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Dr. Sandy Simpson


Forensic mental health services

Meeting the challenge of illness and offending

The forensic system exists to help people who have fallen foul of the law get back into care, into health and into their communities. To this end, the Law and Mental Health Program at the Centre for Addiction and Mental Health (CAMH) in Toronto provides a range of services: court triage and diversion; 165 inpatient beds for assessment; treatment and recovery programs; an outpatient team; and specialized outpatient services for people with problems of sex offending or abnormal sexual drive.

Why do we have these services? Why are they distinct from other mental health services? And why are they not part of the criminal justice system?

We know only too well that people with serious mental illness are at greater risk of arrest and imprisonment, in part because the nature of their illness gives rise to poverty, substance misuse and homelessness, which may bring them into contact with the law. For others, their illness causes behaviour that results in serious harm to others. The courts and criminal justice system need help determining the right way to respond.

If someone is acutely mentally unwell, they may not be able to understand what is occurring in court or to defend themselves properly. They need to be helped into care to restore their competence so they become fit to stand trial. Our staff in the region’s courts provide assessments to the court and arrange treatment in this situation.

After a period of treatment, or if the person can enter a plea, the court has two major concerns. First, if the charges are relatively minor and if mental health care is what the person really needs, the court may divert the person into care rather than prosecute through the criminal justice system. These programs, which include mental health court, are provided in part by CAMH, and with community partners.

If the charges are more serious and it is felt that the person has a defence against the charges as being not criminally responsible (NCR) because of mental illness, we can provide expert testimony to help the court make that finding. If the defence is accepted by the court, the person is sent to hospital under the supervision of the Ontario Review Board (ORB) under our clinical care.

Once found NCR or unfit to stand trial and ordered under the ORB, most individuals come to an inpatient bed initially to develop a rehabilitation and recovery plan. The person is under the authority of the ORB, which oversees their pathway through care, balancing their needs with the safety interests of the public. Within the parameters set by the ORB, the person progresses through levels of more secure to less secure care as their wellness improves, their understanding of their need to stay well in the long term grows and the risk to the public decreases.

Individual and group work and developing social and vocational skills are very important, in relation to the person’s illness, generally, and in relation to how risk re-emerges in their lives, specifically. Family relationships and supports are also key.

As people progress on this journey, most can return to the community. Our large outpatient service facilitates community reintegration. We support other act teams and transitional case management teams that have ORB clients. More than 280 people are cared for by our outpatient follow-up services. When the ORB finds they no longer represent a threat to the public, they cease to be ORB clients and return to care under general mental health services.

Unfortunately, most people with serious mental illness coming before the courts do not come to hospital; rather, they go to prison. Between 15 and 20 per cent of inmates have a serious mental illness, and between 70 and 85 per cent have a substance use disorder. In Ontario, mental health care for these people is in the hands of the Ministry of Community Safety and Correctional Services, with contracts with health care staff to provide sessional time. But services are inadequate. The period of imprisonment should be taken as an opportunity to link people to care. Most inmates have short sentences, and developing pathways for follow-up upon release is very important for both individual health and public safety. CAMH does only a small amount of this work, but we are helping to develop good care pathways for inmates with mental illness.

Dr. Sandy Simpson is clinical director of the Law and Mental Health Program at the Centre for Addiction and Mental Health, and associate professor in the Law and Mental Health Program at the University of Toronto.

Fast facts

The Ontario Review Board for 2010–2011 reports:

171 ORB members
1,972 ORB hearings
248 new accused
94 absolute discharges
1,622 accused under jurisdiction of ORB

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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

Community Mental Health Initiative (Correctional Service Canada)

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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