Forensic Treatment

Levels of Prevention (ecological approach): ◦ Primary, Secondary, Tertiary

Levels of Intervention: ◦ Individual◦ Family or Group◦ Community◦ Institutional, Society◦ Policy/Law

Primary prevention takes place before a problem is developed and is directed at a population in general rather than specific individuals.

Secondary prevention programs are directed at specific groups, but the intervention takes place early before significant problems have developed.

Tertiary prevention takes place long after problems have developed, and are usually quite costly as they often involve institutional care and intensive case management. Also, serious criminal behavior, including violence, has already occurred.

Law

Community

Peers

Family

Individual

Levels of Intervention

Law

Community

Peers

Family

Individual

Individual

Levels of Intervention

Mental disorder as a main focus of intervention:◦ Unfit defendants

◦ Defendants found NCRMD

Mental disorder as a secondary focus:◦ Mentally disordered offenders

◦ Sexual offenders

◦ Offenders at high risk for violence

In 1994/95, 1.2 per 1,000 cases in adult criminal court were diverted to Review Boards while in 2003/2004, this rate had increased to 1.8 per 1,000 cases – a 50% increase over the 1994/95 rate. ◦ Reflects impact of changes resulting from Swain case.

Latimer and Lawrence reported data from Quebec, Ontario, Alberta, and British Columbia showing that a total of 8,639 accused were found NCRMD or UST during the period 1992-2004. ◦ The majority of these cases were accused found

NCRMD, as there was a total of 1860 unfit accused, about 22% of the total.

Psychotropic mediation most common

Educational treatment programs

Programs geared toward defendants with intellectual deficits

Treatment Success Variable, depends on program & defendant MR defendants only 18% (Anderson & Hewitt, 2002)

Evidence unclear for educational programs Most are restored within six months

Challenging conditions (Mossman, 2007) Irremediable cognitive disorders (MR, FASD) Chronic psychosis with lengthy hospitalization

history Serious lack of literature and research

Length of Confinement Relationship between severity of crime and

length of confinement◦ Punishment may have higher priority than

treatment

Conditional Release Minority status, substance abuse diagnosis,

prior criminal history predict revocation

Treatment issues for NCRMD acquittees

Predominant diagnostic categories1. Psychotic disorders2. Personality disorders3. Co-occurring substance use disorders

Inpatient treatment focus◦ Reduce psychotic symptomatology Medication Cognitive behavior therapy

RB has no power to impose a condition that an accused submit to treatment unless the accused consents.

Even though the RB may not order treatment without consent, accused persons detained in hospital under Review Board orders receive treatment under sections 30 and 31 of the provincial Mental Health Act, which “deems” such persons to have consented to treatment. 

There is no “deemed consent” provision for persons discharged to the community on conditions. This means that it is ultimately for each accused, while in the community, to decide whether to take their medication. ◦ If they choose not do so against the recommendation of their

Treatment Team and the Review Board, this could be a factor in their return to hospital or in future Review Board decision-making.

Should those found NCRMD have the right to refuse medication?

Supreme Court of Canada considered this issue.

Review facts of case and decision. Question: How do you weigh rights of

individuals versus benefits of treatment?

Too much focus on primary disorders, neglect of co-occurring disorders

Comorbid depression & anxiety are common

Other important interventions Life skills training Social skill training Management of anger, aggression, &

violence

Mentally disordered individuals increasing in jails (pretrial facilities)

Overall, percentage ranges considerably from jail to jail

Our research shows a 15% rate in Pretrial facilities in the Lower Mainland

After the lesson was over, she walked through the prison with strong objections from the jailer. Dorothea went down to the lower level of the building. They were called the dungeon cells where insane were chained. She saw miserable, wild and stuporous men and women chained to walls and locked into pens--naked, filthy, brutalized, underfed, given no heat, sleeping on stone floors. It was this visit that started Dorothea on her life's work to improve conditions for the mentally ill.

Dorothea DixIn 1841 in Boston, Dorothea volunteered to teach a Sunday School class of 20 women inmates at a Massachusetts jail.

