Browsing by Author "Kaliski, Sean"

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    A comparison of attitudes around collaboration held by traditional healers and professional nurses in the Western Cape
    (2024) Tyhala, Brenda; Kaliski, Sean; Mgweba-Bewana, Lihle
    Background Many mental health care system users consult traditional healers while also seeking biomedical forms of healing. Despite this, there is no formalized working relationship between these two systems, which operate in parallel and independently. The government has taken considerable steps towards facilitating collaboration; however, this has not yielded the desired outcome, because of educational gaps, lack of appreciation, recognition, mutual respect, and mistrust between the two systems. Building a trusting relationship and learning from each other should be prioritized. Aim This study aimed to survey the attitudes of Xhosa-speaking professional nurses and Xhosa-speaking traditional healers, on the treatment of mentally ill people, to assess whether their respective professions could cooperate with regards to the diagnosis and treatment of mentally ill individuals, and to determine the feasibility of future collaboration towards comprehensive mental health care services. Method Thirty Xhosa-speaking professional nurses and 30 Xhosa-speaking traditional healers completed a structured questionnaire. The questionnaire covered practice details, attitudes, perception of the other profession, diagnosis and management of mental illness. Results There was recognition of the one profession by the other and willingness to collaborate for the benefit of the patient by both, professional nurses and traditional healers. There is still an element of mistrust, gaps in knowledge and a superiority complex from both systems. Conclusion There is room for collaboration between traditional healers and biomedical practitioners. Efforts to afford opportunities for both systems to interact and learn from each other need to be supported and prioritized by the government and both professions.
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    A retrospective audit comparing state patients with schizophrenia and bipolar mood disorder who have committed violent crime admitted to the male forensic unit at Valkenberg Hospital
    (2018) Maharaj, Avani; Kaliski, Sean
    Background There is a consensus that psychosis confers a modest risk toward violent offending. Most research to date has shown that a statistical relationship does exist between schizophrenia and bipolar disorder, and violence and aggressive behavior In forensic mental health, state patients are rehabilitated in a general program regardless of diagnosis. It is not known whether different rehabilitation management strategies should be implemented on those with bipolar disorder as compared to those with schizophrenia. This study is an attempt to ascertain if there are differences between those diagnosed with schizophrenia and bipolar disorders, and if so, whether these have implications for their rehabilitation programs. Objectives The study aims to compare the demographic profiles and comorbidities (in terms of substance use and personality disorders) of state patients with bipolar disorder and schizophrenia who have offended violently. Methods This was a quantitative, cross sectional study. State patients who were diagnosed with schizophrenia and bipolar disorder and committed a violent crime were included in the study from the 1st January 2000 to 31st December 2014. The study population comprised a total of 93 male state patients. Of these 46 patients had a diagnosis of bipolar disorder and 47 patients had a diagnosis of schizophrenia. Results The results show that in general the differences between the schizophrenia group and the bipolar disorder group are marginal. A higher percentage of patients with schizophrenia committed murder at 17.02% and attempted murder at 12.77%. The bipolar disorder group had a significantly higher number of patients diagnosed with co morbid personality disorder at 59.57% (p value of 0.01.) Substance abuse was common in both groups. The mean age at admission was 31,23 years in schizophrenia and 36,85 years in bipolar disorder. This demonstrates an earlier onset of criminality in the group with schizophrenia. Patients with bipolar disorder were more likely to be married (13.04%), divorced (10.8%) or separated (2.17%). Conclusion There were no major differences elicited between the 2 groups of patients. Certain aspects such as therapeutic programs for personality disordered patients and social interventions in patients with poor social support would contribute to improving the quality of the rehabilitation programs currently used. The commonalities found in the 2 groups suggest that a common approach to rehabilitation would be adequate in this setting.
