40th birthday of the Italian Mental Health Law 180 - perception and reputation abroad, and a personal suggestion.

How things are perceived from a distance may help better understand their nature. Perceptions at home are likely to shape perceptions abroad. The mutual cross-references between local and distant perspectives on the Italian Mental Health Law 180 may help understand the process which preceded and resulted in the reform. This editorial argues that Law 180 came about at a unique - enabling - time in history. It argues that the run-up to and passing of Law 180 constituted a great accomplishment by professionals, the wider public and politicians/administrators. This editorial goes on to argue that the profession managed to cope with (many) adverse effects of the reform. The attention that Law 180 has received internationally should be devoted to other national (or regional) mental health reform processes as this may help us to understand how mental health care systems evolve and what defines 'windows of (operative) opportunity' or 'moments for (public) action'.

The importance of the patients deemed not guilty by reason of insanity for the psychiatric reform.

According to the Greek Penal Law if someone "because of a morbid disturbance of his mental functioning" (article 34) is acquitted of a crime or misdemeanour that the law punishes with more than 6 months imprisonment, then the court orders that this individual should be kept in a public psychiatric institution if the court reaches the conclusion that this person poses a threat to public safety.1 Individuals who have broken the law and deemed "not guilty by reason of insanity" are treated in psychiatric units of Psychiatric Hospitals according to the article 69 of the Penal Code. In Athens, in the Psychiatric Hospital of Athens and the Dromokaiteion Psychiatric Hospital, and in Thessaloniki in the Unit for "Not guilty by reason of insanity (NGRI)". The person who is deemed not guilty by reason of insanity following a crime is facing double stigmatisation and marginalisation from both the legal and the health system. He/she is usually treated initially with fear and later since there is no therapeutic aim but only the court instruction for "guardianship", with indifference. The patient who is committed by the courts in a psychiatric unit for being "NGRI" is facing a unique legal and psychiatric status.2 In this respect he/she is disadvantaged when compared to either convicted criminals or psychiatric inpatients. If the patient was not found "NGRI" (ie innocent as far as sentencing is concerned) he would have been punished with loss of liberty for a certain (specific) amount of time, and like all individuals convicted in court he/she would have the right to appeal and reduce his/her sentence in a higher court and maybe released from prison earlier for good behaviour etc. In this respect the individual found to be "NGRI" is disadvantaged when compared to a convicted felon since he/she is kept for an undefined period of time. Additionally, he/she will be allowed to leave the psychiatric unit following a subjective assessment of a judge with no psychiatric knowledge who will decide that this certain individual has "ceased to be dangerous". These problems are accentuated by the difficulties that the Greek justice system is facing. On the other side, from the psychiatric point of view, the "NGRI" patient who is an inpatient is not receiving the holistic, (bio psycho social) treatment and assessment of needs he/she requires. The psychiatric team looking after him, once the acute symptomatology is controlled is just getting used to a patient who will not be discharged in the immediate future. These patients form the "new chronic asylum psychiatric inpatients" for whom the treating psychiatrists are not allowed to discharge back into the community whilst it is unclear whether they can be transferred to supported rehabilitation units. It is a medical but also legal paradox to assign to contemporary psychiatric units aiming mainly to treat patients in the community to "keep and guard" inpatients whilst these psychiatric units should focus on care and rehabilitation of the patients (including the "NGRIs").3 Keeping patients like these in psychiatric units creates problems in the functioning of the units. These patients are "kept" in acute beds for long periods of time (5 to 6 years minimum) with patients treated voluntarily or against their will and cannot be discharged without a court's decision. The problems are obvious if one realises that the average time of hospitalisation is not exceeding 2 months for the vast majority of psychiatric patients. With the prolonged stay patients of the "article 69" (NGRIs) they not only burden the already limited resources (there is an established lack of psychiatric beds nationwide) but also this prolonged hospitalisation increases their stigmatisation and marginalisation. Thus the prolonged hospitalisation for "safety" reasons according to the court decision leads to the absence of a therapeutic aim other than maintaining the patient on the ward. Greece has agreed that there is an urgent need in developing community psychiatry services and closure/transformation of the big psychiatric hospitals (asylums). It is impossible to close hospitals where "NGRIs" are kept. The decision to move them into the community is not a medical-psychiatric but a legal one. In this respect it is imperative to establish a Forensic Psychiatric Unit for these patients. In our country as the "Psychargos" external evaluation highlighted, there are great gaps in the provision of Forensic psychiatric services.3 It must be emphasised that these gaps affect negatively psychiatric reform and social reintegration not only for the forensic psychiatric patients but for the whole of mentally ill individuals. Given that forensic Psychiatric services are developed in Athens and Thessaloniki and that training in Forensic Psychiatry has moved forward, it is imperative that the state should build upon the existing knowledge and experience and create specialist forensic units aiming to treat and rehabilitate this special and important group of patients.4 Only when the patients found "not guilty by reasons of insanity" have their own (safe for the society and them) therapeutic and rehabilitative services the aim of de-institutionalisation will be visible and realistic to implement.

