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Criminalization of the mentally ill : a study of psychiatric services within the Lower Mainland Regional… Chow, Lily Lucia 1991

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CRIMINALIZATION OF THE MENTALLY ILL: A Study of Psychi a t r i c Services Within The Lower Mainland Regional Correctional Centre, Health Care Centre By / LILY LUCIA CHOW B.A., Simon Fraser University, 1986 B.S.W., The University of B r i t i s h Columbia, 1987 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK i n THE FACULTY OF GRADUATE STUDIES SCHOOL OF SOCIAL WORK We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA June 1991 ®Lily Lucia Chow, 1991 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia Vancouver, Canada DE-6 (2/88) A B S T R A C T This paper examines the p l i g h t of the incarcerated mentally i l l . After a consideration of the h i s t o r i c a l factors which have contributed to the current philosophy and pattern of services throughout North America, and s p e c i f i c a l l y i n B r i t i s h Columbia, the paper reports on a q u a l i t a t i v e study using pa r t i c i p a n t observation, informal and formal interviews, and Strauss' Constant Comparative Methods which was undertaken to i d e n t i f y the needs of the mentally i l l i n d i v i d u a l s who are serving a term of imprisonment i n the Health Care Centre of the Lower Mainland Regional Correctional Centre. Altogether there were eighteen formal p a r t i c i p a n t s . They included s i x mentally i l l offenders, six c o r r e c t i o n a l personnel, and s i x health care professionals. A c r i t i c a l analysis of the major findings -alienation, lack of organizational commitment, and the incongruencies between our s o c i a l p o l i c i e s and practices -provided the basis for program recommendations. The challenge l i e s i n the building of a v i s i o n that values humane treatment for the marginal members of our society. T A B L E O F C O N T E N T S PAGE ABSTRACT i i LIST OF TABLES V LIST OF APPENDICES v i CHAPTER 1 BACKGROUND TO THE STUDY 1 History of the North American Mental Health System.. 1 Moral Treatment and the Asylum 2 The Mental Hygiene Movement and Psychopathic Hospitals 4 Community Mental Health Movement 6 The Community Mental Health Movement i n Canada.. 9 The.Community Mental Health Movement i n B r i t i s h Columbia 11 Summary 14 The Criminalization of the Mentally 111 15 Cost Versus Care: The Dilemma 19 2 SYSTEMS OF CARE FOR THE MENTALLY ILL IN THE PROVINCE OF BRITISH COLUMBIA . 21 Riverview Mental Hospital 21 Forensic Psychiatric Services 24 Lower Mainland Regional Correctional Centre .... 28 Entry to the System 33 Concluding Comment 38 3 THE RESEARCH DESIGN 40 Defining Mentally 111 Offenders 40 Purpose of Research 43 Issues Selected for Research 45 Research Design 46 Methodology 47 (i) Data C o l l e c t i o n 47 ( i i ) Sampling 48 ( i i i ) The Interview 52 (iv) Data Analysis 52 (v) Ethics 53 (vi) Discussion 54 - i v -4 RESEARCH FINDINGS AND DISCUSSION 58 Characteristics of the Sample 58 (i) Mentally 111 Offenders 58 ( i i ) Service Providers 59 Findings and Discussion 61 I Alienation 61 (i) Mentally 111 Offenders 61 ( i i ) Correctional Personnel 65 ( i i i ) Health Care Professionals 70 Discussion 74 Implications of the Alienation Finding 75 (i) Mentally 111 Offenders 75 ( i i ) Service Providers 76 II Organizational Commitment 78 Discussion 82 Implications of the Organizational Commitment Finding 86 Summary 89 III Where Do They Belong? 90 (i) Mentally 111 Offenders 91 ( i i ) Correctional Personnel 91 ( i i i ) Health Care Professionals 92 Discussion 95 Implications of the Finding on the Incongruencies Between Stated S o c i a l P o l i c i e s and Actual Practices 96 Summary and Concluding Comment 100 Footnotes 103 Bibliography 104 Appendices 113 A Young Adult Chronic Patients ...113 B Interview Guide 115 C Consent Form For Mentally 111 Offenders 116 D Consent Form For Service Providers 118 E Data Analysis 120 F Memorandum 123 G I n i t i a t i v e s and a Look to the Future 124 - v -L I S T O F T A B L E S Number PAGE 1 Sample D i s t r i b u t i o n 50 - v i -L I S T O F A P P E N D I C E S APPENDIX A - Young Adult Chronic Patients B - Interview Guide C - Consent Form for Mentally 111 Offenders D - Consent Form for Service Providers E - Data Analysis F - Memorandum G - I n i t i a t i v e s And A Look To The Future - V l l -When I consider the b r i e f span of my l i f e , Swallowed up i n the ete r n i t y before and behind i t , The small space that I f i l l , or even see, Engulfed i n the i n f i n i t e immensity of spaces, Which I know not, and which know not me, I am a f r a i d . And wonder to see myself here rather than there, For there i s no reason why I should be here, Rather than there; now, Rather than then. On beholding the blindness and misery of man, On seeing a l l the universe and man without l i g h t , L e f t to himself, as i t were, Astray to t h i s corner of the universe, Knowing not who has set him here, What he i s here f o r , or what w i l l become of him, Incapable of a l l knowledge, I begin to be a f r a i d . As a man who has been c a r r i e d while asleep To a f e a r f u l desert i s l a n d , And who w i l l wake not knowing where he i s , And without any means of g u i t t i n g the is l a n d , And thus I marvel that people are not seized With despair at such a miserable condition. Blaise Pascal (1623-1662) - 1 -C H A P T E R OISJE B A C K G R O U N D T O T H E S T U D Y XM'X'RODTJCTIQM To understand our current delivery of mental health services, i t i s e s s e n t i a l that we examine the various h i s t o r i c a l and contemporary s o c i a l factors that have influenced the overt manifestation and control of mental i l l n e s s . This s o c i o l o g i c a l perspective i s supported by Mechanic (1983) i n his a r t i c l e The Contributions of Sociology to the Understanding of  Mental Disorder. He states: " i t i s d i f f i c u l t to conceive of a mental i l l n e s s process outside the contours of a p a r t i c u l a r culture and society" (p.17). This chapter surveys the h i s t o r i c a l evolution of the North American mental health system. H I S T O R Y O F T H E WORTH A M E R I C A N MEKTTAT- H R K T . T H S Y S T E M In t h e i r a r t i c l e Cycles of Reform i n the Care of the Chronically Mentally 111, Morrissey and Goldman (1984) suggest that i n the treatment of the mentally i l l , there are three separate cycles of reform, with each i n i t i a t i n g "a new environmental treatment and new locus of care" (p.785). The authors reviewed the development of the mental health service delivery system, and coined the term "a c y c l i c a l pattern of i n s t i t u t i o n a l reforms" (p.785). The pattern of i n s t i t u t i o n a l - 2 -reforms can be summarized i n three stages as follows: 1) moral treatment and the asylum; 2) the mental hygiene movement and the psychopathic h o s p i t a l ; and 3) the community mental health movement and the community mental health centres. WORM. T R E A T M E N T AMD T H E A S Y L D H Prior to the 19th Century, the mentally i l l i n d i v i d u a l was not ostracized from the community. The lunatics or the insane were generally treated no d i f f e r e n t l y than the other groups of s o c i a l deviants such as the morally disreputable, the indigent, the vagrants, the criminals, the possessed, and the p h y s i c a l l y handicapped. Individuals who deviated from the s o c i a l norm were either the r e s p o n s i b i l i t y of t h e i r families or were l e f t to t h e i r own devices, languishing i n the countryside. Only the behaviourally v i o l e n t i n d i v i d u a l s were confined i n j a i l s 3 - . The early 19th Century gave r i s e to a "broad-based s o c i a l reform movement aimed at bettering the conditions of the less fortunate members of society" (Morrissey and Goldman, 1984, p.786). This sentiment was highly influenced by the works of two Europeans and one American - P h i l l i p p e P i n e l i n France, William Tuke i n England, and Dorothea Dix i n the United States. These three individuals were the early reformers i n the i n s t i t u t i o n a l management of the mentally i l l . While Pinel - 3 -ordered the release of chains and the abolishment of barbaric treatment, Tuke revolutionized the i n s t i t u t i o n a l environment, and advocated for the development of asylums. Dix was responsible for revealing the shocking conditions endured by the confined mentally i l l to the State Legislature of Massachusetts. Her e f f o r t s resulted i n the construction of s p e c i a l i z e d f a c i l i t i e s for mentally i l l i n d i v i d u a l s . As Morrissey and Goldman (1984) state: "The 'moral treatment'...[Pinel, Tuke, and Dix]...championed contributed to the growing acceptance of a medical-psychological rather than a theological model of mental i l l n e s s and led to the establishment of asylums for i t s treatments" (p.786). The b e l i e f of moral treatment was e s s e n t i a l l y the b e l i e f that "insanity could be cured by segregating the 'distracted 1 into small, pastoral asylums" (Morrissey & Goldman, 1984, p.786). Asylums were defined as small public i n s t i t u t i o n s where 'patients' would receive humane care and gain s k i l l s i n an atmosphere of kindness. However, with the r i s e of urban population and rapid i n d u s t r i a l i z a t i o n , the number of patients i n need of care increased dramatically. Asylums became overcrowded and understaffed. The transformation from "small therapeutic asylums to large, custodial i n s t i t u t i o n s " (Ibid) lent support to the increased use of physical control, and the concept of i n d i v i d u a l i z e d moral treatment was l o s t . Mentally i l l i n d i v i d u a l s were confined i n remote areas, and were soon neglected, i s o l a t e d , and abandoned. Treatment was synonymous with warehousing. As Morrissey & Goldman (1984) point out: - 4 -"By the 1870s...the function of state asylums had been c l e a r l y delineated. The cen t r a l purpose was defined by state l e g i s l a t u r e s i n terms of custodial care and community protection; treatment was of secondary importance. Emphasis was placed on the custody of the largest number of patients at the lowest possible cost. The small pastoral retreat that offered hope and humane care had been transformed i n a general-purpose solution to the welfare burdens of a society undergoing rapid i n d u s t r i a l i z a t i o n " (p.786). T H E M E N T A L H Y G I E N E MOVEMENT AND P S Y C H O P f l T H I C H O S P I T A L S The demise of the moral treatment movement eventually gave r i s e to the second cycle of i n s t i t u t i o n a l reform, the mental hygiene movement. This movement was highly influenced by three European p s y c h i a t r i s t s , namely Emil Kraepelin, Eugene Bleuler, and Sigmund Freud. The works of these individuals generated a great deal of optimism within the ps y c h i a t r i c profession. In order to be recognized as part of the mainstream medical profession, p s y c h i a t r i s t s as a group, began to seek for professional legitimacy by devoting t h e i r e f f o r t s to s c i e n t i f i c research. In his a r t i c l e H i s t o r i c a l Origins of D e i n s t i t u t i o n a l - i z a t i o n , Grob (1983) points out that emphasis was placed on the empirical study of the etiology, pathology, diagnosis, and treatment of mental disorders. And as such, the choice between the 'curing of disease' or the 'caring for the mentally i l l ' was no longer a professional dilemma. "The concern with new technigues r e f l e c t e d a commitment to medical science and disease rather than to patient care" (Grob, 1983, p.26). - 5 -In his autobiography, A Mind That Found I t s e l f , C l i f f o r d Beers (1908) aroused a tremendous amount of public sympathy regarding the abysmal treatment of the mentally i l l . Subsequently, Beers successfully gained the support of various professionals and formed the National Committee for Mental Hygiene. According to Morrissey and Goldman (1984), "This reform organization revived the notion of the t r e a t a b i l i t y of mental disorder, e s p e c i a l l y by early intervention with acute cases. Mental Hygienists advocated creating a 'psychopathic h o s p i t a l 1 , an acute treatment or reception f a c i l i t y a f f i l i a t e d with u n i v e r s i t y t r a i n i n g and research i n s t i t u t e s " (p.787). Although o f f to a good s t a r t , i t wasn't long before i t became evident that these 'psychopathic hospitals' were providing care for a heterogenous group - the aged, the p h y s i c a l l y disabled, and indiv i d u a l s whose undesirable behaviors were d i r e c t l y linked to somatic disorders (Grob, 1983). A case i n point i s Grob's reference to the decline of l o c a l almshouses for the e l d e r l y i n the U.S.: "The decline, however, was more apparent than r e a l , for the number of aged mentally i l l persons committed to mental hospitals was r i s i n g s t e a d i l y . What occured, i n e f f e c t , was not a d e i n s t i t u t i o n a l i z a t i o n movement, but r a t h e r a t r a n s f e r of i n d i v i d u a l s between d i f f e r e n t types of i n s t i t u t i o n s . The s h i f t was l e s s a f u n c t i o n of m e d i c a l or humanitarian concerns than a consequence of f i n a n c i a l c o n s i d e r a t i o n s . . . l o c a l public o f f i c i a l s seized upon the f i s c a l advantages inherent i n redefining s e n i l i t y i n p s y c h i a t r i c terms...[as]...the burden of support would be transferred to the state" (Grob, 1983, p.17). (my emphasis) - 6 -Again, psychopathic hospitals became overcrowded and understaffed. The goals of the mental hygiene movement f e l l by the wayside i n the absence of government f i n a n c i a l support. In-patient f a c i l i t i e s became undesirable places of employment for p s y c h i a t r i s t s primarily because they were perceived to be outmoded and passe. P s y c h i a t r i s t s who were employed i n hospitals received less f i n a n c i a l remuneration than th e i r counterparts who were employed i n community mental health centres. Therefore, many sought to practice at out-patient c l i n i c s . Many of the p s y c h i a t r i s t s who stayed behind i n the psychopathic hospitals devoted t h e i r time and int e r e s t s into the- development of various somatic treatment techniques; such as, i n s u l i n therapy, electroconvulsive therapy, and psychosurgery, but not patient care. (Grob, 1983) COHMTJNITY MKMTM. H E A L T H H O V E H K H T The advances i n psychopharmacology during the 1950s lent a ce r t a i n optimism to the treatment of the mentally i l l . The introduction of Chlorpromazine, an antipsychotic drug, promised to a l t e r the future of Psychiatry. Not only did t h i s change minimize the use of int r u s i v e somatic treatment techniques but also, a shorter i n s t i t u t i o n a l stay for p s y c h i a t r i c patients became a viable a l t e r n a t i v e . Studies by Barton (1959) and Goffman (1961) i d e n t i f y i n g the d e b i l i t a t i n g e f f e c t s of i n s t i t u t i o n a l i z a t i o n provided additional ammunition to revolutionize public and professional attitudes towards the - 7 -mentally i l l . The C i v i l Rights Movement also served as a major impetus. As Bachrach (1983) notes: "the movement emphasized the inalienable r i g h t s of the mentally i l l and t h e i r legitimate claim on society.... D e i n s t i t u t i o n a l i z a t i o n sought to exchange p h y s i c a l l y i s o l a t e d treatment settings for services to be provided i n the patients' home communities on the assumption that community based treatment i s more humane and therapeutic. Since the physical i s o l a t i o n of patients was understood to be in e v i t a b l y accompanied by an insidious s o c i a l exclusion that had to be corrected, those who pioneered i n d e i n s t i t u t i o n a l i z a t i o n objected to both the content and g u a l i t y of care i n large, often secluded, mental hospitals" (p.7). Prompted by the foregoing factors, Robert F e l i x (1961), direc t o r of the American National I n s t i t u t e of Mental Health, put f o r t h the f i r s t major proposal for the Community Mental Health Movement. In 1963, President Kennedy made the f i r s t and only p r e s i d e n t i a l address on mental i l l n e s s . He stated that p s y c h i a t r i c i n s t i t u t i o n s were: "understaffed, overcrowded, so unpleasant that i t makes death the only hope of release....Central to a new mental health i s community care, and pouring funds into outmoded i n s t i t u t i o n a l care should be replaced because i t makes l i t t l e difference to the mentally i l l " (cf. Group for Advancement of Psychiatry, 1978, p.302).. Hence, reform i n movement the emergence of the t h i r d cycle of i n s t i t u t i o n a l the United States - the community mental health was formally endorsed by the Community Mental Health Centre Act i n 1963. Community psychiatry, and the s o c i a l p o l i c y of d e i n s t i t u t i o n a l i z a t i o n were the r e s u l t of several factors: the abandonment of p s y c h i a t r i c hospitals by the p s y c h i a t r i c profession; the advent of psychotropic medication; changing public attitudes towards the mentally i l l ; the C i v i l Rights Movement; and f i n a l l y , the anticipated economic savings. After a l l , " I f community based care was better (both more therapeutic and humane) and cheaper (less costly) how could i t s su p e r i o r i t y be denied?" (Bachrach, 1983, p.7). In t h e i r 1985 a r t i c l e The Alchemy of Mental Health Policy: Homelessness and the Fourth Cycle of Reform, Goldman and Morrissey i d e n t i f i e d one of the key d e f i c i t s of the Community Mental Health Centre Act of 1963. That i s , i t did not provide s p e c i f i c mandates for the mental health centres to "coordinate t h e i r e f f o r t s with state mental hospitals or to care for chronic patients" (p.728). "As a r e s u l t , mental health centres primarily served new populations i n need of acute services and f a i l e d to meet the needs of acute and chronic patients discharged i n ever increasing number from public . ho s p i t a l s . Furthermore, centres were not required to provide for housing or income support for discharged mental patients. Homelessness and indigency were predictable outcomes for many" (Ibid). Leona Bachrach (1978) adds: "Perhaps the most serious single issue i s the f a c t that the d e i n s t i t u t i o n a l i z a t i o n movement, which was o r i g i n a l l y designed to provide the c h r o n i c a l l y mentally i l l r e l i e f from the inhumane conditions of - 9 -i n s t i t u t i o n s , has l e t these patients ' f a l l through the cracks'. These p a t i e n t s — t h e very ones who have been dehumanized through oversight and denial i n past--have somehow, i n the process of reducing state h o s p i t a l populations, l a r g e l y been l o s t to the service d e l i v e r y system" (p.575). The question of how we can account for the vast difference between our ideals of the 1950s and the current r e a l i t i e s has been discussed at length i n the l i t e r a t u r e . The r e a l i t y remains that our mentally i l l population within the community i s s o c i a l l y i s o l a t e d , economically impoverished, pervasively exploited, vocationally disadvantaged, emotionally disengaged, and repeatedly rejected; a far cry from being a part of the mainstream society. Certainly, the l i t e r a t u r e during the past f i v e years strongly supports Gralnick (1983)'s comment: "mental i l l n e s s has always presented an enormous problem to society. D e i n s t i t u t i o n a l i z a t i o n has aggravated rather than lessened i t " (p.12). T H E COMMLHI-LTY MKNT * T . H R A L T H MOVEMENT 331 CATiATXA In t h e i r review of the hi s t o r y of mental health 'depopulation' i n Canada, Herman and Smith (1989) assert that "What i s c e r t a i n i s that mental hospitals massively declined i n population" (p.386). Furthermore, t h i s population "continues to decline" (Ibid). Although the impact of the community mental health movement has been less extensively documented i n Canada than the United - 10 -States, what i s documented shows remarkable s i m i l a r i t i e s . For example, A l l o d i and Kedward (1973) concluded that i n the absence of a comprehensive support system, "former mental hos p i t a l patients w i l l return to pre-nineteenth-century conditions, and become a s o c i a l outcast [ s i c ] , with no d e f i n i t e i d e n t i t y or sp e c i a l i z e d services" (p. 289). Kedward, Eastwood, A l l o d i , and Duckworth of Toronto published an a r t i c l e i n 1974 t i t l e d The Evaluation of Chronic Psych i a t r i c Care, and i n i t , the authors state: "While nobody would wish to return to the unhappy conditions of indifference and apathy found i n asylums i n the past, a rigorous examination of recent mental health s t a t i s t i c s does not necessarily j u s t i f y the assumption that the modern mental ho s p i t a l i s wholly redundant or anachronistic....If, i n addition, as some authors suggest, large numbers of patients discharged from mental hospitals have joined the ranks of the homeless and the prison population, the r a d i c a l changes i n management of severe ps y c h i a t r i c syndromes i n western countries during the l a s t decade or more may prove to have had a less s a t i s f a c t o r y impact upon patient status than i s commonly supposed" (pp.522-523). S i m i l a r l y , Herman and Smith (1989) made the following commentary: "But i n Canada l i k e the United States, there was no absence of problems. Few mourned the shrinkage or loss of mental hospitals, but soon, there were complaints of patients being 'dumped' into the community with some ending up i n nursing homes, gaols, or ghettos. The issues of homelessness and chronic i l l n e s s , though less prominent than - 11 -in the United States, were s i m i l a r l y decried by many s o c i a l planning agencies and interested groups.... In Canada, as a whole, the a v a i l a b i l i t y of universal medical care has favourably influenced i t s d i s t r i b u t i o n , [sic]...However, removal of the f i n a n c i a l b a r r i e r s does not guarantee that those more i n need of care a c t u a l l y receive i t . The chr o n i c a l l y mentally i l l are not the most popular patients, and the g u a l i t y of care available to them varies from province to province" (p.387). F i n a l l y , perhaps what i s most troubling for s o c i a l p o l i c y makers, i s the r e a l i z a t i o n that community care i s simply not cheaper than i n s t i t u t i o n a l care (Herman and Smith, 1989). T H E COMMUMITV MKHTAI. H ^ » T . T H » K ) V K H B B T I H B R I T I S H C O L U M B I A The year 1957 marked the beginning of the community mental health movement within the province of B r i t i s h Columbia. I t was the year when the f i r s t community mental health c l i n i c was established. In 1959, the B.C. government consulted with the American Psychiatric Association regarding the future d i r e c t i o n s of the pr o v i n c i a l mental health system. The recommendation was clear - mental health services should be r e g i o n a l i z e d . 