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Forensic Mental Health: Clearing Misconceptions

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Title: The Trialectic: Balancing Risk, Recovery, and the Ontario Review Board Author: hmoulden Last modified by: Fred Created Date: 3/7/2012 1:31:55 PM – PowerPoint PPT presentation

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Title: Forensic Mental Health: Clearing Misconceptions


1
Forensic Mental Health Clearing Misconceptions
  • Susan McGowan, BSW, MSW, RSW
  • Mary Lou Solow, BA, RegN
  • Forensic Services
  • April 10, 2013
  • Introduction to Mental Health Studies and the
    Law, Forensics
  • Mohawk College

2
Purpose
1
2
3
  • To explain the forensic mental health system in
    Ontario and the responsibilities of clinical
    teams as well as the Ontario Review Board.

To discuss and dispel many common myths, clearing
up misconceptions that contribute to stigma and
fear.
To engage in discussion about our experience and
your interest in Forensic Mental Health
3
What is Forensic Mental Health?
  • Intersection between the Criminal Justice system
    and the Mental Health system
  • Assessment of individuals for Fitness to Stand
    Trial or Criminal Responsibility
  • Care and treatment of people under auspices of
    the Ontario Review Board

4
What is Forensic Mental Health?
  • Protection of the public by assessment,
    monitoring and supervision
  • Authority to allow or restrict access to the
    community
  • Active treatment rehabilitation
  • Balancing significant risk and recovery

5
Navigating the Forensic System
6
Fitness to Stand Trial
  • Understand charges
  • Understand roles in court Judge, Crown Counsel,
    and Defense Counsel
  • Ability to communicate with Counsel
  • Understand three pleas and consequences
  • Understand concept of oath and perjury

7
Criminal Responsibility
  • Not Criminally Responsible (NCR)
  • did not appreciate criminal act was wrong
  • result of a mental disorder
  • Court determines
  • detention order
  • conditional discharge
  • absolute discharge

8
Clinical Team
  • Nurses
  • Occupational Therapists/Assistants
  • Psychiatrists
  • Psychologists
  • Social workers
  • Recreational Therapists
  • Vocational Counsellors

9
Ontario Review Board
  • A formal quasi-judicial tribunal comprised of
    Judge/senior lawyer (as chair), legal
    representative, public member, and either
    forensic psychiatrist and forensic psychologist
    or two forensic psychiatrists

10
ORB Hearing
  • Hospitals representative presents recommended
    disposition
  • Crown counsel may challenge or support hospitals
    position
  • The patients counsel may or may not support
    hospitals position
  • All parties may present evidence
  • All parties may challenge evidence presented

11
Dispositions
  • ORB disposition must be the least onerous and
    least restrictive
  • absolute discharge
  • conditional discharge
  • detention order
  • ORB reviews every patient under their purview at
    least every 12 months

12
Dispositions
  • Absolute discharge no jurisdiction over patient
  • Conditional Discharge patient can only be
    returned under the Mental Health Act
  • Detention Order patient may be returned at any
    time

13
Dispositions
  • Reporting
  • Accommodations
  • Access to community (escorted, indirect and
    direct)
  • Approved persons
  • Substance use and testing
  • Contact
  • Weapons
  • Etc

14
Patient Rights and Medication
  • ORB cannot order treatment
  • Patient has the right to refuse treatment
  • If incapable to consent to treatment a legal
    substitute decision maker provides consent
  • Patients have the right to appeal to the Consent
    Capacity Board (CCB) under the Health Care
    Consent Act

15
Some Stats
  • In 2008
  • 1419 patients under the purview of the ORB in 10
    Forensic facilities
  • Every level of criminal seriousness represented
    from mischief to murder
  • In 2012 SJHH
  • 45 adult forensic in-patients (secure and general
    units)
  • 63 out-patients patients residing in community
    under hospital supervision

16
Who Do We Serve?
  • Most Patients
  • Lived below poverty line and without income or
    dependent on OW/ODSP
  • Mental illnesses/disorders are often chronic and
    difficult to treat
  • Have strained relationships with families/friends
  • Burned bridges

17
Who Do We Serve?
  • Most common DSM IV-TR diagnoses
  • Schizophrenia
  • Schizoaffective Disorder
  • Bi-Polar Disorder
  • Delusional Disorder
  • Poly-Substance Abuse
  • Cluster B Personality Disorders

18
Who Do We Serve?
  • Patients with other mental disorders
  • Acquired brain injury (ABI)
  • Intellectual Disability and Autism
  • Huntingtons Chorea
  • Dementia (various causes)

19
Assessing Risk
  • Risk assessment is the formulation of the
    likelihood of criminal and violent behaviour, and
    under what circumstances they are likely to
    occur
  • What is the likelihood of the behaviour?
  • What is the individual likely to do?
  • Who is the individual likely to act against?
  • When is the behaviour likely to occur?
  • What are the factors that acutely impact on risk?

