Schizophrenia Society of OntarioSchizophrenia Society of Ontario Demystifying the Justice and Mental Health System: Demystifying the Justice and Mental Health System:

A Conference for FamiliesA Conference for FamiliesMay 3, 2008May 3, 2008

Forensics vs Corrections: Forensics vs Corrections:

Pathways and Experiences Through Parallel SystemsPathways and Experiences Through Parallel Systems

Derek Pallandi, MD, FRCP(C)Derek Pallandi, MD, FRCP(C)

Centre for Addiction and Mental HealthCentre for Addiction and Mental HealthMental Health Centre, PenetanguisheneMental Health Centre, Penetanguishene

University of TorontoUniversity of Toronto

OutlineOutline

Who am I? Who am I? What is “forensic psychiatry” anyway?What is “forensic psychiatry” anyway?What is the “Forensic System”?What is the “Forensic System”?Treatment and rehabilitationTreatment and rehabilitationGetting outGetting outGetting back in againGetting back in againCoercion: myths and realitiesCoercion: myths and realities

ObjectivesObjectives

Give an overview Give an overview Clarify misconceptionsClarify misconceptions Identify opportunitiesIdentify opportunities Interactive discussion Interactive discussion

Who are you?Who are you?

Who am I?Who am I?

What is a forensic psychiatrist?What is a forensic psychiatrist?

MDMDSpecialist in psychiatrySpecialist in psychiatryParticular interest (?peculiar interest) in Particular interest (?peculiar interest) in

the areathe areaDedicated training Dedicated training Dedicated practiceDedicated practiceEventually…experienceEventually…experience

What is the “forensic system”?What is the “forensic system”?

In Ontario, a system in place to address In Ontario, a system in place to address specific needs for those:specific needs for those:

ReferredReferred for assessment (fit / NCR) for assessment (fit / NCR)DetainedDetained via the ORB via the ORB In diversion programmesIn diversion programmes

“ “Forensic system” mythForensic system” myth

People who are behaving in violent or other People who are behaving in violent or other problematic ways, have criminal records, problematic ways, have criminal records, or are unmanageable or difficult to place or are unmanageable or difficult to place and / or discharge by hospitals can beand / or discharge by hospitals can be

““sent to the forensic system…”sent to the forensic system…”

In Ontario:In Ontario:

Access: via courts / Review BoardsAccess: via courts / Review BoardsBased on Based on specificspecific circumstances and circumstances and

criteriacriteria

Fitness for TrialFitness for Trial

Accused, via the court, can be assessed Accused, via the court, can be assessed for this specific issue in the following:for this specific issue in the following:

Mental Health CourtsMental Health CourtsBrief Assessment UnitsBrief Assessment Units Inpatient Units (min-max; up to 60 days)Inpatient Units (min-max; up to 60 days)Out of custodyOut of custody

Unfit to Stand TrialUnfit to Stand Trial

Being found “Unfit” by the Court after an Being found “Unfit” by the Court after an assessment is another entry point into assessment is another entry point into

the system…the system…

Treatment OrdersTreatment Orders

Once found unfit – typically MMIOnce found unfit – typically MMILikely to respond (become fit)Likely to respond (become fit)Risk not disproportionate to benefitRisk not disproportionate to benefit

Specific Specific Court-mandatedCourt-mandated treatment up to treatment up to 60 days, in hospital60 days, in hospital

Treatment OrdersTreatment Orders

Intrusive? Intrusive? YesYes

Effective? Effective? YesYes

A long-term fix? A long-term fix? NoNo

Criminal ResponsibilityCriminal Responsibility

Historically “Insanity” or “Insanity defence” Historically “Insanity” or “Insanity defence”

People are presumed responsible for their People are presumed responsible for their actions, unless shown otherwiseactions, unless shown otherwise

Not Criminally ResponsibleNot Criminally Responsible

Being found “NCR” after an assessment, is Being found “NCR” after an assessment, is another entry point into the system, another entry point into the system,

typically via the ORB…typically via the ORB…

Mental Health DiversionMental Health Diversion

A short-term entry point into the systemA short-term entry point into the systemComprehensive intervention Comprehensive intervention Largely voluntaryLargely voluntary ““Treatable” disordersTreatable” disordersMinor chargesMinor chargesGoal is to stay charges (no record)Goal is to stay charges (no record)

So…what is the “forensic system”?So…what is the “forensic system”?