Coming Full Circle

In one of our studies of about 800 defendants (SCID interviews):

◦ 15.9% Major mental disorder (schizophrenia, major affective disorders)

◦ 85.9% Substance Use Disorders◦ 64.3% Antisocial personality disorder

DISORDER % Any major mental disorder 17.1 Major depression 32.9 Generalized anxiety disorder 19.7 Psychosexual dysfunction 34.2 Antisocial personality 36.8 Alcohol use/dependence 63.2 Drug use/dependence 50.0

Douglas, Ogloff, & Nicholls, 1999; Nicholls, Ogloff & Douglas, 2004◦ Evaluated mental health and violence risk in

severely mentally ill psychiatric patients◦ Sampled 193 civilly committed patients◦ File reviews

123 (64%) persons had prior arrests/convictions 78 (40%) for violent offences

6.1

15

3.4

13.7

0

22.3

0

5

10

15

20

25

Men

Women

See Teplin, Abram, & McClelland, 1996; Abram, Teplin & McClelland, 2003

Teplin et al. (1996)

-1272 female jail detainees in Chicago-80% met criteria - one or more lifetime disorders-70% had symptoms in the month prior to admission

Major Mental Disorders 19.71. Bipolar Affective Disorder 0.82. Major Depression 15.73. Psychotic Disorder NOS 0.84. Schizoaffective Disorder 2.4

Substance Use Disorders 60.91. Alcohol 24.02. Cannabis 16.53. Cocaine 10.24. Hallucinogens 1.65. Opioids 5.56. Sedative Hypnotics 3.17. Polydrug 15.0

Source: J. Ogloff (1996)

Prevalence of Mental Illness Among Prevalence of Mental Illness Among Admissions to the Surrey Pretrial Services Admissions to the Surrey Pretrial Services

CentreCentre

70%

25%

5%

Routine Intake

Mental Disorder

Severe Mental Disorder

•Estimating from the literature, as many as one in every four inmates will require a referral for mental health services and/or specialized placement (JSAT; Nicholls, Roesch, Olley, Ogloff, & Hemphill, 2005)

•Best Practice Guidelines•link scientific evidence, theory and practice to provide an efficient, reliable and valid means of accomplishing the task of identifying inmates with mental health problems.

SFU doctoral students Screening interview of all admissions to jail,

approximately 400 per month Screen for suicide and violence potential;

mental health problems Refer to mental health team--about 25% of

admissions Importance of community follow-up

See Roesch, R. (1995). Mental health interventions in pretrial jails. In G. M. Davies, S. Lloyd-Bostock, M. McMurran, & C. Wilson (Eds.), Psychology, law and criminal justice: International developments in research and practice (pp. 520-531). Berlin: De Greuter.

Intake Screening

Mental Health Program

Inmate requires evaluation or intervention?

SpecializedPlacement

No serious mental health problem

Regular Living Unit

YesAbout 25% referred

Emphasis on early identification, prevention and management◦ First step in providing cohesive mental

health services in pretrial correctional facilities is to initiate comprehensive intake screening

Err on the side of caution◦ Preferable to commit false positives

Screener as part of a team (nurses, correctional officers, psychologists, psychiatrists)

(a) Moral/Ethical responsibility 1. Provide care and prevent decompensation;2. Reduce and manage risk of suicide, violence,

victimization3. Prevent non-high profile/clearly MD from slipping

through cracks(b) Legal duty

(a) Manage risk of liability(c) Minimize conflicts among inmates and between

inmates and correctional staff; (d) Prevent unfair/differential treatment of MD inmates; (e) Reduce recidivism and cycle of admissions to

correctional and healthcare settings(f) Minimize staff stress and risk of injury

Incarceration can serve to exacerbate a mentally disordered inmate’s mental health functioning◦ some individuals develop mental health

problems over the course of their time in custody (Hodgins, 1995)

Highlights the importance of conducting mental health screening at the time of admission and to provide for continued monitoring (Ogloff, 1998)

The suicide rate among male jail inmates ◦ estimated to be double that of sentenced/prison

inmates (Hayes, 1995)

◦ 9 to 14 times higher than within the general population (Farmer et al., 1996; Hayes, 1989 1994; McKee, 1998)

In a sample of 1,272 female jail inmates, Charles et al. (2003) found more than half of the women reported prior suicide ideation or behavior (53%) and more than 1 in every 5 women reported a prior suicide attempt.