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    An Investigation of Male Observation Cases That Had Been Charged With Murder to Compare Those Diagnosed With Schizophrenia to Those Diagnosed With Bipolar or Schizoaffective Disorders
    (2021) Gondwe, Saulos Kalizga; Kaliski, Sean
    Background The prevalence of violent crime, including murder, is moderately but significantly increased amongst those with severe mental illness compared to the general population. Understanding the characteristics of mentally ill murder offenders may help in the application of evidence-based treatment and rehabilitation strategies. Rationale In the Republic of South Africa (R.S.A), little is known about the characteristics of patients with severe mental illness who are charged with murder. This study has the potential of improving our understanding of these patients. This would subsequently facilitate the development of evidence based interventions in the South African context. Aims The current study aimed to describe the demographic, clinical and criminological characteristics of murder offenders with a diagnosis of schizophrenia or bipolar/schizoaffective disorder and to establish if there are any differences between the two patient groups. Methods Clinical records of male patients diagnosed with schizophrenia or bipolar/schizoaffective disorder following a charge of murder who had been admitted as State patients to the forensic unit of Valkenberg Hospital (VBH) were reviewed. Purposive sampling was used. Data were collected using a questionnaire specifically designed for the study. Those with comorbid intellectual disability (ID) or a neurocognitive disorder and those with missing information were excluded. Ethical approval was obtained from the University of Cape Town, faculty of health sciences human research ethics committee. Results Thirty-seven male patients were included in the study. Twenty-three had a diagnosis of schizophrenia and fourteen had a diagnosis of bipolar/schizoaffective disorder (SCAD). The mean age of the sample was 32.54 years (range: 17-50). Most had a secondary school level of education and were unemployed. There were no sociodemographic differences between the two groups. Persecutory delusions were the most common symptom for both groups (67.57%). The majority of patients had a psychiatric admission prior to the index offence (62.16%). The modal duration of illness for schizophrenia prior to the index offence was less than one year (37.5%) and more than ten years for bipolar/SCAD patients (57.14%). Comorbid personality disorder (PD) was present in 62.5% of the sample. Antisocial PD was the most prevalent. The most commonly used substances were cannabis (70.27%) and alcohol (59.46%). Bipolar/SCAD patients were more likely to use other substances than alcohol or cannabis compared to schizophrenic patients. 89% of the victims were known to the offenders. Family members were victims in 65.2% of the murders. Most of the victims were male (70.27%). Most of the murders occurred at home (75.68%). Schizophrenia patients were more likely than bipolar/SCAD patients to commit the murder at home. Stabbing with a knife was the most common method of murder for both groups (49.45%). Conclusions and Recommendations It can therefore be concluded that patients with schizophrenia or bipolar/SCAD share most demographic, clinical and criminological characteristics which are thought to play a causative role in the commission of murder. Hence, they do not require different rehabilitation strategies. However, general rehabilitation programs for both patient groups should cover several important areas including: social deficits, occupational functioning, substance misuse, treatment adherence and family involvement. Forensic rehabilitation programs should also fully integrate dual diagnosis interventions. Risk assessment and management in both civil and forensic psychiatry services should specifically address persecutory delusions. This should include optimising psychotropic treatment, cognitive behavioural approaches and emphasis on clinicians' duty to warn any potential imminent victims. There should be more robust assessment for comorbid personality disorders as this has a significant impact on the course of illness and the risk for recidivism. In future, a South African multicentre study of similar design should be conducted to increase the sample size and improve the generalisability of the study findings. Future studies should also examine female murder offenders as a separate sample as they may essentially be different from male murder offenders.
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    Chapter 1: An Introduction and General Principles
    (Edutech, 2022-07-01) Kaliski, Sean; Kaliski, Sean
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    Chapter 1: An Introduction and General Prinicples
    (Edutech, 2022) Kaliski, Sean; Kaliski, Sean
    This chapter provides a foundational overview of the complex, multidisciplinary field of Forensic Mental Health (FMH), with a particular focus on the legislative and practical landscape in South Africa. It addresses the historically complicated definitions of forensic expertise, highlighting how boundaries vary globally based on local laws, culture, and healthcare infrastructure. The author outlines the critical skills required of FMH practitioners—spanning diagnostic acumen, legal literacy, report writing, and risk assessment—while addressing the fundamentally disparate communication styles and objectives inherent to the law-psychiatry interface. Furthermore, the chapter examines the clinical and legal determinations of decision-specific capacity, the diagnostic pitfalls and reliability issues associated with classification systems like the DSM, and the systemic challenges within the South African forensic care pathway. Concluding with a look at modern shifts, the text explores the insertion of the Recovery Model into secure environments and addresses enduring ethical controversies, including dual agency, the insanity defense, and coerced treatment.
