It has been well documented that Adverse Childhood Experiences (ACEs) lead to unfavorable outcomes in later life, especially with regard to health and psychological outcomes. Recent research has demonstrated the impact of early childhood adversity on the onset of aggression and illegal behavior. However, often those with mental illness diagnoses with comorbid behavioral problems exhibit trajectories that include both arrest and hospitalization. While some are arrested for their criminal behavior, others are hospitalized. This begs the question: are those with mental illness and behavioral problems more likely to be arrested, or hospitalized, for their early behavioral problems? In the current study, it was hypothesized that arrest precedes hospitalization for the majority of these offenders, and that specific diagnoses of a mental illness are related to outcome. It was also hypothesized that early exposure to environmental adversity, as measured by the age of earliest ACE and total ACE score, would impact whether offenders were arrested or hospitalized first. The data for this study were gathered from comprised sample of 182 adult psychiatric inpatients in a secure forensic facility. Data were archival and retrospective in nature. All participants had been hospitalized following acts of violence or aggression, exhibiting a history of both behavioral problems as well as mental illness. A series of logistic and linear regressions were used to examine the relationship between reason for first admission to a psychiatric facility, diagnosis of a mental disorder, and early childhood adversity to clarify whether early problematic behaviors resulted in initial arrest or psychiatric hospitalization. Results indicate that subjects were much more likely to be hospitalized initially than arrested (33.5% arrested first, 66.5% hospitalized first). A diagnosis of impulse control disorder was significantly related to whether initial incident led to arrest or hospitalization (p=0.030), while the diagnosis Page 54 2016 Appalachian Student Research Forum of ADHD neared significance (p=0.056). No significant relationship was found between incidence of initial arrest or hospitalization and age that drug/alcohol abuse began. Other findings and implications for future research will be discussed.

Psychological evaluations administered by forensic psychologist in personal injury cases are surrounded by complex issues. Although empirically-based research has legitimized that psychological damages do exist in personal injury cases there is a missing link in the way forensic psychologists are conducting these evaluations. Prior researchers suggested that some personal injury evaluations had been dismissed or overlooked due to a lack of a standard of care. Addressing the current literature, this study examined how a diverse group of 14 licensed forensic psychologists, operating in different judicial jurisdictions (Daubert, Frye, and Independent) were conducting personal injury evaluations and their perspectives on the implementation of a standard of care. A qualitative thematic analysis design was used to gain a more in-depth understanding of this phenomenon. Systems theory was the conceptual framework that informed this study and guided the methodology employed. The identified themes were organized into steps reflected in an adapted version cube model. The study promotes positive social change by fostering confidence in the field of psychology and personal injury evaluations with regard to bolstering the overall credibility, reliability, and validity of the practice and processes involved. Further, positive change can occur through the development of framework that assists in leveling the practice by keeping evaluations flexible, but consistent; basing the decision regarding implementing a standard of care on the utility of the framework, along with future findings and developments in the field.

This dissertation critically investigates the current framework for psycholegal assessment of accused persons who are suspected or alleged to have lacked criminal incapacity at the time of committing an offence. This system must function as effectively as possible to ensure the interests of justice and the community are best served. Issues that impact how effectively the criminal justice system collaborates with psychologists and psychiatrists, who act as expert forensic mental health assessors, are identified and recommendations are made accordingly. The study first examines the theoretical base regarding the terminology surrounding criminal capacity, mental illness and automatism, with regard to how the understanding of concepts differ in law and psychology and psychiatry and how this negatively affects the process of assessment. The study then investigates the constitutional rights of accused persons admitted for observation, the effect this has on the patient and legal process, the accuracy and reliability of the diagnosis and the admissibility of expert evidence. Next a comparative study is made utilising English Law as a tool for analysis. The main findings are that lack of understanding and clarity are the main issues that hinder the collaboration between the legal and mental health care professions and that this may be remedied by a system of registration and education for forensic psycholegal assessors. An alternate and concurrent method of direct referral is also suggested as it may relieve some of the strain on the current system. / Dissertation (LLM)--University of Pretoria, 2011. / Public Law / unrestricted

