyowing to lack of skills and knowledge in the health and legal professions in the field ofinvestigation and documentation of torture. The IRCT is engaged in a process to increase theprovision and use of high quality forensic documentation in legal proceedings for allegedtorture cases. A panel of experienced forensic experts, psychologists, and psychiatrists hasbeen established to serve as a reference point, provide advice on technical issues, andparticipate in missions to examine torture survivors and assist with bringing cases to court.The group has developed a manual of procedures and standards to guide the conduct ofmedical investigation missions and expect to perform at least 15 such missions in the comingyears. The experts will also continue to advocate for the increased use of medical evidenceand contribute to the development of a body of knowledge on the subject of forensicdocumentation. The experiences derived from this project will be shared with the audience.Evaluation of Psychological Consequences of TortureMechthild Wenk-Ansohn, The International Rehabilitation Council for Victims of Torture,Copenhagen, Denmark([email protected])Physical and psychological torture methods are in most cases used together. In moderntimes torturers avoid leaving scars, so that it is more difficult to prove that torture has takenplace. Psychological forms of systematic torture are also increasingly used. The long termsequelae of both physical and psychological torture methods are frequently on thepsychological and psychosomatic level and take the form of posttraumatic stress disorderand comorbid psychological disorders. For asylum procedures, or for a process against a4

torturer before local or international courts, the evaluation of the psychological impact onthe survivor can be very useful. Psychological reports can give an indication that the survivorhas been tortured. Standards for examination and reporting based on the Istanbul Protocoland discussions with lawyers and forensic psychologists will be presented, and experiencesfrom Germany shared.Effectiveness of Forensic Psychiatry Reports in Court Cases of Victims of Torturein GeorgiaMariam Jishkariani, Psycho-Rehabilitation Centre for Victims of Torture, Violence andPronounced Stress Impact, Empatia, Tbilisi, Georgia([email protected])The main goal of forensic psychiatry evaluation in cases of torture is to document thepsychological outcomes of torture. The presentation shares the results of the researchconducted by Empathy in Georgia. Based on observations for the period 2009 - 2010, acuteaftereffects were identified in 348 cases (61%) out of a total of 573. Chronic effects amongadults: From the 446 cases studied, a total number of 344 (77%) persons were diagnosedwith mental health problems; and in a further 102 (23%) cases, various forms ofpsychological problems requiring psychological assistance or medical consultations wereidentified. Among children: From a total number of 127, the following observations werenoted: Total number of clients with mental health problems amounted to 54 persons (43%of 127). Psychological problems were identified in a further 73 cases (57% of 127). Thepresentation will furthermore share observations on the shortfalls in the legal proceedings,which do not contain any mandatory articles on the necessity of forensicpsychiatry/psychological evaluations in cases of torture. Finally the presentation sharesconclusions and recommendations. Forensic psychiatry evaluation in court cases is essentialto the pursuit of adequate legal redress and compensation. State authorities shouldincorporate specific articles in the criminal procedural legislation regarding the necessity offorensic psychiatry evaluation in court cases of torture.The Use of Medical Evidence and Expert Opinions in International and RegionalHuman Rights TribunalsAsger Kjærum, International Rehabilitation Council for Victims of Torture, Geneva,Switzerland([email protected])5

Traditionally, the focus of torture prevention activities has evolved around the establishmentand implementation of effective legal frameworks and monitoring mechanisms. Theseefforts have significantly increased the protection against torture through the emergence ofnational, regional and international legal standards, whose implementation is monitored byeither judicial or independent expert bodies. However, there is still a significantimplementation gap, which is partly caused by the inability of alleged victims to substantiatetheir allegations. The Istanbul Protocol provides an internationally recognised standardguiding health and legal professionals on how to most effectively document evidence oftorture. This presentation examines how different international human rights tribunalsutilise forensic medical evidence of torture in cases involving allegations of torture and illtreatment and seeks to provide an overview of best practices and challenges faced by thedifferent bodies in ensuring an effective evidence assessment. The presentation concludesthat despite significant capacity constraints on their evidence assessment, the bodies underreview generally do utilise forensic medical evidence of torture when available. This isespecially prevalent in the European and Inter-American regional systems, which also havethe most well developed criteria for evaluation of this evidence.The Role of the Interpreters in the Psychotherapy of Torture SurvivorsLilla Hárdi, Cordelia Foundation for the Rehabilitation of Torture Victims, Budapest, Hungary([email protected])This presentation provides an example of how interpreters are being prepared for thisspecial task at Cordelia Foundation and how they are can be protected from vicarioustrauma and burnout. The interpreters need a preliminary training before taking the role oftranslating seriously traumatic psychological material. They receive regular mental supportafter each working days spent with therapy. The importance of supervision sessions issomething to be emphasized not only during case discussions but the team-building aspectis also inevitable. A special challenge is “the interpretation” of the non-verbal sessions orthe non-verbal psychological material. The presentation deals with the transferencecountertransference situation and the interpreter’s place and role in it.2. Access to Justice: Positive and Negative Impact on the MentalHealth of Torture Victims6