2 Regionalization of services included p r o v i n c i a l t r a v e l l i n g c l i n i c s , in-patient p s y c h i a t r i c emergency services within l o c a l h ospitals, aftercare for discharged p s y c h i a t r i c patients, boarding home programs, regional mental health c l i n i c s , and a - 12 -new Mental Health Act. A l l of these were designed to complement the goals of the D e i n s t i t u t i o n a l i z a t i o n philosophy and p o l i c y . In t h e i r 1967-68 annual report, the Mental Health Branch of the Ministry of Health redefined i t s role from a service provider to the f a c i l i t a t o r of reorganization of the p r o v i n c i a l mental health programs. In 1976, Dr. John Cumming and his colleagues published Community Care Services i n Vancouver: I n i t i a l Planning and Implementation, an a r t i c l e that has had major influence on the development of mental health services within B r i t i s h Columbia. The authors made the following observation: "The burden on Vancouver General Emergency resulted i n low morale and l i t t l e therapeutic work, most s t a f f time being invested i n finding hostels or other places i n which to dispose of patients. Worse s t i l l were the l a r g e numbers of p a t i e n t s who found access t o treatment o n l y through the p o l i c e , j a i l o r c o u r t s where they were e i t h e r c e r t i f i e d o r remanded t o the mental h o s p i t a l " (p.20). (my emphasis) In 1979, Dr. John Cumming was requested by the p r o v i n c i a l government to assess the ex i s t i n g mental health services and make some recommendations for future action. In t h i s Report of  the Mental Health Planning Survey, also known as the Cumming's Report, perhaps the only n o n - c r i t i c a l comment made regarding the p r o v i n c i a l p s y c h i a t r i c h o s p i t a l was: "While many settings were depressing, none were [ s i c ] shocking" (p.57). What Cumming found most troubling was that "In practice many e l i g i b l e - 13 -patients are refused admission or placed on a waiting l i s t . . . . t h e number of patients that are admitted become a d i r e c t function of considerations other than where the patient resides or what l e v e l of care he needs" (p.55). This i s supported by the findings within the community care teams. For example, "Almost a l l team members mentioned d i f f i c u l t y i n getting h o s p i t a l care during periods of relapse" (p.17). With respect to the discharged p s y c h i a t r i c patients, "Team members believe some patients are being exploited and i l l - t r e a t e d and f e e l able to do l i t t l e about i t " (p.25). Generic c r i t i q u e s such as 'fragmentation', 'lack of cohesion', 'lack of coordination', and 'duplication of services' found commonly i n the American l i t e r a t u r e also found t h e i r way into t h i s report. During t h i s same time period, the C i t y of Vancouver conducted a study on the Hard to House Psychiatric C l i e n t s . What became evident was that our l o c a l experience was remarkably si m i l a r to the American experience. That i s : "A small percentage of ' d i f f i c u l t ' cases i n the community are u t i l i z i n g a disproportionately large percentage of available services on a continuing basis without s a t i s f a c t o r y improvement i n t h e i r l i f e condition" (p.6). In his a r t i c l e The Homeless Mentally 111: A Report from Vancouver, Simon Davis (1987) made the following observation: "Overall, the survey revealed that, for many of the mentally i l l , l i f e i n the inner c i t y meant a tenuous, unstable, s o c i a l l y impoverished sort of existence, with people - 14 -struggling - often unsuccessfully - to maintain interpersonal relationships and a sense of independence" (p.12). SUMMARY In t h e i r analysis of the three 'cycles of i n s t i t u t i o n a l reforms' - the moral treatment and asylums; the mental hygiene movement and psychopathic hospitals; and the community mental health movement and community mental health c l i n i c s - Goldman and Morrissey (1985) made the following comment: "Each of these reforms promised that early treatment of acute cases would prevent chronic mental i l l n e s s . Each innovation proved successful with acute and milder - not chronic - forms of mental disorder yet f a i l e d to eliminate c h r o n i c i t y or to fundamentally a l t e r the care of the severely mentally i l l . In each cycle, the optimism of reform gave way to pessimism and therapeutic n i h i l i s m towards increasing numbers of incurable chronic mental patients. In the face of an expanding population of needy patients, public support turned to neglect" (p.727). Moreover, "The zeal of community mental health a c t i v i s t s for tr y i n g to solve s o c i a l problems without also focussing on the need for humane care of the ch r o n i c a l l y mentally i l l , i n part...contributed to the new set of s o c i a l problems associated with d e i n s t i t u t i o n a l -i z a t i o n " (p.728). In summary then, as Brad Pearce (1990) states: "The United States began and progressed with d e i n s t i t u t i o n a l i z a t i o n at a much faster pace than Canada, hence many of the unanticipated problems and conseguences of d e i n s t i t u t i o n a l i z a t i o n , such as homelessness, c r i m i n a l i z a t i o n , community resistance and poverty, were f i r s t evident there. These problems are now c l e a r l y e v i d e n t i n Canada as we 'catch up 1 t o the U n i t e d S t a t e s " (p.2). (ray emphasis) THE CRIMINMJZATiaN OF THE MENTALLY UJ. Review of professional journals, academic l i t e r a t u r e , and popular press indicates a plethora of c r i t i c i s m s regarding the problems generated from the Community Mental Health Movement. In his a r t i c l e Care of the Chronically Mentally 111 - A National Disgrace, Robert Reich (1973) maintains that: "Freedom to be sick, helpless, and i s o l a t e d i s not freedom....Our present p o l i c y of discharging helpless human beings to a ho s t i l e community i s immoral and inhumane. I t i s a return to the Middle Ages, when the mentally i l l roamed the streets and l i t t l e boys threw rocks at them" (p.912). S i m i l a r l y , Dumont (1982) concludes that d e i n s t i t u t i o n a l -i z a t i o n i s : "nothing more or less than a p o l i t e term for the cutting of mental health budgets. Under a patina of community mental health rhetoric we are returning to the pre-Dorothea Dix sit u a t i o n " (p.367). Although Reich was describing the experience of New York State, s i m i l a r sentiments have been expressed by various individuals a l l across North America. Within Canada, Lightman (1986) for example, suggests that " D e i n s t i t u t i o n a l i z a t i o n , not as a concept but rather as a practice, must rank as one of the greatest frauds of our day" (p. 26). Although i t i s agreed that treatment of the mentally i l l i s the r a i s o n d'etre of - 16 -the Community Mental Health Movement, many argue that i t has "become increasingly apparent that society has chosen the easy and cheap way out" (Zusman and Lamb, 1977, p. 887). One of the easiest and cheapest ways out i s the c r i m i n a l i z a t i o n of the mentally i l l . Perhaps one of the most freguently c i t e d American a r t i c l e s i n t h i s area i s that of Marc Abramson's (1972) The Criminalization of Mentally Disordered Behavior: Possible Side-Effect of a New Mental Health Law. In t h i s a r t i c l e , Abramson argues as follows: " I f the entry of persons exh i b i t i n g mentally disordered behavior into the mental health system of s o c i a l control i s impeded, community pressure w i l l force them into the criminal j u s t i c e system of s o c i a l control. Further, i f the mental health system i s forced to release mentally disordered persons into the community prematurely, there w i l l be an increase i n pressure for use of the criminal j u s t i c e system to r e i n s t i t u t i o n a l i z e them....From my own vantage point as a p s y c h i a t r i c consultant...mentally d i s o r d e r e d persons are b e i n g i n c r e a s i n g l y s u b j e c t e d t o a r r e s t and c r i m i n a l p r o s e c u t i o n . . . . P o l i c e seem to be aware of the more stringent c r i t e r i a under which mental health professionals are now accepting r e s p o n s i b i l i t y for involuntary detention and treatment, and thus regard arrest and booking into j a i l as a more r e l i a b l e way of securing involuntary detention of mentally disordered persons. Once the criminal j u s t i c e machinery i s invoked, i t i s freguently hard to stop" (p.15).(my emphasis) Within Canada, and s p e c i f i c a l l y Toronto, A l l o d i et a l (1977)'s research findings support the "hypothesis that the - 17 -reduction of h o s p i t a l beds has been associated with an increment i n the number of p s y c h i a t r i c patients i n j a i l " (p.3) between 1969 and 1973. S i m i l a r l y , Borzecki and Wormith (1985) from Ottawa conclude that: "There i s a l i m i t to society's a b i l i t y to absorb the large numbers of people discharged....Therefore, when people with p s y c h i a t r i c i l l n e s s e s show symptomatic bizarre behavior, the public tends to invoke the criminal j u s t i c e system to remove them from the community...changes i n c i v i l commitment proceedings and more lim i t e d p s y c h i a t r i c placements have placed bureaucratic obstacles i n the way of emergency admissions. Therefore, arrest becomes a much less cumbersome method to remove the disruptive p s y c h i a t r i c a l l y i l l person. The p o l i c e cannot be faulted on such a p r a c t i c e . . . . I f the ' f o r f e i t e d ' patients continue to be s o c i a l l y disruptive and continue to be excluded from p s y c h i a t r i c f a c i l i t i e s , they w i l l be r e a d i l y accepted by the criminal j u s t i c e system. In e f f e c t , i t has become the system 'that can't say no'" (pp.242-3). Furthermore, i n the a r t i c l e Criminalization of the Mentally 111: Part I, the authors Holley and Arboleda-Florez (1988) from Calgary, asserted that although: "the prevalence of p s y c h i a t r i c i l l n e s s among criminal populations i n Canada has been poorly documented, available data indicate that as much as 65 percent of p r o v i n c i a l l y j a i l e d offenders may be mentally i l l . Evidence from other countries shows a range of between 10 and 50 percent (pp.81-82). Within our own l o c a l system, Stephen Hart and James Hemphill (1989) conducted the f i r s t research study to determine the prevalence of and service u t i l i z a t i o n by Mentally Disordered Offenders (MDOs) at the Vancouver P r e t r i a l Services Centre (VPSC). As part of t h i s study, Hart and Hemphill assessed 576 admissions, (459 d i f f e r e n t inmates) over a period of three months. Assessment was based on a series of psychometric tests as well as review of each indi v i d u a l ' s medical and s o c i a l h i s t o r y . Hart and Hemphill concluded that: "The prevalence rate of MDOs among admissions observed i n the survey—23.8%—was high i n an absolute sense. Because of the methodological strengths of the survey, however, we are confident that t h i s figure i s an accurate one. As well, i t i s well within the range reported by other researchers" (p.45). With respect to the future of the Vancouver P r e t r i a l Services Centre, Hart and Hemphill suggest that: "there are two factors that may foreshadow a r i s e i n the prevalence of MDOs. F i r s t , the trend towards d e i n s t i t u t i o n a l i z a t i o n i s continuing. Should the p r o v i n c i a l government follow through on i t s stated plans to trim the population at Riverview, VPSC can expect to receive a s i g n i f i c a n t number of those patients discharged into the Greater Vancouver area....A second relevant factor i s the imminent closure of the Lower Mainland Regional Correctional Centre (LMRCC). At present, because i t has a r e l a t i v e l y large health care centre, LMRCC houses a number of inmates (both remanded and sentenced inmates) with serious mental disorders. If the f a c i l i t i e s currently under construction to replace LMRCC have fewer h o s p i t a l and segregation beds available for MDOs, VPSC can probably expect to receive some of the 'excess' MDOs" (p.46). - 19 -COST VERSES CARE: THE DILKHWft In t h e i r a r t i c l e , Borzecki and Wormith (1985) raised the question of "why a public alarm should be raised over the s i t u a t i o n since the cr i m i n a l i z a t i o n phenomenon may simply r e f l e c t changes i n the r e l a t i v e use of two methods for dealing with the s o c i a l l y aberrant. I t i s obvious from a simple a c t u a r i a l , f i n a n c i a l model that society finances both systems, and i t may be less expensive to detain persons i n j a i l " (p.246). Although Belcher (1988) was not responding d i r e c t l y to t h e i r question, he does argue that "Responsibility for these indivi d u a l s needs to remain i n the mental health system and not be displaced to a criminal j u s t i c e system that i s not designed to appropriately care for the mental health needs of these in d i v i d u a l s " (p.194). Furthermore, "to the extent that society e t h i c a l l y subscribes to a r e h a b i l i t a t i v e model, the mentally i l l should be put i n f a c i l i t i e s which s p e c i a l i z e i n t h e i r treatment and care" (Borzecki and Wormith, 1985, p.246). (my emphasis) In his plea for a broad public p a r t i c i p a t i o n i n the choice of mental health services i n Canada, Lightman (1986) argues quite convincingly that: " a l l s o c i a l and economic p o l i c y i n any society i s b u i l t upon fundamental value choices. The frequently-cited argument of economic necessity - that we have no choice but to cut back government spending i n the s o c i a l and health areas i n order to conquer - 20 -i n f l a t i o n and to concomitantly reduce the d e f i c i t - i s f a l l a c i o u s . I t i s not a statement of any objective f a c t or r e a l i t y , but rather r e f l e c t s a p a r t i c u l a r c o n s t e l l a t i o n of presumed s o c i a l p r i o r i t i e s . The message for professionals and others concerned to protect our s o c i a l and health systems i s that future debate must address fundamental questions of values and not become bogged down i n econometric technologies" (p.25). - 21 -C H A P T E R T W O S Y S T E M S O F C A R E F O R T H E M E N T A T . T . Y m _ i I M T H E P R O V I N C E O F B R I T I S H C O L U M B I A IMTBODDCTIOH T h i s chapter w i l l b e g i n by b r i e f l y d e s c r i b i n g the two p r o v i n c i a l p s y c h i a t r i c i n s t i t u t i o n s w i t h i n the Lower Mainland designed t o accommodate the c h r o n i c a l l y m e n t a l l y i l l p o p u l a t i o n . I t w i l l then move on t o the one p r o v i n c i a l c o r r e c t i o n a l i n s t i t u t i o n t h a t , e i t h e r by d e f a u l t or by d e s i g n , f i n d s i t s e l f housing a group of m e n t a l l y i l l i n d i v i d u a l s . RIVKRVIKW MKHTaL HOSPITAL In 1964, the B r i t i s h Columbia P r o v i n c i a l Mental H o s p i t a l amalgamated w i t h Crease C l i n i c , a s h o r t s t a y p s y c h i a t r i c u n i t , and formed what i s now the p r i n c i p a l i n - p a t i e n t p s y c h i a t r i c f a c i l i t y of the p r o v i n c e , Riverview H o s p i t a l . During t h i s time p e r i o d , a s e r i e s of community f a c i l i t i e s began t o emerge. Of importance i s the development of i n - p a t i e n t p s y c h i a t r i c u n i t s w i t h i n the l o c a l g e n e r a l h o s p i t a l s . Examples are the P s y c h i a t r i c Assessment U n i t of Vancouver General H o s p i t a l , the E r i c M a r t i n P a v i l i o n of Royal J u b i l e e H o s p i t a l i n V i c t o r i a , the Maples Adol e s c e n t Treatment Centre i n Burnaby, and the H e a l t h Sciences Complex a t the U n i v e r s i t y of B r i t i s h Columbia. I m p l i c i t i n t h i s d e c e n t r a l i z a t i o n movement was the i n t e n t t h a t the l o c a l h o s p i t a l s would o f f e r short-term treatment f o r - 22 -acutely mentally i l l patients, and refer c h r o n i c a l l y mentally i l l patients to Riverview Hospital for long-term treatment. However, as the Cumming's Report (1979) indicated: " D i f f i c u l t y i n arranging admissions of patients to Riverview i s almost u n i v e r s a l l y complained of by s t a f f members of services throughout the province" (p.56). What became evident was that despite the development of various p s y c h i a t r i c units i n l o c a l hospitals, the needs of the chronic mentally i l l remained unmet. Under the auspices of the community mental health movement and consistent with the d e i n s t i t u t i o n a l i z a t i o n p o l i c y , patients were discouraged from seeking admission to any p s y c h i a t r i c f a c i l i t y . The B.C. Mental Health Act (1964) required and s t i l l requires that, except for emergencies, the i n d i v i d u a l must be seen by two medical p r a c t i t i o n e r s . Only i f i t i s agreed between the two physicians that the i n d i v i d u a l i s of 'unsound mind' and a 'danger' to s e l f or others, can the i n d i v i d u a l be admitted to a p s y c h i a t r i c f a c i l i t y . The irony of t h i s i s that many mentally i l l individuals are denied admission to l o c a l p s y c h i a t r i c units simply because they may present a 'danger' to s e l f and/or to others. They are frequently turned away from the ho s p i t a l because the f a c i l i t y i t s e l f i s not equipped to accommodate th e i r psychopathology. Often, the acute l o c a l hospitals do not have s u f f i c i e n t s t a f f resources to ensure security nor do they have the appropriate room to contain the patient's acting-out - 23 -behaviors. I t would seem l o g i c a l then, that these 'dangerous' patients should be transferred to Riverview Hospital. After a l l , Riverview was designed "for the benefit of 'patients who do not f i t ' - - t h e most severely and c h r o n i c a l l y i l l , f or whom adequate assessment and treatment i s not possible within the acute ho s p i t a l or i n community outpatient settings. This capacity i s required for cases where the i n d i v i d u a l or the community must be protected and also when the mental i l l n e s s i s so severe that patients require structure and good nursing care, not to mention the safety and security of an asylum-like environment" (Mental Health Consultation Report, Ministry of Health, Province of B.C., 1987, p.13). However, the r e a l i t y i s that Riverview i s at present undergoing a major d e i n s t i t u t i o n a l i z a t i o n process i t s e l f . As stated at a l o c a l conference sponsored by Riverview Hospital (November 1989), while the in-patient population of Riverview was approximately 5,500 i n 1950, i n 1989 i t s t o t a l was approximately 800. While i t i s commendable that Riverview Hospital i s able to c u l t i v a t e a respectable number of resources for i t s patients for community placements, the key issue here i s the s t r i c t admission c r i t e r i a . That i s , many individuals who meet the statutory guidelines of the Mental Health Act are denied admission because, amongst other reasons, there i s an informal agreement to refuse patients who may have had involvement with the criminal j u s t i c e system or are currently before the court. - 24 -I t i s assumed that these patients are too 'violent', ' d i f f i c u l t ' , or 'dangerous' for t h e i r f a c i l i t y , and that they are the r e s p o n s i b i l i t y of either the Forensic Psychiatric Services or the criminal j u s t i c e system. FORENSIC PSYCHIATRIC SERVICES The B r i t i s h Columbia Forensic Psychiatric Commission was established i n 1974. Its primary mandate, under the B.C. Forensic P s y c h i a t r i c Services Act, i s to provide p s y c h i a t r i c assessments for the courts and to provide treatment for individuals who are held at the d i r e c t i o n of the Lieutenant Governor. In addition, the Forensic Psychiatric Outpatient Services provide community follow-up care for i n d i v i d u a l s who are required by t h e i r probation orders to receive p s y c h i a t r i c treatment. The Forensic Psychiatric I n s t i t u t e i s an in-patient p s y c h i a t r i c f a c i l i t y located at Port Coquitlam designed for those in d i v i d u a l s who meet one or more of the following c r i t e r i a : 1) remanded by court for p s y c h i a t r i c assessment; 2) found 'Unfit to Stand T r i a l ' ; 3) found 'Not Guilty by Reason of Insanity'; 4) serving a p r o v i n c i a l j a i l sentence (two years less a day) and are c e r t i f i e d under the B.C. Mental Health Act. A b r i e f discussion of these four groups i s warranted. - 25 -The primary mandate of the Forensic Psychiatric Commission i s to provide court ordered p r e - t r i a l p s y c h i a t r i c assessments. This mandate i s based on the long held view that i n d i v i d u a l s who are before the court should be able to f u l l y comprehend and appreciate the nature of a t r i a l . The court requires assurance that an i n d i v i d u a l i s able to p a r t i c i p a t e i n his or her own defence. A common misconception i s that an i n d i v i d u a l who i s remanded for p s y c h i a t r i c assessment i s also receiving treatment. This i s not necessarily the case as the primary goal i s to determine i f the i n d i v i d u a l i s ' F i t to Stand T r i a l ' . An i n d i v i d u a l who i s found 'Unfit to Stand T r i a l ' , a l e g a l rather than a p s y c h i a t r i c term, must be returned to the Forensic Psychiatric I n s t i t u t e for treatment u n t i l he or she i s found ' F i t ' . Individuals who are severely mentally i l l or of li m i t e d i n t e l l i g e n c e may never become ' F i t ' . I t should also be noted here that an i n d i v i d u a l can be c e r t i f i e d as m e n t a l l y d i s o r d e r e d under the Mental H e a l t h A c t and c o n c u r r e n t l y be deemed 1 F i t t o Stand T r i a l ' . Once the i n d i v i d u a l i s found ' F i t ' to stand t r i a l , the court may wish to address the mental state of the i n d i v i d u a l at the time of the offence. Insanity i s not a defence of preference as i n d i v i d u a l s who are found 'Not G u i l t y By Reason of Insanity' have to be returned to the Forensic P s y c h i a t r i c I n s t i t u t e and, under the Warrant of Committal, remain at the pleasure of the Lieutenant Governor indeterminately u n t i l the order i s rescinded. - 26 -The l a s t group comprised of individuals who have been c e r t i f i e d under the Mental Health Act while serving a p r o v i n c i a l prison sentence. This group i s of low p r i o r i t y for admission to the Forensic Psychiatric I n s t i t u t e . Depending on the demand for bed spaces, some of these indiv i d u a l s are returned to t h e i r host i n s t i t u t i o n immediately following i n i t i a l signs of s t a b i l i z a t i o n . To be f a i r , since these individuals are placed at the Forensic Psychiatric I n s t i t u t e on a Temporary Absence Status from t h e i r host c o r r e c t i o n a l i n s t i t u t i o n , they have to be confined i n the maximum security area. As a r e s u l t , they do not have the benefit of the r e h a b i l i t a t i o n programs and only receive psychopharmacological treatment. During the past two years, a protocol has been established between the Forensic P s y c h i a t r i c Outpatient and Inpatient Services, where an outpatient c l i e n t can be admitted to the Forensic