This is a mixed research methods study based at the forensic mental health unit of Weskoppies Psychiatric Hospital in Pretoria, Gauteng Province, South Africa. The overarching aim of the study was to help add insights that could indirectly inform the wider discourse on sexual offending in society and to the body of knowledge on the prevention of sexual violence – including in forensic mental health. Qualitative and quantitative methods were applied through concurrent and transformative mixed research methods, premised on the philosophical stance of pragmatism. Records of individuals accused of sexual offences were explored and in-depth interviews with individuals accused of sexual offending and / or other types of charges referred for observation in terms of the Criminal Procedure Act, 51, 1977 (CPA 1977) were conducted. Psychiatric and psychosocial features and general perspectives on sexual offending were explored. Data collection was done from the end of 2014 to the end of 2015. In terms of findings, the record-based component of the study revealed that the majority of those referred were mentally capable, were known to the victims and lived in close proximity to them. Boys and girls, elderly women and socially isolated individuals seemed the most vulnerable irrespective of the mental capacity of the accused at the time of an alleged incident. In-depth interviews revealed scepticism, myths and new locally relevant ways of defining sexual violence. Socio-economic determinants of health seemed to render potential perpetrators of sexual offending vulnerable to violence and included adverse childhood events, poverty, unemployment and inequality. Experiences during and after arrest revealed possible human rights violations of alleged offenders by communities and law enforcement systems. Mental illness worsened stigma even in the hands of law enforcement systems. Central phenomena viz. ‘the perceived oppression of men’ and ‘vulnerability’ of potential victims and potential perpetrators emerged. A tentative theory of ‘vulnerability’, as an explanation and an approach to preventing sexual and other forms of violence in society, is proposed for both victims and potential perpetrators. Public health, socio-ecological frameworks of sexual violence prevention and other explanatory and prevention frameworks on sexual offending seem aligned to the study’s findings. Patriarchy, collective violence inherited from South Africa’s past, social cognitive theory on learning, trauma re-enactment, and other factors seem to play a role. In terms of mixed research contributions, a need for robust ways of studying diverse populations such as South Africa is emerging. Further, an initial stance of studying prevention of sexual violence from a victim-centred advocacy lens, has been transformed to yield accused individuals’ advocacy issues as well. Multi-system prevention approaches involving at-risk potential perpetrators, and not just victims, seem to be the next frontier for research and interventions. The study reveals insights that may contribute to the field of violence prevention. / Thesis (PhD)- University of Pretoria, 2018. / Psychiatry / PhD / Unrestricted

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Prior research suggests a greater degree of suicidality and self-harm behavior in those involved with criminal justice and forensic mental health systems. Such individuals also evidence increased exposure to early childhood adversity, which is often associated with suicide risk. Other significant predictors of suicidality have been noted within forensic populations, however, including indicators of specific psychopathology and situational and demographic factors. These populations present with overlapping risk factors that remain underexamined. In the current study, 182 persons residing in secure forensic psychiatric care following incidents of illegal and aggressive behavior were evaluated. Adverse childhood experiences and other empirically derived potential predictors of suicide attempts and self-harm were examined via binomial logistic regression. Findings indicate frequent experiences of early adversity across participants, and that a combination of race, individual adverse childhood experiences, number of biological children, and diagnoses of either posttraumatic stress disorder or borderline personality disorder were significant predictors of suicide attempts, self-harm behavior, and first hospitalization resulting from a suicide attempt. Clinical and research implications are discussed.

Au Canada et ailleurs dans le monde, le système judiciaire occupe une place de plus en plus importante dans la prise en charge des personnes vivant avec un trouble mental grave. Le rôle du système judiciaire comme levier d'accès aux soins est particulièrement évident dans le cas des personnes déclarées non criminellement responsables pour cause de troubles mentaux (NCR). La vaste majorité des personnes déclarées non criminellement responsables pour cause de troubles mentaux (NCRTM), formant la clientèle principale des services psycho-légaux, était déjà connue des services de santé mentale. Cela questionne la présente capacité du réseau à répondre aux comportements perturbateurs et fait ressortir la possibilité de prévenir le potentiel passage à l’acte et la trajectoire judiciaire subséquence. La présente thèse de doctorat utilise des données administratives provenant des secteurs de la santé, de la justice et de la sécurité publique pour plus de 1 000 personnes qui ont reçu un verdict de non-responsabilité criminelle au Québec. Ces données sont complétées par des entrevues qualitatives avec des parties prenantes. Ensemble, l’analyse de ce corpus de données permettent de mettre en lumière les barrières à l'accès aux soins et les interruptions de services que subissent, dans leur parcours de soins, les personnes atteintes de troubles mentaux sévères et ayant des comportements perçus comme perturbateurs ou dangereux qui les rendent susceptibles d’être judiciarisés. Le premier article décrit les tendances d’utilisation de services de santé et des réclamations de médicaments sur ordonnances dans l’année précédant une infraction qui a entraîné un verdict de NRCTM. Les résultats indiquent que – bien que des résultats antérieurs montrent que plus de 70 % des personnes NCRTM avaient déjà été en contact avec des services pour des raisons de santé mentale – moins de la moitié des personnes déclarées NCRTM avaient bénéficié d’une réelle prise en charge médicale avant l’incident. Les résultats montrent également qu’une personne sur cinq avait commis l’infraction moins d'une semaine après le contact de santé mentale le plus récent. Parmi celles qui avaient au moins une prescription pour un antipsychotique, près de la moitié ne prenaient pas d’antipsychotique