CAMH Forensic Psychiatrist

35. Tindog Tacloban! – The Outpatient Program

March 22, 2014 By StevenCohen-CAMH

The jeepney sets out at about 8:15am. It looks like a battered old short-bus, but instead of back seats, it has two long bench seats along the sides, and an open back and sides. If there is no air conditioning, this is the most comfortable way to travel.

Three counsellors. One of whom is an MD, the other two have an undergraduate degree in psychology. All have had previous training with another MSF project in the Philippines. We’re constantly bantering and discussing cases along the way.

First we attend Tanauan Central School Evacuation Centre. There had been a planned time for follow-up sessions with some persons identified as having difficulty adjusting to post-typhoon conditions, whether above the threshold for a diagnosis of mental illness or not. The tent city locale was empty. Almost completely empty, in that there were even no kids about, which is a rare thing out here. Turns out that the whole camp had gone to a place called Pago to work on the more permanent structures to where they would be moving eventually.

We moved on to a small displaced persons camp, mostly made of up tents. We met with the Captain of the local region, and he warmly greeted us, but advised that there was a food distribution going on, which clearly took priority over the planned psycho-education session that we had arranged. We rescheduled for that afternoon, and hopped in the Jeepney toward the next stop.

The Assumption evacuation centre was similarly empty. Again, the inhabitants had gone to Pago to work on the housing structures there.

So we decided to do the most expedient thing and headed to Pago. There was a single concrete structure erected, and the start of many others. Building materials were stacked up in neat, organized piles. Large groups of people were working on different projects: moving wood, cleaning metal beams, concrete mixing, brick-laying, etc.

The MSF counsellors split up to find the persons with whom they had follow-up sessions planned, and they retreated under the shade of a tree to do their work. If possible, returning to work is almost always a good thing. It aids with depressive and anxious symptoms, of which post-traumatic distress is included. Work tends to be social and provides a sense of purpose, worth, and community-building.

The housing units are provided in order of need, and there is an equation that takes into account the size of the family, number of children, destruction of property, distance from shoreline, and other factors. My small poll suggested that most people thought that this was fair, and that they wanted to move in as soon as possible.

Next stop lunch. We ate, discussed the cases, and planned the afternoon. Fish, rice, some meat stew that might have been pork. Like most prepared food here, there is too much sugar and salt. The fish was fantastic. The lunch room was a small open-air establishment that had been built mainly since the typhoon. On one side was the road with cars driving by, and on all other sides the visible debris from the storm. It had been arranged into piles of metal sheeting, wood that seemed to come from docks, and broken cars and other forms of transportation that had been destroyed. The region, Bislig, is one that was hard-hit, and is also being targeted by our Outreach team.

We then returned to Magay for that psychoeducation centre. A bell was rung and the milling-about crowd grew from 20 to over 100 persons. It was a lively group. Many mothers holding babies, some who had been born since the storm. The Barangay Captain, a white-haired septuagenarian fellow who wore crisp jeans and a jean-shirt, curiously unaffected by the blistering heat and humidity, introduced our team. The counsellors launched into their routine, which was in the local dialect of Tagalog, called Waray Waray. One of the counsellors translated some of the on-goings, but more than anything I was fixed by the cadence and energy of the group. It was fast, interactive, and thoroughly engaging to the participants. The group called out answers to questions, made comments that struck home to easy laughter, and asked for clarification if the need arose. It was warm and intimate. I want to write that it had this tenor “despite” the setting, which was a slightly shaded area, 20 or so seats, with the rest of the people standing. But of course, it had almost everything to do with the setting.

Psychoeducation sessions are necessary here. It is very common to have people brought to the hospital by family for non-specific or unexplained medical symptoms such as bodily aches, irritability, sleep problems, and decreased functioning in the social, family or work sphere. No mention of sadness and anxiety is made, but on inquiry, there is significant concern in these areas. There are also more cases than I would have suspected involving persons who have been psychotic for years, and were never brought to the attention of a mental health professional. Some teaching of common symptoms of mental illness, and the availability of free MSF services, is a good thing. Of course, one wants to be aware of local ways of expressing emotions and behaviours associated with illness (idioms of distress and styles of reasoning), as we don’t want to prime people how to “properly” exhibit illness. But it seems that even moderate to severe symptoms may go unrecognized and unattended to by available health resources. There is much more to say on this topic, but I’ll leave it there for now. Something interesting happened.

At one moment during the 20-minute session, one of the counsellors asked the group if anyone had a family member or someone close to them who was killed by Typhoon Yolanda. There were many hands that went up. Then someone made a comment that got everyone laughing, and some were looking at a 60-ish year-old woman who was in the front row. She laughed, turned a bit red from the attention, and then started to cry. She covered her face, but motioned that she was ok, and for the talk to continue. The counsellor went to stand beside her, put a hand on her shoulder, as had several others who were sitting beside her or standing near her. The counsellor continued the session, and after a few minutes moved back to a central location. When the session was over, the counsellor sat down beside her and they spoke for 15 minutes or so. There were about three or four women who had pulled up chairs to take part in the discussion.