Psychiatric I n s t i t u t e when c e r t i f i e d under the Mental Health Act. Naturally, t h i s i s also dependent on the a v a i l a b i l i t y of bed spaces. Perhaps what i s important with t h i s protocol i s that i t i s a broadening of admission c r i t e r i a to the Forensic Psychiatric I n s t i t u t e , i n d i r e c t response to the s t r i c t admission c r i t e r i a of other p s y c h i a t r i c f a c i l i t i e s . Within the Forensic Psychiatric I n s t i t u t e , there i s also a group of patients who are of c i v i l 'Involuntary' status. In - 27 -simple terms, t h i s i s a group of ind i v i d u a l s kept at the f a c i l i t y not because of the l e g a l requirements of the criminal law, but only under the c i v i l provisions of the Mental Health Act. Individuals i n t h i s group are generally severely and c h r o n i c a l l y mentally i l l , respond poorly to t r a d i t i o n a l psychopharmacological treatment, and require a long period of in-patient treatment. The alleged offences that brought them into the Forensic system o r i g i n a l l y have been 'stayed' by the Crown Counsel o f f i c e which has agreed that these indiv i d u a l s require and would benefit from treatment for an extended period of time rather than being processed through the criminal j u s t i c e system. Although t h i s group should be transferred to Riverview Hospital, t y p i c a l l y Riverview Hospital because of i t s s t r i c t admission c r i t e r i a , does not accept them. As a r e s u l t , t h i s group remains at the Forensic Psychiatric I n s t i t u t e , i n some cases for years, awaiting a transfer to Riverview Hospital. Indeed, there are occasions when the patient i s not placed on the transfer l i s t for fear that he or she w i l l be discharged prematurely under the d e i n s t i t u t i o n a l i z a t i o n p o l i c y . What we have seen then, i n the past two years, i s the expansion or the increased f l e x i b i l i t y of admission c r i t e r i a within the Forensic Psychiatric I n s t i t u t e i n response to the demands that have emerged from the d e i n s t i t u t i o n a l i z a t i o n movement. While t h i s f a c i l i t y was designed for the maximum capacity of 121 patients, i t has been operating recently at a r e l a t i v e l y stable capacity of 145 patients. - 28 -The primary problem, as I see i t , i s that regardless of what the leg a l status may be, professionals and public a l i k e , continue to f e e l ambivalent towards mentally i l l i n dividuals who have been involved with the Forensic Psyc h i a t r i c system. While they may sympathize with t h e i r experience and circumstances, they are also reluctant to work with or accept them i n the same manner. This group's his t o r y with Forensic Psychiatric Services w i l l always weigh heavily against them. I t i s often used to r a t i o n a l i z e f a i l u r e to provide them with much needed services. TnURW MUTWT.ailD REGIQHAL CQRBECTIQHBL CEHTRE The Lower Mainland Regional Correctional Centre (LMRCC), also known as Oakalla, was established i n 1914, and for many years i t was the only p r o v i n c i a l maximum security c o r r e c t i o n a l i n s t i t u t i o n i n B r i t i s h Columbia. Its maximum capacity was twelve hundred inmates per day during the 1950's. The average number of inmates i t houses currently (1990), i s between four to f i v e hundred on a given day. Within the i n s t i t u t i o n , inmate behaviors are guided by the Correctional Centre Rules and Regulations of the Corrections Act. The Health Care Centre of Lower Mainland Regional Correctional Centre i s now a d i s t i n c t and separate building located within the confines of the co r r e c t i o n a l grounds. Its maximum capacity i s approximately 65, although i t seldom houses - 29 -that many as there are not enough beds available. The Health Care Centre i s composed of s i x wards and two independent rooms. Wards one and two, which are located on the main f l o o r , are designed for the inmates who have physical i l l n e s s ; e.g. broken leg, heart problem, etc. Wards f i v e and s i x , located on the second f l o o r with the other wards, are primarily for inmates who are mentally i l l . Wards three and four contain inmates who are p s y c h i a t r i c a l l y vulnerable, but are generally higher functioning than inmates i n wards f i v e and six either because t h e i r i l l n e s s e s are less severe or because t h e i r i l l n e s s e s are i n remission. This group appears to engage i n fewer acting-out behaviors. Health care i s provided by a c o n s t e l l a t i o n of health care professionals, most of whom are employed on a part-time sessional/contract basis. They include: two medical doctors, one p s y c h i a t r i s t , three psychologists, two f u l l - t i m e pharmacists, one physiotherapist, one dentist, one dermatologist, one optometrist, one dental hygienist, and one orthopaedic s p e c i a l i s t . Up u n t i l August 1989, there was twenty-four hour regular nursing s t a f f coverage. This has now been cut back to only seven a.m. to eleven p.m. coverage. Inmates who require surgery or laboratory tests are transferred to the l o c a l acute hospitals, and are often returned to the Health Care Centre for follow-up care. As well, there are o n - c a l l p s y c h i a t r i s t s available i n the evenings and weekends for p s y c h i a t r i c emergencies. - 30 -Health care professionals provide services to a l l the inmates from the whole i n s t i t u t i o n . Not a l l inmates are seen at the Health Care Centre, however. Many are seen by either a medical doctor and/or nurse during t h e i r d a i l y 'sick parades'. Discretion i s l e f t to the inmates to submit a request, and the co r r e c t i o n a l s t a f f to inform the health care professionals of the request to be seen. When the health care professional finds i t appropriate, he or she w i l l request that the inmate be transferred to the Health Care Centre for closer monitoring. Upon admission, each inmate i s 'screened' by a c l a s s i f i c a t i o n o f f i c e r . Screening consists of reviewing the inmate's his t o r y of offences, past i n s t i t u t i o n a l behaviors, court recommendations, medical history, and conducting a d i r e c t interview with the inmate. I t should be noted here that information may not be available at the time of the admission. Inmates who require protective custody due to the nature of t h e i r offence, or who are perceived to be h o s t i l e , threatening, and/or dangerous--that i s , a security concern—are often i s o l a t e d i n the Westgate B c e l l block. Inmates who are a security and suicide r i s k may be placed i n South Wing for close observation. Inmates from Westgate B and South Wing Observation usually receive health care i n t h e i r c e l l s rather than being transferred to the Health Care Centre. - 31 -Inmates who have a known ps y c h i a t r i c h i s t o r y are often sent d i r e c t l y to the Health Care Centre, p a r t i c u l a r l y i f they exhibit signs of unusual or bizarre behaviors at the time of th e i r admission. Naturally, t h i s i s dependent on the a v a i l a b i l i t y of space as well as the security clearance as i d e n t i f i e d e a r l i e r . Inmates who do not exhibit unusual or bizarre behaviors at the time of t h e i r admission may be placed i n with the general population u n t i l there are indications of mentally disturbed behavior. Inmates who become acutely psychotic, and present a danger to s e l f and/or others may be c e r t i f i e d under the B.C. Mental Health Act by two physicians. In these circumstances the inmate could either v o l u n t a r i l y accept psychopharmacological treatment at the Health Care Centre and/or be transferred to the Forensic Psychiatric I n s t i t u t e v i a a Temporary Absence application. Involuntary treatment can not be imposed since the Health Care Centre of Lower Mainland Regional Correctional Centre i s not a designated p s y c h i a t r i c f a c i l i t y . As mentioned e a r l i e r , Riverview Hospital w i l l not accept indiv i d u a l s who are serving a sentence i n a cor r e c t i o n a l i n s t i t u t i o n . Transfer to Forensic Psychiatric I n s t i t u t e i s dependent on the a v a i l a b i l i t y of bed space. On some occasions, inmates are released into the community before they can be transferred. - 32 -Each inmate of the Health Care Centre i s assigned a corr e c t i o n a l s t a f f member who i s responsible for the inmate's care management. The actual substance of the case management i s highly dependent on the inmate and the assigned c o r r e c t i o n a l s t a f f member. The primary focus i s placed on helping the inmate adapt to his period of incarceration rather than any other kind of planning. At the recommendation of the cor r e c t i o n a l s t a f f member/case manager, inmates can be e l i g i b l e for the 'work program'. This program b a s i c a l l y e n t a i l s j a n i t o r i a l duties, meals preparation, laundry services, and yard maintenance. Inmates receive a small sum of money i n return for t h e i r work, as well as a greater degree of freedom and time to spend i n the games room. Within the Health Care Centre, inmates from Wards one and two ( i . e . inmates with physical i l l n e s s e s only) are usually considered f i r s t for the work program. S i m i l a r l y , inmates from Wards three and four are more e l i g i b l e for the work program than the inmates from Wards f i v e and s i x , as the former group i s perceived to be more stable and higher i n t h e i r l e v e l of functioning. There i s a woodworking area i n the basement of the Health Care Centre. At one time t h i s was u t i l i z e d as a r e h a b i l i t a t i v e workshop for the mentally i l l inmates under the supervision of an Occupational Therapist. During the past year, t h i s area has - 33 -not been used at a l l , primarily due to s t a f f i n g shortage and f i s c a l constraints. F i n a l l y , there are regular Alcoholics Anonymous and S p i r i t u a l Guidance meetings available for a l l inmates who choose to attend, subject to security management of course. When the prison sentence imposed by the court has expired, the c o r r e c t i o n a l system must release the inmate. In these circumstances, the released p s y c h i a t r i c a l l y impaired inmate could remain i n the treadmill of a kind of 'greyhound therapy'. That i s , bouncing back and fort h , almost l i k e a 'ping pong b a l l ' between the community, the mental health system, and the criminal j u s t i c e system. ENTRY TO THE SYSTEM Our mental health system enables an i n d i v i d u a l to vo l u n t a r i l y admit him or herself into a p s y c h i a t r i c f a c i l i t y for a duration of h o s p i t a l i z a t i o n as deemed necessary. I t also permits a concerned family member or f r i e n d to escort the p s y c h i a t r i c a l l y impaired i n d i v i d u a l to a ho s p i t a l and seek admission for ps y c h i a t r i c intervention. However, there i s a group of mentally i l l i n d i v i d u a l s i n our community who do not have the benefit of or enjoy close f a m i l i a l and interpersonal t i e s . The reasons for t h i s 'disconnectedness' are manifold and complex and they w i l l not be addressed i n t h i s section. S u f f i c e to say that t h i s group of 'disconnected' p s y c h i a t r i c a l l y - 34 -impaired individuals i s often unable or unwilling to reach out for the necessary help i n a s o c i a l l y acceptable manner. As a r e s u l t , i n d i v i d u a l s i n t h i s 'disconnected' group who behave i n a s o c i a l l y inappropriate manner are more l i k e l y to be brought to the attention of law enforcement o f f i c i a l s than mental health professionals. Individuals i n t h i s group f i n d themselves caught between the mental health system, the community, and the criminal j u s t i c e system. In B r i t i s h Columbia, a p o l i c e o f f i c e r has the discretionary power either to take the apprehended i n d i v i d u a l to a p s y c h i a t r i c f a c i l i t y or, a l t e r n a t i v e l y , to lay criminal charges and place the i n d i v i d u a l i n j a i l pending his or her being processed through the criminal j u s t i c e system. From my own experience, I have found that the l a t t e r i s dependent on the nature of the offence and the f e a s i b i l i t y of admission into a p s y c h i a t r i c f a c i l i t y . When a l l the p s y c h i a t r i c f a c i l i t i e s are on "diversion"--that i s , when there are no p s y c h i a t r i c beds available or, when the i n d i v i d u a l i s deemed unsuitable for the f a c i l i t y because he or she i s not c e r t i f i a b l e under the Mental Health Act or i s too p o t e n t i a l l y aggressive—the p o l i c e o f f i c i a l i s l e f t with l i t t l e choice but to lay criminal charges and to remove the i n d i v i d u a l from the community to the l o c a l j a i l . - 35 -While the i n d i v i d u a l i s i n the l o c a l j a i l , he or she may be seen by a medical doctor i f such was the recommendation of the p o l i c e o f f i c i a l . From the r e s u l t s of the Mental Status Examination and the review of the available information, the medical doctor w i l l make recommendations based on the c l i n i c a l findings. The primary focus i s on the i n d i v i d u a l ' s 'Fitness to Stand T r i a l ' . 'Fitness to Stand T r i a l ' i s a l e g a l term, and i s based on the i n d i v i d u a l ' s understanding of the court process and the a b i l i t y to i n s t r u c t h i s or her l e g a l counsel. I t i s important to recognize that an i n d i v i d u a l can be p s y c h i a t r i c a l l y impaired and s t i l l be deemed ' f i t to stand t r i a l ' . Oftentimes, the decision i s deferred, and the physician recommends i n court the following day that the i n d i v i d u a l be remanded for a lengthier period of time at the Forensic Psyc h i a t r i c I n s t i t u t e for a comprehensive p s y c h i a t r i c assessment. Individuals who are deemed ' f i t ' by the presiding judge are processed through the j u d i c i a l system i n the same manner as a non-psychiatrically impaired i n d i v i d u a l . That i s , a t r i a l takes place, a verdict i s rendered, and sentencing or a c q u i t t a l follows. An i n d i v i d u a l who i s found ' f i t ' following a period of p s y c h i a t r i c remand at the Forensic Psychiatric I n s t i t u t e , i s returned to court and processed through the criminal j u s t i c e system i n the same manner as mentioned above. An i n d i v i d u a l who i s found 'Unfit to Stand T r i a l ' i s returned to the Forensic - 36 -Psychiatric I n s t i t u t e for treatment and eventually returned to court when i t i s determined by his or her attending p s y c h i a t r i s t or the Review Board that he or she i s ' F i t to Stand T r i a l ' . Again, once ' F i t ' , the i n d i v i d u a l i s processed through the criminal j u s t i c e system as with the case of any other i n d i v i d u a l charged with a criminal offence. There are many sentencing options. Some of them are: suspended sentence, f i n e , probation, a prison term and/or a combination of these. When an i n d i v i d u a l i s sentenced to a period of incarceration, he or she i s reviewed by a c l a s s i f i c a t i o n o f f i c e r . The c l a s s i f i c a t i o n o f f i c e r determines the appropriate c o r r e c t i o n a l f a c i l i t y the i n d i v i d u a l should be placed i n , based on the a v a i l a b i l i t y of the following information: the nature of offence, the past h i s t o r y of incarceration including past i n s t i t u t i o n a l behaviors, the recommendations of the court, past and current medical and psyc h i a t r i c h i s t o r y and needs, the geographical home base of the i n d i v i d u a l , and so on. I t should be noted that a l l the information may not be available during the i n i t i a l c l a s s i f i c a t i o n stage; and c e r t a i n l y , i n t e r - and i n t r a - f a c i l i t y transfers occur depending on the emerging needs of the in d i v i d u a l , and the a v a i l a b i l i t y of additional information, as well as i n s t i t u t i o n a l space and security demands. - 37 -Perhaps what i s unique about the Lower Mainland Regional Correctional Centre i s that, unlike other regional c o r r e c t i o n a l centres, i t does have a separate health care f a c i l i t y . As a r e s u l t , inmates who require medical (including psychiatric) attention that can not be provided at the host i n s t i t u t i o n , are often transferred to Lower Mainland Regional Correctional Centre. Sometimes, an i n d i v i d u a l who i s c e r t i f i e d under the Mental Health Act, and i s awaiting a bed i n the Forensic Psychiatric I n s t i t u t e may f i n d himself i n Lower Mainland Regional Correctional Centre. (This does not apply to female inmates as Lakeside Correctional Centre, located within the grounds of Lower Mainland Regional Correctional Centre, i s the only female p r o v i n c i a l c o r r e c t i o n a l f a c i l i t y . The c l a s s i f i c a t i o n process i s greatly s i m p l i f i e d for the female population as there i s only one f a c i l i t y . Female inmates can be transferred to Forensic Psychiatric I n s t i t u t e for p s y c h i a t r i c intervention.) S i m i l a r l y , an i n d i v i d u a l may be returned from Forensic P s y c h i a t r i c I n s t i t u t e to Lower Mainland Regional Correctional Centre instead of the host i n s t i t u t i o n only i f the l a t t e r i s not equipped to meet the needs of the inmate. In sum, how an i n d i v i d u a l enters the system, and where the i n d i v i d u a l ends up i n the system are l a r g e l y dependent on a multitude of factors. In addition, while the general p o l i t i c a l and economic climate influences our s o c i a l p o l i c i e s , these - 38 -p o l i c i e s i n turn, shape agency mandates, and provide i n d i v i d u a l caregivers the parameters of professional a c t i v i t i e s , including t h e i r discretionary powers. CONCX.UDJLMG CCMMKBPT For the past four years, I have been a c t i v e l y involved with mentally i l l offenders both within the l o c a l community and i n our p r o v i n c i a l i n s t i t u t i o n s . During the Spring of 1987, I attended a l o c a l conference, the f i r s t of i t s kind, t i t l e d The  Mentally Disordered Offender 3. A l l the speakers and participants at t h i s conference, from federal and p r o v i n c i a l , public and private sectors, i d e n t i f i e d the ' c r i m i n a l i z a t i o n of the mentally i l l ' as one of the most alarming and demanding problems that challenges us today. Of concern to me, i s the increasing number of mentally i l l individuals who have been repeatedly arrested and incarcerated for offences that are symptomatic of t h e i r p s y c h i a t r i c i l l n e s s . Moreover, I began to question whether the inherent l i m i t a t i o n s of the e x i s t i n g service agencies and s o c i a l systems are creating a new 'career' path for our p s y c h i a t r i c a l l y impaired patients. Picture the following scenario: a "mental health t r a f f i c cop" d i r e c t i n g individuals with mental i l l n e s s from the h o s p i t a l into the community. While some of these indivi d u a l s manage to stay i n the community, others return to the h o s p i t a l again and again and again. As the community becomes less - 39 -tolerant and the hospitals become more r e s t r i c t i v e i n t h e i r admission c r i t e r i a , some of our mentally i l l patients who are caught i n the 'over-flow' are being detoured into the criminal j u s t i c e system; the only system that cannot say no. These individuals are subsequently l a b e l l e d and categorized into the mentally i l l offender group and are led into a 'career' option previously not r e a d i l y available to them. And as i f that i s not enough, we furnish t h i s group of mentally i l l i ndividuals with the context to stay within t h e i r new 'career' and l i t t l e hope for change. Several issues that have emerged for me during the past few years are: Is t h i s group of mentally i l l offenders d i f f e r e n t from the 'generic' mentally i l l population? Does t h i s added option of entering the criminal j u s t i c e system contribute p o s i t i v e l y or constructively to the well being of the mentally i l l individual? What are the negative consequences when we cri m i n a l i z e the mentally i l l individual? How can we, as service providers improve or a l t e r the current state of a f f a i r s ? And f i n a l l y , where do we go from here? - 40 -CHAPTER 3 THE RESEARCH DESIGN This study was designed to gain an understanding of the concerns and needs of mentally i l l offenders while they are incarcerated within a corr e c t i o n a l i n s t i t u t i o n . In t h i s chapter, I w i l l : 1) define 'mentally i l l offender'; 2) describe the purpose of the research study; 3) i d e n t i f y the issues selected for the research; and 4) describe the research methodology. A short summary of the l i m i t a t i o n s of the design and the methodology w i l l follow. DKFIHIHG MEHTALLY U J . OFFERDKRS There i s l i t t l e consensus regarding the d e f i n i t i o n of the term 'mentally i l l offender'. Monahan and Steadman (1983) i d e n t i f i e d four subgroups. These are: 1) those who are found Not G u i l t y By Reason of Insanity; 2) those who are found U n f i t To Stand T r i a l ; 3) mentally disordered sex offenders; and 4) mentally disordered inmates who are transferred to a mental h o s p i t a l . In his monograph The Mentally Disordered Offender, Halleck (1987) makes a d i s t i n c t i o n between the "formally categorized 1 - 41 -and the 1non-formally categorized' mentally disordered offender. B a s i c a l l y , Halleck's f i r s t group embodies the four subgroups Monahan and Steadman i d e n t i f i e d . Although Halleck recognizes that the second group "may share many c h a r a c t e r i s t i c s with formally designated mentally disordered offenders... the two groups are managed quite d i f f e r e n t l y by the criminal j u s t i c e system....