Judges pushing back, calling mental health systems opaque. Lawyers bellicose, saying the situation is Kafkaesque and that we are at war. Really? Where lies the truth?
Well, as H.L. Mencken once said, "There is always an easy solution to every human problem: neat, plausible, and wrong." If there was a simple answer to the issues in forensic mental health, it would have been found long ago.
What we do know is that more people are entering the forensic system from the courts despite increased use of diversion from the criminal justice system. Also there is little evidence of an increase in the likelihood of violence by people with serious mental illness than there was 20 years ago. So why the rising pressure?
Is there a lack of resources in mental health? Yes, of course, from children's mental health care right through to care for the growing seniors population. Do we need more forensic hospital beds? Yes, we do. Toronto's Centre for Addiction and Mental Health has been working closely over the past several months with the Ontario government to develop more forensic beds. So will that solve the problem? Well, it will help but, no, "solutions" are more complicated.
Deinstitutionalization is undoubtedly the right policy, but to be successful it needs comprehensive services to assist people in the community. Too little financial, housing, social, clinical or crisis support gives rise to people falling out of care, into substance misuse with problem behaviours emerging. Services burn out, families become desperate, and eventually people are charged with a criminal offence in the hope that it will leverage care. Although the motive for laying a complaint with the courts may be well meant, the effect may be incarceration in prison, long periods in hospital and worsening social isolation. Not the ends that anybody wants. A recent report by Ontario's Select Committee on Mental Health and Addictions described these problems very clearly.
So what is the role of forensic mental health services? Our role is to provide care for people with serious mental illness who come before the courts, are in prison, are unfit to stand trial, are found not criminally responsible for a crime committed. We must reach into the courts and the prisons to provide care for people, to provide inpatient beds for assessment and rehabilitation, to provide care in the community for people in recovery from illness and offending.
Needing forensic mental health care often represents a tragic moment in someone's life. At the court level, we must provide assessments and help divert people back into care and out of the criminal justice system if their offending is minor, as it very frequently is. Forensic hospitalization is reserved for those who are very ill, and who present a major risk to the public.
This presumes a continuum of care where those who are not so acutely ill can receive the treatment they need in the community. There are currently gaps in this continuum, meaning that care can be delayed or in venues where persons should not be held. New resources to develop community-based care for persons before the courts are being developed with Ontario's Health Ministry. New beds will come, as well as new services to courts and prisons.
But we can't do this work alone. We need a "whole of sector" approach to meet the needs of a mentally ill person before the courts: the person and their family, community services who should be providing care to them, the court, counsel for the person, prison authorities and health-care providers. Currently, courts are using restrictive orders advocated for by counsel for the person that results in delays in care for everyone, and longer hospital care than people need.
Whilst we look forward to expanding CAMH forensic services, so too do we need respectful engagement of all parties to make the system work.
Sandy Simpson is clinical director of the law and mental health program at the Centre for Addiction and Mental Health.