It was explained to me afterwards what happened. The woman’s name was the international call-sign name of the storm, and her husband died in the typhoon. When the group was asked if anyone was killed by “Yolanda,” someone joked that she had killed her husband. I double-checked that I heard that correctly. It’s hard to imagine a large setting in which humour like this wouldn’t be off-side back home in Canada.

I work at a Toronto hospital called the Centre for Addiction and Mental Health (CAMH). It’s one of the largest mental health institutions in the country. I could not even fathom humour such as this being mobilized in this way, but I started to wonder what it would take. I’m still wondering.

Here in Tacloban city and environs, in this most remarkable of places, humour is used with great deftness in the integration of psychologically traumatic events in a coherent and tolerable narrative. This is healing behaviour. It struck me that this was a shining example of the concept of resiliency.

(The winds hit gusts of 365km per hour; many stores that have reopened include the name Yolanda.)

31. Correctional Psychiatry in Canada – Commentaries

February 12, 2014 By StevenCohen-CAMH

Commentary #1: Bridging the Gaps for Former Inmates with Serious Mental Illness

Anthony C. Tamburello, MD, and Zoe¨ Selhi, MA, MD

Serious mental illness is a prominent and vexing problem within the correctional systems of North America. Simpson and colleagues draw attention to the epidemiology, special characteristics, and management problems relevant to Canadian inmates with serious mental illness. Of great interest to those in the forensic psychiatric field is the matter of continuation of care for mentally ill prisoners, in that untreated or under-treated psychiatric problems are strongly associated with poor social functioning and criminal recidivism. In this commentary, we expand on the discussion in Simpson et al. of the effectiveness of assertive community treatment teams for those former inmates at greatest risk for future involvement with the criminal justice system. We also propose outpatient civil commitment as one strategy to facilitate the successful return of select inmate patients to the community.

J Am Acad Psychiatry Law 41:510–3, 2013

Simpson and colleagues1 draw our attention to the epidemiology, special characteristics, and management of inmates with a serious mental illness (SMI) within the Canadian prison system. We think that this article identifies important shared clinical and academic interests for correctional psychiatrists in both the United States and Canada. First and foremost is their conclusion that SMI is common in correctional settings. As the authors point out, the seriously mentally ill are more likely to be incarcerated than admitted to a hospital2–4 for treatment. The corollary to this conclusion, confirmed by epidemiological research in both the United States and Canada, is that SMI is more prevalent in a correctional setting than it is in the community.5–9 As the SMI represent those most in need of psychiatric care for poor functioning, whether in a community10 or a prison setting,11 meeting these needs is critically important to all stakeholders.

Some aspects of the review by Simpson et al. limit its generalizability to prison systems. Most relevantly relevantly, their use of the term prison inmate refers to both pretrial detainees and those serving a sentence after criminal adjudication. Thus, data are included in their review on inmates who might be housed in a jail or detention center. Although the article at times points out which type of inmate was included in the cited study, interpretation of this information requires awareness of the differences between pretrial and sentenced inmates. First, the rate of mental illness in general, and serious mental illness in particular, may be moderately higher in jails than it is in prison. The most recent survey by the Bureau of Justice comparing the rate of mental illness in U.S. jails and prisons illustrates this point: psychotic symptoms were reported by approximately 24 percent of jail inmates versus 15 percent of state prisoners. 12 A second, related point mentioned by Simpson et al. includes the acuity level of mental illness in these two populations. Pretrial detainees are more likely to experience symptoms of their illness, given the predictable psychosocial stressors related to their recent incarceration and the uncertainty about their legal fate. The stress of their situation may explain the higher suicide rate observed in jails compared with that in prisons.13 Finally, although substance abuse was not the focus of Simpson et al., the rate of substance use disorders appears to be higher in inmates in jail than in their counterparts in state prison.14

It is hard to argue about the point that Simpson and colleagues make that SMI is a major problem for correctional psychiatrists and the systems in which they serve. The untreated or under-treated mentally ill are at greater risk for unemployment, homelessness, needing emergency services or hospitalization, substance abuse, suicide, being victims of crime, engaging in violence toward others, and poor quality of life.15,16 They have a shorter life expectancy, most likely related to a combination of under-treated medical problems, unhealthful lifestyle, suicide, accidents, and victimization by others.17 The mortality of persons with SMI is much higher than would be expected after release to the community, most often related to drug overdose, cardiovascular disease, suicide, and homicide.18 Notwithstanding the moral imperative and professional duty of physicians and other mental health workers to alleviate suffering and reduce risk, the treatment of mental illness in incarcerated individuals is mandated by the U.S. Constitution19 and by federal regulations in Canada.20 We have no doubt that a prison sentence has saved the lives of some persons with serious mental illness. It is not uncommon to hear of a returning inmate patient who did not connect with aftercare services (or dropped out of treatment), became noncompliant with medication, and resumed using illegal substances as a prelude to violating parole or committing another crime. Whether incarcerated or in the community, patients with SMI may lack the insight, understanding, or appreciation of their condition that is necessary to make a well-reasoned decision to accept or decline health care services. As discussed by Simpson et al., Lennox et al.21 reported that only 4 of 53 SMI patients with an aftercare plan including the involvement of a Community Mental Health Care team were still in contact with their team six months after release.