[That i s , ] . . . i f they are treated the usual purpose i s to a l l e v i a t e t h e i r s u f f e r i n g or help them adjust to a p a r t i c u l a r environment. No s p e c i f i c l e g a l purpose underlies t h e i r treatment, such as restoring t h e i r competency or r e h a b i l i t a t i n g them, and those who treat them do not usually report the progress to j u d i c i a l agencies" (p.3). He further comments that "The routine of prison l i f e and i n p a r t i c u l a r the degree of i s o l a t i o n i t imposes upon inmates allows seri o u s l y disordered offenders, including many who may be psychotic, to go undetected....My experience i s not unique....If blatant psychosis can be hidden or undetected i n prison, severe depression, which i s much easier to conceal, i s probably even more prevalent....If p s y c h i a t r i s t s are available to examine individuals who frequently occupy punitive segregation units, they usually discover a high incidence of psychosis and major a f f e c t i v e disorder.... the personal v u l n e r a b i l i t i e s of many of these inmates i n protective custody can be best described as manifestations of serious mental disorders....The number of these indiv i d u a l s eventually designated as mentally disordered offenders i s unknown, but probably many are not" [sic] (pp.4-6). - 42 -For a much broader d e f i n i t i o n , Jemelka, Trupin, and Chiles (1989) use the term 'mentally i l l offender' to mean "Those indivi d u a l s i n prisons and j a i l s who have a diagnosable major p s y c h i a t r i c disorder (schizophrenia, unipolar and bipolar depression or organic syndromes with psychotic features)" (p.482) (my emphasis). The Community Action for the Mentally 111 Offender (CAMIO), a non-profit organization i n Seattle, Washington, describes i t s target population as "any i n d i v i d u a l who, by virtu e of a chronic mental i l l n e s s , that i s , schizophrenia and/or a major a f f e c t i v e disorder, i s unable to independently maintain law-abiding behavior. This includes those individuals who are i n pre- or post-conviction status... either incarcerated or i n the community". For the purpose of t h i s paper, the term mentally i l l offender w i l l not include those indiv i d u a l s who are found Not Gu i l t y By Reason of Insanity, U n f i t to Stand T r i a l , or Sex Offenders who do not have a major mental i l l n e s s that i s l i s t e d i n the DSM-III-R, the o f f i c i a l manual of nomenclature of the American Psychiatric Association. I t i s also not concerned with the group of mentally i l l i n d i v i d u a l s who have been diverted by the arresting p o l i c e o f f i c e r s into the mental health system. The group of mentally i l l offenders t h i s paper i s r e f e r r i n g to consists of ind i v i d u a l s who have a major mental disorder that i s found i n the Axis I category of the DSM-III-R, and are eith e r : - 43 -1) discharged p s y c h i a t r i c patients who have d i f f i c u l t i e s i n coping with community l i v i n g and are consequently processed through the criminal j u s t i c e system for engaging i n primarily minor petty crimes; 2) the emerging Young Adult Chronic Patients (See Appendix A) who are r e s i s t a n t to being categorized as mentally i l l , and are therefore, s i m i l a r l y r e s i s t a n t to mental health treatment and s o c i a l intervention. As a r e s u l t , they are resurfacing amongst the criminal subcultures; and/or 3) offenders who become p s y c h i a t r i c a l l y impaired while incarcerated or under community supervision. Indeed, an i n d i v i d u a l with a major mental i l l n e s s can ' f i t ' into more than one of these groups at any given time, or over time, as these groups are not mutually exclusive. I am interested i n t h i s group because i t i s the group that i s most vulnerable to being l o s t i n the system. P O R P O S E O F B R S K u n r H In 1857, Edward J a r v i s , an American p s y c h i a t r i s t , describes the experience of a mentally i l l offender as follows: "[He]...has nowhere any home: no agency or nation has provided a place for him. He i s everywhere unwelcome and objectionable. The prisons thrust him out and the hospitals are unwilling to receive him; the law w i l l not l e t him stay at his house, and the public w i l l not permit him to go abroad. And yet humanity and j u s t i c e , the sense of common danger, and a tender regard for a deeply degraded brother-man, a l l ,agree that - 44 -something should be done for him" (cf. Halleck, 1987, p.11). In reference to Dr. J a r v i s ' comment, Halleck, a criminologist, c l i n i c i a n , and administrator, summarized the American conditions i n 1987 as follows: "These words s t i l l apply to mentally disordered offenders today. We remain uncertain how to treat them. We are unwilling to leave them alone, yet most agencies seek to avoid r e s p o n s i b i l i t y for t h e i r care. We confine them to prisons and to p r i s o n - l i k e hospitals where they are sometimes treated worse than other offenders. They almost always receive worse treatment than mental patients i n public or private mental hospitals" (p.12). The a v a i l a b i l i t y of documented information within Canada, and s p e c i f i c a l l y B r i t i s h Columbia, regarding the experiences of and with mentally i l l offenders i s very limited. Yet, there i s an acute awareness amongst the d i r e c t caregivers i n our health care, s o c i a l services, and criminal j u s t i c e agencies of both public and private sectors, that there i s an apparent increase of mentally i l l i n d i v i d u a l s who are emerging as a d i s t i n c t i v e group i n our l o c a l criminal j u s t i c e system. 4 The urgency to address the needs of t h i s group of mentally i l l offenders has been i d e n t i f i e d p a r t i c u l a r l y by the P r o v i n c i a l Corrections Branch. In an unpublished discussion paper prepared for the Branch dated May 22nd, 1990, i t was stated: " i t has become increasingly more common for c o r r e c t i o n a l centre s t a f f to comment on an increase i n the number of MDOs [Mentally Disordered Offenders] i n t h e i r i n s t i t u t i o n s . - 45 -Correctional Service of Canada (CSC) has also i d e n t i f i e d the MDO as an area for concern and s p e c i a l i z a t i o n . Corrimunity Corrections s t a f f are under growing pressure to provide programming appropriate to these offenders" (p.2). Furthermore, "The Branch i s experiencing pressure to provide services to a group of offenders that i t f e e l s i l l equipped to deal with. In large part these offenders may be i n gaol, not because of extensive c r i m i n a l i t y , but because of mental disorder. I t , therefore, becomes d i f f i c u l t to reconcile services which have been designed for the 'average' inmate with the demands/requirements of the mentally disordered offender" (p.3). I S S T J K S SKT.RrTwn P Q R R K S P B P P H In t h e i r review of the l i t e r a t u r e on mentally i l l offenders, Jemelka, Trupin and Chiles (1989) pointed out that: "Much more has been written about the l e g a l issues i n providing p s y c h i a t r i c treatment i n j a i l s and prisons than has been written about the treatment i t s e l f . L i t t l e i s available i n the l i t e r a t u r e to guide decisions about designing treatment programs" (p.485). Given that there i s a dearth of information regarding the experiences and needs of mentally i l l offenders, t h i s research study intends to: 1) explore the experiences of mentally i l l i n d i v i d u a l s who have been incarcerated; - 46 -2) explore the problems that confront health care professionals and c o r r e c t i o n a l personnel who provide care for mentally i l l indiv i d u a l s who have been incarcerated; and 3) i d e n t i f y the needs of mentally i l l offenders as perceived by themselves and t h e i r caregivers. RESEARCH DESIGN One way to determine the experiences and service needs of incarcerated mentally i l l offenders i s to ask them. Given the complexity of t h i s topic area, a q u a l i t a t i v e design was chosen. Such a design: "attempts to gain a f i r s t hand, h o l i s t i c understanding of the phenomenon of i n t e r e s t by means of a f l e x i b l e strategy of problem formulation and data c o l l e c t i o n shaped as the inves t i g a t i o n proceeds...understanding the system from the perspectives of the actors involved rather than through the imposition of the researcher's t h e o r e t i c a l views" (Reid and Smith, 1981, pp.88-89). In order to generate information from the point of view of the various actors involved, the study must be n a t u r a l i s t i c and exploratory i n nature. N a t u r a l i s t i c i n t h i s case meant that the research would be conducted within the c o r r e c t i o n a l i n s t i t u t i o n context; exploratory means that the intent " i s to gain an i n i t i a l look at a piece of r e a l i t y and to promote ideas about i t " (Reid & Smith, 1981, p.67). - 47 -With respect to data c o l l e c t i o n , the researcher f e l t i t was important to A) get close enough to be almost d i r e c t l y involved; B) capture and record what a c t u a l l y happens i n a non-j udgemental manner; C) record extensive descriptions of events; and D) record d i r e c t quotes from a l l p a r t i c i p a n t s . (Patton, 1980, p.36). The accumulated findings w i l l be used to i d e n t i f y the problem areas of the ex i s t i n g services, and to f a c i l i t a t e future program planning and p o l i c y development, as well as to i d e n t i f y p r a c t i c a l knowledge that can be applied i n sim i l a r settings. F i n a l l y , through the process of Constant Comparative Methods as described by Glaser and Strauss (1967), a set of related concepts and hypotheses w i l l emerge for future research studies. By design, t h i s study does not address the incidence and prevalence rate of mentally i l l individuals who have been incarcerated. This research design i s primarily exploratory and retrospective i n nature. METHODOLOGY (i) DATA COLLECTION Descriptive, q u a l i t a t i v e data was c o l l e c t e d by the researcher between March 1989 and March 1990, by means of - 48 -part i c i p a n t observation, supplemented with formal and informal semi-structured interviews. (See Appendix B) While some of the interviews were tape recorded, the researcher had to record i n writing and summarize the important points made by some of the participants during and/or afte r the interviews since permission to be recorded was not always given. The researcher used a "phenomenological approach" which included an informal unstructured conversational interview during the i n i t i a l phase of the research study, followed by a formal interview using an interview guide, and then c l o s i n g with s p e c i f i c open ended questions. In essence then, two interview procedures were followed - an i n i t i a l informal interview as well as a guided formal interview. ( i i ) SAMPLING The sampling strategy was purposeful, rather than random. A l l subjects were approached i n person by the researcher to determine t h e i r i n t e r e s t i n p a r t i c i p a t i o n . They were also selected, by the researcher, based on the premise that they would represent the various i n t e r e s t groups that might be affected by the c r i m i n a l i z a t i o n process of the mentally i l l . There are two d i f f e r e n t sampling populations. They are: a) mentally i l l offenders, and b) service providers. - 49 -Representatives from both groups are selected from the Health Care Centre of the Lower Mainland Regional Correctional Centre, as well as from the community. The mentally i l l offenders group consisted of s ix male ps y c h i a t r i c patients -- four of whom were incarcerated at Lower Mainland Regional Correctional Centre at the time of the interviews, and two of whom were ex-inmates of the same f a c i l i t y . The service providers group consisted of health care professionals and cor r e c t i o n a l personnel. The health care professional group consisted of three registered nurses and one psy c h i a t r i c nurse. The corre c t i o n a l personnel group consisted of one cor r e c t i o n a l administrator, one p r i n c i p a l o f f i c e r , and two cor r e c t i o n a l s t a f f members—all of whom were from the Health Care Centre of Lower Mainland Regional Correctional Centre. In addition, t h i s sample group included two health care professionals who were fa m i l i a r with mentally i l l offenders population as well as the corre c t i o n a l system, and two cor r e c t i o n a l o f f i c e r s from the Vancouver P r e - T r i a l Centre. (See Table 1) The t o t a l sample size was eighteen. - 50 -TABLE 1 DISTRIBUTION OF PARTICIPANTS WHO WERE FORMALLY INTERVIEWED IN LMRCC IN COMMUNITY TOTAL Mentally 111 Offenders 4 2 6 Correctional Personnel 4 2 6 Health Care Professionals 4 2 6 TOTAL 12 6 18 The sample was chosen as follows. With respect to the mentally i l l offender population within the i n s t i t u t i o n , the researcher began by asking the s t a f f members to i d e n t i f y those inmates at the Health Care Centre who might have a hist o r y of mental i l l n e s s . While some of them were known to the researcher already, i n a l l cases there was the opportunity to review the relevant f i l e s . Following t h i s , the researcher i n v i t e d various p o t e n t i a l participants to an i n d i v i d u a l 'get to know each other' interview with the researcher. Each i n d i v i d u a l was informed v e r b a l l y and i n writing (via the consent form, see Appendix C) the purpose of the research study. Each p o t e n t i a l p a r t i c i p a n t was aware that p a r t i c i p a t i o n - 51 -was purely voluntary, and would have no influence whatsoever on his stay i n the Health Care Centre of the Lower Mainland Regional Correctional Centre. Several mentally i l l offenders within the community formerly known to the researcher were also asked i n person i f they were interested i n p a r t i c i p a t i n g i n the research study. The purpose of the study was explained to them verbally and i n writing. Arrangements were made to meet them i n the community, and the interviews took place i n the o f f i c e where the researcher had previously worked. With respect to the sel e c t i o n of service providers within the Health Care Centre of the Lower Mainland Regional Correctional Centre, the researcher spent an i n i t i a l block of time just to get f a m i l i a r with t h e i r roles and the structure of the i n s t i t u t i o n . Informal discussions provided the opportunity to i d e n t i f y those s t a f f members who might be suitable and interested i n p a r t i c i p a t i n g . (Individuals who were unfamiliar with the co r r e c t i o n a l system and/or the Health Care Centre either because they were recently hired, temporary r e l i e f , and/or a u x i l i a r y status were considered unsuitable candidates.) Each s t a f f member was informed verbally and i n writing (via the consent form, see Appendix D) regarding the purpose of the research study. Again, each was aware that p a r t i c i p a t i o n was voluntary, and c o n f i d e n t i a l i t y would be respected. In addition, several c o r r e c t i o n a l o f f i c e r s and health care workers within the community formerly known to the researcher were - 52 -asked i f they were interested i n p a r t i c i p a t i n g i n the research study. Arrangements were made to meet them i n the community, and the interviews took place either i n t h e i r o f f i c e or the o f f i c e s where the researcher previously worked. ( i i i ) THE INTERVIEW An open-ended semi-structured interview guide (See Appendix B) was designed by the researcher to ensure that the same general topic areas would be explored during the formal interviews. Such a guide permits f l e x i b i l i t y , d e t a i l e d probing, and the opportunity for expressions of personal attitudes, experiences, perception, and ideas. Information gathered from the early interviews was used to ask more succinct and pertinent questions i n the subsequent interviews. (iv) DATA ANALYSIS The raw data consists of: s i x tape recorded interviews transcribed verbatim by the researcher, and information c o l l e c t e d from twelve interviews, recorded i n writing by the researcher, since permission to record by tape was refused. The information c o l l e c t e d from these interviews.was used as basic concept indicators and subsequently used for comparisons with the rest of the f i e l d notes. (For d e t a i l s of the analytic process, see Appendix E). f - 53 -The analytic process used accommodates the i n d i v i d u a l preferences of the p a r t i c i p a n t s . In an i d e a l s i t u a t i o n , i t i s the opinion of the researcher that a l l interviews should be tape recorded. This would allow closer adherence to Glaser and Strauss' Constant Comparative Method where verbatim, sequential l i n e - b y - l i n e coding, memoing and analysis would be maintained; and the degree of s u b j e c t i v i t y on behalf of the researcher would greatly diminish. That the modified version of data c o l l e c t i o n was not a 'pure type' i s acceptable as "In practice any p a r t i c u l a r evaluation may employ several...strategies or combinations of approaches" (Patton, 1980, p.205). After a l l , the strength of q u a l i t a t i v e research i s the a b i l i t y to accommodate the i n d i v i d u a l i t y of the subjects and s t i l l be able to gather a r e l a t i v e l y uniform body of relevant data. In short, the researcher considers the data c o l l e c t i o n methods used were optimal for the circumstances, and have yielded v a l i d data. (v) ETHICS This research study was approved by the University of B r i t i s h Columbia Research Screening Committee as well as by the Ministry of S o l i c i t o r General, B.C. Corrections Branch. A l l interviewed participants were required to sign a consent form and were informed of t h e i r r i g h t to decline p a r t i c i p a t i o n i f they chose, as well as withdraw t h e i r consent to p a r t i c i p a t i o n at any time during the interview(s). Their i d e n t i t i e s remained c o n f i d e n t i a l and a l l i d e n t i f y i n g information has been destroyed. - 54 -(vi) DISCUSSION Some of the li m i t a t i o n s of t h i s study are as follows: 1) The sample size of eighteen l i m i t s the g e n e r a l i z a b i l i t y of the data. In addition to a larger sample s i z e , obtaining data from inmates of the 'general population', ethnic minority groups who are also mentally i l l offenders, and female mentally i l l offenders, would be useful i n terms of i d e n t i f y i n g s i m i l a r i t i e s and differences of service needs between the d i f f e r e n t groups. In an i d e a l s i t u a t i o n , obtaining data from h o s p i t a l i z e d p s y c h i a t r i c patients, again i n comparing the s i m i l a r i t i e s and differences, would also be guite i l l u m i n a t i n g . The use of comparison between the d i f f e r e n t data would elucidate the problems and needs presented by mentally i l l offenders. The pursuit of such studies i n the future i s strongly recommended. 2) The research study was conducted within the Health Care Centre of a medium and maximum security c o r r e c t i o n a l i n s t i t u t i o n within the Lower Mainland. The r e s u l t s of the data analysis apply therefore only to t h i s setting, and have limited u t i l i t y i n a d i f f e r e n t s e t t i n g , rendering the conclusions useful only i n generating hypotheses for future research studies. The conclusions are important primarily because of the conceptual s i g n i f i c a n c e , p a r t i c u l a r l y i n i d e n t i f y i n g s a l i e n t variables for future studies. - 55 -3) One of the extraneous variables that must not be ruled out, given the non-randomness of the sample selection, i s the phenomenon of 'demand c h a r a c t e r i s t i c s ' . That i s , when researchers "wittingly or unwittingly give subjects cues about how they are supposed to behave" (Kidder and Judd, 1986, p.97). Furthermore, voluntary subjects "are p a r t i c u l a r l y l i k e l y to respond to signals and demands they perceive i n the experimental se t t i n g " (p.97). Although the authors note that the "potential i s greater i n randomized laboratory experiments" (Ibid), the issue remains that individuals who have a d i f f e r e n t attitude or perspective may decline to p a r t i c i p a t e . In addition, i n s t i t u t i o n a l i z e d p s y c h i a t r i c patients tend to be either eager to please or r e s i s t a n t when they i n t e r a c t with 'system representatives', leaving one wondering how much of what they say i s a function of i n s t i t u t i o n a l i z a t i o n . In other words, t e l l i n g the researcher what one thinks he or she may want to hear. As a r e s u l t , the s e l f - s e l e c t i v e process could conceivably skew the types of data obtained, and not represent the f u l l r e a l i t y of the area of i n t e r e s t . 4) At the time of the study, the B.C. Ministry of S o l i c i t o r General, Corrections Branch, has been i n the process of decentralizing the Lower Mainland Regional Correctional Centre. As a r e s u l t , there has been a great deal of uncertainty with the impending r e - s h u f f l i n g of s t a f f members. This undoubtedly had influence on the s t a f f morale, the p o l i t i c a l context of the study, and the general i n t e r e s t i n p a r t i c i p a t i n g i n the study. Several new programs were brought into the Health Care Centre during the Spring of 1989, shortly af t e r the researcher had started her study. They were: a s o c i a l s k i l l s group, an alcohol and drug program, and a community based program, (the I n t e r - M i n i s t e r i a l Project). As well, the' researcher herself, at the request of some of the s t a f f members, brought i n a r t i c l e s on behavior management. While some of these programs were more enduring than others, they a l l i n part, had an impact on the i n s t i t u t i o n , the mentally i l l offenders, and the s t a f f . I t may well be that the participants i n t h i s study were more a r t i c u l a t e i n terms of i d e n t i f y i n g what they perceived the needs to be since those programs were s t i l l fresh i n t h e i r memories. To see the programs a c t u a l l y operating might have influenced t h e i r perceptions regarding the f e a s i b i l i t y and d e s i r a b i l i t y of implementing c e r t a i n programs within a c o r r e c t i o n a l setting. - 57 -Notwithstanding the abovementioned l i m i t a t i o n s , i t was decided that the research design and methodology were appropriate. - 58 -C H A P T E R F O U R R E S E A R C H F I N D I N G S A N D D I S C U S S I O N As stated i n the previous chapter, the data c o l l e c t i o n consisted of two methodological processes - the informal par t i c i p a n t observation and the formal guided interviews. As with other studies of a q u a l i t a t i v e nature (See Appendix E), the findings can only be f u l l y understood i n the context i n which the study took place and through understanding the process by which the findings were generated. CHaRACTKRISTICS OF THE SAMPLE Readers should refer to Table 1 for further c l a r i f i c a t i o n . (i) mentally i l l offenders Altogether, s i x mentally i l l offenders p a r t i c i p a t e d i n the formal data c o l l e c t i o n of t h i s study. Of the six par t i c i p a n t s , four were inmates serving t h e i r j a i l sentence at the Health Care Centre of the Lower Mainland Regional Correctional Centre at the time of the study and two were ex-inmates of the same f a c i l i t y , who were residing i n the community at the time of the interviews 5. I t should be noted that none of the participants of t h i s group was acutely psychotic at the time of the interviews'. - 59 -The age range of the mentally i l l offender group f a l l s between mid-twenties and mid-forties. A l l are single men, who have never been married. Several other commonalities that t h i s sample group share are: 1) a diagnosis of mental i l l n e s s i n the categories N of Axis I and Axis II as per the Diagnostic S t a t i s t i c a l Manual, Third E d i t i o n , Revised 6; 2) multiple p s y c h i a t r i c h o s p i t a l i z a t i o n s ; 3) multiple contacts with p o l i c e o f f i c i a l s including p r o v i n c i a l j a i l sentences; 4) a h i s t o r y of substance abuse; 5) periodic contacts with l o c a l community mental health centres; 6) a long hi s t o r y of unemployment; and 7) have been receiving Income Assistance for most, i f not a l l , of t h e i r adult l i v e s . ( i i ) service