20
Relevant Risk Factors
  • Historical/Static
  • Criminal history
  • Childhood/develop-mental factors
  • Current age and age at onset of offending
  • Offence characteristics
  • Presence of mental illness, including personality
    disorder
  • Dynamic
  • Mental illness insight and management
  • Response to treatment
  • Substance abuse
  • Employment
  • Interpersonal functioning
  • Coping skills
  • Social supports

21
Effective Interventions in Forensics
  • Psychopharmacology
  • Milieu structure, professional support, coaching
  • Positive/motivational interviewing approaches
  • Vocational counselling, access to opportunities
  • Service-based programs
  • Cognitive-Behavioural Therapy
  • Dialectical Behavior Therapy
  • Recreation/Social Groups
  • Skills-Based Groups (social skills, life skills,
    etc.)
  • Discharge Preparation/Planning
  • Peer Support/Wellness Recovery Action Plan (WRAP)
  • External agency supports/services (e.g. CMHA)

22
Hope as a Protective Factor in Forensics
  • Hope can be a protective factor An individual
    who possesses risk factors such as impulsivity,
    vulnerability to drug abuse, and paranoid
    thinking presents a lower risk if he or she has a
    meaningful connection to a treater and has hope
    that he can be helped, that he can heal, that
    there is a possibility of a life in the community
    for him
  • Hillbrand Young (2008)

23
Recovery and Hope in Forensic Treatment
  • Focuses on
  • Adaptive behaviours rather than problem
    behaviours
  • New Coping Skills rather than containing
    maladaptive behaviours
  • Promotes
  • Healthy leisure time
  • Effective self-soothing
  • Proper illness management
  • Strengthening self-esteem and self-efficacy
  • Promoting reciprocity in relationships

24
Misconceptions
  • Mental illness is rare
  • All mentally disordered offenders are dangerous
  • Aggressive behaviour is very predictable
  • Once an offender always an offender (aka
    rehabilitation is ineffective)
  • Mentally disordered offenders should be locked
    away forever
  • Forensic patients need to be punished

25
Misconceptions
  • Drug/alcohol abuse is a separate issue from
    mental health issues
  • Forensic patients are not trying hard enough to
    change
  • I have never seen a forensic patient
  • It is common to fake mental illness to avoid
    prison and it is hard to detect
  • It is advantageous to try for NCR status
  • Forensic patients get an easy ride

26
Stigma
  • All forensic patients experience double stigma
    mentally ill a criminal
  • Almost all experience triple stigma mentally ill
    a criminal economically marginalized
  • Some experience discrimination for other reasons
    as well e.g. ethnic minority, senior citizen,
    LGBTQQ, obese, low IQ, differently-abled, etc.

27
The Case of Vincent Li
  • In 2008, Vincent Li decapitated fellow Greyhound
    passenger Tim McLean
  • Li had an undiagnosed and untreated case of
    paranoid schizophrenia
  • Apparently had a delusional belief that McLean
    was a demon and he had to kill him and devour
    body parts to save self
  • Found Not Criminally Responsible and detained in
    Manitoba psychiatric facility

28
The Case of Vincent Li
  • He has since responded very well to psychiatric
    treatment and is a model patient symptoms are
    well managed
  • Last year, Li was granted 21 security escorted
    hospital grounds privileges by the Manitoba
    Review Board
  • McLeans mother and many in the public are
    outraged that he be allowed off the locked ward
    for any reason

29
The Case of Vincent Li
  • Is the outrage warranted?
  • What rights do victims have?
  • What responsibility do the review boards have?
  • What is the responsibility of the clinical
    team/psychiatrist signing the order?
  • What is the patients responsibility?
  • What is the best balance between risk and
    recovery?

30
Recovery
  • The concept of recovery is rooted in the simple
    yet profound realization that people who have
    been diagnosed with mental illness are human
    beings.
  • Pat Deegan (1996)

31
Questions? Comments? Feedback?
32
THANK-YOU
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