Despite the fact that prisoners with SMI are often lost to follow-up, Simpson et al. highlight the important role that mental health providers in correctional settings play in preparing their patients to return to society. Discharge (or re-entry) planning has long been regarded as a standard of care by the National Commission for Correctional Health Care22 and the American Psychiatric Association.23

Simpson et al. describe the use of assertive community treatment (ACT) teams in re-entry planning for former Canadian inmates with SMI, but they point out that traditional ACT services have not yet been shown to reduce recidivism.24,25 They suggest that the forensic assertive community treatment (FACT) model may be better, with a focus on pretrial diversion by taking referrals from jails, adding probation officers to the team, providing housing assistance, and offering treatment for co-morbid substance use disorders. Similar specialized programs geared toward the re-entry of SMI patients may also show promise. For instance, the Forensic Transition Team (FTT) in Massachusetts seeks to attend to the needs of persons with SMI exiting the correctional system and offers coordinated care services to both pretrial and sentenced inmates. Despite the voluntary nature of the program, outcome data26 show that 46 percent of former inmates with SMI were engaged in services after three months in the community. Of interest, patients who had misdemeanour charges for which they typically served six to nine months were the most likely to be lost to follow-up and to return to the criminal justice system.

Prison systems have advantages over other settings for the management of patients with SMI who are unwilling or unable to accept necessary psychiatric treatment voluntarily. Convicted individuals in the United States may be eligible for involuntary psychiatric medication in an administrative procedure modeled after Washington v. Harper.27 These inmates may be asymptomatic or greatly improved as they approach release, thanks to structure created by the presence (or likelihood) of nonemergency forced medication. When released from prison, they are no longer subject to the findings of a Washington v. Harper-type panel. Local civil regulations for forced medication are typically stricter and usually require inpatient civil commitment. Given the stability brought about by forced medication in prison, many of these patients will not meet criteria for inpatient civil commitment. Although some jurisdictions such as California have a formal process for the civil commitment of inmates with SMI who would otherwise be a danger in the community,28 such processes are the exception rather than the rule. Civil commitment imposes restrictions on liberty grievous enough, and different enough vis-a`-vis incarceration, to deserve additional due process.29 The typically strict standards for inpatient civil commitment often render hospitalization a short-term solution for those who, with treatment, will not become dangerous in the foreseeable future.30 Even when psychiatric medications mitigate the symptoms and behavioural problems associated with SMI, improvements in insight and judgment may lag behind other gains.

For select cases, involuntary outpatient commitment (IOC) may close the gaps in legal protections that create a revolving door of hospital and correctional recidivism. Most provinces in Canada have provisions for outpatient commitment in the Community Treatment Order (CTO). CTOs in Ottawa have been shown to reduce the number and duration of inpatient stays and to increase access for SMI patients to housing and mental health services.31 Outpatient commitment is legal in 45 states, although its implementation in the United States has been inconsistent. 32 The best example of the benefits of outpatient commitment in the United States is New York’s Kendra’s Law or assisted outpatient treatment (AOT). Research has shown that outpatient commitment reduces arrests, the number of hospitalizations, inpatient length of stay, homelessness, violent acts, and suicidal behaviour; improvements were noted in medication compliance and social functioning.33–36 For those enrolled in AOT for at least seven months, these improvements were maintained even after the patient was no longer mandated to outpatient treatment by court order.37 We believe that outpatient commitment, especially when it links former inmates with SMI to intensive treatment services, community support, and housing, would be a formidable tool to reduce recidivism and improve health care outcomes.

Involuntary outpatient treatment is not without controversy. A Cochrane review in 2011 concluded that the existing evidence from randomized controlled trials on outpatient commitment at the time was weak regarding outcome measures such as reducing hospital admissions, homelessness, and arrests.38 Criticisms of outpatient commitment include concerns about inadequate funding, diversion of public funds away from voluntary outpatient services, liability associated with managing dangerous persons outside of a hospital, unwillingness of judges and police to enforce the conditions of outpatient commitment, and the violation of a patient’s rights by using coercion to enforce compliance.32,39 Economic analyses to date suggest that, even with the cost of providing comprehensive outpatient services pursuant to Kendra’s Law in New York State, such services are cost effective32 and need not siphon resources from voluntary outpatient services.40 Similar to inpatient commitment, civil rights are protected by jurisdiction-specific criteria and the need for a court order for outpatient commitment. Whether a patient is appropriate for outpatient commitment is a clinical judgment requiring the same level of skill necessary for decisions to medicate, to reduce observation status, or to discharge from the hospital. It does not replace the option to hospitalize, but rather allows for the management of appropriate patients who are stable with treatment (yet reluctant to comply), in a less restrictive environment. Psychiatrists, especially forensic psychiatrists, can play a role in educating law enforcement and the judiciary about outpatient commitment and in advocating for appropriate enforcement.