Justice Heals: The Relation between Combating Impunity and the Recovery ofSurvivors of Severe Human Rights ViolationsKnut Rauchfuss, Medical Care Service for Refugees, Bochum, Germany([email protected])Bianca Schmolze, “Justice Heals”, Bochum Germany([email protected])Case studies show that the persistence of impunity in their home countries severely impactstraumatized refugees who are survivors of serious human rights violations. The recovery ofsurvivors of serious human rights violations is impeded by ongoing impunity, or absence oflegal justice, exemplified by the legal protection of the perpetrators through impunity laws,incomplete truth finding, missing integral reparation and a lack of the acknowledgement bysociety of the wrongs done. According to several reports, a high percentage of survivorsdemonstrate an increased mental vulnerability due to impunity. Mental health problemsresulting from traumatic experiences can persist or be reactivated by certain events. Forexample, family members of the forcibly disappeared are unable to properly mourn theirloved ones due to their uncertain fate. In a climate of impunity, the ongoing search for theforcibly disappeared puts family members under a high risk of re-traumatisation. Studiesfrom other continents also show that impunity severely affects the mental health of thesurvivor. Due to the global nature of impunity, evidence of the positive impact of justice onmental health is limited. Nevertheless, a few examples, in particular from Latin America,show that the combined implementation of memory, truth and justice programmes can havea healing impact on those suffering from trauma. These examples demonstrate that the fightagainst impunity fulfils a basic need for the sustainable recovery of survivors, as well asconstituting a legitimate moral struggle for human rights.Psycho-Social Support of Torture Survivors Involved in Legal ProceedingsLibby Arcel, International Rehabilitation Center for Torture Victims, Copenhagen, Denmark([email protected])In order to heal, torture victims need recognition of the wrong-doing by society, for theperpetrators to be held accountable, and guarantees of non-repetition. Justice is a humanneed that no person should be denied and satisfaction of that need can contribute to therestoration of the idea of “a just world” in the mind of the victim. These needs can besatisfied by testifying in front of the court, but they also might be disappointed in their7

expectations. In many countries today torture victims face significant barriers and challengeson different levels in accessing and participating in legal proceedings, including lack of accessand information, threats and reprisals, and re-traumatisation. While sharing their story maybe empowering for some victims, it can also be highly traumatising. It is often difficult forsurvivors to share the specific things that were done to them with others, even friends andfamily. To disclose very personal information publicly can add even more stress to thetorture victim and put their recovery at risk. The presentation will outline the need forvictims for psycho-social support in legal proceedings before, during and after the trial andshare experience from working with victims in the former Yugoslavia.Courts’ Responses to the Needs of Victim WitnessesMiriam Reventlow, International Rehabilitation Center for Torture Victims, Copenhagen,Denmark([email protected])Under international law, states are obliged to prosecute alleged perpetrators of torture andprovide reparations to the victims. Victims of torture may participate in the justice process invarious ways; this includes providing evidence in the form of medical reports, appearing aswitnesses in court, providing testimonies, or by following the proceedings as an observer orclaimant. However, torture victims often face significant barriers and challenges on variouslevels in accessing justice and participating in legal proceedings. While sharing their storymay be empowering for some victims, it can also be highly re-traumatising to providetestimony in court, be questioned by prosecution, judges and lawyers, and not least, facethe perpetrator again. In practice the justice system and approach of the court andinvestigating personnel often does not fully take into consideration and respond to theneeds and expectations of victims throughout the legal process. As prosecutors rely to alarge extend on the account of eye witnesses and primary victims to substantiate their case,trials would benefit from increased efforts to provide adequate support and avoid retraumatisation or disappointment of the witnesses not only for the well-being of theindividual but also for the success of the proceedings. The presentation will address some ofthe core challenges and responses developed by courts.Experience of Supporting Victims in Torture Cases against El Salvador Generalsin the U.S.Karen Hanscom, Advocates for Survivors of Torture and Trauma, Baltimore, USA([email protected])8