A review of the new provisions for sanctioning mentally disordered offenders in China, in a broader historical context.

Reforms of the criminal justice system in China in recent years have included the 2012 Code of Criminal Procedure (CCP), which resulted in new disposals for mentally disordered offenders. From a Western perspective, changes in Chinese criminal law are sometimes clichéd as toothless window dressing, but they may represent a genuine step forward in safeguarding human rights. Taking a historical perspective, this paper reveals that in the East, as much as in the West, there is a 'moral tradition' of not punishing mentally disordered offenders who are not considered responsible for their acts. There are clear differences in disposal for those acquitted having been found 'not guilty by reason of insanity'. Whereas Western jurisdictions have offered (criminal) courts the opportunity for commitment in (forensic) mental hospitals from the early 19th Century, in China, disposal has remained, until the recent changes, the responsibility of the administration (mainly the police) or the family of the offender. A few high profile cases brought to light the inadequacy of these arrangements and the general disregard of obvious mental health issues when sentencing offenders. There was lack of clarity regarding who would take responsibility for treatment and issues of future public protection arising from a mental disorder. The 2012 CCP introduces the power of mental health commitment by the judiciary for those found non-responsible for an offense because of a mental disorder. Similar to provisions in Western jurisdictions there remain human rights concerns regarding aspects of 2012 CCP and the role of 'preventive detention' for mentally disordered offenders on indeterminate secure mental health detention. Nevertheless, the shift to judicial decision making in such cases and the possibility of mental health commitment are welcome steps in improving the human rights of this vulnerable population.

Experiences of Detention under the Mental Health Act for Adults with Anorexia Nervosa.

UNLABELLED: People with Anorexia Nervosa are often resistant to treatment and can be detained under the Mental Health Act. Detention can be distressing for some client groups; however, there is little research to explore how people with Anorexia Nervosa experience detention and how these experiences impact on recovery. This study utilized a qualitative methodology to develop a model for understanding how people perceive, experience and process detention under the Mental Health Act. Data from 12 participants was analysed using constructivist grounded theory. Four overarching categories conceptualize their experience over time: 'the battle', 'the bubble', 'stepping out of the bubble' and 'the anorexic self'. Within each overarching category are further subordinate categories that represent the nuances of the data. The resultant model is discussed in relation to the literature, whilst recommendations have been made to embed person-centred, recovery practice into inpatient services. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: People detained under the mental health act with anorexia nervosa often respond by engaging in a battle with clinicians. This follows by the person withdrawing into a 'bubble' where the individual starts to feel some relief that they are no longer in control of their eating, but this competes with the lack of self and the emerging anorexic self. Clinicians need to be aware that individuals detained may have mixed feelings about their hospital admission.

The development of an innovative music therapy treatment method: trial competency through music.

