Through treatment of BPD is complicated, many CBT therapist can learnschema therapy (ST) principles and strategies to used them as an additionaltool. ST began as an extension of Beck's cognitive therapy model and has grownto become a unique integrative treatment for the personality disorders. Aschema is a extremely stable, constant negative pattern which develops duringchildhood and is elaborated during person's life. There are two main schemaoperations: healing of schema and schema maintenance.STdevotes considerable attention to modes, the predominant emotions, schemas, or coping reactions working for an individual at a particular time. The aim of the therapy is to engage in schema healing processes, which areintended to reduce the early maladaptive schemas and coping styles, and buildup the person's healthy side. The history of the schemas, modes and copingstrategies are systematically discussed, their origin are explored, they are linked to current problems, and theopportunity of modifying is explored. In treatment phase, the therapistflexibly uses cognitive, emotional/experiential, behavioral, andrelational/interpersonal strategies to change schemas and change maladaptivecoping styles with healthier forms of behavior. Schema therapists use therelationship itself quite extensively, in two main ways. First, it is a area inwhich behaviors modes, and schemas can be observed, assessed, and modified. Second, the relationship is used as a 'corrective emotional experience”. Through what schema therapy terms 'limited reparenting,” the therapist acts inways that supply as an cure to early unmet needs.

Countertransference occurs in CBT when the relationship with the patientactivates automatic thoughts and schemas in the clinician, and these cognitionshave the potential for influencing the therapy process. Countertransferencealso occurs during supervision and is an indispensable part of the supervisor's response to the supervisee. CBT is typically short-termtreatment – intensity of transference is usually muchlower than in longer-term, dynamically oriented psychotherapy. Neverthelessduring the long-term CBT of the personality disorder or other complex cases, high intensity of transference and countertransference can develop.

Schema therapy shares the view thatschemas are crucial to understanding of personality disorders, but also canhelp to understand the emotional reaction of therapist. A mode is the set ofschema operations that are in one moment functioning for a person. It is acircumscribed complex pattern of emotional, cognitive a behavioral experiences, which operate in typical situations. When therapist suspects that countertransferencemay be developing, he/she could try to identify her/his automatic thoughts andschemas. More comprehensive approach is to quickly identify in which modehim/her are at that moment and reflect it such reaction is for the patientbenefit or not. Understanding therapist countertransference reactions andtheirs management are a significant point of supervision. Self-reflection and realizing the countertransference can therapist help toovercome it and may be necessary for overcoming stagnation in therapy.

Understanding own mode and theirflipping into the therapeutic session is an important tool in psychotherapy andsupervision.

Childhood trauma may be accompanied by biologicalchanges that are caused by the stressful events. Once the events take place, amount of inner changes happen in the child. Thought suppression, developmentalregressions, deliberate avoidance, sleep problems, exaggerated startleresponses, fears of the mundane, irritability, and hypervigilance are prominentamong these. Terr (1991) describes four characteristics related to childhoodtraumas that appeal to last for long periods of life. These are visualizedmemories of the traumatic event, trauma-specific fears, repetitive behavioralpatterns, and changed attitudes about others, life, and the future. The intendof therapist during imagery rescripting is to improve the patient memorizingthe traumatic events and expressing affective experience and then help him/herto rescript experience to less painful. Therapist helps the patient tounderstand, how symptoms connected with the events from childhood and how theyare interconnected with actual problems in life (Smucker & Neiderdee 1995). Therapeutic process can be divided into of several steps (Prasko et al 2012c, Vyskocilova & Prasko 2012b):

1. 1. formation of the therapeutic atmospheres (with feelings of security and control, acceptance, approbation, validation of any emotions);

2. 2. description of the painful memories;

3. 3. formulating the needs of the child in this situation;

4. 4. discussing 'safety person”, who could help the child;

5. 5. imagination the event rescripted with the experience of better resolution in imagination – rescripting the story;

6. 6. general calm down.

Imagery with rescripting techniques that focus onchanging unpleasant memories have also been used as main components of schematherapy programs

Meaningful cognitiveand simultaneously experiential technique for working with deepemotional schemas, formatted in childhood, is writing therapeutic letters. Inclusions of emotion regulation skills in the treatment especially forpatients with personality disorder enhance the efficacy of CBT. Therapeuticletters are intended to extend the work of therapy beyond the consultingroom door by continuing the meaning-making that occurred in a therapeuticconversation.