Other strategies to alleviate the burden of serious mental illness in correctional facilities may also be worth considering. Mental health courts authorized to order a person with SMI into treatment in lieu of incarceration have shown promise for reducing recidivism and violence.41–43 Warrants for emergency room evaluations of suspected seriously mentally ill persons, such as the emergency petition process in Maryland, may serve as an early diversion from the correctional system.44 A post-conviction approach would be to coordinate with the parole department when developing an aftercare plan for an inmate with SMI. Defining treatment compliance as a condition of parole could have the same effect as outpatient commitment in reducing recidivism for those former inmates apt to respond to structured consequences for noncompliance. The difference unfortunately is that a violation of parole would be expected to result in reincarceration, rather than potential hospitalization in the event of a violation of the terms of an outpatient treatment order. Simpson et al. point out research showing that those with SMI are already at greater risk of recidivism because of technical violations of parole.45

In summary, we agree that serious mental illness in correctional settings in North America is a common and important problem. Bridging the effective management of SMI from the prison clinics to treatment centers in the community has implications for general and forensic psychiatrists in all settings. Providing comprehensive community services for these patients, whether through FACT teams, outpatient civil commitment, mental health courts, or other creative means, is a promising approach to maximizing functioning and minimizing risk, at the least possible cost to civil liberties for those already well familiar with not being free.

——————————————-

Commentary #2: Mentally Disordered Offenders in Prison—Old Problems That Still Require Solutions

Carla Rodgers, MD, and John A. Baird, MD

We commend Simpson et al. for addressing an important topic: the care and treatment of prisoners with serious mental illness. We welcome the authors’ conclusions, but we identify some problems that can often frustrate attempts to improve services to this group.

J Am Acad Psychiatry Law 41:514–5, 2013

Simpson and colleagues1 are to be congratulated for highlighting again a topic of great importance in forensic psychiatry. Within that part of the speciality that is responsible for the care and treatment of mentally disordered offenders, concern for the inmates’ mental status should not be overlooked. Experience gained through work of this kind will be helpful and complementary to the role of expert witness, assisting psychiatrists in speaking with greater confidence and authority during testimony. The authors highlight the rising number of prisoners who have serious mental illness (SMI) and the disproportionate increase in the number of prisoners from ethnic minorities who have higher rates of SMI. They pose several questions that arise from these trends.

One particular minority group to which reference is made in the review is Canadian First Nations people. The authors discuss the challenges that the increasing number of inmates from First Nations groups represents for mental health services. They helpfully exclude personality disorders and substance misuse from consideration, in that these are better treated as separate topics. They include suicide and attempted suicide in prison, which is perhaps an important and related topic. They conclude that SMI is becoming more common in the prison population. They discuss the effects of imprisonment on SMI and find that these effects are less severe than postulated. They question whether treatment in prison is effective, concluding that particular problems arise when prisoners are returned to the community but lost to mental health follow-up.

The rate of serious mental illness among prisoners has been of interest since the specialty of forensic psychiatry started to develop a strong identity during the middle years of the 20th century. For example, an early study in Scotland2 found significant rates of SMI in a Scottish prison at a time when the large Victorian psychiatric hospitals were still in existence and inpatient psychiatric beds were readily available. The process of deinstitutionalization has since led to an increased number of people who have SMI returning to the community without adequate followup. It is inevitable that some of these individuals will find their way to prison. Also, in view of considerable research that identifies that SMI increases the risk of certain types of offending,3 it is to be expected that the number of persons with SMI in prison will be greater than the number in the community.

Jurisdictions vary considerably in whether an offender with SMI is more likely to be committed to prison or to a secure hospital. Jurisdictions also vary in the options for transfer of a prisoner with SMI to a secure hospital, if there is a clinical need to do so. People in the community who have SMI often receive assistance from family and friends, but how can this support be replicated within a prison? Confidentiality and stigma are much more complex difficulties to deal with in prisons. Finally, can prisons ever be a safe and suitable location for the administration of medication without consent?

Forensic services could never meet the needs of all SMI prisoners and should not be responsible for doing so, since the bulk of offenders in custody with SMI are minor offenders who do not require specialist forensic care. Community services may be reluctant or downright unwilling to become involved with patients with SMI who have offended, even if the offence is minor. In some jurisdictions, effective aftercare can be arranged when prisoners with SMI come to the end of their sentences and are not fit for release. The prison health care service may refer them to local hospitals in the same way as if they had a physical condition. Further organizational complications arise within a health service that is predominantly in the private sector, as in the United States. These hindrances help explain the failure of community aftercare that Simpson and his colleagues identify.

Another aspect of the stigma faced by the SMI inmate is worthy of mention. It is often believed that prejudice in mental health services against mentally disordered offenders is a recent phenomenon, but that is not the case. There is evidence that such discrimination goes back a long way. In Scotland in the mid-19th century, when the first modern cellular prison was commissioned, it was found from the outset that mental hospitals or, as they were known then, asylums, in the surrounding community were unwilling to accept prisoners for treatment who were deemed to be insane.4 Another example of there being nothing new under the sun.