providers. Altogether, twelve service providers p a r t i c i p a t e d i n the formal data c o l l e c t i o n of t h i s study. Of the twelve par t i c i p a n t s , s i x were cor r e c t i o n a l personnel and s i x were health care professionals. - 60 -(a) c o r r e c t i o n a l personnel Of the six co r r e c t i o n a l personnel, a l l were male. Four were employed at the Health Care Centre of the Lower Mainland Regional Correctional Centre at the time of the study, and the remaining two were employed at a d i f f e r e n t c o r r e c t i o n a l f a c i l i t y at the time of the interviews. The length of years i n experience ranged from a minimum of f i v e years to the maximum of twenty f i v e years. This group brought to the research study a v a r i e t y of experiences within the co r r e c t i o n a l system, including front l i n e custodial work, case management, c l a s s i f i c a t i o n , unit management, administration, program planning, and p o l i c y analysis. (b) health care professionals Of the six health care professionals, four were employees of the Health Care Centre of the Lower Mainland Regional Correctional Centre at the time of the study. They comprised of two female registered nurses, one male registered nurse, and one female p s y c h i a t r i c nurse. As for the remaining two male health care professionals, one was a p s y c h i a t r i s t on contract, and the other was a community mental health s o c i a l worker. The length of years i n experience ranged from a minimum of nine years to the maximum of t h i r t y years. This group of health care professionals brought to the research study a range of - 61 -c l i n i c a l experiences within the c o r r e c t i o n a l , medical, and mental health systems. A l l the participants i n t h i s sub-group worked with mentally i l l offenders either during t h e i r period of incarceration and/or when they were residing i n the community. FINDINGS AMD DISCUSSION I. Alienation A primary f i n d i n g that emerged from t h i s study i s the sense of a l i e n a t i o n shared by a l l the p a r t i c i p a n t s . Alienation, as defined i n the Webster's New Collegiate Dictionary i s the act of withdrawal, detachment, and separation. To alienate i s to f e e l estrangement, to disconnect, and to distance from the s e l f and/or the external environment. I t can be achieved through i n s u l a t i o n by the s e l f or i s o l a t i o n by the external world. (i) mentally i l l offenders Individuals who suffer from major chronic mental i l l n e s s e s such as schizophrenia and a f f e c t i v e disorders (Axis I as per the DSM III-R) often experience a form of displacement. This i s because mental i l l n e s s intrudes upon the i n d i v i d u a l and - 62 -mounts up a psychological barricade that separates the in d i v i d u a l from his or her own s e l f and the external world. As i s indicated i n the following examples, mentally i l l individuals are oftentimes l e f t with an e x i s t e n t i a l void or a sense of emptiness. "I don't r e a l l y know how I f e e l sometimes. It' s l i k e I can only stare you know. There's no thoughts going on i n my head." "I don't get the audio hallucinations anymore. I miss that. I t was my l i f e . I t was what I b u i l t my l i f e around. Without that, I don't have my l i f e anymore." In the same vein, a health care professional who part i c i p a t e d i n t h i s study made the following observation: "The impression I get i s that they are ch r o n i c a l l y neutral about everything....It's l i k e they are f i g h t i n g against t h i s condition that's a psychological vacuum that sucks a l l the l i f e out". What emerges then, i s a sense of detachment, as one becomes more i s o l a t e d and withdrawn. Withdrawal, assumes d i f f e r e n t forms. Take the following for example: "I used drugs a l o t to escape from r e a l i t y " ; "I've cut other people out of my l i f e " ; "I don't want to s t e a l . I'm not a t h i e f " ; and " I t became an excuse for me to cop out". Withdrawal, be i t into drugs, one' s e l f , or the criminal subculture, i n e v i t a b l y leads to further i n s u l a t i o n , - 63 -estrangement, and despair. In order to cope with the sense of disconnectedness and helplessness, the mentally i l l i n d i v i d u a l f e e l s increasingly i n d i f f e r e n t towards him or her s e l f and the external environment. This i s best i l l u s t r a t e d by the following examples: "I couldn't do anything. I never t r i e d . As an i n d i v i d u a l , I'm a f a i l u r e " " J a i l s and hospitals are places for me to hide. Hide from myself and other people....They become l i k e hotels....Being i n j a i l s and hospitals broke up my time"; and "I can't envision anything d i f f e r e n t or what I want because i f there i s something I want, i t may give me the motivation to go out and get i t " . As part and parcel of the sense of helplessness, there i s a p a s s i v e acceptance of the external world regardless of how unsatisfying i t may be. The lack of hope, despair, and the absolute p a s s i v i t y are evident i n the following narrations: " I t was hard. I was there, being the end of my l i f e . This i s what my l i f e had come to. I thought i t was the end"; "Here, I get up and have breakfast, and get back to bed. I get up around ten or ten - t h i r t y , maybe have a shower, and then have lunch. Then I play cards, crash out for awhile, get ready for dinner, maybe read a b i t or write something down. Just phone numbers, make sure I don't lose them, that's a l l " ; "I see the p s y c h i a t r i s t once a week or once every two weeks. Actually, no, I see the psychologist. I don't know what you can get - 64 -out of a three minute conversation, but i t seems to be a l r i g h t . I walk i n there and he goes, How are you Mr. . I say fi n e . How did the medication go? O.K. Well, we'll keep you taking the medication u n t i l you get out. That's i t ! Then he says next! And you just go back upstairs again"; and "Well, i t ' s just the way l i f e i s . I t ' s only who you come into contact with. Well, how people react to you. Favourable or not".. The onset of mental i l l n e s s i s often an insidious process. From my c l i n i c a l experience, early warning signs such as s o c i a l withdrawal and i s o l a t i o n , poor coping s k i l l s , poor interpersonal relationships, self-medication through alcohol and i l l i c i t drug use, an i n a b i l i t y to maintain employment, are often overlooked, tolerated, and/or dismissed by the individual's family, friends, and s o c i a l network. In other words, many mentally i l l i n d i v i d u a l s ' premorbid psychosocial functioning, i n retrospect, may be considered at best marginal. This i s further exacerbated by the disease process. In sum then, individuals with mental i l l n e s s often lack the motivation and the capacity to develop the s o c i a l and l i f e s k i l l s necessary to cope e f f e c t i v e l y . They also experience great d i f f i c u l t i e s i n communicating with t h e i r family, friends, s o c i a l network, and caregivers. The i n a b i l i t y to express t h e i r feelings and t h e i r needs can be s t r e s s f u l , and i n turn, creates estrangement and encourages s o c i a l withdrawal. Their lack of s o c i a l competence alienates them and fosters a sense of - 65 -helplessness which compromises t h e i r q u a l i t y of l i f e , leaving them a l l the more vulnerable to another relapse of t h e i r i l l n e s s . A l l the mentally i l l offenders who p a r t i c i p a t e d i n t h i s study gave evidence of t h i s process. ( i i ) c o r r e c t i o n a l personnel In review of the findings, and p a r t i c u l a r l y i n view of the researcher's i d e n t i f i c a t i o n of a l i e n a t i o n as a major issue, some further elaboration on the context of the study and the process by which the study was conducted i s required. At the time of the study, a number of changes were taking place within the c o r r e c t i o n a l f a c i l i t y . 1. A noticeable loss of senior c o r r e c t i o n a l s t a f f members to the p r o v i n c i a l government's early retirement program; r e s u l t i n g i n 2. a high s t a f f turnover; and 3. an increased use of a u x i l i a r y o n - c a l l a u x i l i a r y s t a f f members. In addition, the P r o v i n c i a l Corrections Branch was working on i t s long term plan of 'regionalization'. Regionalization meant the systematic cl o s i n g down of the e x i s t i n g Lower Mainland Regional Correctional Centre and the development of smaller - 66 -l o c a l c o r r e c t i o n a l centres. As with any major re-organization, informal discussions and 'rumors' were rampant and there was a sense of uncertainty i n the a i r . Although I have spent time at the Health Care Centre before, and the s t a f f had generally been f r i e n d l y towards me, a great deal of time was spent on engaging the c o r r e c t i o n a l s t a f f members. I t became apparent that a formal approval from management (See Appendix F) was required i f I was to carry out the research study with the least amount of suspicion and the greatest degree of cooperation. E s s e n t i a l l y , the authorization memorandum gave s t a f f members the formal permission to disclose information to the researcher. The researcher wore two hats; one that of a student and the other, of an i n d i v i d u a l with professional expertise i n the f i e l d . The 'student' role was useful as i t encouraged the s t a f f members to share t h e i r knowledge with the researcher. The 'professional' role was useful as i t allowed the researcher to be supportive and empathic, which minimized some of the d i s t r u s t on the part of the c o r r e c t i o n a l personnel. Even then, a l o t of e f f o r t was required to assure the s t a f f members of t h e i r anonymity. The fa c t that I was a Social Worker meant that I remained a suspect to some. In order to obtain the data for my study, I had to concede to some interviews without a tape recorder and on two occasions, I was sworn to secrecy and had to promise that I would not share the information with the 'nursing s t a f f . - 67 -The physical structure of the building and the nature of custodial work demand that the c o r r e c t i o n a l personnel remain at t h e i r work s i t e s . Therefore, geographically, they were separated. For example, one s t a f f member i s positioned by the front gate, two i n the 'control centre', one i n the adjoining o f f i c e who i s responsible for Units one and two, two upstairs who monitor the inmates from Units three, four, f i v e and s i x , one i n the basement who monitors the work program, and a couple of others who serve as escorts. What became apparent was that the physical s e p a r a t i o n of c o r r e c t i o n a l personnel from one's peers, the health care professionals, and the inmates, discouraged communication and information sharing. For example, "Their f i l e s are scattered i n four d i f f e r e n t places. I don't know what the problem i s " ; "Sometimes, an inmate would ask me about what's out there for them, I don't know what to t e l l them. I know there's a Red Book, and put together a resource book, but they're kept i n the nursing o f f i c e , I think. I haven't seen i t for a long time, we should have one up here"; and "We don't even have time to t a l k to each other between r e l i e f " . In short, the lack of r e c i p r o c a l exchange led, i n the case of the c o r r e c t i o n a l personnel, to the development of p s y c h o l o g i c a l d i v i s i v e n e s s , and a l i e n a t i o n , not unlike the experience of the mentally i l l . What occurred was that the - 68 -cor r e c t i o n a l personnel withdrew into t h e i r own 'camp' and the distance allowed them to become detached. Some of them further insulated themselves by s t r i c t l y adhering to the Rules and Regulations of the f a c i l i t y . This i s best i l l u s t r a t e d by the following comments: "Our p r i o r i t y i s security"; and "The co r r e c t i o n a l perspective i s the f i n a l perspective"; and to a lesser degree, "It's a good thing we have some d i s c r e t i o n , or else every time we turn around t h e y ' l l be charged with something". In the process of withdrawal then, the c o r r e c t i o n a l personnel can be deemed to have a l i e n a t e d themselves from the mentally i l l inmates. And as the 'gap' widened, what emerged were f e a r s and f r u s t r a t i o n s towards t h i s group as well as a sense of powerlessness. There are many examples: "I don't know enough to know i f they're sick or i f they're cons....I can't t a l k to them the same way". "I don't know what to expect! These guys can be quite unpredictable"; "This group's hygiene i s generally very poor. They don't take care of t h e i r l i v i n g area"; "I'm not l i k e you, I don't know why they're the way they are"; and "They make working here dangerous. I'm more concerned with my own safety. As far as I'm concerned, the c o r r e c t i o n a l o f f i c e r s are put at r i s k " . - 69 -How the fears and f r u s t r a t i o n s of the c o r r e c t i o n a l personnel impact on the mentally i l l inmates i s captured i n the following comment made by one of the part i c i p a n t s i n the mentally i l l offender group: "They make fun of me. People. They laugh at me at Oakalla. I prefer the old guards 'cos they're good to me. They give me tobacco, they leave me alone. The new guards, sometimes they make fun of me. Is i t wrong to hear voices?" Also, some of the c o r r e c t i o n a l personnel f e l t overwhelmed by t h e i r sense of powerlessness and helplessness and f e l t unable to create p o s i t i v e changes. This i s evident i n the following: "These guys don't belong here, but they keep coming back!"; "I'd love to be able to do more than just t h i s , but i f there's not enough s t a f f , i t ' s just no way"; "I'd l i k e to be involved with the programming....I would enjoy i t but the problem i s the lack of s t a f f " ; "I've asked for t r a i n i n g before, but I won't do i t on my own time"; and "What you see here i s the revolving door syndrome. A l o t of guys have been here before!" Based on the information I have gathered, i t i s apparent that the t r a i n i n g of c o r r e c t i o n a l personnel i s l a r g e l y limited to the Rules and Regulations of the Corrections F a c i l i t y Act, - 70 -and the various security measures and procedures available to maintain order and control. The basic t r a i n i n g speaks to the issue of psychopathology to a very small extent, and does not address the nature of mental i l l n e s s , the signs and symptoms of mental i l l n e s s , or how to deal more e f f e c t i v e l y with the mentally i l l . I t i s not surprising then, that the lack of knowledge i n t h i s area would rapid l y lead to fears, f r u s t r a t i o n s and disengagement. Isolated, c o r r e c t i o n a l personnel would na t u r a l l y f e e l compelled to use what s k i l l s they do have to make t h e i r d a i l y routine less threatening. Moreover, the c o r r e c t i o n a l environment becomes f e r t i l e ground to breed resentment, passive resistance and a l i e n a t i o n when expressions of motivation to learn more information or to t r y out d i f f e r e n t s k i l l s are discouraged or c u r t a i l e d . ( i i i ) health care professionals Again, i n considering the findings, i t i s necessary to take into account the context of the study and the process used to generate the data. At the time of the study, the one major change that occurred for the health care professionals was that t h e i r hours of operation were cut back from a twenty-four hour service to a - 71 -seven a.m. to eleven p.m. schedule. This loss of working hours resulted i n : 1) a cut-back of s t a f f i n g ; 2) an increase i n work load; and 3) fewer opportunities for communication. In addition, there was an a n t i c i p a t i o n that the plan of 'regionalization' might mean that the health care component of the P r o v i n c i a l Corrections Branch would be contracted out. Again, there was a sense of uncertainty i n the a i r . My presence at Health Care Centre was greatly welcomed by the health care professionals for one primary reason. That i s , they perceived me to be a resource for them, and t h e i r peer. They were aware that I was f a m i l i a r with many of the mentally i l l inmates, I was able to share information with them, they were able to consult with me for ideas on management issues such as discharge planning, community resources, etc., and I was able to spend time with the inmates when they were not able to do so. Whenever possible, they involved me i n t h e i r a c t i v i t i e s and they paved the way to make i t easier for me to conduct my research. The nursing o f f i c e i s located on the main f l o o r of the building. Adjacent to t h i s i s the medical examination room, both of which were quite enclosed, away from the rest of the a c t i v i t i e s of the f a c i l i t y . Contacts with the co r r e c t i o n a l - 72 -personnel were large l y l i m i t e d to a public announcement system, when inmates were escorted to and from the nursing o f f i c e , and when the nursing s t a f f was escorted through the various units to dispense medication. While there i s no physical separation of the health care professionals from t h e i r peers as there i s only one nursing o f f i c e , there i s a physical separation from the c o r r e c t i o n a l personnel and the inmates. A case i n point i s provided i n the following comment made by one of the health care professionals who p a r t i c i p a t e d i n t h i s study: "I don't work with the c o r r e c t i o n a l s t a f f . I have very l i t t l e dealings with them". An even more poignant example was an observation made by one p a r t i c i p a n t who was working i n the community with mentally i l l offenders at the time of the interviews: "The only attention people get i s when they have medication, or, i f they have a medical problem. Otherwise they don't get any attention at a l l " . Again, the distance turned into a psychological detachment, and the health care professionals, as a group, can be seen as insulated from the c o r r e c t i o n a l personnel and the mentally i l l inmates. In the process, they can become frustrated and withdraw into t h e i r framework of reference, the medical model. - 73 -For example: " A l l I do i s paper work, not patient care!"; "I'd love to spend more time t a l k i n g to these guys, but I have too much paper work to do"; and "I work i n a place that i s p h i l o s o p h i c a l l y against r e h a b i l i t a t i o n " . Frustrations turn into detachment and a sense of powerlessness. This i s i l l u s t r a t e d i n the following examples: "I was trained as a RN, not a p s y c h i a t r i c nurse...I don't know that st u f f very well. I only took one course i n psychiatry and that was a long time ago"; "I think the [correctional] s t a f f who deal with these guys on a day to day basis should get more t r a i n i n g . They don't have any and some of the ways they handle these guys are, are abysmal! I take the time to t e l l them sometimes, but i t ' s not my job"; "There's no s o c i a l work s t a f f unfortunately who could coordinate discharge planning and so many other things for the mentally i l l . . . T h e r e should be on-site s o c i a l workers whom I can l i a i s e with, help for housing and follow-up and s t u f f l i k e that"; "The impression I get i s that they [the mentally i l l ] are c h r o n i c a l l y neutral about everything....It's l i k e they are f i g h t i n g against t h i s condition that's a psychological vacuum that sucks a l l the l i f e out"; and "sometimes when I see the way they [correctional s t a f f ] handle them [mentally i l l inmates]...they treat them l i k e the other guys and they're not! And then they get upset because they don't respond the way they should". - 74 -The degree of estrangement and a l i e n a t i o n between the health care professionals and the cor r e c t i o n a l personnel was explored by a senior corr e c t i o n a l s t a f f member who par t i c i p a t e d i n t h i s study. He states: "As a general statement, yes, there are tensions between the cor r e c t i o n a l security o f f i c e r ' s view of how things should operate as compared to the nurses.... i t does take awhile to work through that understanding, and b a s i c a l l y the use of authority and power...Until he or she has made that accommodation to be able to use that authority well, there may be an acceleration or an increase of those kinds of tensions". Based on the information I have gathered, i t appears that the amount of formal t r a i n i n g the health care professionals have i n the area of psychiatry varies. For some, t h e i r t r a i n i n g took place on the job. Naturally, t h i s would lead to a varying degree of fears, f r u s t r a t i o n s , and s t r i c t adherence to the medical model. The opportunity to communicate and share information i s compromised by the demand and the burden of paper work, and i n turn, perpetuates the detachment, the i n s u l a t i o n , the sense of powerlessness, and the sense of a l i e n a t i o n already remarked upon. DISCUSSION In summary then, common threads of meaning were discovered between the three groups of participants - mentally i l l offenders, c o r r e c t i o n a l personnel, and health care professionals. Through the process of content analysis emerged - 75 -as a major theme ali e n a t i o n . Alienation i s characterized by estrangement, detachment, separation, withdrawal, distance, i n s u l a t i o n , and i s o l a t i o n . Although the causes, the p r e c i p i t a t i n g factors, and ultimately the solutions may vary, what i s important i s that the personal experiences and the process with which we deal with these experiences, are a l i k e for the three groups, and therefore can be presumed to support one another; i n other words, to reinforce the pathological processes already at work i n mental i l l n e s s . IMBLICATIOHS OF THE aLIEHATIOM FTHDIHG The above findings h i g h l i g h t some of the problems experienced by the mentally i l l offenders, the correc t i o n a l personnel, and the health care professionals who par t i c i p a t e d i n t h i s study. The implications with respect to program planning are many. (i) mentally i l l offenders Some of the problems mentally i l l offenders encounter p r i o r to, during, and subsequent to t h e i r term of imprisonment are s o c i a l i s o l a t i o n , homelessness, substance abuse, amotivation, denial of the i l l n e s s , the lack of vocational opportunities, the absence of meaningful interpersonal relationships, the i n a b i l i t y to obtain the required services, and the sense of powerlessness and ali e n a t i o n . - 76 -Any e f f o r t s to provide t h i s group with the opportunity to successfully re-integrate into the community and improve t h e i r q u a l i t y of l i f e would therefore seem to demand a vari e t y of programs. Some of them are: occupational therapy, pre-employment t r a i n i n g , work programs, job search, symptom awareness and management, resource awareness and access, l i f e s k i l l s , communications, substance abuse counselling (which incorporates the concept of dual diagnosis), interpersonal relationships, money management, recreation and le i s u r e development, assertiveness t r a i n i n g , and anger management, to