We usedtherapeutic letters to help the patient identify difficult feelings, processthem in a way that maybe they could not in a therapy session, and finally getrelease and freedom from them.

Typicaltherapeutic letters are address to important close persons from thepatient life, like parents, siblings, a partner and friends, children. Thepatient uses the letter to impress his/her feeling and needs, inclusivedefenses of his rights in past and present.

Patientwrites a letter at home, and he brings it then into the session and reads it tothe therapist. These letters are not intended to be sent to thatimportant person, but to process strong emotions inside the patient.

In fact thepatient writes a letter to his inner representation of an important person,who was connected with the development of the maladaptive schemas. Theletter-writing process is inherently collaborative and enables the patient towork at his or her own pace while also facilitating patient empowerment.

Mental health records are increasingly kept in fully electronic format. This offers potentially transformative research opportunities because of both the very large samples and the depth of the data contained. However, there are clearly substantial challenges in ensuring both adequate anonymity and robust governance for these sensitive data. In addition, the depth of information is often not exploited because most of this is contained in text rather than structured fields. Natural language processing (NLP) offers a potential solution to this, but NLP application in health records data is in its infancy. The Clinical Record Interactive Search (CRIS) application will be discussed, which was developed at the Maudsley Hospital in south London and which offers a robust and patient-led de-identification and governance model for records-based research. NLP applications have now been developed which comprehensively profile a range of symptoms, interventions and outcomes in routine mental healthcare, providing both breadth (250,000 cases) and depth of information, and supporting both novel research output and decision support for clinical services.

Electronic Health Records (EHRs) have opened up the possibility of data re-use, to support both clinical practice, and clinical research. In order to achieve this re-use, we have to address the issue that EHRs contain both structured and unstructured data. By structured data, we mean formally described and organised data, such as that entered via forms, prescriptions, and lab results. By unstructured data, we mean the free text, narrative portion of the record such as patient encounter notes, and correspondence. It is estimated that 80% of the information content of the record is in this unstructured portion. Free text enables the clinician to express complex concepts, events, and uncertainties, in a way that is not possible in the structured record. Unlike structured data, however, free text creates difficulty for re-use and for statistical analysis. These difficulties include the incompleteness of the free text record, the inherent ambiguity of natural language, the noisy nature of the data, dependence on the context in which the record was written, and the author's assumptions about the target audience. Natural Language Processing (NLP), the computerised processing of human language, provides tools and processes to tackle some of these difficulties, and is increasingly used to extract clinically significant information from the textual component of the EHR. We examine ways in which NLP has been used to this end. We review some of the NLP systems and methods used over clinical records, focusing on the techniques of Classification and Information Extraction (IE), and using examples of NLP in use on the South London and Maudsley mental health case register. We will consider some of the NLP tools and resources available to health informaticians, their benefits and their costs.

This talk will focus on the ongoing development of a mental health section within the Andalusian Health System Medical Records Software (DAE). The system is a multidisciplinary mental health medical records system and has two levels of complexity. On the one hand, there are a variety of áreas to reach different care placements covering specific services' needs. On the other hand, there are also several different levels of care software packages to accommodate to particular recording needs for different types of mental health professionals: psychiatrists, psychologists, nursing staff, social workers and occupational therapists. The mental health área is one of many within DAE software which also has a general common structure for all specialties both at the emergency and standrad levels of care. Examples of utitilty for both research and improvement of clinical standards will also be presented.

Workshop Coercion in psychiatric services in different European countries

Coercion in psychiatric services in Finland

Anu Putkonen, MD, PhD

This presentation in the workshop “Coercion in psychiatric services in different European countries” is a brief summary of the requested issues concerning coercion in psychiatric services in Finland. The aim is to provide national data for discussion of various involuntary practices and laws in four European countries. The subjects are: the changes in legislation within the last decade, involuntary admission procedures, involuntary outpatient treatment, use of involuntary medication, seclusion, restraint and other containment measures, changes in clinical practice, and expected developments