Despite these organizational challenges, the future, as Simpson et al. conclude, must ensure improvements in the quality of the mental health care of SMI prisoners. The challenges in working to achieve these advances are considerable and vary from one jurisdiction to another but, as the authors emphasize, they must be resolved.

Filed Under: CAMH Forensic Psychiatrist, correctional psychiatry, Steven Cohen CAMH Forensic Psychiatrist Tagged With: Dr. Steven Cohen CAMH, Toronto Forensic Psychiatrist

30. Correctional Psychiatry in Canada – Article

January 10, 2014 By StevenCohen-CAMH

CHALLENGES FOR CANADA IN MEETING THE NEEDS OF PERSONS WITH SERIOUS MENTAL ILLNESS IN PRISON

(Alexander I. F. Simpson, MB, ChB, BMedSci, Jeffry J. McMaster, MD, and Steven N. Cohen, MA, MD)

The number of prison inmates is predicted to rise in Canada, as is concern about those among them with mental illness. This article is a selective literature review of the epidemiology of serious mental illness (SMI) in prisons and how people with SMI respond to imprisonment. We review the required service components with a particular focus on care models for people with SMI in the Canadian correctional system. An estimated 15 to 20 percent of prison inmates have SMI, and this proportion may be increasing. The rate of incarceration of aboriginal people is rising. Although treatment in prison is effective, it is often unavailable or refused. Many of those with SMI are lost to follow-up within months of re-entering the community. There is much policy and service development aimed at improving services in Canada. However, the multi-jurisdictional organization of health care and the heterogeneity of the SMI population complicate these developments.

(J Am Acad Psychiatry Law 41:501–9, 2013)

Canada’s 2008 incarceration rate of 116 per 100,000 people has been stable over recent years, and while similar to many Western European countries, is 15 percent of the U.S. rate of incarceration.1 The Canadian rate is predicted to increase, however, with the government’s tough-on-crime legislative reforms.2 With this, the mental health of Canadian prison inmates is a community concern and the Mental Health Commission of Canada has made it a matter of strategic importance.3 The purpose of this review is to summarize the current knowledge regarding serious mental illness (SMI) in prisons, with particular focus on Canadian prisoners. The findings of several recent meta-analyses covering aspects of SMI, substance misuse, and personality disorders in prisons, provide the context for discussion of the particular challenges for Canada in developing its service response to SMI in prisons. This review of the current provision of mental health services in Canadian prisons highlights the need for a coherent strategy to improve them. In this article, the term prison inmates includes pretrial and sentenced inmates. SMI refers to psychotic, bipolar, and major depressive disorders, although we will also discuss the risk and management of suicide in custody. Although substance use and personality disorders are very common in prisons and are often co-morbid with SMI, this article does not cover treatment needs for those disorders.

Epidemiology of SMI in Prisons

The prevalence of SMI in prisons was the subject of a comprehensive meta-analysis by Fazel and Seewald in 2012.4 Their review of 109 samples included 33,588 prisoners in 24 countries. Of the male prisoners, 3.6 percent had psychotic illnesses, and 10.2 percent had major depression. Of the females, the prevalence rates were similar, at 3.9 and 14.1 percent, respectively. These results are consistent with those reported in a 2002 meta-analysis by Fazel and Danesh.5 However, the 2012 study reviewed rates of psychosis in prisoners in low- and middle-income countries and found that the rates were significantly higher than in high-income comparators. Commonly, 15 to 20 percent of prison inmates have disorders that require psychiatric treatment, such as psychosis, major depression, and bipolar disorder.6,7 These studies and other recent reviews have indicated that the rates of SMI are substantially higher in prisons than in the general population.8,9 In the United States, this overrepresentation may be attributable to the significantly higher likelihood that persons with SMI will be jailed rather than hospitalized. 10 Teplin11 reported that individuals who display symptoms of SMI have a 67 percent higher probability of being arrested than do individuals who do not display such symptoms. Following arrest, individuals with SMI are more likely to be detained in jail (as opposed to being released on their own recognizance or having their cases dismissed) and, once jailed, they stay incarcerated 2.5 to 8 times longer than their non-mentally ill counterparts.12 Suicide is the cause in up to 75 percent of pretrial inmate deaths and 50 percent of sentenced inmate deaths. These rates are 3 to 11 times higher than in the general communities from which the prisoners are derived.13 Canadian prison suicide rates are similar to those in New Zealand and Australia and are generally lower than in Europe. The suicide rate of released inmates remains higher than that of the general population.14 Factors most strongly related to prison suicide include solitary cell placement, a life sentence, pretrial status, recent suicidal ideation, current psychiatric diagnosis, and treatment with psychiatric medication.15

Is Mental Illness Becoming More Common in Prisons?