Competence to stand trial is necessary for a defendant in criminal adjudication. Recent estimates indicate that between 50,000 and 60,000 defendants in the United States raise the question of competence each year, with approximately 20 percent found incompetent to stand trial (IST). Most of these defendants are committed to an inpatient facility for competence restoration. Although psychopharmacological intervention is a critical component of restoration, as most defendants are found incompetent because of a psychotic disorder, many other modalities of treatment are used. Traditional treatment methods include the use of standardized testing and psychoeducational group sessions. This article discusses the development of an innovative intervention using music therapy. Music as the catalyst provides a forum in which psychiatric patients are engaged and observed within a structured environment designed to address both their factual and rational knowledge and abilities to assist their attorneys in their defense. Trial competency training through a specific music therapy method called Competency Through Music (CTM) is presented, including examples of how music can be used to educate patients and assess trial competence.

[Psychiatric treatment--legal aspects]. / Rechtliche Aspekte einer Behandlung in der Psychiatrie.

Doctors want to save lives and promote health. But their patients have the right to decide for themselves about what doctors do with them, and they are free to refuse treatment, even if it is unreasonable from a medical perspective. The law acknowledges this freedom even if a patient is incapable of responsible self-determination as a result of (mental) illness. Treatment contrary to the patient's declared intention will be allowed only under specific, narrow circumstances. These requirements must be legally established in a clear and precise manner.

[Involuntary treatment in psychiatry]. / Zwangsunterbringung und Zwangsbehandlung in der Psychiatrie.

Involuntary treatment in psychiatry should be reflected under the German constitutional right of self-determination und the ethical principles of autonomy and beneficience. Forced treatment in psychiatry should be applied only as a last resort. A narrative perspective reconstructs the case of Gustl Mollath who was hospitalized in forensic-psychiatric institutions because of an alleged delusion. Psychiatric experts should be aware of the potential of misuse when defining what is real and what seems to be a delusion.

Subjective experiences of compulsory treatment from a qualitative study of early implementation of the Mental Health (Care & Treatment) (Scotland) Act 2003.

Compulsory psychiatric treatment is highly contested, and little research has focused specifically on direct experiences. The Mental Health (Care & Treatment) (Scotland) Act, 2003 introduced new roles and provisions including community treatment orders, and was designed to increase participation, ensure treatment was beneficial and was the 'least restrictive' alternative. This article draws on findings from semi-structured interviews with 49 individuals, who had experienced compulsion under this new legislation during 2007-2008, that were part of a broader cohort study. Interviews with service users were conducted at two stages with 80% agreeing to be interviewed twice. The sample included people on a variety of compulsory orders from four Health Board areas, some of whom had been detained for the first time, while others reported 'revolving door' experiences. Peer researchers who were mental health service users carried out the interviews in partnership with professional researchers. The findings suggest that legislation had a limited impact on participation in the process of compulsion. Consensus was that although service users felt there was increased opportunity for their voices to be heard, this was not matched by having increased influence over professional decision-making, especially in relation to drug treatments. According to people's direct experiences, the passing of the legislation in itself had done little to change the dominant psychiatric paradigm. While providing a foundation for improving the process of compulsion, the findings suggest that as well as legislative reform, fundamental shifts in practice are needed both in terms of the nature of therapeutic relationships, and in embracing more holistic and recovery perspectives.

Evaluating shame transformation in group treatment of domestic violence offenders.

Offender rehabilitation, pitting the rational ability of criminal justice against the seeming irrationality of criminal behavior, remains controversial. Psychology highlights the importance of emotions in mediating individual behavior. Borrowing from restorative justice as a more emotionally intelligent form of justice, this article examines the role of shame and guilt in a domestic violence offender treatment program. The emotions are differentiated and then activated, similar to the use of reintegrative shaming in restorative justice, to promote greater offender accountability and empathy. Using a two-group comparison of male domestic violence offenders, measurements were taken on three sets of scales in assessing the outcome of the shame transformation process. Statistically significant effects were found for self-esteem and empathetic concern. Findings and future research are discussed.

[Involuntary Hospitalization in Frankfurt/Main, Germany--anachronism or up-to-date?--the psychiatric information system PISA]. / Zeitgemäb oder anachronistisch? Zwangseinweisungspraxis in Frankfurt am Main--Psychiatrisches Informationssystem Stationär-Ambulant (PISA).