The use of different aspects of coercion in mental healthcare currently underlies extensive ethical, legal and professional discussionsand aspects of clinical practice have been changing within the last decade. Based on available evidence and knowledge of legislation and politicaldiscussions, an overview is given on the following aspects in Switzerland:1. changes in legislation withinthe last decade2. involuntary admissionprocedures3. involuntary outpatienttreatment4. use of involuntary medication5. use of seclusion, restraint, and other containment measures6. changes in clinical practice7. expected developmentsIn 2013 a new legislation concerning several aspects of involuntary admission, mandatory treatment and legal guardianship has been introduced in Switzerland(Kindes- und Erwachsenenschutzrecht, KESR). The revision of relevant chaptersof the civil code led to various discussions among mental health professionalsand on a societal level about the implications on clinical practice and qualitymanagement. Before the introduction, formal and factual criteria as well asprocedures of involuntary admission varied considerably between cantons, regions and authorities. Attitudes of mental health professionals and thegeneral population towards psychiatric patients and involuntary treatmentpractices are intertwined with the legislation. The effects of the new legislation concerning admission procedures, treatment practices and staff attitudes are discussed. Measures of involuntarytreatment have been introduced in basic documentation (PSYREC) on a nationallevel in 2012. Evaluations of changes in clinical practice associated withalterations in legislation are needed.

The use of different aspects of coercion in mental healthcare currently is under discussion in terms of ethics, clinical practice, human rights, and legal regulations. The author gives an overview on the current situation in Germany. Rates of involuntary admissions have been rising within the past 15 years due to different reasons while quotas (percentages of admissions) have remained unchanged. Nationwide data on the use of seclusion and restraint are not yet available, but data from some hospital groups, showing a big variance between hospitals as known from other countries. Involuntary outpatient treatment has never been legalized in Germany. The use of involuntary medication for in-patients has been considerably restricted since a decision of the Constitutional Court in 2011, requiring an independent expert review and a separate decision by a judge. There is evidence that the temporaneous inadmissability of involuntary medication led to an increase of seclusion and restraint. Changes in legislation in the Mental Health Acts of the 16 Federal states are under way, focusing more than previously on aspects of patient's autonomy and a balanced and limited use of coercive measures. The financing system for psychiatric hospitals to be introduced within the next years probably will be an obstacle for a further reduction of the use of coercion.

Over the past few decades, psychiatry and medicine have embraced the goal of wellness as comprising more than just the absence of disease. As practitioners who apply the science of well being to help our patients lead happier and more fulfilling lives, we should also broaden the concept of wellness to include milestones, challenges, and achievements that specific communities may face. In the LGBT communities, we have addressed coming out as an important facet of well being, but now we have also begun to embrace the role that marriage and the creation of families of choice play in the lives of our patients. This presentation will explicate role of wellbeing in medicine and psychiatry and explore specifically how we can use concepts of wellness to help our LGBT patients achieve greater health and meaning in life.

While pre-surgical assessments by an internist are relatively common, those by psychiatrists are much more rare. With the exception of bariatric surgery and live donor organ transplantation, sex reassignment surgery (SRS) is the only category of surgeries for which a mental health assessment is routinely done as part of the standard of care. This presentation will outline the assessment process as performed at the Gender Identity Clinic at the Centre for Addiction and Mental Health in Toronto, Canada, which sees and approves individuals in the Canadian province of Ontario seeking to have sex reassignment surgery through the provincial health care insurance plan.

There are three main tasks of the assessment, diagnosis / differential diagnosis, eligibility assessment, and readiness assessment. Diagnosis, while controversial among some in the transgender community, is generally required by most medical professionals and insurance plans that might cover surgical transition procedures. In Ontario diagnosis is a regulated professional activity and can only be done formally by physicians and clinical psychologists.

Eligibility relates to certain specific requirements broadly applied to those seeking surgery that are outlined in international standards of care. For genital surgery, this includes one year of living a full time, continuous gender role experience (GRE) in the chosen gender role.

Readiness is the part of the assessment that most resembles a general psychiatric assessment, in which a full biopsychosocial formulation of the client's current status leads to recommendations for improving readiness for SRS.

Children and adolescents who self-identify as gay, lesbian, bisexual or transgender experience specific stressors in the juvenile justice system. Clinical and support services for youth who identify as members of sexual orientation and/or gender identity minority populations within child welfare and forensic systems will be reviewed, with particular focus on the comparative example of a North American major municipal context.

Medical doctors have a powerfull profession with a high degree of freedom in their therapeutic relationship and treatment. Although there are some disadvantages with regard to this power and freedom.