It remains unclear whether the absolute number of persons with SMI in prison is rising simply because more people are being imprisoned, because more mentally ill people are being detected through better screening of those entering prison, or because the prevalence of SMI among those incarcerated is increasing. Three major studies have examined this question. In Washington state, Bradley-Engen et al.16 found no increase in the prevalence of major mental disorders from 1998 to 2006, although they did find a rise in co-morbid substance misuse. Sawyer et al.17 found no difference in the prevalence of mental disorder in young people in detention in 2008–2009, compared with that reported 10 years prior. However, a Finish study of psychiatric hospitalizations of prisoners18 found that 2.6 percent of prisoners had a diagnosis of psychosis in 1984 –1985, whereas 6.5 percent had the diagnosis in 1994–1995. There was also a significant increase in substance use, but rates of depression remained stable. Fazel and Seewald4 noted that in the 17 U.S. cross-sectional samples, there appeared to be a trend of increasing prevalence of depression over the 31 years from 1975 to 2005. However, no statistically significant increase in the prevalence of either psychosis or depression was found.

What Happens to the Severity of Illness During Imprisonment?

Being imprisoned is a stressful experience, and prisons are inherently stressful environments. However, the effects of these stressors on people with SMI have not been rigorously investigated. There are studies showing that acute psychotic symptoms19,20 and overall levels of distress21,22 decrease during the early period of incarceration. Hassan et al.20 noted that there was a reduction in symptoms among the sentenced men but not among pretrial male and female inmates, who continued to report persistent levels of distress. Longer periods of incarceration of SMI inmates may lead to more mental health symptoms.23 If SMI is left untreated, lengthy imprisonment may lead to disruptive, noncompliant, and aggressive behaviour in the inmate in reaction to the requirements of prison life.24 Psychiatric instability may be increased by placement in solitary confinement25 or sexual and physical assault while in custody.24 Further, institutional misconduct prevents individuals with SMI from participating in programs, thus limiting parole eligibility.26 In contrast, Fazel and Seewald4 reported that there was no significant overall difference in the prevalence rates of depression or psychosis between pretrial and sentenced prisoners in pooled cross-sectional studies.

Does Treatment in Prison Work?

Despite the availability of mental health treatment, inmates with SMI may choose not to participate in treatment because of concerns about reputation and confidentiality, prior experience, and individual demographics (e.g., minorities in prison report more negative attitudes about mental health services) or because of symptoms of mental illness.27 The presence of SMI often limits the individual’s insight into his illness and the need for medication and other health services.28 Skogstad et al.29 and Howerton et al.30 found that inmates who are suicidal may intentionally hide their mental state out of concerns about restrictions. Two studies found that about half of the most disturbed inmates received no services for a period of up to one year.31,32 A national U.S. survey conducted from 2002 to 2004 showed that a third of prisoners with diagnoses of schizophrenia or bipolar disorder were not treated with psychotropic medication.33 In terms of efficacy, a recent review by Morgan et al.34 suggested that interventions for offenders with mental illness effectively reduces symptoms of distress, improves offenders’ ability to cope with their problems, and results in improved institutional adjustment and behavioural functioning.

Mental Illness in Canadian Prisons

Canadian prevalence studies of SMI in prisons are summarized in Table 1. These findings are generally similar to those of international studies. Overall, SMI rates are as much as three times higher than in the general population,43–45 yet there is some variation between studies, given the smaller sample sizes. Similar to meta-analytic findings, there is no significant gender difference in SMI inmate prevalence rates.

From 1996–1997 to 2009–2010, the average annual suicide rate among Canadian federal inmates was about 3.7 to 7.4 times higher than in the age-matched general population.46 This rate is similar to the increased risk found in most Western nations.47 Serious self-injurious behavior with suicidal intent has been found to be similar across pretrial and sentenced populations and is higher in women (35%) than in men (20%) (Brown GP, unpublished data). Evidence from self-reported data and rates of prescriptions given for psychotropic medications suggest that the problem of SMI in prisons is getting worse. A recent federally commissioned report48 using self-report data found that 12 percent of male inmates and 21 percent of female inmates have significant symptoms of SMI on admission to a federal correctional institution. This rate is an increase of 61 and 71 percent, respectively, since 1997. However, the data have not yet been validated against a research-based diagnostic tool, and it is therefore unclear whether this rising rate of reported distress translates into increased rates of specific disorders. As regards prescription rates, the number of persons entering the federal system who are given psychotropic medication has nearly doubled in the past decade, to a 2008 rate of 21 percent of inmates receiving these medications while incarcerated.1

A comparison of needs assessments conducted by Correctional Services of Canada (CSC) in 1996 and 2002 also indicated that SMI is an increasing concern for federally sentenced women. A 1996 needs assessment for federally sentenced women found there were very few female inmates with a major mental illness (e.g. schizophrenia, psychotic depression, bipolar disorder, or an organic syndrome).49 By 2002, a report50 indicated that incarcerated women had a lifetime prevalence of schizophrenia of 7 percent and a lifetime prevalence of major depression of 19 percent (compared with community prevalences of 1% and 8.1%, respectively), in contrast to the “very few” mentioned in the 1996 assessment.49 The factors accounting for an increased prevalence of SMI in prisoners in Canada are very likely the same as those found in the rest of the developed world. As previously noted, inmates with a diagnosis of a mental disorder are less frequently granted full parole and, once released, are more likely to be reincarcerated for technical breaches of the conditions of release.43 In an Ontario, Canada study, Brown found that having a high number of severe symptoms of SMI correlated with a lower mean time to reincarceration; that is, those individuals with multiple symptoms were reincarcerated more quickly than those with fewer symptoms. However, time to reincarceration was not related to the severity of symptoms among SMI inmates (Brown GP, unpublished data).