In Ontario:In Ontario:

1000 patients (and growing)1000 patients (and growing)10 designated facilities (security spectrum)10 designated facilities (security spectrum)600-700 designated beds (and growing)600-700 designated beds (and growing)Several hundred community detaineesSeveral hundred community detainees

CAMH – Law and Mental Health CAMH – Law and Mental Health ProgrammeProgramme

40 medium secure beds40 medium secure beds72 minimum secure beds72 minimum secure beds8 SOTU beds8 SOTU beds180 outpatients180 outpatientsSpecialty clinicsSpecialty clinicsConsultation ServiceConsultation ServiceMental Health CourtsMental Health Courts

ORB populationORB population

HopefullyHopefully……

The mentally ill:The mentally ill:Schizophrenia / MoodSchizophrenia / MoodDementiaDementiaMRMR

““Correctly” identified as NCR or unfitCorrectly” identified as NCR or unfit

ORB populationORB population

TypicalTypical offense types: offense types:

Manslaughter / murderManslaughter / murderAssaults (simple/ACBH/with weapon)Assaults (simple/ACBH/with weapon)Sexual offences Sexual offences Threatening / HarassmentThreatening / HarassmentWeapons offencesWeapons offencesOther miscellaneousOther miscellaneous

LAMHP OPS populationLAMHP OPS population

NN 140 clinic patients140 clinic patients

GenderGender > 80% males> 80% males

AgeAge 35 y35 y

DiagnosesDiagnosesSchizophrenia; Mood Schizophrenia; Mood Disorders; Other Psychoses; Disorders; Other Psychoses; MR; ParaphiliasMR; Paraphilias

ComorbidityComorbidity PD; Substances; ParaphiliaPD; Substances; Paraphilia

Treatment and RehabilitationTreatment and Rehabilitation

Inpatient (max – medium – minimum)Inpatient (max – medium – minimum)Outpatient (variable reporting)Outpatient (variable reporting) ““Cascade” notionCascade” notion

ORB-governedORB-governed

Treatment and RehabilitationTreatment and Rehabilitation

Multidimensional rehabilitation:Multidimensional rehabilitation:MedicationMedicationGroupsGroupsRecreationRecreationVocationalVocationalEducationalEducationalSocialization / social skillsSocialization / social skills

Treatment and RehabilitationTreatment and Rehabilitation

Multidimensional rehabilitation:Multidimensional rehabilitation:MDMDSWSWRNRNOTOTPTPTPharmacistPharmacistRTRTDieticianDietician

Treatment and RehabilitationTreatment and Rehabilitation

Goals:Goals:Protect public safety / manage riskProtect public safety / manage riskReintegrate the accusedReintegrate the accused

Treatment and RehabilitationTreatment and Rehabilitation

Life “inside”Life “inside”

Depends on security levelDepends on security levelAt minimum – indistinguishable from civilAt minimum – indistinguishable from civilGroups, outings, recreation, school , workGroups, outings, recreation, school , workFamilies highly involvedFamilies highly involved

Treatment and RehabilitationTreatment and Rehabilitation

Life “outside”Life “outside”

Various types of housingVarious types of housingDiffering reporting frequenciesDiffering reporting frequenciesWork, family, relationships, productivityWork, family, relationships, productivityCan be minimally intrusiveCan be minimally intrusive

Getting OutGetting Out

Do what you are supposed toDo what you are supposed to

Don’t do what you are notDon’t do what you are not

Getting OutGetting Out

Respond and be amenable to treatmentRespond and be amenable to treatmentParticipate in groupsParticipate in groupsUse privilegesUse privilegesReintegrateReintegrateRemain free of aggression / reoffenseRemain free of aggression / reoffenseRemain free of substancesRemain free of substancesStructure / skillsStructure / skills

Getting Back in AgainGetting Back in Again

It happens…It happens…minimizeminimize stigmastigma::

SubstancesSubstancesNon-compliance (meds / reporting)Non-compliance (meds / reporting)Re-offenseRe-offenseDecompensationDecompensationRisk managementRisk management

““Coercion”: RealitiesCoercion”: Realities

It is a therapeutic environmentIt is a therapeutic environmentGoal is reintegrationGoal is reintegrationOutcomes are very very goodOutcomes are very very goodFailures are rareFailures are rareResource-richResource-rich

““Coercion”: MythsCoercion”: Myths

Providers benefit from ongoing detentionProviders benefit from ongoing detentionThe system cures allThe system cures allOnce in, always inOnce in, always in It is inhumaneIt is inhumane