au moment de l’infraction. Le deuxième article identifie les facteurs individuels et contextuels facilitants et ceux faisant obstacles à l’accès aux services de santé mentale dans la période avant le délit. Les considérations géographiques jouent un grand rôle dans la possibilité d’accéder et de recevoir les services de santé mentale spécialisés – au-delà des facteurs individuels liés aux besoins. De plus, vivre avec des proches diminue de moitié la probabilité d’aller chercher des services de santé mentale et diminue l’intensité de l’utilisation de services de santé mentale spécialisés, même en tenant compte et ajustant les modèles pour les besoins. Finalement, le troisième article repose sur l’analyse d’entretiens individuels et de groupes d’entretiens focalisés avec 16 personnes ayant de l’expérience vécue (pairs aidants, proches aidants), des praticiens et des administrateurs. Les résultats mettent en évidence comment les expériences passées de stigmatisation, de traumatisme, d'inefficacité et de discrimination au sein d'un système hospitalo-centrique influencent la capacité des utilisateurs de services et des proches aidants à chercher et à s'engager dans les soins. Les mécanismes d'accès existants en période crise, tels que l'intervention policière et les services d'urgence, sont des options inacceptables pour les utilisateurs de services et leurs aidants familiaux et sont donc souvent considérés comme des derniers recours. Par conséquent, les utilisateurs de services entrent dans le système de santé avec des besoins complexes qui sont difficiles à traiter avec les connaissances cliniques actuelles et qui résultent bien souvent en des mesures coercitives plutôt qu’axées sur le rétablissement. Les résultats peuvent être interprétés à la lumière de la stigmatisation structurelle, qui fait référence aux politiques et pratiques institutionnelles qui ont un impact négatif sur les opportunités des personnes atteintes de maladies mentales. Dans le cas présent, la stigmatisation structurelle réduit l'accès aux soins en raison d'une allocation de ressources inadéquate, d'un manque de collaboration intersectorielle et d'intégration des soins, d'attitudes et de pratiques négatives des praticiens de la santé, et d'une surutilisation d'approches coercitives. Nous proposons des stratégies pour réduire les barrières à l’accès liées au système et aux prestataires de soins. / In Canada and elsewhere, the justice system is playing an increasingly important role in the care of individuals with severe mental illness. The role of the justice system as a lever for accessing care is particularly evident in the case of individuals found not criminally responsible on account of mental disorder (NCR). The vast majority of individuals found NCR, who make up the majority of forensic mental health service users, were already known to mental health services. This raises questions about the current capacity of the mental health system to respond to disruptive behaviors and highlights the potential for preventing future justice involvement. This doctoral thesis uses administrative data from the health, justice, and public security sectors for over 1,000 individuals who received a verdict of NCR in Québec. These data are complemented by qualitative interviews with stakeholders. Together, the analysis of this data corpus highlights the barriers to accessing care and service interruptions that individuals with severe mental illness and behaviors perceived as disruptive or dangerous encounter in their care pathway, leading to the risk of judicial involvement. The first article describes trajectories in health services use and prescription drug claims in the year preceding an offense that led to a NCR verdict. The results indicate that, although previous research has shown that over 70% of NCR individuals had already been in contact with mental health services, less than half of NCR individuals had received no consistent care prior to the offense. The results also show that one in five individuals committed the offense less than a week after their most recent mental health contact. Among those who had at least one prescription for an antipsychotic, nearly half were not taking an antipsychotic at the time of the offense. The second article identifies individual and contextual factors that facilitate or hinder access to mental health services in the period prior to the offense. Geographic considerations play a major role in the possibility of accessing and receiving specialized mental health services, beyond individual factors related to needs. Additionally, living with family members decreases the likelihood of seeking mental health services by half and decreases the intensity of specialized mental health service use, even after adjusting for models based on needs. Finally, the third article is based on the analysis of individual interviews and focus groups with 16 individuals with lived experience (peer support workers, family caregivers), practitioners, and administrators. The results highlight how past experiences of stigma, trauma, inefficiency, and discrimination within a hospital-centric system influence the ability of service users and family caregivers to seek and engage with care. Existing access mechanisms during crisis periods, such as police intervention and emergency services, are unacceptable options for service users and their family caregivers and are often considered as a last resort. As a result, service users enter the healthcare system with complex needs that are difficult to address with current clinical knowledge and often result in coercive measures rather than recovery-oriented care. The results can be interpreted in light of structural stigma, which refers to institutional policies and practices that negatively impact the opportunities of people with mental illness. In this case, structural stigma reduces access to care through inadequate allocation of resources, lack of intersectoral collaboration and care integration, negative attitudes and practices of healthcare practitioners, and overreliance on coercive approaches. We propose strategies to reduce system-level and provider-level barriers to access.