In this paper, some common vulnerabilities and psychiatric disorders in doctors/psychiatrists will be reviewed. Next, according to Gunn (2006), there are, perhaps, eight ways in which psychiatric power can be abused: 'social purification', people who are mentally normal treated as mad, psychiatric techniques used for oppression, the punishment of mentally disordered people, general maltreatment, excessive/inappropriate use of treatments, cruel and dangerous experiments, and not treating a mental disorder. Finally, the Nazi system was the most extreme example of 'social purification' using medical techniques by violent doctors.

Within the field of psychiatry there is a broad consensus that sexual contact of any kind with a patient is unacceptable under any circumstances. We know from ethics committees and indurance trusts that sexual misconduct is a significant but under-reported problem. On this workshop we will discuss the modus operandi of offender-professionals and the dynamics of the interaction between victims, offenders and institutions. Their ‘silence’ triggers the ‘slippery slope’ toward boundary violations. The understanding of the path of abuse is the basis of effective intervention strategies.

Violence against health professionals impacts both on the individual and on healthcare systems. Almost 25% of workplace violence belongs to the health sector. In 2001-2002, UK registered 14 incidents per month per 1,000 healthcare workers. In Spain, one third of physicians reported in 2004 having experienced a violent episode during his career. In a study in 2006, 11% of healthcare professionals suffered physical assaults and 64% psychological violence (26.9% and 51.6% respectively at Psychiatric Services), but only a 3.7% of physical assaults and no cases of threats or insults were officially reported.

Rates of complaints are alarmingly low, which requires a comprehensive approach. The UK launched in 1999 the “Zero Tolerance Zone Campaign” and reported incidents increased substantially, with a reverse trend in their severity.

Many prevention plans, records, training courses and awareness campaigns have been developed in Spain and the Supreme Court started considering the assault on a public health professional as a “crime of assault of a public official” in 2007, which increased the penalty. The Unit for Violence Against Physicians (UVAP) was created in Catalonia by Barcelona’s College of Physicians in 2010, and gives comprehensive advice to doctors. The UVAP handles 3-4 incidents per month, mainly of low-level violence and UVAP actions ranges from legal or security advice to legal action against the aggressor. Cases handled by the UVAP represent only the tip of the iceberg, but a short survey among physicians suggest that the mere existence of the unit decreases increases the feeling of safety.

Stalking may be defined as obsessive following (1) forcibly and continuously invading another's privacy (2)(3); behaviors which: are directed at a particular person; are felt by the object person to be unwanted and invasive; arouse fear and/or concern in the object person. (4)

Mester, Birger and Margolin(5) referred to 3 types of interventions in response to stalking:

police intervention, legal intervention and medical intervention . They also refer to possible mixed types of intervention strategies.

In this presentation we will relate to legal aspects of stalking, taking into account social, clinical and policy related considerations. A focus will be made on the 2001 Israeli law for preventing threatening harassment, and the main tools it provides a subject with: turning to court for an injunction, complaining to the police in case an injunction has been violated. Other legal tools will also be discussed – such as damages claims related to privacy infringements, libel etc.

In summary we will inquire whether these legal tools are effective in putting an end to disruptive stalking behaviors and to what extent should those legal possibilities play a part in an anti-stalking action plan for a stalking victim.

Every individual is born into culture and has cultural values, norms and models integrated in their being. Cultural values affect cognitive schema and therefore our world view. Cultures determine deviance and abnormality and suggest which health care systems to be followed and what resources should be allocated to them. There is little doubt that, both in physical and mental illness, culture impacts upon presentation, development and perpetuation of symptoms. Cultural psychiatry has developed as a speciality in its own right during the last 75 years or so. Cultural competency is defined as an ability to understand and be aware of cultural factors in the therapeutic interaction between the therapist and the patient. These include awareness of social, cultural, religious factors, attitudes, behaviours, models and explanations. This should be applicable to all patients and all therapeutic interactions. Cultural competency training at its core is about good clinical practice and the clinicians. It is about an understanding of the concepts of culture and how cultures can influence human behaviour, interpretations of that behaviour and how that behaviour is evaluated. It is about the ability to understand one's own prejudices, a willingness to identify and explore one's own cultural base (values, beliefs and attitudes) and to identify useful and culturally appropriate strategies for working with people from diverse cultural backgrounds. The therapist must be aware of their own likes, dislikes, beliefs stereotypes, of their own identity; and must possess an ability to be neutral and open-minded, an ability to learn about other cultures and differences as well as the strengths and weaknesses of their own/other cultures.