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    Chapter 2: The Forensic Mental Health Assessment
    (Edutech, 2022-11-16) Kaliski, Sean; Kaliski, Sean
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    Chapter 2: The Forensic Mental Health Assessment: How to be a Mind Detective
    (Edutech, 2022) Kaliski, Sean; Kaliski, Sean
    This chapter provides a comprehensive, practical guide to conducting a Forensic Mental Health Assessment (FMHA), framing the mental health practitioner's role as that of a "mind detective." Unlike traditional therapeutic assessments aimed at treatment, an FMHA is a clinical evaluation tailored specifically for legal and juridical purposes. The author delineates the generic framework of the forensic assessment process, which encompasses navigating the initial referral, clarifying distinct psycholegal questions across criminal and civil domains, and compiling the final report. Crucial operational paradigms are detailed, including verifying the practitioner's scope of practice, managing the ethical minefield of "dual agency" and conflicts of interest, and securing valid informed consent or court orders. The chapter provides rigorous guidelines for conducting face-to-face interviews, examining the procedural complications introduced by online assessments during the COVID-19 pandemic, and navigating the linguistic and cultural nuances of interpreter-mediated interviews. Furthermore, the text underscores the vital necessity of gathering and cross-referencing collateral data from third-party interviews, legal dockets, and digital footprints (such as social media) to test the consistency and truthfulness of an examinee's self-reported narrative. The author concludes by outlining defensive practices for ordering special investigations, mitigating adversarial cross-examination, and translating complex psychiatric findings into clear, jargon-free reports for judicial decision-makers.
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    Chapter 3: Assessing The Accused
    (Edutech, 2024-10-29) Kaliski, Sean; Kaliski, Sean
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    Chapter 3: Assessing the Accused
    (Edutech, 2022) Kaliski, Sean; Kaliski, Sean
    This text examines the assessment of criminal defendants within the South African forensic mental health system under Sections 77, 78, and 79 of the Criminal Procedure Act 51 of 1977 (CPA). It addresses the complexities that emerge from the uncodified nature of South African substantive criminal law, highlighting a recurrent lack of mutual understanding between mental health practitioners and the courts regarding the exact elements of criminal liability (actus reus versus mens rea). The chapter details the multi-departmental referral process, contrasting South Africa’s system—where entry is almost exclusively precipitated by a criminal offense—with systems like the United Kingdom's. It critiques the historical conflation of fitness to stand trial (Section 77) and criminal responsibility (Section 78) by practitioners, advocating for separate inquiries to preserve procedural justice. Furthermore, the author evaluates the statutory thresholds of adjudicative competence, drawing comparisons with the United States' Dusky standard to structure evaluations. It outlines the legal and constitutional evolutions following the De Vos (2015) ruling and the Criminal Procedure Amendment Act 4 of 2017, which granted courts the discretion to order less restrictive care for unfit defendants instead of relying on automatic, indefinite institutionalization. Finally, the text analyzes the limitations of the classic cognitive and conative tests of insanity, arguing that modern neuropsychiatry challenges the law's artificial separation of cognition and impulse control.
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    Chapter 4: The Perils of Disclosure: Writing the Forensic Report
    (Edutech, 2024-05-22) Kaliski, Sean; Kaliski, Sean
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    Chapter 4: The Perils of Disclosure: Writing the Forensic Report
    (Edutech, 2022) Kaliski, Sean; Kaliski, Sean
    This chapter examines the complexities, ethical obligations, and practical methodologies involved in drafting a forensic mental health report. Historically delivered via oral testimony, contemporary legal standards necessitate comprehensive written documentation that balances an examinee's right to privacy with the court's evidentiary needs. The author outlines a triaged framework for data disclosure, distinguishing between information that must be disclosed (e.g., credentials, legal boundaries, methodologies), data requiring caution (e.g., verbatim examinee accounts, vulnerable or unverified third-party collateral information), and information that must not be included (e.g., derogatory remarks or groundless speculations). Additionally, the text provides critical guidance on navigating diagnostic limitations within legal environments—specifically cautioning against the absolute use of pejorative labels like "malingering"—and offers structural templates and formatting advice to ensure clarity, objectivity, and resilience under cross-examination. Ultimately, the forensic report is framed as a tool of persuasive rhetoric that demands a rigorous, structured narrative capable of translating complex psychiatric evaluations for a sophisticated lay audience.