OBJECTIVE: The evaluation of local mental health and complementary psychosocial care remains a difficult venture. For this reason systematic development of appropriate services is barely possible. The present study aimed to get reliable data of psychiatric in- and out-patient treatment as well as of complementary psychosocial care. METHODS: In the city of Frankfurt/Main the PISA project was initiated by the municipal mental health Mo-Ruservice. 677 involuntary hospitalizations were examined in the psychiatric clinics of the city of Frankfurt/Main with regard to diagnoses, socio-demographic data, complementary psychosocial outpatient care and circumstances of hospitalization. RESULTS: Any complementary psychosocial care was missing in more than seventy percent of patients. Only 10 percent of involuntarily admitted patients were examined by a physician before reaching the hospital and in only 1.3 percent the municipal mental health service had been consulted. CONCLUSIONS: Results show that a systematic improvement of precautionary complementary psychosocial care for risk patients is needed as well as the obligation of psychiatric emergency consultation before involuntary hospitalization.

Trends and developments in public psychiatry in France since 1975.

OBJECTIVE: The authors present an account of the current state of sectorization in France and its development over the last decade. METHOD: The paper is based on statistics collected by the French Health Ministry and on relevant laws and regulations. Comments by patients, families and professionals are presented. RESULTS: The supply of mental health care is usually satisfactory, and there is a tendency for in-patient units to be converted into day hospitals. There is a large disparity between regions, especially in child and adolescent psychiatry. The 1838 law governing compulsory admissions was revised in 1990, and this revision was the object of a commission of inquiry in 1995. Psychiatric units work on the borders between health and social services and are forging new links between the two. CONCLUSION: Psychiatric care requires an integrated health and social perspective. In the field of mental health legislation European recommendations are called for.

Assessment of coercive and noncoercive pressures to enter drug abuse treatment.

This paper reports preliminary data derived from a standardized interview scoring procedure for detecting and characterizing coercive and noncoercive pressures to enter substance abuse treatment. Coercive and noncoercive pressures stemming from multiple psychosocial domains are operationalized through recourse to established behavioral principles. Inter-rater reliability for the scoring procedure was exceptional over numerous rater trials. Substantive analyses indicate that, among clients in outpatient cocaine treatment, 'coercion' is operative in multiple psychosocial domains, and that subjects perceive legal pressures as exerting substantially less influence over their decisions to enter treatment than informal psychosocial pressures. Implications for drug treatment planning, legal and ethical issues, and directions for future research are proposed.

Multiple personality disorder in criminal law.

The authors review the recent literature on multiple personality disorder (MPD), the most severe and chronic of the dissociative disorders, in relation to court cases of competence to stand trial, the insanity defense, and research on malingerers feigning MPD. Issues relevant in the assessment of competency and insanity are described. Features characteristic of MPD, including amnesia and alterations in consciousness and personality, have varying degrees of influence over the criminal behavior of an individual with MPD. As in other psychiatric disorders, the influence of MPD on an individual's competence to stand trial, and sanity, can be evaluated systematically. This article discusses a specific diagnostic tool, the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D), an extensively field tested instrument that is potentially quite useful in forensic assessment of suspects manifesting dissociative symptoms and disorders. The particular advantages of the SCID-D will be reviewed in the context of some well known criminal cases involving MPD. Further research using diagnostic interviews for the systematic assessment of dissociative symptoms and MPD in criminal cases will continue to clarify the influence of these symptoms in a forensic context.

Brown versus New York: the Rashomon of delivering mental health services in the 1990s.

This article examines a case study of one homeless mentally ill woman in New York City to show the differing perspectives on mental illness among mental health consumers, family members, mental health professionals, and advocates. Different issues emerge, and different priorities for care become clear. The social worker as case manager must design intervention strategies based on these differing perspectives, a crucial challenge for the profession. This article reviews the current literature on case management and suggests a holistic approach that better meets the needs of mentally ill people, their family members, and the community.