Mental illness that affects an accused’s fitness to stand trial is an ill-explored topic in the South African criminal justice system. The necessity to explore this topic is motivated by the increasing number of persons with mental illness moving into the criminal justice systems in South Africa, Canada, and the United States of America. An accused’s fitness to stand trial is assessed once concern about his ability to follow the proceedings, or give proper instructions to his legal representative, is in doubt. The assessment is conducted in the forensic system where the vastly different fields of law and psychiatry meet. The South African forensic system is plagued with resources and skills shortages. These inadequacies cause delays in resolving pre-trial issues for an accused in respect of whom fitness is at issue. The accused is oftentimes detained in a correctional facility awaiting fitness assessment for anything between three months to two years. Generally, detention in a correctional facility has a negative effect on the mental state of a person with a mental illness. The logistics of fitness assessments differ between the three jurisdictions referred to above. However, the threshold for fitness in these jurisdictions is relatively low, with the result that the majority of accused persons sent for fitness assessments are found fit to stand trial. Such a finding does not imply that the accused is not mentally ill; it simply means that the illness does not affect his understanding of the court proceedings and that it does not influence his ability to communicate with his legal representative. An accused with a serious mental illness such as schizophrenia or major depression can, for example, be found fit to stand trial. After a fitness assessment, a court may either find an accused fit to stand trial or unfit to stand trial. The fact that many persons found fit to stand trial have a mental illness suggests that there is a third category on the fitness continuum that must be acknowledged, namely, fit but mentally ill accused persons. No alternatives to traditional prosecution currently exist in South Africa for this third group of accused persons despite the fact that their situation in the criminal justice system calls for a therapeutic response. The South African legislative framework that regulates fitness assessments and the processes associated therewith are not without challenges. The assessment practices have recently been under scrutiny by the Constitutional court, which judgment changed the position for the accused found unfit to stand trial. The position of the fit but mentally ill accused remains unregulated. The Canadian and American criminal justice systems have implemented diversion programmes for fit but mentally ill accused persons in the form of Mental Health Courts. The underlying principle of a Mental Health Court is therapeutic jurisprudence. Therapeutic jurisprudence evaluates the impact of the law on those in conflict with it. It promotes the inclusion of expertise from other disciplines to improve the effectiveness of the law in a particular set of circumstances. Many South African scholars acknowledge the need for mental health expertise in the criminal justice system, and suggestions have been made for the diversion of mentally ill accused persons charged with minor offences. Those above notwithstanding, no formal diversion programmes exist in South Africa for the fit but mentally ill accused. This research investigates the Mental Health Court as a therapeutic response to the mentally ill accused in the South African criminal justice system. The Mental Health Court models as employed in Canada and the United States of America are studied to identify elements thereof that can be employed in the South African context to provide an effective alternative to traditional prosecution for the mentally ill accused. The Toronto Mental Health Court is studied in the Canadian context as a court that is not a diversion programme as such but has a diversion component attached to it. Diversion in Canada is reserved for those charged with less serious offences, and only these accused persons are allowed into the diversion component of the Mental Health Court. However, the Canadian Mental Health Court assists those who do not qualify for diversion but who need the specialised skills of the Mental Health Court for purposes of, for example, a bail application. The Brooklyn Mental Health Court in the United States of America is investigated as a model that constitutes a complete diversion programme and considers diversion of accused persons charged with more serious offences. The unique structure and procedure of each of these Mental Health Courts are investigated with due consideration to the eligibility criteria of each and the sanctions employed for non-compliance of the court-monitored treatment programmes. Further, the successes and challenges of each model are highlighted. Finally, a proposal is made for a Mental Health Court model mindful of the uniquely South African factors that have to be taken into account when building such a model. Amendments to the existing legislative framework are proposed to incorporate a Mental Health Court as a therapeutic response to mentally ill accused persons in the South African criminal justice system. / Criminal and Procedural Law