The Beginning...

The Beginning...

Saturday, July 28, 2012

Three Months Working in Forensic Mental Health

Alright, so maybe the picture of Arkham Asylum is a bit distasteful but but I like the taste of a lot of things. It's also a media portrayal of the "criminally insane" which, at least in Canada, is not even a correct term. Forensic mental health is something that is not well understood by most people. I would like this blog to give a little more understanding for people who find themselves slapped with this unfortunate forensic stigma. (And if you don't know what the Arkham Asylum reference is for... shame on you. Go read up on your Batman!) 

Quick history on Asylums - Individuals with mental illness have been perceived differently depending on the era they live. Once they were considered possessed by evil spirits. Once they were considered wise men or shamans in some cultures. Some people believed it was the influence of the moon and thus the term lunatic was created. (Root word luna, the latin for moon) Western culture let these "idiots" - the proper term at the time - wander the streets. In the early 1800's (this is Ontario Canada history now) the first institutions were built to get these people off the streets. They were called Asylums. There were some doctors who had the idea that there was something medically wrong, not spiritually wrong, with these people and they would benefit from treatment like any other disease. The problem was they had no idea how to treat it. All sorts of weird treatments arose like spinning in a 360 degree chair to reset the brain to the infamous lobotomy where a piece of the frontal lobe was removed. Some just thought hard work would cure them. But who was mentally ill was also an issue. Well I read some report from 1888 from doctors explaining why some people were admitted to the asylum. You could be admitted for being old, being considered dull to converse with, for masturbation, or just unwanted by your family. It became a dumping ground for all unwanted people. There was often abuse, cover ups and despite well meaning doctors just terrible treatment in general. It was also a popular Sunday afternoon outing to go visit the asylum and poke fun at the people there. Animals they were. They had the appearance of humans but they had no soul so it was okay to mock them and provoke them. Get them into a psychotic rage behind their bars for your entertainment. Imagine you go to a treatment facility because you are depressed and then people come in to laugh at you. Few people would want treatment and would rather hide and avoid these places in possible. There was and still is a very negative stigma for mental health.

However, several decades ago a de-institutionalization policy began which attempted to have people treated from home. The asylum began to fade away. In their place now exists hospitals which focus on mental health.  But lets talk about forensic mental health or the criminally insane as you may know them by. The technical term actually is Not Criminally Responsible or NCR. This occurs when someone with a mental illness commits a crime while in a psychotic state due to the mental illness. They are not considered responsible for their actions and receive treatment rather than punishment. This is a system which is greatly misunderstood by many people.

First of all, there are people of all walks of life who are considered NCR. Some of them career criminals while others very friendly and seemingly ordinary people. What matters is that when the accused crime was committed, the individual was psychotic - meaning their perception of reality was altered. They were unable to understand and appreciate the situation and actions. This is hard for some people to swallow. Let's use the example of Vince Li - the Greyhound killer from a few years ago. Here is a man who reportedly believed he was killing an alien who was a threat to the earth. In reality he beheaded a young man and ate his flesh on the bus in front of everyone. While not psychotic he showed great remorse. I've heard people say "but his delusion doesn't make sense to his actions. If he really believed he was killing an invading alien why would he disfigure and consume the flesh?" Here's the thing - LOGIC HAS NO PLACE WITH PSYCHOSIS. Imagine something you believe to be true 100%. Now imagine someone telling you that not only is it false but you are insane for believing it. I've seen a woman with Fragoli syndrome (believing 2 people are one in the same) see the two people she believes are one in the same in the same room together and still deny it. One is an actor and its a conspiracy is how it was reasoned. My point is that when these crimes are committed the person is NCR because they truly do not understand the situation or the consequences as they are in the reality the rest of us seem to share. So they are not treated like criminals who are fully aware of their actions. Still they are clearly dangerous so something must be done but to treat them like criminals would not be fair or just. 

Remember the movie "One Flew Over the Cuckoos Nest"? Jack Nicholson pleaded insanity to avoid going to prison even though he was just an ordinary criminal. Some people think this is preferable to prison. Sure, forensic hospitals are more comfortable but once you are in the forensic system you can be stick there for decades for even minor crimes. You can not leave until a team of mental health professionals and a Review Board think you are no longer a threat. 

This is how it works: There are secure and general units. No longer are they called maximum, medium and minimum secure. There are privileges that patients (not inmates) can earn. They range from going outside with 2 or more supervisors for a half hour to going out for weekends unsupervised in the community and being able to work a full time job during the week. Privileges are given in increments at the discretion of the mental health team. Good behaviour and insight to mental illness help get more privileges. Once privileges are maximized then the next step is moving into a supervised group home in the community. Once there they must still report back on a regular basis and get regular urine tests for alcohol and drugs which are prohibited. Any breach of rules then they are brought right back into the hospital. It takes a very long time to receive an absolute discharge. So... three months in prison for assault or 10-15 years in the forensic mental health system for pleading "insanity". There are still many issues to work out with the system. 

I had one patient say to me "even though I'm NCR, people still treat me like a criminal". Not only does he have schizophrenia to deal with but people think he's now some criminal low life. It's incredibly difficult for these people to find jobs even if they are capable. No one wants to hire the friggin Joker. Even finding a place to live is difficult. No one wants to rent a room to a violent lunatic. People freaked out when Vince Li was given 30 minutes with supervision off the unit he is kept on. They thought he was suddenly stalking the streets again for children to eat. People are calling for his head as a proper retribution for his actions and that he's faking his mental illness to evade the law! That man will never have much of a life again as a result of his illness, NOT a result of his concious actions. Do we really need to call for his blood and ridicule him on top of that? Even if he receives an absolute discharge and completely manages his symptoms he will always have the stigma.

Back in May this year a murder occurred at the hospital. While outside on hospital grounds one patient viciously beat the other to death. The trial has not happened yet but the murderer was not psychotic at the time. It is likely that the charge will be criminally responsible. Like I said , some people are career criminals and others are not. He happened to be a psychopath. (Anti-social Personality Disorder but the difference is a topic of another blog) I've done quite a bit of research on that. As much as the media would like to portray all forensic patients like that man it is simply not true. He was an exception. 

So Arkham Asylum needs a modern update. The Arkham Center for Integrated Healthcare would be a better name. (If anyone knows what I'm referencing then good for you! You win the big no prize!)