Screening for mental health concerns upon admission to jails/pretrial facilities is particularly important given that empirical research demonstrates the significance of temporality to suicide risk. ◦ In particular, the initial hours of detention are

high risk for suicide attempts (McKee, 1997)

◦ Moreover, the pretrial environment has been characterized as particularly stressful (Felthous, 1994)

◦ More recent research shows the time frame extends to days and months (Goss et al., 2002) important to continually monitor!

Research consistently demonstrates that MDIs are at greater risk than nonMDIs to be physically and sexually victimized during custody (e.g., Cooley, 1992; Torrey, 1992). ◦ Clearly then, early identification of MDIs is

essential to ensure appropriate placement.

Some studies have documented higher rates of rule violations and disruptive institutional incidents among inmates with mental health problems

infractions that can be considered the result of “diminished capacity,” should be recognized as such and treated accordingly. ◦ As Adams (1986) noted, punitive actions may

exacerbate an inmate’s mental health problem(s) and/or violate Constitutional prohibitions against cruel and unusual punishments (see Canadian Charter of Rights and Freedoms, s. 12; U.S. Constitution, Eighth Amendment).

Early identification of MDOs can serve to reduce staff stress.

Kropp, Roesch, Hart, & Cox (1989) found that correctional officers describe MDOs as ◦ less predictable, ◦ less rational, ◦ more mysterious than other inmates, and ◦ considered MDOs to be more dangerous than

mentally ill patients. ◦ A significant proportion (90%) of correctional

officers reported less confidence in their ability to work with MDOs than with other inmates and most (89%) stated that it adds to their work stress level

MDIs frequently cycle through health care and correctional settings repeatedly ◦ Conceivably, a procedure such as the one we

recommend should serve to identify inmates with mental disorders, substance use disorders or dual diagnoses, expedite their referral to necessary services, and ultimately reduce their risk for general and violent recidivism.

Housing and Support for Adults with Severe Addictions and/or Mental Illness in British Columbia.

The report, completed last month, says its research shows that approximately 130,000 people in B.C. have a severe addiction and/or a mental illness; about 26,500 of those people are "inadequately housed and inadequately supported," including 11,750 who are "absolutely homeless."

The authors said that at the time the report was written, there were 7,741 supported housing units in B.C. for people with mental illness and/or addictions, and therefore concluded an estimated 18,759 vulnerable people were at "imminent risk of homelessness."

Cost is $55,000 per person, or an annual total of $644.3 million in health, corrections and social services spending for all the homeless in B.C.

But report concludes that B.C. taxpayers could even save money if that cash was instead spent directly on supported social housing.

If housing and support were offered to these people, it would cost the system much less -- just $37,000 a year.

Also called Mental Health Courts, Drug Courts. Downtown Community Court in Vancouver

opened in September, 2008 as Canada’s first community court.

Deal with pretrial accused with mental health and/or addiction issues.

Focus is on treatment not punishment. Accused are diverted. Vancouver either stays

the charges or expunges the record of the defendant upon successful graduation from the program.

A case management plan was developed for offenders, focusing on strategies to address the risk to re-offend and also needs such as housing, employment, financial assistance, associates, mental health and addictions.

Uses a “triage team,” composed of

professionals from a wide array of domains, from housing representatives to case workers to crown counsel who provide assurance of availability and connections to community resources and treatment, and also monitor and impose sanctions based on offender compliance.

The court addresses summary conviction type offences, mainly theft (33%), assault (14%), possession of drugs (9%) and mischief (5%), as well as administrative offences (2%) and other offences (12%).

The court deals with an average of 62 case appearances per day.