name a few. Even more important however, i s that the programs must be designed: 1) to motivate; 2) to engage; and 3) to empower t h i s group rather than waiting for them to become motivated spontaneously. ( i i ) service providers Some of the problems the group of service providers encounter are: a geographical separation, the i n a b i l i t y to access information regarding the inmates, the lack of communication amongst peers, the lack of an i n t e r d i s c i p l i n a r y approach to patient care, the u n a v a i l a b i l i t y of adequate resources, the lack of knowledge base and t r a i n i n g , the sense of i s o l a t i o n , and the lack of organizational support. - 77 -E f f o r t s to f a c i l i t a t e the optimum use of the s t a f f expertise and the development of job s a t i s f a c t i o n must address these problem areas. For example, a redesign of the physical structure of the f a c i l i t y could promote the development of a therapeutic community. This would address the need for a central area that contains a l l the information regarding the inmates, i n t r a - and inter-professional communication, and a team approach where information can be shared. There must be both i n i t i a l o rientation and in-service t r a i n i n g that would address the following: the nature of mental i l l n e s s , how to i d e n t i f y and recognize the p o s i t i v e and negative symptoms of the major mental i l l n e s s e s and the various personality disorders, the unique needs of the mentally i l l , and how to work more e f f e c t i v e l y with t h i s group without compromising security. In addition, management may wish to consider adding a s o c i a l work p o s i t i o n to the organization. A s o c i a l worker would o f f e r s i g n i f i c a n t contributions i n the areas of release planning, program development and implementation, and the 'bridging' of the health care professionals and the c o r r e c t i o n a l personnel. F i n a l l y , for changes and program implementation to be successful, s t a f f members must have a sense of ownership. They must be viewed as an important resource and be involved and be consulted i n the process. Non-involvement c l e a r l y contributes to the feelings of helplessness and despair graphically described by the research p a r t i c i p a n t s . - 78 -I I . Organizational Commitment A second major finding that emerged from t h i s study for the researcher i s the evidence of a lack of organizational commitment i n providing services for the mentally i l l population within the c o r r e c t i o n a l health care s e t t i n g . Commitment, as defined i n the Webster's New Collegiate Dictionary, i s the state of being obligated and emotionally compelled to do something. I t i s the agreement and the engagement to assume a r e s p o n s i b i l i t y . I t contains two equally important dimensions. The w i l l and the act. As stated i n an e a r l i e r chapter (See Chapter 2), a number of programs were available during the time when the study was conducted. They included a work program, an alcoholics anonymous group, a s p i r i t u a l guidance program, a s o c i a l s k i l l s group, an alcohol and drug treatment group, and a research study of an intensive case management program from the community. E f f o r t s were made by the researcher to learn about the content as well as the 'mechanics' of these programs. The researcher attended some of the s o c i a l s k i l l s , and the alcohol and drug treatment groups. Informal interviews with the 'leaders' who were involved as well as formal interviews with the inmates who attended them were conducted. In addition, part of the informal and formal interviews with the - 79 -service providers focused on the d e s i r a b i l i t y and the v i a b i l i t y of these programs. What became evident from the informal interviews was that the 'leaders' of the groups were contractors from external agencies. The contract agreements with the P r o v i n c i a l Corrections Branch were intended for the whole Lower Mainland Regional Correctional Centre, the Health Care Centre notwithstanding. The 'leaders' were experienced i n working with offenders/inmates, not offenders or inmates with mental i l l n e s s . Informal interviews with the service providers, indicated to the researcher that there was very l i t t l e awareness of these programs. This i s demonstrated by the part i c i p a n t s ' lack of knowledge of the groups' existence, t h e i r lack of knowledge of when they occur, and t h e i r lack of knowledge as to which inmates were attending. Furthermore, i t was a consensus that although these programs might be useful for the inmates, they could only accommodate the inmates' p a r t i c i p a t i o n providing there were enough s t a f f members available to ensure security. The following observation, made by a health care professional who p a r t i c i p a t e d i n the study, summarizes the r e a l i t y of program design and implementation within the Health Care Centre quite accurately. He states: - 80 -"every now and then, I think they have had programs...they seem to be sporadic, no one i s quite sure when i t ' s gonna happen or i f they happen. They seem to happen for a month or two and then they stop, and then they happen again a couple months l a t e r . I assume that that's because they contract these jobs out. T h e y ' l l work for awhile, and then t h e i r contract would run out. Then they'd s t a r t out again. Someone else w i l l s t a r t another one. There doesn't seem to be any sustained program, and the people are s i t t i n g there doing time, hour afte r hour, with very l i t t l e to do". To be f a i r , interviews with the mentally i l l inmates revealed a r e l a t i v e l y p o s i t i v e attitude and response towards these programs. They can be summarized by the following comments: "I was glad to know that people care, and that other people had the same problems. Actually, I looked forward to going...I wish i t was longer. I think they should have more of that, more programs l i k e that"; and "We need more programs to help us. Here's a l o t of people who are i n a l o t of trouble that want to get straightened out. They just need some help. I t ' l l get the time go by faster too". The discrepancy between the lack of sustained programs and the expressed i n t e r e s t i n p a r t i c i p a t i n g i n programs by the mentally i l l offenders can be better understood i n the context of the following comments made by a senior c o r r e c t i o n a l o f f i c i a l and a senior health care professional, both of whom part i c i p a t e d i n the study. They are as follows: - 81 -"The j a i l environment, over the l a s t years, have not been program development or attempting to tr e a t . So providing the structure program that has treatment as one of the goals, Corrections just hasn't been conducive to t h a t " [ s i c ] ; "Corrections do not see themselves as a hos p i t a l treating p s y c h i a t r i c patients. So, to say I want to design some sort of treatment program for ps y c h i a t r i c patients, I think, runs contrary to what they see themselves as"; and "I think i t i s ph i l o s o p h i c a l l y an issue. It's either a prison or i t ' s a hospital....1 mean, we can get into a whole personal view of r e h a b i l i t a t i o n to begin with. I mean, I think i t costs us thousands of d o l l a r s more than i t should because we don't properly t r a i n people. I don't see why we can't t r a i n people. They s i t i n t h e i r c e l l s twenty three hours at a time, doing nothing. I t doesn't make any sense, i t ' s r i d i c u l o u s . . . So, i f you're not gonna t r a i n them, i f you're not gonna tr e a t them, i f you're not gonna help them with job finding or anything l i k e that, i t ' s so simple i n i t s concept! There're so many people I see who can benefit so much from some type of job program, some job search, that they can benefit from or look forward to when they get out. Not everyone i n prison i s hopeless. Not i n our eyes anyways. I work i n a place that i s ph i l o s o p h i c a l l y against r e h a b i l i t a t i o n " . In summary then, the Health Care Centre of the Lower Mainland Regional Correctional Centre d i d o f f e r some programs to t h e i r inmates. However, these programs were not an i n t e g r a l part of the f a c i l i t y , nor were they designed s p e c i f i c a l l y for the mentally i l l population. Although they were found to be useful and were appreciated by the mentally i l l inmates, the - 82 -'ad hoc 1 nature of the programs raised some very important issues for the researcher. The primary one was how the way such programs are implemented plays a role i n fostering the pervasive sense of al i e n a t i o n expressed by the various participants of the study. Also, the o r g a n i z a t i o n a l commitment to the act of providing services that are sensitive to the needs of the mentally i l l i s c l e a r l y unsystematic, haphazard, and vulnerable. DiscassiQH A l l formal organizations such as the B.C. Corrections Branch, are guided by t h e i r mission statements. The mission statement indicates the guiding philosophy or superordinate goal and conveys the organization's o v e r a l l purposes. I t provides a framework that lends "continuity to the organization over time by serving as a f o c a l point for strategy formulation and the application of i n d i v i d u a l and group work e f f o r t s " (Schermerhorn, 1984, p.150). In t h e i r B e l i e f s , Goals, and Strategies publication (Queen's Printer, revised 1986), the B.C. Corrections Branch i d e n t i f i e s one of i t s primary mandates as: t o c a r r y out the sentences imposed by t h e c o u r t s . I t i s stated that sentences are based on f i v e p r i n c i p l e s . They are: r e t r i b u t i o n , r e h a b i l i t a t i o n , deterrence, incapacitation, and reparation. For the purposes of t h i s paper, the following discussion w i l l focus on the p r i n c i p l e of r e h a b i l i t a t i o n only. - 83 -As stated i n t h e i r document, one of the mandates of B.C. Corrections Branch i s to provide sentenced offenders: "reasonable opportunity for p o s i t i v e and constructive a c t i v i t i e s within operational and resource l i m i t a t i o n s and consideration for the protection of the public... c o r r e c t i o n a l programs [should] provide opportunities for work, s o c i a l , educational, and recreational a c t i v i t i e s and s p i r i t u a l development. Offenders are encouraged to take advantage of these opportunities....When offenders admitted to co r r e c t i o n a l programs require treatment for medical, physical, or psychological problems, the branch provides appropriate treatment or makes community health resources available to them. Although r e h a b i l i t a t i o n does occur within c o r r e c t i o n a l programs, the programs alone cannot r e h a b i l i t a t e offenders. While programs can encourage behavioral change, rehabi l i tat ion i s the responsibi l i ty of offenders themselves"(my emphasis)(pp.5-6). Opportunity, as defined i n the Li v i n g Webster Encyclopedic Dictionary, i s a convenient or favorable p o s i t i o n or chance. Chance i s defined as an event occurring without apparent cause or control; a purposeless cause of unexpected happenings; a possible or probable occurrence. According to Cormier (1989), the demise of the r e h a b i l i t a t i o n concept within c o r r e c t i o n a l services was sparked by the infamous paper written by Robert Martinson i n 1974 t i t l e d Nothing Works 1 The t i t l e of t h i s a r t i c l e speaks for i t s e l f . Although t h i s was an American publication, i t s influence on the Canadian Correctional system was profound. - 84 -Thus, Cormier states: " I r o n i c a l l y , Martinson's controversial a r t i c l e appeared at a time when r e h a b i l i t a t i o n was beginning to occupy a stronger p o s i t i o n i n the Canadian Penitentiary Service" (Cormier, 1989, p.7). By 1977, the Canadian Federal Corrections Agency Task Force recommended that the ' r e h a b i l i t a t i o n model' be replaced by the 'opportunities model'. That i s , the c o r r e c t i o n a l system would "provide c o r r e c t i o n a l opportunities designed to a s s i s t the offender i n the development of d a i l y l i v i n g s k i l l s , confidence to cope with his personal problems and s o c i a l environment and the capacity to adopt more acceptable conduct norms" (Ibid, p.30). The B.C. Corrections Branch maintains that t h e i r program, po l i c y , procedures, and services rendered are guided by a set of values and b e l i e f s . Included i n t h e i r set of b e l i e f s i s the provision of "opportunities for inmate work, education, recreation, l i f e - s k i l l s and s p i r i t u a l development that a) encourage responsible personal, decision-making; and b) contribute p o s i t i v e l y to the individual's q u a l i t y of l i f e , to the branch, and to the community" (p.10). Furthermore, i t i s responsible for the assurance of the " a v a i l a b i l i t y of medical, dental, and p s y c h i a t r i c services comparable to those generally available to the public" (my emphasis) (Ibid). - 85 -Es s e n t i a l l y , the disenchantment with the r e h a b i l i t a t i o n model had led to a s h i f t i n the goals of our p r o v i n c i a l c o r r e c t i o n a l services. Emphasis i s p l a c e d on the p e r s o n a l i n i t i a t i v e of i n d i v i d u a l inmates t o take advantage o f the o p p o r t u n i t i e s made a v a i l a b l e t o them. As observed by several participants of t h i s study, program development for mentally i l l offenders has not been a p r i o r i t y within the P r o v i n c i a l Corrections Branch during the past decade or more. Other contributing factors such as: the f i s c a l constraints; the heterogeneity of the inmate population; the nature of mental i l l n e s s i t s e l f ; and the sentiment that mentally i l l individuals do not belong i n the cor r e c t i o n a l system; a l l play an active role i n discouraging the provision of p s y c h i a t r i c services to mentally i l l offenders. Together, a l l these factors translate into the introduction of sporadic, time-limited programs managed by outside contractors who may or may not be f u l l y oriented to the needs of mentally i l l offenders. When the ex i s t i n g s t a f f members who interact with the mentally i l l offender the most are not provided with the necessary t r a i n i n g , are not involved and are not consulted i n program development and implementation, the p o s s i b i l i t y of developing a therapeutic milieu i s precluded. When programs implemented by outside contractors are not reviewed and evaluated for t h e i r relevancy, and e f f i c a c y , the - 86 -contractors are not held accountable. There are no safeguards i n place to ensure that the contractors d e l i v e r t h e i r services e t h i c a l l y . Furthermore, time-limited contracts do not command commitment on the part of the contractors. When programs are unavailable, inaccessible, and/or non-accountable, one i s l e f t with the sense that the Correctional Services have taken a clear departure from the 'opportunities model' to an 'on the off-chance model', where mentally i l l offenders have very s l i g h t hope of even taking advantage of substandard programs that are haphazardly structured and implemented. To imply that these services are comparable to those available to the general public i s rather alarming. m P L I C M I O H S OF THE QRGAMXZATXCnMAT. e X I M M X T J M K B F T FJJMUJLMO Given that the 'opportunities model' i s the stated predominant guiding philosophy of the B.C. Corrections Branch, the following section w i l l examine how t h i s model i s applied at the Health Care Centre of the Lower Mainland Regional Correctional Centre, with s p e c i f i c focus on i t s application to the mentally i l l population. To begin with, i t could be said that the mentally i l l offender has the o p p o r t u n i t y to be placed i n the Health Care Centre while serving the duration of the sentence. This, - 87 -however, depends on whether there i s a bed space available. A v a i l a b i l i t y i s dependent on the number of inmates from the general population who may require medical attention, the l e v e l of functioning of the other mentally i l l offenders, and the criminal j u s t i c e h i s t o r y of the i n d i v i d u a l . Secondly, the mentally i l l offender has the opportunity to obtain psychopharmacological treatment on a voluntary basis. However, i f he becomes f l o r i d l y psychotic, delusional, paranoid, and i s unable or unwilling to consent to treatment, he w i l l remain dangerous to s e l f and/or others without the benefit of medical intervention u n t i l transferred to a p s y c h i a t r i c f a c i l i t y such as the Forensic Psychiatric I n s t i t u t e . Meanwhile, the mentally i l l offender has the opportunity to be subjected to the humiliation of open scrutiny by the fellow inmates, s t a f f , and v i s i t o r s of the Health Care Centre. I t should be noted here that the inmate at t h i s time i s usually semi-naked, p a r t i a l l y shackled, and engaging i n 'creative' a c t i v i t i e s such as smearing feces on the wall. For the quiet psychotics, or the passively withdrawn i n d i v i d u a l who i s c l i n i c a l l y depressed, there i s the opportunity to experience the lonely disease or dysphoria i n i s o l a t i o n . These indivi d u a l s have the opportunity to be vulnerable to abuse and be preyed upon by other inmates. This - 88 -group i s e a s i l y overlooked since they are non-disruptive; unless they attempt suicide, of course. For the mentally i l l offender who i s either s t a b i l i z e d on medication or whose mental i l l n e s s i s i n remission, there i s the opportunity to see the psychologist for at least a "three minute conversation", or t a l k to the nursing s t a f f as long as the s t a f f member does not "have too much paper work to do". The mentally i l l offender also has the opportunity to take advantage of u t i l i z i n g the co r r e c t i o n a l s t a f f members as a resource to take personal r e s p o n s i b i l i t y for his r e h a b i l i t a t i o n . This i s possibly therapeutic and encouraging for the mentally i l l offender. That i s , the opportunity to f i n d out that the only resource person that i s available to a s s i s t him i n set t i n g up linkages with the community knows as much, or l e s s , than he does. This group also has the opportunity to take advantage of the 'work program' providing that there are positions u n f i l l e d by the non-mentally i l l offenders, and the i n d i v i d u a l i s not a 'security concern', and has some basic s k i l l s . Mentally i l l offenders who do not have the necessary experience have the opportunity to seek asylum i n t h e i r c e l l s and eat, sleep, and look forward to returning to the community with less confidence i n t h e i r a b i l i t i e s to survive, and wait. - 89 -As a l l sentenced inmates of the p r o v i n c i a l c o r r e c t i o n a l system receive a determinate sentence, a l l inmates have the opportunity to leave without completing the programs they may be involved i n . Furthermore, they have the opportunity to leave the f a c i l i t y , for example, on a long weekend, and have no sense of how they can obtain basic food and lodgings when most of the services are not available, or "what happens ten minutes l a t e r " . Unlike the patients i n a p s y c h i a t r i c f a c i l i t y , mentally i l l offenders have the opportunity not to remain i n the Health Care Centre v o l u n t a r i l y , or completing the programs on an out-patient basis. Instead, mentally i l l offenders have the opportunity to return to the community more i l l prepared, and without the benefit of 'release planning'. SUMMARY The basic premise of the 'opportunities model' i s that the inmates are r a t i o n a l and purposeful beings who only require minimal encouragement to take advantage of the available services, and take personal r e s p o n s i b i l i t y for t h e i r r e h a b i l i t a t i o n . This model does not apply well to the needs of an inmate who may be p s y c h i a t r i c a l l y impaired, with possible cognitive and s o c i a l d e f i c i t s . In f a c t , i t neglects some very important features of t h e i r i l l n e s s . The r e a l i t y i s , many of our chronic mentally i l l patients lack the personal capacity and s o c i a l competence to seek out or i n i t i a t e interpersonal contacts. Their impoverishment leads to l i m i t e d behavioral - 90 -repertoires, s o c i a l i s o l a t i o n and withdrawal, and f i n a l l y the exacerbation of p s y c h i a t r i c symptoms. One can only surmise that, l e f t to t h e i r own devices, mentally i l l offenders are unable to thri v e or f l o u r i s h under the 'opportunities model'. Programs that do not emphasize consistency, continuity, e f f i c a c y , a v a i l a b i l i t y , and a c c e s s i b i l i t y are not opportunities. At least not for the chronic mentally i l l population. I I I . Where Do They Belong? A t h i r d theme that emerged from t h i s study for the researcher i s the question of whether mentally i l l i n d i v i d u a l s belong i n the c o r r e c t i o n a l f a c i l i t y . Belong, as defined i n the Webster's New Collegiate Dictionary, i s to be suitable, appropriate, or advantageous. Although t h i s research study's intent was to explore the experiences of mentally i l l offenders and t h e i r service providers within the Health Care Centre of the Lower Mainland Regional Correctional Centre, the issue of whether t h i s group belongs i n t h i s f a c i l i t y at a l l was raised by several of the participants of the study. In other words, i s the c o r r e c t i o n a l f a c i l i t y an advantageous, or suitable or an appropriate place for the mentally i l l ? - 91 -(i) mentally i l l offenders Consistent with the e a r l i e r findings, the mentally i l l offenders who participated i n t h i s study were rather i n d i f f e r e n t to the milieu they found themselves i n . Their p a s s i v i t y can be i n part attributed to the nature of t h e i r i l l n e s s and t h e i r preference to be associated with the criminal subculture rather than with the stigma of being p s y c h i a t r i c a l l y impaired. Furthermore, some f e l t that i t was preferable to be serving a d e f i n i t e sentence instead of an indeterminate period of h o s p i t a l i z a t i o n . This i s because detention i n a hos p i t a l for some, was perceived to be ar b i t r a r y , a decision that i s dependent on t h e i r progress or l e v e l of functioning. As one participant stated: "I prefer Oakalla because you know when you're gonna get out". ( i i ) c o r r e c t i o n a l personnel According to one of the parti c i p a n t s , i n d i v i d u a l s with mental i l l n e s s e s "do not belong" i n a cor r e c t i o n a l setting as they present a r i s k to the s t a f f members. This view i s evidently further supported by one of his peer who made the following comment: "These guys don't belong here, but they keep coming back!" - 92 -However, t h i s sentiment was not shared by a l l . A community health care professional who p a r t i c i p a t e d i n t h i s study made the following observation: "Every now and then you run into a guard who seems r e a l l y t i r e d and worn out, and seems to think that