A factor that may contribute to increased rates of SMI in Canadian prisons is the growing aboriginal prison population. While the First Nations, Metis, and Inuit aboriginal peoples comprise less than 4 percent of the general population, they account for 20 percent of the federal prison population.46 Aboriginal women offenders comprise 33 percent of the female inmate population under federal jurisdiction, which represents an increase of almost 90 percent in the past 10 years. The proportion of aboriginal inmates with SMI at admission increased from 5 percent in 1996–1997 to 14 percent in 2006–2007, but was down to 9 percent in 2008–2009.51 Male and female aboriginal inmates reported similar rates of serious self-injurious acts (30%) (Brown GP, unpublished data).

Necessary Service Responses

Livingston52 described minimum standards and best practices of mental health services in prisons. He noted that prison inmates have full rights to receive care appropriate to their health needs in accordance with internationally recognized principles.53,54 The U.S. Supreme Court55 has reaffirmed in California that medical and mental health care for prisoners is a right guaranteed by the Fourteenth Amendment of the U.S Constitution. Essential services for inmates include screening for mental disorders at reception, acute and non-acute treatment services, programs to meet their needs while in custody, and preparation for release and engagement with community mental health services on release.

In shorter stay prisons, the major functions are screening, assessment, and stabilization, with handover to community agencies on release. In longer stay (federal) institutions, services must include a full continuum, including pharmacological treatment, services for special populations, residential treatment for offenders with serious mental illness, crisis observation and intervention (which may take place in psychiatric wards at local hospitals), disciplinary housing treatment (higher security prisons or areas), inpatient psychiatric hospitalization, and prerelease treatment services.

Screening for SMI is a crucial component of prison mental health services and is usually performed by a primary health care professional at the point of reception into custody. The aim of screening tools is to detect persons likely to have an SMI who require more detailed mental health assessment. There are three major tools developed for this purpose. The Brief Jail Mental Health Screen (BJMHS)56 is widely used and comprises eight questions (six symptom questions and two historical questions). It has been validated against the Structured Clinical Interview for DSM-IV (SCID-L) for men and women.57 Another is a mental health screen of only five questions on past treatment and current criminal charge developed by Grubin58 in the United Kingdom. The third tool is the Correctional Mental Health Screen,56 which has a structure similar to that of the BJMHS, but with 12 items.

Evans et al.59 found that either the BJMHS or the Grubin tool worked adequately for detecting psychotic illness, but neither performed well at detecting depressive disorders, because inmates commonly endorse depressive symptoms at entry into prison. Screening for suicide risk and follow-up assessments are essential, and policies for suicide risk reduction should be built into the design and function of prisons.60 Bauer et al.24 defined treatment for inmates with SMI as including basic mental health and rehabilitation services, the latter focusing specifically on reducing criminal behavior and recidivism. Rehabilitation should attend to both mental health treatment and criminogenic factors most commonly embraced by the risk-need-responsivity model.61 Sawyer and Moffitt62 noted that, although reducing recidivism is an important goal for those working within the criminal justice system, correctional treatment is often focused on more proximate goals, such as symptom reduction and assisting inmates with mental illness to cope in the correctional environment. Specialized psychiatric care units, also known as residential treatment centers, have been identified as best practice for dealing with the difficulties associated with mainstreaming inmates needing mental health services.52,63

Specialized care units are most appropriate for inmates with mental health problems who are unable to function adequately in the general offender population, but do not require hospitalization. 64,65 The purpose of these specialized care units is to enable adequate observation of inmates with SMI and to stabilize and transition them into the prison mainstream. These units have been associated with reductions in institutional crises and management problems and improvements in inmate quality of life.64

Preparation for release and engagement with follow-up are essential. In a systematic review, Fazel and Yu66 found that persons with SMI have a moderately higher risk of repeat offending than do persons without SMI and noted that improvements in their treatment and management while in custody and after release have the potential to make a positive impact on public health.

Comprehensive discharge planning should follow community standards and include a guaranteed supply of medication and appointments with outpatient clinics, psychiatrists, or other counseling services. The involvement of prison and parole authorities is vital in achieving successful care transition into the community. A recent study found that nearly all of those with SMI are lost to follow-up after six months in the community.67 This population can be difficult to engage on a long-term basis and may require special assertive community treatment (ACT) team involvement. After release and while on parole, traditional ACT models may improve engagement and symptom reduction, but they do not appear effective in keeping persons with mental illness out of the criminal justice system.68,69 Enhancing ACT to include criminogenics (so-called forensic ACT or FACT) has a limited, but promising, body of literature to support it. Lamberti et al.70 performed a national survey of FACT teams in the United States and identified a set of common structural elements that distinguish them from traditional ACT models. These elements include the goal of preventing arrest, receiving referrals from local jails, incorporating probation officers as FACT team members, and having a supervised residential component for consumers with SMI and substance abuse disorders. Jennings68 argues that emerging research from the forensic continuum of care model suggests that community aftercare programs such as ACT can be enhanced by pretreatment in prison or in a community residential treatment precursor.

