Believing in 2nd chances:
Social Work Services under the Mandatory Treatment Order in
Singapore
26 July 2014
Loving Hearts, Beautiful Minds
Singapore General Quick Facts 2010
• Total land area: 712.4 sq km or 275 sq mile
• Total GDP: $257,640.4 million
• Total population: 5,076m
• Population profile by race:
• Chinese
74.1%
• Malays
13.4%
• Indians
9.2%
• Others
3.3%
• Four official languages: English, Malay, Chinese and Tamil.
English is used administratively and as medium of instruction
in education and at work
Loving Hearts, Beautiful Minds
Outline
1. Forensic Psychiatry Services in Singapore
2. Community based sentencing orders in
Singapore
3. What is Mandatory Treatment Order (MTO)
4. Case example: Role of social work in the MTO
5. Issues faced in MTO
6. Future directions
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Forensic Mental Health Services provided by IMH
Police arrest
Diversion
Programme
Court
hearing
Serving
sentence
Released from
sentence
Psychiatric
Assessment
Report
(including
PACP)
PACP
Forensic Psychiatry
Community Service
Court
Appearance
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Psychiatric
Housing Unit
Other services
Mandatory
Treatment
Order
MHCTA
(Form 3 & 5)
CPC
Preparation
for stepdown care
Community Based Sentencing in Singapore
Community-Based Sentencing (CBS)
• Introduced in the Criminal Procedure Code 2010 to
provide greater flexibility in sentencing.
• Implemented in January 2011.
• CBS includes:
1. Mandatory Treatment Order (MTO)
2. Community Service Order (CSO)
3. Day Reporting Order (DRO)
4. Short Detention Order (SDO)
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MTO Programme Characteristics
Definition:
A sentencing option that allows the Courts to order an offender to undergo
compulsory psychiatric treatment for a period not exceeding 24 months.
(Section 339 of Criminal Procedure Code)
Objectives:
1. Effective and targeted approach to rehabilitating mentally ill offenders
2. Better utilization of resources which would otherwise be allocated to
incarceration
3. “Second chance” for mentally ill persons charged with (relatively) minor
offences
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MTO Programme Characteristics
Eligibility Criteria
1. Offenders with recognizable and treatable psychiatric illnesses
2. A causal, or substantive link between the psychiatric condition and
the offending behaviour
3. Must be willing to undergo monthly psychiatric appointments for up
to a 2 year period
4. Willing to be compliant to prescribed treatment in any form
5. Be prepared to be contacted/home-visited regularly by clinical staff
6. Adequate family/social support (preferred)
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MTO Treatment Framework
Court
CWO, DRO etc.
Sentencing
Potential for
community based
sentencing options
No potential for
community based
sentencing
Not suitable for MTO
Potential for MTO
Psychiatrists to
assess by MTO
service provider
(IMH)
Jail/Fine etc
Suitable for MTO
& upon approval by
Courts
Defaults treatment /
does not improve
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Processes
•Appointment of bailer
•Treatment program
•Submission of 6-monthly
progress report
•Funding & payment
Refer to
Court for
follow-up
action
Completes
treatment
MTO Team
FY2014:
•
1 Program Director (Senior Consultant Psychiatrist)
•
1 Program Executive
•
4 Case Managers
•
3 Medical Social Workers
•
1 Administrative Assistant
•
1 Clinic Coordinator
•
1 OT
•
1 Psychologist
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Illness Inclusion & Exclusion Criteria
Generally, diagnoses which are included (DSM-IV-TR/ICD-10)
• Psychotic Disorders – Schizophrenia, delusional disorder
• Mood Disorders – Depression, bipolar disorder
• Anxiety Disorders – GAD, phobic disorders, panic disorder, anxiety disorders
(e.g. OCD), PTSD
Generally, diagnoses which are excluded:
• Purely Personality Disorders, Substance abuse & addictive disorders,
Intellectual disability
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Operations Flow for MTO assessment
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Operations Flow for MTO assessment
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MTO Dashboard as of 11 July 2014
Assessments since January 2011
N = 523
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MTO Duration (by months)
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Age at time of MTO assessment
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Gender
N = 297
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Index offences
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Diagnosis
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MTO status
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Case Example
Kat (not her real name)
Demographics:
• 44 year old female / Malay / Muslim / Married
• Employment status: Unemployed. Previously helped mother in her stall.