they r e a l l y shouldn't be dealing with these people, and i f only mental health would do t h e i r job, then they wouldn't have to. But most of these guys I've run into have pretty well resigned to the f a c t that they have these guys there that are mentally i l l who are t h e i r r e s p o n s i b i l i t y and they just want to know more about i t " . ( i i i ) health care professionals Most of the health care professionals who p a r t i c i p a t e d i n t h i s study accepted the f a c t that there i s an increasing number of mentally i l l individuals who are being housed i n the corre c t i o n a l f a c i l i t y . The issue of whether t h i s i s advantageous, suitable or appropriate was not raised. For the most part, pragmatism p r e v a i l s , a l b e i t with some discomfort. This group tends to focus on providing the best possible care within the confines of the limited resource. However, the f r u s t r a t i o n of having mentally i l l indiv i d u a l s i n the co r r e c t i o n a l system was a r t i c u l a t e d by a senior health care professional who p a r t i c i p a t e d i n t h i s study. He states: "Somehow, the system has broken down v i a the Criminal Code...if someone i s arrested by the p o l i c e or arresting personnel, either friends or family who suggest that something i s wrong with them mentally, they're to have a p s y c h i a t r i c examination. They should go - 93 -before the court so that a judge can decide whether or not the person may be mentally i l l and should be remanded for t h i r t y days at a p s y c h i a t r i c f a c i l i t y l i k e FPI. Well sometimes that process doesn't happen! And so, the patient who i s mentally i l l , probably not even competent to i n s t r u c t counsel, has a duty counsel who doesn't even know them, ends up i n the system, sort of crazy out of t h e i r mind. They go there to Oakalla. I'm sure a l o t of cases are missed i n the system. So the whole system, the whole Criminal Code, the whole thing doesn't work! And then, there are those who are remanded, i n custody, who are mentally i l l , awaiting for t r i a l , same thing!...I don't think prison i s a place for psychotic patients. And I think i t ' s r i d i c u l o u s that they are there. I t ' s not f a i r to them, not f a i r to the s t a f f . They should be treated i n a h o s p i t a l , an appropriate h o s p i t a l , not prison....Most of them who are psychotic probably should be found Not Guil t y By Reason of Insanity anyways. Or they should have a d i f f e r e n t kind of sentence, or should be diverted....Why they end up there, with lengthy sentences, being c h r o n i c a l l y i l l , i s a f a i l u r e of the system. Part of the problem i s that some of these people don't want to be found NGRI...Now, the new Criminal Code i s gonna change that. You're gonna get a determinate sentence even i f you're found NGRI...It would be d i f f e r e n t . I t may pick up some of them. At least maybe some of the defence counsel w i l l use i t a b i t more....But i t ' s a philosophical thing, the major mental i l l n e s s e s , as far as I'm concerned has no place i n prison....But ri g h t now, what's even worse, FPI i s jammed to the r a f t e r s . I have very sick patients. I t ' s l i k e a patient with an acute abdominal problem who cannot go to the ho s p i t a l for surgery. I've got these patients who are psychotic, who hears voices, delusional, who are out of t h e i r minds, c e r t i f i e d and s i t t i n g i n Oakalla and I can't treat them 'cos I don't have a mental health f a c i l i t y . Some of them i t ' s OK to treat them, but a l o t of them can't give consent to treatment, and I've got nowhere to put them. So they stay there. I t ' s criminal!...I need ho s p i t a l beds!" - 94 -In summary then, the issue of whether the cor r e c t i o n a l f a c i l i t y i s an advantageous, suitable, or appropriate place for the mentally i l l was met with a vari e t y of responses. The mentally i l l group for the most part, was i n d i f f e r e n t although they did voice some preference for the ' f i n i t e ' nature of the cor r e c t i o n a l system. In view of the e a r l i e r findings, i t i s un l i k e l y that t h i s group f e e l s that they belong anywhere. While some of the service providers who pa r t i c i p a t e d i n t h i s study passively accepted the existence of the mentally i l l i n dividuals i n a cor r e c t i o n a l f a c i l i t y , t h e i r comments indicate that they accept them begrudgingly. F i n a l l y , some of the service providers, both co r r e c t i o n a l personnel and health care professionals, f e l t very strongly that the mentally i l l do not belong i n a cor r e c t i o n a l f a c i l i t y . Their reasons for t h i s , however, d i f f e r . For some of the co r r e c t i o n a l personnel, the mentally i l l evoke fear and f r u s t r a t i o n s , as i l l u s t r a t e d i n the previous findings. Like a l l of us, i t i s easier to r e j e c t what threatens us. With respect to the health care professionals, t h e i r convictions are founded on a set of philosophical b e l i e f s . They can be summarized as follows: 1) the b e l i e f that i n d i v i d u a l s with mental i l l n e s s e s should receive the best available medical treatment; 2) the b e l i e f that an i n d i v i d u a l who i s not able to f u l l y appreciate the nature of h i s or her a c t ( s ) , or the omission of, as a r e s u l t of a mental i l l n e s s should receive treatment rather than punishment; and - 95 -3) the b e l i e f that indiv i d u a l s with mental i l l n e s s e s should receive humane care. D I S C D S S I O M The f a c t that each of the above mentioned b e l i e f s are formally endorsed at a p o l i c y l e v e l either i n the Criminal Code of Canada, or i n the D e i n s t i t u t i o n a l i z a t i o n p o l i c y of the Mental Health System, raises three important questions. They are: 1) Why i s there a noticeable increase of arrest rates among the mentally i l l population?; 2) Why are individuals with major mental i l l n e s s e s sentenced to a c o r r e c t i o n a l f a c i l i t y instead of a designated p s y c h i a t r i c f a c i l i t y where they can receive the necessary, suitable, and appropriate medical treatment?; and 3) Which system should be i s responsible for t h i s group? To begin with, there are no s p e c i f i c formal documents regarding the change i n arrest rates of mentally i l l individuals available at t h i s time. At least none that would meet the r i g o r of s c i e n t i f i c research. Having sai d that, there i s ample information i n the l i t e r a t u r e , as reviewed i n an e a r l i e r chapter, that discusses the phenomenon of the - 96 -cri m i n a l i z a t i o n of the mentally i l l , suggesting that there i s an increase i n the number of mentally i l l i n d i v i d u a l s who are i n the criminal j u s t i c e system. A possible inference one could draw from t h i s observation i s that p s y c h i a t r i c a l l y impaired indivi d u a l s are simply engaging i n more criminal a c t i v i t i e s . However, a more compelling explanation i s one that i s supported by many experts i n the f i e l d . That i s , the increase i n the arrest rates of mentally i l l i n d i v i d u a l s i s a d i r e c t r e s u l t of a poorly implemented s o c i a l p o l i c y , D e i n s t i t u t i o n a l i z a t i o n . Furthermore, the provisions within our Criminal Code lend support to t h i s c r i m i n a l i z a t i o n process. IMPLICaTiaNS O F T H E F I M D I H G OH T H E TJUCUMGHUKNCIES B E T W E E N S T A T E D S O C I A L P O L I C I E S AMD ACTUM. P R A C T I C E S Whether one argues that the d e i n s t i t u t i o n a l i z a t i o n p o l i c y of p s y c h i a t r i c patients was founded on naive idealism or calculated f i s c a l pragmatism, the r e a l i t y remains that there i s a large body of i l l - p r e p a r e d p s y c h i a t r i c patients residing i n the community. Many of these 'ex-patients' are unable to care for themselves, unable or unwilling to seek treatment, unable to access the necessary services and support, and are engaging i n s o c i a l l y inappropriate behaviors more noticeably. The community i s becoming increasingly intolerant of t h i s group and i s demanding po l i c e intervention. As Progrebin and Poole (1987) note: "Police departments have become the most u t i l i z e d agencies for p s y c h i a t r i c r e f e r r a l i n our society" (p.119). - 97 -Consistent with the D e i n s t i t u t i o n a l i z a t i o n p o l i c y , admission to the l o c a l or p r o v i n c i a l p s y c h i a t r i c f a c i l i t i e s i s often d i f f i c u l t , cumbersome, and time-consuming. Police o f f i c i a l s are often discouraged by t h i s process, e s p e c i a l l y when t h e i r judgements are disputed by p s y c h i a t r i c c l i n i c i a n s . (Borzecki and Wormith, 1985) Consequently, p o l i c e o f f i c i a l s ' often f e e l t h e i r only recourse i s to lay criminal charges and remove the mentally i l l i n d i v i d u a l s from the community by placing them i n the l o c a l j a i l . I t i s assumed that the 'system' i n place would address the needs of the mentally i l l i n d i v i d u a l . However, as Lang (1986) points out i n her a r t i c l e The F o l l y of Fitness: "Paradoxically, a doctrine which ostensibly exists for the protection of the mentally disordered accused often works to h i s disadvantage" (p.221). The current provisions within the Criminal Code are also fraught with problems. For the purposes of t h i s discussion, the focus w i l l be on how i t e f f e c t s mentally i l l i n d i v i d u a l s who are accused for committing non-capital offences. B a s i c a l l y , the ' i n d e f i n i t e ' nature of the d i s p o s i t i o n i f the accused i s found not g u i l t y by reason of insanity and/or u n f i t to stand t r i a l i s perceived to be excessive, a r b i t r a r y , and unfair. Widely publi c i z e d horror s t o r i e s such as the 'purse snatcher' who was found Not G u i l t y By Reason Of Insanity and had been 'incarcerated' i n the backwards of a p s y c h i a t r i c f a c i l i t y for twenty years, generate great reluctance on the - 98 -part of the accused to raise the issue of whether he or she was suffering from a mental disorder at the time of the offence so as to be exempt from criminal r e s p o n s i b i l i t y . Equal reluctance has probably been generated by the story of an i n d i v i d u a l charged with a breaking and entering offence, was found u n f i t to stand t r i a l and was subsequently detained for three years before being returned to the court when i t was determined that there was not s u f f i c i e n t admissible evidence to even place him on t r i a l . Such s t o r i e s serve to deter accused persons from r a i s i n g the issue of whether they were suf f e r i n g from a mental disorder. In b r i e f , the fear that one could be detained for a period of time that far exceeds the stated maximum possible sentence encourages the mentally i l l accused to avoid Section 16 of the Criminal Code even though i t was designed to protect them from criminal r e s p o n s i b i l i t y . Instead, the mentally i l l i n d i v i d u a l may prefer to be t r i e d and found g u i l t y and sentenced to a cor r e c t i o n a l f a c i l i t y . There can be many disadvantages for the mentally i l l i n d i v i d u a l who i s diverted into the criminal j u s t i c e system. The primary one i s the lack of opportunity for access to the appropriate and necessary treatment. Also, the l a b e l 'mentally i l l offender' weighs heavily against the i n d i v i d u a l , and access to mental health and s o c i a l services becomes increasingly d i f f i c u l t . The mentally i l l i n d i v i d u a l i s then l e f t a l l the more vulnerable, which i n turn perpetuates the c r i m i n a l i z a t i o n process. - 99 -Understandably, the juxtaposition of law and psychiatry has received much c r i t i c i s m - both i n i t s philosophical and p r a c t i c a l implications. Depending on one's philosophical b e l i e f s , one could argue that a l l individ u a l s who are p s y c h i a t r i c a l l y impaired should not be processed through the criminal j u s t i c e system. Instead, they should be hos p i t a l i z e d where they can receive medical treatment. Others could argue that a l l individuals who behave ' i l l e g a l l y ' should be incarcerated and receive the same opportunities as a l l inmates regardless of th e i r p s y c h i a t r i c impairment. Common sense t e l l s us that the best solution can be found i n the balance of the two extreme b e l i e f s . I t would appear that a reasonable and responsible solution must include the protection of the public and the provision of treatment and humane care for the mentally i l l . The d e b i l i t a t i n g e f f e c t s of incarceration have been well documented. Incarceration without any r e a l opportunity for s k i l l s development has no therapeutic value; but rather, i t impedes the po t e n t i a l for successful community reintegration. Part of the problem l i e s i n the fac t that c i v i l l i b e r t a r i a n s and defence counsel frequently prefer a term of imprisonment on behalf of th e i r c l i e n t s rather than demanding responsible and appropriate treatment for t h e i r mentally i l l c l i e n t s . When one examines the experiences of mentally i l l - 100 -offenders - which include the revolving door syndrome, t r a n s - i n s t i t u t i o n a l i z a t i o n , homelessness, and psychosocial impoverishment - i t i s evident that t h i s group i s not receiving the treatment and support that meet t h e i r needs. Individuals with mental i l l n e s s e s should have a r i g h t to treatment. Without such treatment they w i l l remain disconnected and alienated. We can a l l be part of the solution. A responsible, humane, and e t h i c a l society requires that we assume personal r e s p o n s i b i l i t y as well as demand a c o l l e c t i v e r e s p o n s i b i l i t y and accountability. After a l l , the most important sign of c i v i l i t y i s how a society treats i t s marginal members. SUMMARY AMD COMCI.13DXBW3 COHMEHT This paper began by presenting a b r i e f review of the hi s t o r y of the North American mental health system that led to the current community mental health movement and i t s D e i n s t i t u t i o n a l i z a t i o n p o l i c y . For many of our mentally i l l patients, d e i n s t i t u t i o n a l i z a t i o n meant the additional burden of coping with socio-economical impoverishment and the lack of asylum. The c r i m i n a l i z a t i o n of the mentally i l l has been i d e n t i f i e d as a d i s t i n c t problem that i s worthy of recognition. A study was undertaken by the researcher to look at the experiences of mentally i l l offenders and t h e i r service - 101 -providers. I t was motivated by the i n t e r e s t to i d e n t i f y service and program needs for t h i s s p e c i f i c group within a corr e c t i o n a l s e t t i n g . I t was determined that a q u a l i t a t i v e research design would be most appropriate to achieve t h i s goal. Three primary themes emerged from the findings. They are: ali e n a t i o n , lack of organizational commitment, and the incongruencies between the stated s o c i a l p o l i c i e s and actual practices. E f f o r t s were made by the researcher to understand the ori g i n s of these three themes and analysis of them led the researcher to conclude that the problems are inter-dependent. Although some concrete alternatives were presented, the hesitancy to make s p e c i f i c program recommendations stems from the fear that the central issue may get l o s t i n the process. Information on programs that are sensi t i v e to the varying needs of the mentally i l l are r e a d i l y available. I t i s not necessary to re-invent the wheel. During the past few years, a number of individ u a l s within our l o c a l agencies and organizations have worked i n collaboration with each other to develop s p e c i f i c programs for mentally i l l offenders - both i n the community and i n the various i n s t i t u t i o n s . (See Appendix G) In addition, d i s t i n c t e f f o r t s are being made i n the reform of the P r o v i n c i a l Mental Health Services, the B.C. Mental Health Act, and the Criminal - 102 -Code of Canada. A l l i n response to the i d e n t i f i e d problems experienced by the chronic mentally i l l population. While these i n i t i a t i v e s appear encouraging, the e f f e c t of these programs and the anticipated p o l i c y changes would be highly dependent on the actual commitment of our p o l i c y makers. Individual excellence can only endure i f there i s e x p l i c i t p o l i t i c a l w i l l and active organizational support. Of utmost importance, r e a l l y , i s that i n our pursuit for solutions, we are not seduced by 'quick f i x e s ' . I t would appear that what i s lacking i s a common v i s i o n . A v i s i o n that i s based on the fundamental values of human digni t y , mutual respect, and active partnership. A v i s i o n that would give society the courage to put an end to the abandonment of our mentally i l l . Very obviously, a v i s i o n without action i s nothing more than an academic exercise. What i s required i s for p o l i c y makers and service providers to engage i n continuous, open and v i g i l a n t consultative processes to strengthen collaborative e f f o r t s . In conjunction, concrete actions with a c r i t i c a l evaluative component must be undertaken. After a l l , we are a l l responsible. - 103 -FOOTNOTES For example, see Hobbs, (1964); Foucalt, (1965); S c u l l , (1977); and Grob, (1983). Province of B r i t i s h Columbia, Ministry of Health, Mental Health Branch, Annual Report, 1967-1968. Queen's Pri n t e r : V i c t o r i a . The Mentally 111 Disordered Offender. May, 1987. Conference Sponsored by Simon Fraser University, Forensic Psychiatric Services, B.C. Corrections, and Mental Health Services. Vancouver, B.C. Ibid. An exploratory study was conducted by the researcher as part of a course requirement of the S o c i a l Work 551 i n the Spring of 1989. As a r e s u l t of t h i s study, one of the recommendations i n the student paper was to include non-incarcerated mentally i l l offenders, and service providers who are not employed at the said f a c i l i t y . "This would bring i n relevant data that would either confirm the i d e n t i f i e d themes and/or allow the emergence of d i f f e r e n t r e a l i t i e s from the perspectives of other key actors. In p a r t i c u l a r , i s the retrospective data of non-incarcerated mentally i l l offenders, and how t h e i r past experiences of incarceration impact on t h e i r current experiences, and what they perceive as perhaps b e n e f i c i a l now. The i n c l u s i o n of a varied sample d i s t r i b u t i o n would provide a riche r perspective for the understanding of the service needs for mentally i l l offenders" (p.48). Axis I of the DSM-III-R consists of major mental i l l n e s s e s such as schizophrenia, a f f e c t i v e disorders, organic brain syndromes, etc. Axis II of the DSM-III-R consists of personality disorders such as a n t i s o c i a l , borderline, schizoid, h i s t r i o n i c , passive aggressive, etc. - 104 -B I B L I O G R A P H Y Abramsom, M.F. (1972). The Criminalization of Mentally Disordered Behavior: Possible Side-Effect of a New Mental Health Law. Hospital & Community Psychiatry. Vol. 23, #4, pp. 13-17. A l l o d i , F.A., Kedward, H.B. (1973). 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Conference Sponsored by Simon Fraser University, Forensic Psychiatric Services, Corrections, & Mental Health Services. Vancouver, B.C. - 112 -The Mentally 111 Offender: Who i s Responsible? November, 1987. 5th Annual Conference of the Washington Council on Crime & Delinquency & Community Action for the Mentally 111 Offender. Seattle, Washington, U.S.A. Tien, G. & Goresky, W. D e i n s t i t u t i o n a l i z a t i o n and the B r i t i s h Columbia Mental Health I n i t i a t i v e . Unpublished. Weller, M.P.I. (1986). Does the Community Care? Public  Health. #100, pp. 76-83. Whitmer, G.E. (1980). From Hospitals to J a i l s : The Fate of Ca l i f o r n i a ' s D e i n s t i t u t i o n a l i z e d Mentally 111. American  Journal Orthopsychiatry. Vol. 50, #1, pp. 65-75. Wilson, D.A. & Buckley, L.R. An Assertive Case Management Programme for Mentally Disordered Offenders: The Inter-M i n i s t e r i a l Project. Unpublished. Zald, M.N. (1962). Power Balance & Staff C o n f l i c t i n Correctional I n s t i t u t i o n s . Administrative Science Quarterly. Vol. 6, pp. 22-49. - 113 -A P P E N D I X A Y O U N G A D U L T C H R O N I C P A T I E N T S The Young Adult Chronic Patient Population has been i d e n t i f i e d as individuals between 18 and 35 who have "spent r e l a t i v e l y l i t t l e time i n hospitals but who present persistent and f r u s t r a t i n g problems to community caregivers...who are p s y c h i a t r i c a l l y and s o c i a l l y impaired, so seriously that they are continually or recurrently c l i e n t s of mental health and other s o c i a l service agencies over a period of years" (Lamb, 1981, p. 463). This group c a r r i e s a vari e t y of labels: schizophrenia, a f f e c t i v e disorder, behavior disorder, personality disorder, substance abuser, attention d e f i c i t disorder, mental retardation, learning d i s a b i l i t y , organic brain syndrome, etc. Regardless of t h e i r c l i n i c a l differences, the one main commonality that t h i s group shares i s that "from the onset of t h e i r illness...