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    Chapter 5: Malingering
    (Edutech, 2024-07-30) Kaliski, Sean; Kaliski, Sean
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    Chapter 5: Malingering: Faking it Till it's Real
    (Edutech, 2023) Roffey MBChB FCPsych(SA), Marc; Roffey MBChB FCPsych(SA), Marc; Kaliski, Sean
    This chapter examines the complex clinical and legal challenges surrounding malingering—the intentional production or gross exaggeration of physical or psychological symptoms motivated by external incentives—within criminal and civil forensic psychiatric settings. Unlike general psychiatry, forensic mental health assessments require a heightened threshold of suspicion, particularly during medicolegal proceedings or when diagnosing antisocial personality disorder. The author outlines Resnick's classifications of malingering (pure, partial, and false imputation) and explores Rogers and Neumann's explanatory frameworks (pathogenic, criminological, and adaptational models). Key clinical differentiations are established between malingering, factitious disorders, and somatic symptom disorders based on conscious versus unconscious symptom production and motivation. The chapter highlights primary assessment indicators, emphasizing the "ABCs" of forensic interviewing (Avoid accusations, Beware of countertransference, Clarification over confrontation, and Security), alongside the role of collateral information and formal validity testing. Finally, it addresses the nuances of identifying fabricated positive psychotic features, such as atypical hallucinations, and provides practical recommendations for reporting findings neutrally without using pejorative language.
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    Chapter 6: Proposed revisions of the criminal procedure Act, 1977 (Act No. 51 of 1977)
    (Edutech, 2025-05-26) Kaliski, Sean; Kaliski, Sean
    This consensus document outlines proposed amendments to Sections 77, 78, and 79 of the Criminal Procedure Act, 1977 (Act No. 51 of 1977), aimed at improving forensic mental health processes in South Africa. The revisions seek to address systemic bottlenecks causing delays in mental health observations, reduce prolonged pre-trial detention, and uphold the human rights of accused persons with mental illness or intellectual disability. Key proposals include: introducing diversion programs for non-violent offenders to general psychiatric facilities; standardizing preliminary mental health screening; clarifying panel composition for forensic evaluations; and expanding judicial options for temporary treatment, outpatient care, and conditional discharge. The document also recommends periodic reviews of state patient certification, alignment with the Mental Health Care Act, 2002, and the establishment of specialized mental health courts. Additional considerations include improving SAPS transport obligations, revising judicial forms, and exploring the inclusion of traditional health practitioners in forensic panels. These reforms aim to enhance efficiency, fairness, and recovery-oriented care within the criminal justice and mental health systems.
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    Chapter 6: Proposed revisions of the criminal procedure Act, 1977 (Act No. 51 of 1977)
    (Edutech, 2023) Kaliski, S; Sokudela, F; Calitz, F; Pillay, A; Mulutsi, E; Motaung, M; Moabelo, K; Mbedzi, B; Kaliski, Sean
    This legislative proposal document, compiled by a specialized Department of Health Task Team led by Prof S. Kaliski, outlines strategic amendments to Sections 77, 78, and 79 of the Criminal Procedure Act (CPA), 1977, alongside a concurrent review of Chapter 6 of the Mental Health Care Act, 2002. The primary objective of these interventions is to resolve critical systemic bottlenecks contributing to prolonged backlogs in forensic mental health observations, while aggressively safeguarding the fundamental human rights of accused individuals referred by the courts. Currently, mentally ill individuals charged with non-violent or petty offenses face inhumane wait times of up to a year in remand prisons before undergoing a mandatory 30-day psychiatric evaluation. This delay significantly disrupts early treatment interventions and complicates clinical recovery.
