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Custody and caring

Striking a delicate balance in a forensic hospital

Social worker Nancy Lynk loves her job. “What I enjoy most in working with patients is finding out how they got to this point, learning their life story,” she says with an infectious smile. “If I won a million dollars, I would still be here.”

But “here” is the maximum security mental health hospital that is part of Waypoint Centre for Mental Health Care in Penetanguishene, Ont. It treats some of the most misunderstood people in society with the severest behaviours associated with mental illness.

The time I spent with Lynk and two nurses at Waypoint (formerly the Mental Health Centre Penetanguishene), painted a vivid picture of the dual role they play, reflecting a delicate balance between caring and custody.

Forensic hospitals are defined by the requirement to treat and care for psychiatric patients who are also offenders. For the clinical staff working there, that means connecting with patients, even when they evoke strong, negative emotions: some have committed frightening crimes, some are threatening or dangerous, some regard those charged with their care as enforcers of their confinement.

Lynk’s patients come to hospital through courts or penal institutions, but the offences with which they are charged vary from lesser offences that could result in harm to themselves or others to sexual assault or murder. Lynk, who has worked at the all-male facility for five years, says slightly more than half of the offences involve assault.

Lynk does court-ordered psychosocial assessments to determine whether the person understood what they were doing when they committed the offence. She also works with the families of patients, explaining the hospital process and helping them sort their way through the day-to-day realities. Many have been trying to get help for their children for years. Lynk explains to them that although the place looks like a prison, it is a hospital, and the purpose of her unit is to assess mental illness, not criminality. (In fact, the government recently approved a $471 million redevelopment project to replace the old facility with a new one designed as a hospital.)

Lynk has an office at one end of a narrow hall, along which are strung meeting rooms, a kitchen, a nursing station and patient rooms that do, in fact, resemble prison cells. The locked rooms have steel doors and thick metal grids over windows opening onto the hall. Each contains a bed, a toilet and a sink, although desks can be added for patients who want one and who are stable. Exterior windows are barred with what look almost like louvers.

On the day I visit, one patient is at the window in one of the rooms, bellowing, and the patients in other rooms sit or recline on the beds. Lynk waves a cheery hello to one of the men as she passes.

Verbal and physical abuse and threats toward staff sometimes happen. But part of the hospital’s work is to minimize the opportunity for harm to patients and staff. Lynk says the structure of the ward’s routine can be helpful to people whose lives have been chaotic.

Down the hill from Oak Ridge, as the maximum security hospital used to be called, is the Regional Forensic Services Program, a 20-bed medium security unit for men and women. It’s clearly more relaxed. Patients lounge in a common room, and on the wards, some are napping in chairs. But patients can arrive at both hospitals handcuffed and accompanied by police. Both places provide seclusion for patients who are volatile, and both use physical restraints, but only as a last resort, says Sarah Morgan, a nurse at the program. Learning how to assess and manage violence risk is necessary because the potential for violence among this population is ever present.

Morgan describes how important the relationships between nurses and patients are in creating a secure environment for everyone. “It’s a priority for nurses to build trust with patients,” she says. “It’s a matter of keeping us functioning as a family because that’s what we are.” That means getting to know patients as individuals, which includes learning their triggers for anger and other emotions.

Forging therapeutic relationships can be a challenging, slow process because some patients view nurses as being part of the system of detention. Many of Morgan’s patients, all of whom are referred by a judge, claim to have been wrongfully accused, and some are defensive because they’ve been in jail. Morgan says that for patients, hearing that the staff are “here to help them” goes a long way to building trust.

But when feelings of natural caring are distorted—and it can happen, given the nature of some of the offences—staff must find a way to respond through ethical caring. Peter Helleman, who has been a nurse at the maximum security hospital for 16 years, says that nurses are obligated through their professional code of ethics to develop a non-judgmental attitude. “You have to tune out the more heinous things and deal with the person,” he says. “You deal with the immediate person, and you deal with signs and symptoms of major mental illness.”

Morgan agrees, saying that as a nurse working with forensic patients “you have to be aware of your own personal beliefs and not bring them to work. You need to keep an open mind and check your beliefs at the door more than anyone [working outside forensic psychiatry].”