[they]...have been treated during the era of d e i n s t i t u t i o n a l i z a t i o n " (Caton, 1981, p. 475). This group i s s o c i a l l y i s o l a t e d , transient, homeless, disengaged, impulsive, victimized, and perpetrators of crime. They are characterized by "assaultive behavior, severe overt psychopathology, lack of i n t e r n a l controls, reluctance to take psychotropic medications, problems with drugs and alcohol i n addition to t h e i r psychoses and i n some cases s e l f destructive behavior" (Lamb, 1982, pp. 466-467). According to Finlayson et - 114 -a l (1984) t h i s group are "involved i n i n i t i a l p o l ice occurrences four times more often than the general population, a d d i t i o n a l l y , most had multiple reported contacts with p o l i c e " (p.638). For the young adult chronic patient, admission to mental i l l n e s s i s admission to f a i l u r e . Consequently, t h i s group s e l f medicates and becomes involved with the criminal subculture. Criminals, at l e a s t , are competent enough to commit a crime. They are unlucky because they get caught. Whereas, being a mental patient i s a clear i n d i c a t i o n of incompetence. - 115 -A P P E N D I X B I N T E R V I E W G U I D E I: Inmate/Patient Nature of Offence Diagnosis Given and One's Understanding of Such Duration of Stay Experience with the Criminal Justice System Other Hospitalizations and/or I n s t i t u t i o n a l i z a t i o n s Community Involvement with Agencies Expectations Experiences Type of Care Currently Receiving Type of Care Received Elsewhere Type of Care that i s Desired What would be most useful for optimizing the current stay? What would be most useful while out i n community? Types of Concerns while Incarcerated Types of Concerns while i n the Community I I : Staff Length of Employment Experience with the Mentally 111 Offender Impact on one's r o l e , and relat i o n s h i p with other colleagues What would be most useful for one as a service provider? What would be most useful for the mentally i l l offenders? Types of Concerns i n working with the Mentally 111 Offender What are the strengths and l i m i t a t i o n s of the current system? - 117 -Your signature below on t h i s page indicates that you have received a copy of the consent form that explains the purpose and procedures of the study t i t l e d , Services for Mentally 111 Offender: An Exploratory Study. I t also indicates your voluntary agreement to p a r t i c i p a t e i n t h i s research study. If you would l i k e to receive a free summary of the r e s u l t s of t h i s study when i t i s available ( l i k e l y Spring 1990) please also p r i n t your mailing address i n the space provided. I understand that I am under no o b l i g a t i o n to complete t h i s consent form. No decisions regarding my stay i n the Health Care Centre of Lower Mainland Regional Correctional Centre would be influenced by my decision to p a r t i c i p a t e or not p a r t i c i p a t e i n t h i s research study. My involvement w i l l be used for research purposes only. My r i g h t s to privacy and c o n f i d e n t i a l i t y w i l l be f u l l y respected. I have the r i g h t to decline to p a r t i c i p a t e i n t h i s research study. I have the r i g h t to withdraw from the research at any time. I understand that I do not have to be tape recorded during the interview(s) i f I do not choose to. I know that the length and number of interviews w i l l be dependent on me. I have read and understood the purpose and procedure of t h i s research study. I understand that the information gathered w i l l be used to a s s i s t the co-investigator, L i l y , i n i d e n t i f y i n g the service needs of mentally i l l offenders. I have read the above statement of my rights and voluntary consent to p a r t i c i p a t e i n the research study by completing the following: Signature Name (Please Print) Address City, Province Postal Code - 119 -Your signature below on t h i s page indicates that you have received a copy of the consent form that explains the purpose and procedures of the study t i t l e d , Services for Mentally 111 Offender: An Exploratory Study. I t also indicates your voluntary agreement to p a r t i c i p a t e i n t h i s research study. If you would l i k e to receive a free summary of the r e s u l t s of t h i s study when i t i s available ( l i k e l y Spring 1990) please also p r i n t your mailing address i n the space provided. I understand that I am under no o b l i g a t i o n to complete t h i s consent form. No decisions regarding my employment i n the Health Care Centre of Lower Mainland Regional Correctional Centre would be influenced by my decision to p a r t i c i p a t e or not p a r t i c i p a t e i n t h i s research study. My involvement w i l l be used for research purposes only. My rights to privacy and c o n f i d e n t i a l i t y w i l l be f u l l y respected. I have the r i g h t to decline to p a r t i c i p a t e i n t h i s research study. I have the r i g h t to withdraw from the research at any time. I understand that I do not have to be tape recorded during the interview(s) i f I do not choose to. I know that the length and number of interviews w i l l be dependent on me. I have read and understood the purpose and procedure of t h i s research study. I understand that the information gathered w i l l be used to a s s i s t the co-investigator, L i l y , i n i d e n t i f y i n g the service needs of mentally i l l offenders. I have read the above statement of my rights and voluntary consent to p a r t i c i p a t e i n the research study by completing the following: Signature Name (Please Print) Address City, Province Postal Code - 120 -A P P E N D X X E  D A T A A N A L Y S I S The plan for data analysis i s seen as consistent with q u a l i t a t i v e methodology. In the process of gathering data, one constantly looks for patterns, themes, or organizing constructs which, as they emerge, form a tentative analytic framework. This framework may involve the construction of categories or hypotheses which, i n turn, guide, and are further modified by, the ongoing c o l l e c t i o n of data. This process of sequential analysis and increasingly focused data c o l l e c t i o n continues u n t i l a s a t i s f a c t o r y grasp of the phenomenon i s achieved. At t h i s point the accumulated data i s subjected to a f i n a l period of systematic r e f l e c t i o n , analysis, and interpretation. This form of q u a l i t a t i v e analysis i s a system of concurrent c o l l e c t i o n and analysis of data, with these two processes sequentially influencing and modifying each other. The s p e c i f i c analysis used was the constant comparative method (C.C.M.) described by Glaser and Strauss (1967). Their methodology stresses that t h i s joint/sequential process of c o l l e c t i o n , coding and analysis i s e s s e n t i a l to the generation of systematic theory - theory which i s t r u l y grounded i n the obtained data. A constant comparison of both s i m i l a r i t i e s and differences i s made. Thus, the researcher i s continually assessing the degree of f i t , or incompatability, as the data i s - 121 -assigned to various categories. The degree of f i t between and within categories i s assessed i n order to begin to sense the s i g n i f i c a n t groupings and t h e i r p o t e n t i a l r e l a t i o n s h i p s . These form the basis of themes and, eventually, of the generation of theory which i s the objective of t h i s research. The Constant Comparative Method system of Glaser and Strauss i s a method which stresses the sequential process of c o l l e c t i o n , coding, and analysis of data; where t h i s data i s obtained from a l i n e - b y - l i n e coding of the researcher's f i e l d notes. To elaborate, the C.C.M. procedure has been employed primarily with participant observation studies i n which the obtained data take the form of the concise summarizations from an observer's f i e l d notes. These summarizations became the primary unit of analysis and were then coded using Glasser and Strauss's open-coding: ...the goal of the analyst i s to generate an emergent set of categories and t h e i r properties which f i t , work, and are relevant for integrating into a theory. To achieve t h i s goal, the analyst begins...[by]... coding the data i n every way possible... [he]...codes for as many categories that might f i t ; he codes d i f f e r e n t incidents into as many categories as possible. During the coding process the analyst sought to continually compare both the s i m i l a r i t i e s and the differences between these units of analysis as they were being assigned to categories. - 122 -This provides an ongoing assessment of the degree of f i t of each piece of data as i t i s being considered for a p a r t i c u l a r category. Such an assignment/analysis process generates the r e f l e c t i o n s and interpretations (memos) which i n turn provide the organizational constructs and tentative a n a l y t i c framework from which the basic themes and theory generation w i l l emerge. This process i s e s s e n t i a l to the emergence of theory which i s t r u l y grounded i n the data, and thus remains consistent with the p r i n c i p l e s of C.C.M. - 124 -A P P K N D I X G I N I T I A T I V E S A N D A L O O K T O T H E F U T U R E As a consequence of the community mental health movement, there has been a s i g n i f i c a n t increase i n the number of p s y c h i a t r i c patients i n the community. Within B r i t i s h Columbia, mental health professionals believe that the d e i n s t i t u t i o n a l i z a t i o n p o l i c y with i t s s t r i c t h o spital admission c r i t e r i a and the patient rights movement have contributed to an increase of mentally i l l i n d i v i d u a l s being processed through the criminal j u s t i c e system. This conclusion has been echoed i n the l i t e r a t u r e on mentally i l l i n d i v i d u a l s i n the community. In the following, I w i l l i d e n t i f y some of the l o c a l agencies and organizational e f f o r t s that have been and are being made i n d i r e c t response to t h i s problem. In addition, d i s t i n c t e f f o r t s i n the reform of the P r o v i n c i a l Mental Health Services, the reform of the B.C. Mental Health Act, and the amendments of the Criminal Code of Canada to respond to t h i s problem w i l l be presented. What becomes apparent i s that the i n d i v i d u a l commitments are there already, and the future of the mentally i l l can be quite encouraging i f there i s p o l i t i c a l and organizational w i l l to act and lend support to i n d i v i d u a l e f f o r t s . In 1984, a group of representatives from d i f f e r e n t B.C. p r o v i n c i a l government m i n i s t r i e s and l o c a l private agencies met - 125 -to discuss the management problems of multi-problem mentally i l l i n d i v i d u a l s . (Buckley et a l . , 1991) I t was agreed that the d e i n s t i t u t i o n a l i z a t i o n p o l i c y had contributed to the c r i m i n a l i z a t i o n of the mentally i l l . I t was apparent to a l l participants that a group of multi-problem mentally i l l individuals were being cycled through various services such as hospitals, mental health centres, alcohol and drug treatment programs, forensic p s y c h i a t r i c services, c o r r e c t i o n a l i n s t i t u t i o n s , community corrections, and other private agencies. In 1985, following a series of inter-agencies meetings, an agreement was reached to j o i n t l y e s t a b l i s h a service coordination program s p e c i f i c a l l y for the service providers of multi-problem mentally i l l i n d i v i d u a l s . (Buckley et a l . , 1991) Part of the mandate of t h i s program i s also to develop a data base of information on t h i s group and to i d e n t i f y the gaps i n the system. Of s i g n i f i c a n c e i s the f a c t that t h i s program i s the f i r s t c ollaborative e f f o r t undertaken l o c a l l y to address the problems of mentally i l l i n d i v i d u a l s who are being cycled through our various systems of care. Also i n 1985, a consultative process was i n i t i a t e d by the Mental Health Services D i v i s i o n of the Ministry of Health. The purpose was to review the province's strategy for the provision of mental health services. P a r t i c i p a t i o n from i n t e r e s t groups and individuals was r e l a t i v e l y widespread. - 126 -In 1987, the Mental Health Consultation Report, based on the consultative process, was completed. I t was viewed as the blueprint for the future of the B.C. mental health system. Reform of the p r o v i n c i a l Mental Health Act was also anticipated. In 1987, the Forensic Psychiatric Services, the B.C. Corrections Branch, and the Greater Vancouver Mental Health Services Society, (three of the s i x sponsoring agencies from the above mentioned program) implemented a community-based assertive case management program s p e c i f i c a l l y for multi-problem mentally i l l i n d i v i d u a l s . The i n i t i a l mandates were simple. They were: 1) to encourage multi-agency collaboration; 2) to engage multi-problem mentally i l l i n d i v i d u a l s ; and 3) to improve t h e i r q u a l i t y of l i f e . What was unique about t h i s program was that there were no budgets a l l o c a t e d , and consequently everyone begged and stole and shared what l i t t l e resources they had including pens and paper. This program has e f f e c t i v e l y achieved i t s primary mandate i n that the senior managements of these three agencies have continued to work c o l l a b o r a t i v e l y i n a l l areas of the services. More importantly, the 'clients* of t h i s program are no longer l o s t to the system. - 127 -In 1988, Riverview Hospital p i l o t e d two assertive outreach research programs for mentally i l l i n d i v i d u a l s who were discharged into the Greater Vancouver Area as well as into the Fraser V a l l e y Area. The Greater Vancouver Area program was met with a great deal of resistance, and was ultimately disbanded. I t seems most l i k e l y that t h i s r e s u l t was due to the lack of consultation and collaborative e f f o r t s with the other agencies. Although the mandates of the program were sim i l a r to the assertive case management program referred to previously, the research component overwhelmed the service component and the ' c l i e n t s ' remained underserved. A lesson to be learned here i s that the l a c k of commitment t o c o n s u l t and t o work c o l l a b o r a t i v e l y t o g e t h e r was met w i t h f a i l u r e r e g a r d l e s s of the s t a t e d mandates. In the summer of 1990, the Assistant Deputy Minister's Committee on D e i n s t i t u t i o n a l i z a t i o n i n v i t e d representatives from Mental Health Services, Forensic P s y c h i a t r i c Services, S o c i a l Services and Housing, Alcohol and Drug Programs, Corrections Branch, Criminal Justice Branch, and the Vancouver Police Department to p a r t i c i p a t e i n a subcommittee that would review the e f f e c t s of multi-problem persons on the Criminal Justice System. The terms of reference given were to: 1) review the management and treatment problems; 2) monitor current issues related to the management of mentally disordered multi-problem persons; - 128 -3) review relevant p r o v i n c i a l and federal l e g i s l a t i o n ; 4) monitor the impact of d e i n s t i t u t i o n a l i z a t i o n on the criminal j u s t i c e system; and 5) suggest strategies to improve treatment and the coordination of treatment services. I t was agreed that the establishment of province-wide i n t e r m i n i s t e r i a l guidelines (completed by November of the same year), would be an appropriate p o l i c y response. The protocols were viewed as the f i r s t step i n the process of improving cooperation between various agencies who share r e s p o n s i b i l i t y for t h i s group. Of significance here i s the following comment: "Governments which have the r e s p o n s i b i l i t y of ensuring the protection of the general public also have the moral and e t h i c a l r e s p o n s i b i l i t y to prevent prisons from becoming the repository for multi-problem mentally i l l persons. One response to t h i s growing s o c i a l problem i n B r i t i s h Columbia i s government policy-making which stresses increasing i n t e r m i n i s t e r i a l cooperation i n service delivery i n order to develop strategies that provide appropriate comprehensive assistance to mentally disordered offenders. The actions of government are not always viewed i n a favourable l i g h t , but here i s an example where government intervention may have a b e n e f i c i a l e f f e c t on an unfortunate and deserving group i n society caught up i n a previously unsympathetic process" (Hightower and Eaves, 1991, p.7). In 1990, the Mental Health I n i t i a t i v e was approved by the Pr o v i n c i a l Cabinet. The I n i t i a t i v e was based on the philosophy that: - 129 -1) treatment and r e h a b i l i t a t i o n should be provided i n settings that are most appropriate to the needs of the i n d i v i d u a l ; and 2) services should work to f a c i l i t a t e the community re-integration process. In addition, a set of p r i n c i p l e s were adopted. They are: comprehensiveness, coordination, continuity of care, a v a i l a b i l i t y and a c c e s s i b i l i t y , and accountability. More importantly, the then Health Minister John Jansen announced that the " p r o v i n c i a l government i s committed to improving the e x i s t i n g mental health care system i n B r i t i s h Columbia" (February 26th, 1990; press release). Moreover, Jansen said that the B.C. Mental Health I n i t i a t i v e was: "a model of p a r t i c i p a t o r y p o l i c y development producing a world-class v i s i o n for the care of the mentally i l l . The government i s dedicated to continuing partnerships as we work together to r e a l i z e our commitment to the mentally i l l " ( Ibid). Also i n 1990, several l o c a l community-based programs were established to provide services for multi-problem mentally i l l i n d i v i d u a l s . For example, the St. James Social Services and Lookout Emergency Services Case Management Projects, and the Mental Patient Society Courtworker Program added a case management component. The newly established Fraser Valley Regional Correctional Centre has a community-based case management program for t h e i r mentally i l l inmates. Similar plans are i n the making for the Vancouver P r e - t r i a l Centre, the - 130 -Surrey Correctional Centre, and the Regional Correctional Centre for Women. The planning process includes consultation and collaborative e f f o r t s between the l o c a l mental health centres, B.C. Corrections, and Forensic Psychiatric Services. In addition, i t should be noted that several months ago the Vancouver P r e - t r i a l Centre i n i t i a t e d s t a f f t r a i n i n g i n the area of mental i l l n e s s as well as an occupational therapy program for p s y c h i a t r i c a l l y impaired remanded i n d i v i d u a l s . Currently various mental health agencies have been i n v i t e d by the Ministry of Health to review and submit recommendations for the reform of the P r o v i n c i a l Mental Health Act. The submission deadline i s June, 1991. I t i s anticipated that the reform of the B.C. Mental Health Act w i l l become a r e a l i t y i n the near future. Some of the recommendations put forward by the Forensic Psychiatric Services appear to be quite encouraging. For example: "That the Act should be patient-centred... should meet the guarantees provided by the Charter of Rights and Freedoms...that i t should r e f l e c t a 'need for treatment model'...an acute or emergency situation,[should] be met with a minimum of administrative interference...recognition [should include the] patient's rights to receive information regarding treatment" (Forensic Psychiatric Services, 1991). Furthermore, with respect to the issue of the c r i m i n a l i z a t i o n of the mentally i l l , the following comments were made: - 131 -"At present, too often we see that appropriate p s y c h i a t r i c care i s not forthcoming...Individuals are l e f t untreated u n t i l t h e i r i l l n e s s r e s u l t s i n actions that compel the intervention of the criminal j u s t i c e system...We are concerned that a 'pure detention model' of mental health statute w i l l aggravate rather than a l l e v i a t e t h i s problem...patients f a l l i n g within the admission c r i t e r i a should be given p r i o r i t y " . (Ibid) As well, " I t i s the Committee's view that the duty of mental, health services continues past an individual's release...there i s the further need to provide for his or her re-integration back into the community. The new Act should acknowledge the s i g n i f i c a n c e of t h i s duty by providing adequate time for discharge planning to meet the continuing needs of the patient". (Ibid) F i n a l l y , "Some form of administrative review i s necessary, but should be keyed to the protection of and respect for patient's rights and to a recognition that i n d i v i d u a l s s u f f e r i n g a mental disorder are often amongst the most vulnerable members of society. Indeed, these person's very v u l n e r a b i l i t y raises the l e g a l standard of care required of medical and c l i n i c a l s t a f f . These factors must be foremost i n ensuring substantive fairness and conscientious conduct i n the c l i n i c a l decision-making process enshrined i n mental health l e g i s l a t i o n " . (Ibid) During the past f i v e years, the Federal Government has c i r c u l a t e d a number of proposals to reform the criminal law i n - 132 -r e l a t i o n to the defense of insanity and the options for the control and treatment of persons found not g u i l t y by reason of insanity. The House of Commons of Canada i s currently considering a sixteenth d r a f t of the proposed amendments. Providing that these recommendations are accepted, a revised Criminal Code would address such issues as: 1) maximum duration of d i s p o s i t i o n made following a verd i c t of Not Guil t y By Reason of Insanity; 2) what to do where a prima f a c i e case for committal for t r i a l cannot be made; 3) appeal process following a d i s p o s i t i o n i n respect of insanity; 4) duties and powers of the Review Board for persons deemed Unf i t To Stand T r i a l or Not Guil t y By Reason of Insanity; and 5) burden of proof i n cases where criminal insanity i s raised. On May 2nd of t h i s year (1991), the Supreme Court of Canada handed down a decision on the case of Owen Swain. (See Swain verses Regina) B a s i c a l l y , the Court had struck down s. 614(2) of the Criminal Code, which provided automatic s t r i c t custody for i n d i v i d u a l s found Not G u i l t y By Reason of Insanity. I t ruled that s. 614(2) v i o l a t e d section seven (the p r i n c i p l e s of fundamental justice) and nine (the ri g h t not to be a r b i t r a r i l y detained) of the Charter of Rights and Freedoms. A six month - 133 -' t r a n s i t i o n a l period' has been granted to the Federal Government to enable enactment of new l e g i s l a t i o n that would meet the requirements of the Charter. This decision should c e r t a i n l y f a c i l i t a t e or "fast-track" the complete amendment of the Criminal Code. At a minimum, the amendments r e f l e c t i n g the Swain judgement w i l l l i k e l y be presented for Parliamentary approval within the next s i x months. The anticipated consequences of the proposed amendments w i l l include three new kinds of ps y c h i a t r i c assessments. They are: 1) assessment to determine appropriate d i s p o s i t i o n ; 2) assessment to determine the person's mental state at the time of the offence; and 3) assessment to determine i f a hos p i t a l order i s appropriate. In most cases, p a r t i c u l a r l y for the NGRI's continued incarceration, a determination must be made by the Lieutenant Governor i n Council within t h i r t y days. F i n a l l y , as the proposed amendments include procedural safeguards such as maximum duration of the d i s p o s i t i o n , the need for a prima f a c i e case to be made, and continuing review, i t i s also anticipated that the mentally i l l accused would raise the issue so as to be exempt from criminal r e s p o n s i b i l i t y more re a d i l y . The end r e s u l t would be of course, that more mentally i l l i n d i v i d u a l s would receive the necessary p s y c h i a t r i c treatment i n an - 134 -appropriate f a c i l i t y that i s sensitive to t h e i r needs, and where the protection of t h e i r rights i s guaranteed, rather than t h e i r being an additional burden on an i l l - p r e p a r e d c o r r e c t i o n a l f a c i l i t y . Assuming that the P r o v i n c i a l Mental Health Services Branch i s committed to the provision of q u a l i t y care, active consultation and collaboration, and programs are designed to meet the f i v e stated p r i n c i p l e s , what we would see then i s a decrease of mentally i l l i n d i v i d u a l s being deposited into the criminal j u s t i c e system or being recycled through the various resources with no place to go. 

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