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    Chapter 7: Expert Testimony: Jack's in the Box!
    (Edutech, 2023) Kaliski, Sean; Kaliski, Sean
    This chapter provides a comprehensive, practical guide for mental health professionals navigating the complexities of delivering expert testimony within the adversarial legal system, with a particular focus on the South African context. Acknowledging the inherent stress and "dismay" that legal summonses cause clinicians, the author dispels common misconceptions like the "Star-Witness Fantasy" and examines foundational systemic limitations, including a lack of peer review for courtroom testimonies and the prevalent perception of experts as "hired guns". The text maps out the progression from pre-trial preparation to courtroom exit. It delineates the roles of "witnesses of fact" versus "expert witnesses" (including treatment and forensic experts) and emphasizes the ethical necessity of avoiding dual-role conflicts. Practical checklists cover ensuring the scope of practice, fee negotiations, data mastery, and pre-trial brief reviews with legal counsel. For the courtroom environment, the author provides tactical advice regarding etiquette, dress, direct evidence-in-chief, and managing aggressive cross-examinations while avoiding "narcissistic excitement". Finally, the chapter contrasts South Africa's reliance on judicial arbitration with international benchmarks like the U.S. Daubert standard, notes the limits of applying group-level scientific data to individuals, details the ethical pitfalls of breaching clinical boundaries, and briefly contemplates the modern challenges of remote testimony via digital platforms.
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    Chapter 7: Export Testimony: Jack's in the Box!
    (Edutech, 2024-10-29) Kaliski, Sean; Kaliski, Sean
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    Chapter 8: Emotionally Triggeres Involuntary Violent Behaviour not Attributed to a Mental Disorder
    (Edutech, 2024) Joubert, Pierre; Joubert, Pierre; Kaliski, Sean
    This chapter introduces and evaluates the clinical and legal construct of Emotionally Triggered Involuntary Violent Behaviour not Attributed to a Mental Disorder (ETIVB). Conceived to resolve ongoing jurisprudential confusion in South African criminal law surrounding "sane automatism" and "non-pathological criminal incapacity" (NPCI), ETIVB provides psychiatrists with a structured, qualitative framework to assess claims of involuntary violent actions executed during intense emotional states.
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    Characteristics of domestic homicide perpetrated by persons with severe mental illness - a forensic psychiatry observation population-based study
    (2017) Bruwer, Marise; Kaliski, Sean
    Background: Domestic homicide (killing of a person aged 16 or older by a family member or a current or former partner) accounts for 50% - 70% of homicides perpetrated by offenders with mental illness. Despite these statistics, surprisingly little is currently known about the characteristics of domestic homicides perpetrated by those with severe mental illness. To the best of our knowledge, domestic homicide in the context of severe mental illness has not been researched in South Africa. Objective: To investigate domestic homicides by offenders with severe mental illness referred to the Forensic Mental Health Service at Valkenberg Hospital for forensic psychiatric observation. Methods: A five-year retrospective folder review was conducted to obtain data on the characteristics of offenders and victims, as well as the circumstances surrounding the homicide. Results: The majority of the offenders in our sample were young (mean age of 31), single, unemployed males who were known to mental health care services. Substance use disorders and non-adherence to medication were common. Psychotic disorders were the most prevalent diagnoses. The majority of victims were male and a significant minority of the domestic homicides were parricides (28.6%). The incident took place at the victim's residence or the victim and perpetrator's shared residence in most cases. Stabbing was the most common method used. Almost half of the perpetrators were psychotic when the incident took place and 60% of these were first episode psychoses. In spite of the high prevalence of substance use disorders (66.7%), only 23.8% of the sample reported that they were intoxicated when they committed the offence. Conclusions: The majority of our sample was known to mental health care services. This implies that there were potential missed opportunities to prevent these lethal assaults. Our research identified treatment adherence, comorbid substance use disorders and aggressive treatment of first episode psychosis as a possible focus of future interventions in order to prevent domestic homicides due to mental illness.