Helleman remembers a patient with schizophrenia who saw snakes coming out of Helleman’s eyes. “He wanted to get those snakes,” he says, and under the circumstances, it seemed like a reasonable reaction. Helleman worked for nine years at Oak Ridge before he had to cope with an actual assault by a patient, and even in that case, he was able to de-escalate the situation quickly. But the potential for violence is one reason to keep communication open with patients, he says, and to let them know exactly what the nurse’s role is and what the patients should do in their own best interests. “It’s like a marriage,” he says. “You have to compromise.”

It’s a relationship in which Helleman gets to know many of his patients as very intelligent people, and as being able to maintain a sense of humour, even in the middle of terrible difficulties. A sign of that is visible on the wall of the quiet room, where patients go when they need to de-escalate. It’s an austere room that contains nothing but a toilet and sink. Over the sink, someone has written a bit of graffiti: “Please sign our guest book.”

One of the strengths of the programs at the maximum security hospital, in Helleman’s view, is that staff mix with patients. Depending on the level of activity patients are allowed, they may be confined to their room or they may be able to enter common areas, taking advantage of recreation and other facilities with various levels of supervision. There are gym and pool facilities, as well as television and recreations rooms.

“We get people who are ‘career criminals’ and we still give them privileges and play pool with them and play catch in the yard,” says Helleman. Some nurses and patients watch hockey games on the television together and nurses take that as an opportunity to reinforce positive behaviour. “A nurse might say to a patient, ‘You’re not just watching TV, you’re modelling pro-social behaviour,’” says Helleman.

For Morgan, such interactions go beyond therapeutic. She says of the patients: “They’re people. They like communicating and having interaction like anybody else.”

And like anybody else, they enjoy simple pleasures. Both Helleman and Lynk mention the patient kitchen in their respective units, where two patients at a time are allowed to cook a meal of their choice. The patients prepare a list of ingredients and a staff member does the shopping. The menu might be an ethnic food that a patient has been missing, or it could be a steak dinner.

Forensic hospitals are beloved of murder-mystery writers and horror-film makers, but one aspect of life there that is often overlooked is that patients who have committed crimes while ill can feel terrible remorse as they recover. Some may have killed a person, possibly even a family member, and have difficulty coping with the enormity of that.

Lynk tries to help her patients cope with these feelings. She tells them, “What you did, it wasn’t you; it was the illness.” She refers some of them to the hospital’s chaplain for help. “In society there is such a lack of understanding of mental illness,” she says. “When people hear ‘murder,’ they automatically think ‘criminal,’ and they can’t get past that, no matter what. People don’t consider that maybe the person is ill, that it was the symptoms of their illness that led to the offence, and that they are actually a kind, loving, person who would not have done such a thing had they not been inflicted with mental illness.”

As for how they themselves cope, Helleman and Lynk respond in different ways. Helleman says of the nature of the crimes some patients have committed, “You just get used to it.”

For Lynk, “It’s a safe place to work. I don’t ever come in here afraid.” But she does admit that work can spill over into her life outside. If she is in a store, for example, and the public address system comes on, her first reaction is to think it’s a code white, and the adrenalin starts rushing. “But then I shake it off and laugh at myself,” she says.

If there is any part of the job that Lynk dislikes, it’s that patients leave the forensic hospital and she may never know how they’re getting along in the outside world. “I hate not knowing,” she says. “I just want to know, are they doing well?” She gives departing patients her card, and hopes they’ll get in touch, but it’s up to them.

One former patient did contact Lynk two years after he left. He had continued to take his medication, found a job and returned to university. It’s not how every story ends, but it brings a smile of satisfaction to Lynk’s face.

Waypoint fast facts (2010–2011)

Provincial Forensic Programs (maximum security):
160 beds
219 admissions
216 discharges
All men

Regional Forensic Services Program (medium security):
20 beds
40 admissions
39 discharges
14 men, 6 women

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Related links

American Academy of Psychiatry and the Law

American Psychological Association – Criminal Justice Section

Canadian Academy of Psychiatry and the Law

Canadian Psychological Association – Criminal Justice Section

Correctional Service Canada

Human Services and Justice Coordinating Committee (Ontario)

International Academy of Law and Mental Health

International Association of Forensic Mental Health Services

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