• Education: Primary 5
• Diagnosis: Depression (1st treated in 2008, irregular)
• Suicidal history: Attempted suicide in 2010 with 6 tablets of panadol
• Substance use history: Nil reported
• Forensic History: Nil reported
• Accommodation: 4 room purchased apartment
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Family Genogram
Father, Retired
in Malaysia,
65yo
Mother,
Housew if e in
Malaysia, 60yo
Mary, Works
w ith Computers,
45yo
Jane,
Works in a
bank, 39yo
55yo
M. 1987,
D. 1992
Sarah,
Childcare
teacher, 23yo
M. 2000
Bob,
Mechanic,
43 yo
Harry, Poly
student,
19yo
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Jack,
student,
10yo
Kat,
unemployed,
44yo
Jim,
student,
8yo
Jerry,
4yo
Case Example
Index offence:
• Voluntarily causing hurt to a domestic helper by slapping
her cheek, pushing her, burning both her arms with
heated iron and injuring her with a knife at her stomach
area.
Court outcome: Kat was granted MTO for
24 months
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Case Example
Social Work Services under the MTO
• Financial Assistance
-
Applied for assistance for treatment fees
-
Referral for financial assistance schemes
• Family Work
-
Referred Kat to therapy services: work on her coping with divorce
proceedings (3 sessions)
-
Family conflict
• Employment assistance
-
Contacts for child care services given
-
Kat set up a food stall in a school
-
In other cases, referral to Job Club or employment placement services
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Case Example
• Family Violence Intervention
-
Home visit was conducted: Eldest son and 2 youngest sons seen
-
Bedroom doors were removed, door knob was missing
-
Worked out safety plans for family – stay in a cheap hostel till court
hearing
-
3 days later, Kat informed that family moved to stay in a park
-
After returning to the flat, Bob hit the 2 youngest children (with a belt and
torchlight) and the children were admitted to a hospital
-
Kat decided to apply for protection order for her children
-
Family stayed at the hospital for the time being
-
Therapy was closed due to crisis management
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Case Example
•
Referral to/Liaise with external services
-
Referred Kat to a Family Service Centre (FSC) for safety monitoring
-
Case conference: Clarification of roles of agencies
•
Accommodation assistance
-
Referred Kat to a crisis shelter
-
Kat stayed at friends place, moved to stayed in school but was warned by the
police, then shifted to a rental place (Daughter stayed separately)
-
In other cases, social worker refers patients to psychiatric residential centres,
halfway houses
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Case Example
• Child Risk management
- 11 year old son reported to a school counselor that Kat
wanted to throw her 5 year old son from an 11th floor, and
was stopped by her other children
- When questioned, Kat admitted having such thoughts,
saying she felt very stressed then as the family had no place
to stay
- Referred Kat to Child Protection Services
- Kat received emergency funds, which
addressed her stressors
- No further risk was assessed towards children
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Case Example
Updates:
• Completed her MTO
• No longer given any appointments in IMH
• Kat had divorced and was selling the matrimonial flat
• Working as a cook in a childcare
• FSC will continue to explore alternative housing and assist
her in parenting her children
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Issues faced in MTO
1. Assessor vs Treating role – Need for role clarity
2. What is defined as treatment? – Need for engagement
3. Managing expectations of family members/service
providers – Being aware of limitations and powers
4. Role of rehabilitation vs role of supervision - Firmness with
flexibility
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Future Directions
1. Research
2. Review on effectiveness of MTO
3. Focus on criminogenic factors
4. Expansion of criteria?
Loving Hearts, Beautiful Minds
Loving Hearts, Beautiful Minds