To attain justice, a torture survivor must sometimes present testimony at a legal trial againsthis or her perpetrators. In this session, the psychological benefits and costs of such publictestimony will be discussed. Comments will be based on the experience of a psychologistfrom Advocates for Survivors and Torture and Trauma (Baltimore and Washington D.C.) whoprovided psychological support to the plaintiffs in a civil “command responsibility” trial inthe United States. The successful trial against Generals Jose Guillermo Garcia and GeneralVides Casanova was filed by the Center for Justice and Accountability in San Francisco,California, USA.3. Human Rights and the Abuse of Psychiatry: A Historical andCultural ContextThe Legal Exclusion of Mental Patients from Public Baths in Modern JapanMiki Kawabata, Ritsumeikan University([email protected])This report focuses on legal regulations of public baths from the Meiji Era to the Showa Erain Japan, with a special emphasis on the clause disqualifying mental patients. According toprevious studies, the first time the disqualification clause appeared was the national PublicBath Law in 1948; those considered liable to inconvenience other bathers were prohibitedfrom public baths, and included those suffering from infectious diseases and mentalpatients. However, in Tokyo, prior to the national Public Bath Law, the first disqualificationclause in legal regulations of public baths appeared in a municipal legal regulation in 1920. Itexcluded sick people shunned by others as well as unsupervised elderly individuals andchildren from public baths. The disqualification clause next appeared in Tokyo in a municipallegal regulation in 1942; it extended the public bathing prohibitions to people withinfectious disease and mental patients. It is clear, then, that a disqualification clauseexcluding mental patients from public baths existed in Japan well before World War II.The Mental Hygiene Act 1950 in Japan and the Liberation of Home CustodyPatientsAkira Hashimoto, Aichi Prefectural University([email protected])9

The Meiji Government enacted the first national law for mental patients, the MentalPatients’ Custody Act (1900-1950). This law allowed those suffering from mental illness to beconfined at home. At the time, the number of psychiatric beds was extremely limited inJapan, and home custody played a major role in treating mental patients. While detailedstandards for confining patients at home were provided by the law, many prominentpsychiatrists criticized the practice, claiming that many home custody patients lived amiserable life; they often expressed a strong belief that the law should be abolished. A newlaw enacted in 1950, the Mental Hygiene Act, stipulated that mental patients be admittedonly to psychiatric institutions, and required that home custody patients be liberated fromtheir confinement rooms. Psychiatrists were sent to patients’ homes to conduct psychiatrictests and judge if there was a need for hospitalization. However, it remained difficult toliberate and hospitalize home custody patients as there were still not enough beds formental patients, particularly in rural areas. In addition, patients and their family often feltvery anxious about treatment in mental hospitals. As a result, illegal confinement at homewas reported even in the 1960s and 1970s.Forensic Psychiatry and the Modernist Mind in Early Twentieth Century JapanAkihito Suzuki, Keio University([email protected])Japan experienced a hectic and turbulent path to modernization in the early twentiethcentury. The establishment of forensic psychiatry during this period was important both forthe psychiatric profession and for society in general. Leading psychiatrists such as Kure Shuzoand Miyake Koichi published collections of cases of forensic psychiatry and provided a publicface for psychiatry. Their presentation of cases was mediated by societal forces, in which thearrival of mass media and the reorganization of the concept of the public and the privateplayed major roles. The construction of the mind of “dangerous individuals” through forensicpsychiatry provides a window to probe into the structure of modernization and modernismin Japan. This paper will present the social history of the making of a psychological societythrough the analysis of two sets of cases of forensic psychiatry published by two professorsat the University of Tokyo: one by Kure Shuzo (1903-9) and the other by Miyake Koichi(1937).Psychiatry in National Socialist Germany: A Case Study from WuerttembergThomas Mueller, University of Ulm10

