1. Schizophrenia Society of Ontario Demystifying the Justice and Mental Health System: A Conference for Families May 3, 2008 Forensics vs Corrections: Pathways and Experiences Through Parallel Systems Derek Pallandi, MD, FRCP(C) Centre for Addiction and Mental Health Mental Health Centre, Penetanguishene University of Toronto

2. Outline 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 rehabilitation Treatment and rehabilitation Getting out Getting out Getting back in again Getting back in again Coercion: myths and realities Coercion: myths and realities

3. Objectives Give an overview Give an overview Clarify misconceptions Clarify misconceptions Identify opportunities Identify opportunities Interactive discussion Interactive discussion

4. Who are you?

5. Who am I?

6. What is a forensic psychiatrist? MD MD Specialist in psychiatry Specialist in psychiatry Particular interest (?peculiar interest) in the area Particular interest (?peculiar interest) in the area Dedicated training Dedicated training Dedicated practice Dedicated practice Eventually…experience Eventually…experience

7. What is the “forensic system”? In Ontario, a system in place to address specific needs for those: Referred for assessment (fit / NCR) Referred for assessment (fit / NCR) Detained via the ORB Detained via the ORB In diversion programmes In diversion programmes

8. “Forensic system” myth “Forensic system” myth People who are behaving in violent or other problematic ways, have criminal records, or are unmanageable or difficult to place and / or discharge by hospitals can be “sent to the forensic system…”

9. In Ontario: Access: via courts / Review Boards Access: via courts / Review Boards Based on specific circumstances and criteria Based on specific circumstances and criteria

10. Fitness for Trial Accused, via the court, can be assessed for this specific issue in the following: Accused, via the court, can be assessed for this specific issue in the following: Mental Health Courts Mental Health Courts Brief Assessment Units Brief Assessment Units Inpatient Units (min-max; up to 60 days) Inpatient Units (min-max; up to 60 days) Out of custody Out of custody

11. Unfit to Stand Trial Being found “Unfit” by the Court after an assessment is another entry point into the system…

12. Treatment Orders Once found unfit – typically MMI Once found unfit – typically MMI Likely to respond (become fit) Likely to respond (become fit) Risk not disproportionate to benefit Risk not disproportionate to benefit Specific Court-mandated treatment up to 60 days, in hospital Specific Court-mandated treatment up to 60 days, in hospital

13. Treatment Orders Intrusive? Yes Intrusive? Yes Effective? Yes Effective? Yes A long-term fix? No A long-term fix? No

14. Criminal Responsibility Historically “Insanity” or “Insanity defence” Historically “Insanity” or “Insanity defence” People are presumed responsible for their actions, unless shown otherwise People are presumed responsible for their actions, unless shown otherwise

15. Not Criminally Responsible Being found “NCR” after an assessment, is another entry point into the system, typically via the ORB…

16. Mental Health Diversion A short-term entry point into the system A short-term entry point into the system Comprehensive intervention Comprehensive intervention Largely voluntary Largely voluntary “Treatable” disorders “Treatable” disorders Minor charges Minor charges Goal is to stay charges (no record) Goal is to stay charges (no record)

17. So…what is the “forensic system”? 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 detainees Several hundred community detainees

18. CAMH – Law and Mental Health Programme 40 medium secure beds 40 medium secure beds 72 minimum secure beds 72 minimum secure beds 8 SOTU beds 8 SOTU beds 180 outpatients 180 outpatients Specialty clinics Specialty clinics Consultation Service Consultation Service Mental Health Courts Mental Health Courts

19. ORB population Hopefully… The mentally ill: The mentally ill: Schizophrenia / Mood Schizophrenia / Mood Dementia Dementia MR MR “Correctly” identified as NCR or unfit “Correctly” identified as NCR or unfit

20. ORB population Typical offense types: Typical offense types: Manslaughter / murder Manslaughter / murder Assaults (simple/ACBH/with weapon) Assaults (simple/ACBH/with weapon) Sexual offences Sexual offences Threatening / Harassment Threatening / Harassment Weapons offences Weapons offences Other miscellaneous Other miscellaneous

21. LAMHP OPS population N 140 clinic patients Gender > 80% males Age 35 y Diagnoses Schizophrenia; Mood Disorders; Other Psychoses; MR; Paraphilias Comorbidity PD; Substances; Paraphilia

22. Treatment and Rehabilitation Inpatient (max – medium – minimum) Inpatient (max – medium – minimum) Outpatient (variable reporting) Outpatient (variable reporting) “Cascade” notion “Cascade” notionORB-governed

23. Treatment and Rehabilitation Multidimensional rehabilitation: Multidimensional rehabilitation: Medication Medication Groups Groups Recreation Recreation Vocational Vocational Educational Educational Socialization / social skills Socialization / social skills

24. Treatment and Rehabilitation Multidimensional rehabilitation: Multidimensional rehabilitation: MD MD SW SW RN RN OT OT PT PT Pharmacist Pharmacist RT RT Dietician Dietician

25. Treatment and Rehabilitation Goals: Goals: Protect public safety / manage risk Protect public safety / manage risk Reintegrate the accused Reintegrate the accused

26. Treatment and Rehabilitation Life “inside” Life “inside” Depends on security level Depends on security level At minimum – indistinguishable from civil At minimum – indistinguishable from civil Groups, outings, recreation, school, work Groups, outings, recreation, school, work Families highly involved Families highly involved

27. Treatment and Rehabilitation Life “outside” Life “outside” Various types of housing Various types of housing Differing reporting frequencies Differing reporting frequencies Work, family, relationships, productivity Work, family, relationships, productivity Can be minimally intrusive Can be minimally intrusive

28. Getting Out Do what you are supposed to Do what you are supposed to Don’t do what you are not Don’t do what you are not

29. Getting Out Respond and be amenable to treatment Respond and be amenable to treatment Participate in groups Participate in groups Use privileges Use privileges Reintegrate Reintegrate Remain free of aggression / reoffense Remain free of aggression / reoffense Remain free of substances Remain free of substances Structure / skills Structure / skills

30. Getting Back in Again It happens… minimize stigma : It happens… minimize stigma : Substances Substances Non-compliance (meds / reporting) Non-compliance (meds / reporting) Re-offense Re-offense Decompensation Decompensation Risk management Risk management

31. “Coercion”: Realities It is a therapeutic environment It is a therapeutic environment Goal is reintegration Goal is reintegration Outcomes are very very good Outcomes are very very good Failures are rare Failures are rare Resource-rich Resource-rich

32. “Coercion”: Myths Providers benefit from ongoing detention Providers benefit from ongoing detention The system cures all The system cures all Once in, always in Once in, always in It is inhumane It is inhumane