The criminogenic risk factors of individuals found not criminally responsible on account of mental disorder must be addressed differently to ensure public safety and promote social reintegration
Posted yesterday at 9:00 a.m.
The triple homicide that occurred in Montreal, whose author was followed by the Commission for the Review of Mental Disorders (CETM), is a tragic event. In the aftermath of such a tragedy, many questions emerged, including the following: how to prevent another “patient from escaping the system”? And, by the way, what about this famous “system”?
The Canadian Criminal Code has established that an individual, because of a mental disorder that deprives him of his ability to distinguish right from wrong or to appreciate the nature or the consequences of his actions, should be found not criminally responsible. Although such situations do occur, usually during severe psychotic episodes, they are rare, and even rarer are those where the disease alone explains the tort dynamic.
The mandate of the CETM is to protect the public, while ensuring the social reintegration of individuals found not criminally responsible on account of mental disorder (NCRTM). She handles many cases each year, from crimes ranging from the theft of cough syrup to murder. For each file, it must determine whether the person poses a “significant risk to public safety”. This notion remains a gray area for psychiatrists, who must make a recommendation based on their own assessment of dangerousness.
Knowledge has evolved in recent years, and tends to show that the relationship between mental disorders and violence is weak.
Since the vast majority of individuals with psychotic disorders are non-violent, hearing politicians loudly proclaim the need to “invest in mental health” when a heinous crime occurs reinforces the stigma associated with a diagnosis of schizophrenia.
Severe mental disorders are not considered to be among the main criminogenic risk factors. These risk factors — history of violence, antisocial cognition, antisocial peers, low occupational level, family problems, drug addiction — are often the result of social inequalities in health, and are found in criminalized clients, suffering from mental disorders, or not. However, traditional psychiatric care remains at the heart of the interventions recommended by the CETM. It is true that individuals can be treated involuntarily with antipsychotic medication if they are deemed unfit to accept or refuse treatment.
However, an individual suffering from a personality disorder or addiction cannot be forced to engage in therapy, and yet these aspects are decisive in improving the prognosis.
When a patient is recognized as NCRTM, it is the responsibility of healthcare establishments to protect the public while promoting their social reintegration. However, while more and more studies highlight the role of anger, impulsivity and social misery rather than psychotic symptomatology in explaining the majority of violent behaviors that occur (rarely) among patients with mental disorders, we must humbly ask ourselves if we have the right therapeutic tools.
Forensic psychiatric services are unevenly distributed across regions, and NCRTM individuals presenting with the psychosis-substance abuse-personality disorder triad represent a significant challenge. If we manage to treat psychosis, what if the patient refuses to cooperate in interventions targeting other issues?
In a hospital environment, teams sometimes have to manage major behavioral problems, risking their safety and that of other patients. Some refractory individuals may remain detained for several years, even for minor offenses (threats, misdeeds, etc.), because the intensive community monitoring teams (MIS) refuse them, judging, with good reason, the risk too high. This greatly undermines their potential for social reintegration. They can also be released into the community, without any follow-up to meet their complex needs, as paradoxical as that may seem.
Several MIS models for forensic clients exist in Canada and the United States, and address criminogenic risk factors (antisocial cognitions, idleness, substance abuse). These models should be implemented in Quebec, initially on a small scale, and added to the residential services already in place. Finally, for non-volunteer clients with rehabilitation approaches, but able to live independently, it would be interesting to develop an intensive surveillance component within these teams, in partnership with police forces skilled in crisis intervention. psychosocial.
The ideas to do better, and to do things differently, exist, as does the will of the stakeholders already in place. We can only hope to be part of the solution.