([email protected])This presentation will offer a psychiatric historical contribution with a focus on patients whonowadays would be treated as forensic patients. I will consider the issue of psychiatry andpsychotherapy in National Socialist Germany by sketching out some of the preconditions andcircumstances which led to the darkest chapter of German psychiatry. I will then discuss theimpact of Nazi ideology on this medical discipline from 1933-1945, as well as portray someof the crucial developments, political decisions, and central personalities in psychiatry duringthis era. Furthermore, I will examine the harsh impact of political decisions on medicaldevelopment by demonstrating the devastating consequences of these decisions onpsychiatric therapy and care. Lastly, I will connect the matters introduced with a case studyof three Wuerttemberg asylums and the regional micro-history of euthanasia, staff,institutions, political administration, and last but not least, the patients involved.Forensic Psychiatry in Poland before 1939Sebastian Kliwicki, Poznao University of Medical Sciences([email protected])Forensic psychiatry was developed in order to aid the judiciary system, and in particular tofacilitate assessment, using specialist psychiatric knowledge. Synonyms such as legalpsychiatry and criminal psychiatry are sometimes used. Forensic psychiatry in Poland datesback to the early 19th century. Andrzej Janikowski’s book “O wątpliwym stanie władzumysłowych” (On the Doubtful Condition of Mental Powers), published in 1845, was the firstmanual of forensic psychiatry in Poland. In 1904, a psychiatry, neuropathology, and forensicpsychiatry division was opened at the Warsaw Medical Association. Issues related to forensicpsychiatry played a very important role in the Polish Psychiatric Association, founded in1920. Six out of the 18 meetings held in the interwar period centred on legal issues. Thediscussed problems included incapacitation of the mentally ill, alcohol abuse in civil andcriminal law, criminal biology, diminished responsibility, organization of penitentiarypsychiatric care, etc. Several mental hospitals had forensic departments, while 5departments for observation and treatment of inmates with mental disorders were openedin prisons. The year 1939 and the outbreak of World War II impeded and delayed thedevelopment of forensic psychiatry in Poland.Forensic Medicine, Berlin (300 Years Charité; 200 Years University of Berlin)Volkmar Schneider, Consulting Forensic Pathologist, Berlin, Germany11

([email protected])In a Cabinet order dated August 16th, 1810, Frederick William III, King of Prussia, allowed“*t he Establishment of a University in Berlin” with links to the Academy of Sciences, Artsand other institutions as also being part of academic instruction. We may note the followingfields for the study of medicine: Comparative and Pathological Anatomy, Osteology,Physiology, Practical Medicine, Surgery, Obstetrics and Materia Medica. Forensic Medicinewas taught not only after the foundation of the University, but since 1724 in the CollegiumMedico-Surgical, i.e. 14 years after the construction of the "House of Pestilence", which waslater called "Charité". The start of Forensic Medicine as an academic discipline is linked withthe name of Wagner, who proposed that a practical educational establishment forpharmacology be set up. Among his successors, we may note Fritz Strassmann, the cofounder with Fraenckel, both from Jewish families, who had examined the body of RosaLuxemburg in 1919. A polemic arose around the body of Rosa Luxemburg in 2009 when thecurrent Chair of the medical school claimed that the (headless) body of Rosa Luxemburg wasin his museum, implying that Professors Strassmann and Fraenckel had participated in afraud by burying someone else’s remains in her place. These allegations remain to this dayunproven. During the presentation, there will be a more detailed discussion of the facts andforensic medicine at different times of political upheaval (Empire, Republic of Weimar, ThirdReich, Division of Germany, and Reunification).4. Human Rights Law and Mental Health in the UK and AustraliaArticle 8 of the Human Rights Act 1998: A Review of Case Law Related toForensic Psychiatry and Prisoners in the United KingdomMartin Curtice, Royal College of Psychiatrists Special Committee for Human Rights, London,UK([email protected])The Human Rights Act 1998 incorporated most of the European Convention on HumanRights into United Kingdom domestic law. Article 8 of the HRA provides the right to respectfor private and family life, home, and correspondence. It is a qualified right, underpinned bythe core principle of proportionality and therefore can be dynamically interpreted. Theforensic psychiatry and prison settings in the United Kingdom have produced numerouscases based on perceived infringements that may or may not have breached Article 8.Particular areas of importance that have emerged from case law include seclusion,12

communication and correspondence, hospital transfers and physical integrity e.g. risk ofacquiring sexually transmitted diseases and other infections associated with illicit drug usein prison; cross-dressing by patients in hospitals. These cases, when analyzed, demonstratethe diversity of situations in which Article 8 can apply and helps to both demonstrate howArticle 8 may be breached in practice and also illustrate key Article 8 principles that can beused and implemented in practice to safeguard both clinicians and patients.Article 3 of the ECHR: Evolving Case Law – Implications for People Detained inHospitals and PrisonsLucy Bacon, South Staffs and Shropshire NHS Trust, Stafford, UK([email protected])The European Convention on Human Rights is playing an ever-increasing role in determiningthe standards of treatment of those detained by the state and hence is of particularimportance for those in hospitals, prisons or similar institutions. The European Conventionon Human Rights is a ‘living instrument’ such that judgments emanating from the EuropeanCourt of Human Rights will continually build upon previous jurisprudence and evolve overtime. As Article 3 case law has evolved, its interpretation has broadened to now include athorough scrutiny of hospital and prison conditions and healthcare provision where peopleare kept in detention. This discussion elucidates evolving areas where Article 3 may beinfringed in prison and healthcare facilities such as: the provision of requisite medical care,the effect of restrictive regimens, multiple complaints and violations within one Article 3claim, procedural effectiveness, conditions of detention and the cumulative effects ofconditions of detention. This review of evolving Article 3 case law describes developmentswhich can be considered in practice.Almost a Revolution (Again): A Theoretically-Informed Ethnographic Study ofReforms to English Mental Health LegislationElizabeth Fistein, University of Cambridge([email protected])In England and Wales, the Mental Health Act 1983 regulates compulsory treatment ofmental disorder. The criteria for detention under the Act were amended by the MentalHealth Act 2007, the controversial product of a decade of debate. As yet, little is knownabout the impact of the new legislation on clinical practice. This paper describes atheoretically-informed ethnography of clinical assessment and decision-making during the13

