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
Outline
Who am I?
 What is “forensic psychiatry” anyway?
 What is the “Forensic System”?
 Treatment and rehabilitation
 Getting out
 Getting back in again
 Coercion: myths and realities

Objectives
Give an overview
 Clarify misconceptions
 Identify opportunities
 Interactive discussion

Who are you?
Who am I?
What is a forensic psychiatrist?
MD
 Specialist in psychiatry
 Particular interest (?peculiar interest) in
the area
 Dedicated training
 Dedicated practice
 Eventually…experience

What is the “forensic system”?
In Ontario, a system in place to address
specific needs for those:
Referred for assessment (fit / NCR)
 Detained via the ORB
 In diversion programmes

“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…”
In Ontario:
Access: via courts / Review Boards
 Based on specific circumstances and
criteria

Fitness for Trial

Accused, via the court, can be assessed
for this specific issue in the following:
Mental Health Courts
 Brief Assessment Units
 Inpatient Units (min-max; up to 60 days)
 Out of custody

Unfit to Stand Trial
Being found “Unfit” by the Court after an
assessment is another entry point into
the system…
Treatment Orders
Once found unfit – typically MMI
 Likely to respond (become fit)
 Risk not disproportionate to benefit


Specific Court-mandated treatment up to
60 days, in hospital
Treatment Orders

Intrusive? Yes

Effective? Yes

A long-term fix? No
Criminal Responsibility

Historically “Insanity” or “Insanity defence”

People are presumed responsible for their
actions, unless shown otherwise
Not Criminally Responsible
Being found “NCR” after an assessment, is
another entry point into the system,
typically via the ORB…
Mental Health Diversion
A short-term entry point into the system
 Comprehensive intervention
 Largely voluntary
 “Treatable” disorders
 Minor charges
 Goal is to stay charges (no record)

So…what is the “forensic system”?
In Ontario:
1000 patients (and growing)
 10 designated facilities (security spectrum)
 600-700 designated beds (and growing)
 Several hundred community detainees

CAMH – Law and Mental Health
Programme
40 medium secure beds
 72 minimum secure beds
 8 SOTU beds
 180 outpatients
 Specialty clinics
 Consultation Service
 Mental Health Courts

ORB population
Hopefully…

The mentally ill:
Schizophrenia / Mood
 Dementia
 MR


“Correctly” identified as NCR or unfit
ORB population

Typical offense types:
Manslaughter / murder
 Assaults (simple/ACBH/with weapon)
 Sexual offences
 Threatening / Harassment
 Weapons offences
 Other miscellaneous

LAMHP OPS population
N
Gender
Age
140 clinic patients
> 80% males
35 y
Schizophrenia; Mood
Diagnoses
Disorders; Other Psychoses;
MR; Paraphilias
Comorbidity PD; Substances; Paraphilia
Treatment and Rehabilitation
Inpatient (max – medium – minimum)
 Outpatient (variable reporting)
 “Cascade” notion

ORB-governed
Treatment and Rehabilitation

Multidimensional rehabilitation:
 Medication
 Groups
 Recreation
 Vocational
 Educational
 Socialization
/ social skills
Treatment and Rehabilitation

Multidimensional rehabilitation:
 MD
 SW
 RN
 OT
 PT
 Pharmacist
 RT
 Dietician
Treatment and Rehabilitation

Goals:
Protect public safety / manage risk
 Reintegrate the accused

Treatment and Rehabilitation

Life “inside”
 Depends
on security level
 At minimum – indistinguishable from civil
 Groups, outings, recreation, school , work
 Families highly involved
Treatment and Rehabilitation

Life “outside”
 Various
types of housing
 Differing reporting frequencies
 Work, family, relationships, productivity
 Can be minimally intrusive
Getting Out

Do what you are supposed to

Don’t do what you are not
Getting Out
Respond and be amenable to treatment
 Participate in groups
 Use privileges
 Reintegrate
 Remain free of aggression / reoffense
 Remain free of substances
 Structure / skills

Getting Back in Again

It happens…minimize stigma:
Substances
 Non-compliance (meds / reporting)
 Re-offense
 Decompensation
 Risk management

“Coercion”: Realities
It is a therapeutic environment
 Goal is reintegration
 Outcomes are very very good
 Failures are rare
 Resource-rich

“Coercion”: Myths
Providers benefit from ongoing detention
 The system cures all
 Once in, always in
 It is inhumane