12 months following implementation of the amendments. The data are audio recordings ofclinical teams deciding whether to detain a person they have assessed, supplemented by indepth interviews with clinicians. Thematic analysis and discourse analysis were used todocument: (i) themes discussed during decision-making; (ii) how these themes were maderelevant to the decision, and (iii) how clinicians justify the decisions they have made. Theresults suggest that the Mental Health Act 2007 has had little impact on day-to-day practice.However, concepts from the Mental Capacity Act 2005 (best interests, assessment ofcapacity) are being discussed during Mental Health Act assessments and made relevant todecisions to detain. Vulnerability to exploitation, which is not one of the criteria fordetention, is also regularly cited as a justification for detention of female patients.The Right to Liberty and the Deprivation DilemmaNeil Allen, University of Manchester([email protected])Following the criticism of English law by the European Court of Human Rights (HL v UnitedKingdom), the former scarcity of procedural regulation surrounding the detention ofcompliant, incapacitated adults can now be contrasted with the sheer complexity of theDeprivation of Liberty Safeguards (‘DoLS’). The scheme only applies to those “deprived” oftheir liberty and not to those whose liberty is merely “restricted”. The boundary betweenthe two is undergoing intense scrutiny as the judiciary seeks to incorporate the guidingEuropean principles into domestic law. We shall consider the issues of principle regardingwhere this line should be drawn and their significance in the context of protecting those ofunsound mind.Social Deprivation and use of Mental Health Legislation in New ZealandAnthony John O'Brien, University of Auckland([email protected])Robert Kydd, University of Auckland([email protected])Christopher Frampton, University of Otago([email protected])14

Low socioeconomic status has consistently been associated with poorer health outcomes.Few studies have used ecological analysis to explore relationships between area measures ofdeprivation and use of mental health legislation. We used an ecological design to exploreassociations between two area measures of relative deprivation and the two mostcommonly used sections of New Zealand mental health legislation. High levels of relativedeprivation were positively correlated with use of both acute and long term community careprovisions of mental health legislation with the correlation with long term care achievingsignificance (r .518; p .016). Low levels of relative deprivation showed negativecorrelations with use of both provisions. The correlation of -.493 between low levels ofrelative deprivation and acute care provisions was significant at p .023. In stepwiseregression proportion of population 15-64 contributed to the model for section 11, butethnicity contributed to neither model. Mental health legislation is used disproportionatelyin areas with high levels of relative deprivation. The results have implications for regionalallocation of funding for mental health and social services to support community based care.Further research is needed to explore other factors which may account for the regionalvariation.5. Recent Developments in PsychopathyOptimization of Standardized Risk Assessment in the Penal System of LowerSaxonyEberhard Heering, Charité Universitätsmedizin Berlin([email protected])In early 2008, the penal system of Lower Saxony established a specialized departmentresponsible for risk assessment of all prison inmates of the state. The department performsan estimated 200 risk assessments a year, with the majority conducted to measure theinmates’ aptitude for social therapy and readiness to be transferred to an open prison. TheInstitute for Forensic Psychiatry of Berlin - Charité plans to follow the work of thisdepartment for a minimum of two years by offering a scientific exchange and by reviewingrandom samples of the risk assessments and verifying the proper application of currentstandards. We are particularly interested in determining which topics are discussed withinmates during the risk assessment, whether or not standardized risk scales are applied, andin evaluating whether the conclusions drawn are based on information that could be takenfrom court and prison files. The results of the study will be presented at the Congress.15

The Importance of Aggressive Beh

Institut Philippe-Pinel, Montréal, Canada Christoph Paulus Co-Chair Humboldt University Berlin, Germany Humboldt University . Institute for Laboratory Medicine, Berlin Hermann Simon Centrum Judaicum, Berlin Andreas Schmitt Vivantes International Medicine, Berlin . 4 1. Strengthening the Case: Mental Health Examinations of Torture