Challenges

There are two main challenges in meeting the mental health care needs of prisoners in Canada. The first relates to the multi-jurisdictional context of health care provision, and the second relates to the demand for services that outstrip the current resources. In Canada, the provision of health services is a provincial responsibility, and each province and territory has its own health system and legislation, including civil commitment laws. Mental health care in all correctional institutions is governed by the mental health act of the province or territory in which it is located, regardless of whether the institution is a federal or a provincial one. The Criminal Code derives from federal legislation, but pretrial inmates and all inmates serving sentences of less than two years are a provincial responsibility. Federal corrections, known as Correctional Services of Canada (CSC), provide services for all prisoners sentenced for two years or longer. Service and delivery of health care in federal prisons are mandated by the Corrections and Conditional Release Act of 1992.71

There is no Canadian health service entity that could undertake delivery of services in all correctional institutions; to create one would most likely require legislative change. Thomas72 concluded that a full transfer of health care provision to a new pan-Canadian body is untenable at this time and that the focus should be on extending the partnership models where CSC maintains full responsibility for health care, but partners with the regional Ministries of Health for the delivery of specialized services. As it stands now, federal regulations require the provision of “essential health care” and “reasonable access to mental health care.” Every institution is required to provide an appropriate clinical response for inmates with an SMI, which includes being placed under close observation of trained staff, assessed by a health professional, and provided support and treatment. A specialist should be available for consultation “at all times.” Transfer to an appropriate health care facility should be available “as soon as possible.” Before disciplinary action is imposed on an inmate identified as having an SMI, consultation should take place with a mental health professional. Inmates with serious acute or chronic mental health problems should be housed in an environment that offers a safe and therapeutic milieu.46 In recent years, this CSC mandate has necessitated significant increases in resources for mental health services in federal institutions.

Progress

In 2004, the CSC instituted a Mental Health Strategy that included an Institutional Mental Health Initiative (IMHI) focusing on intake screening, assessment, and primary mental health care teams. Included in the IMHI is a computerized intake screening system to signal inmate mental distress, which can then be further assessed with a view toward developing an individualized plan by a Primary Mental Health Care Team. To assist in SMI inmates’ reintegration into the community, the CSC implemented a Community Mental Health Initiative (CMHI), which included hiring new staff (discharge planners, mental health care specialists, and parole officers), providing staff training, and working with community health organizations. The IMHI coordinates with the CMHI teams to provide a continuum of care.73

CSC has also established five specialist psychiatric care units, called regional treatment centers. CSC acknowledges that bed capacity in these centers meets only 50 percent of the identified need,46 resulting in occasional double bunking of inmates in segregation. Notably, three of the five women’s facilities in the Atlantic, Quebec, and Prairie regions have an exemption that allows double bunking of women offenders in their secure (maximum security) units. In some provinces, CSC has an arrangement with a provincial hospital to accept transfer of inmates needing acute mental health intervention. This model has shown positive results, and the CSC has recommended expanding this availability for SMI inmates who cannot be treated at specialized psychiatric care units.72 The tragic death by suicide in 2007 of Ashley Smith, a 19-year-old woman detained in a federal institution, has been a significant stimulus to improve services. Several investigations produced broad recommendations for change and spurred dialogue between the CSC48,72 and its critics.74,75 Correctional Investigator Howard Sapers74 recommended a broad review of the provision of mental health care in correctional environments and the consideration of alternative models of care. Needs identified for improvement include training for correctional staff regarding care provision for inmates with mental health needs, triggers for notification and investigation (including self-injurious acts and lengthy segregation periods), consultation by mental health professionals, and improvement in the ease of transfer to a specialized care unit or a hospital.

CSC responded to the call for considering alternative models of care.72 Given the complexities of geography and differing provincial health systems, a one-size-fits-all approach was not feasible across Canada. Instead, a continuum of care was presented that ranged from having CSC be responsible for the health service but contracting various mental health professionals to staff clinics (the usual service model) to the full transfer of responsibility of all health service delivery to provincial health authorities. The latter has been accomplished in some provincial institutions in Nova Scotia and Alberta, as it has in other international jurisdictions such as Norway and the United Kingdom. These transfers, not only of services but also of the legislative responsibility of health care provision, have been costly; a similar proposal in New Zealand failed primarily because of funding concerns. The transfer of health services from corrections staff to health-trained and dedicated staff seems, prima facie, to be beneficial with respect to access, quality, and standards of care. Such a shift in responsibility allows for more effective transition on reintegration into the community, and a strengthening of the voice of mental health services in the correctional environment.

As noted, the multi-jurisdictional context of the Canadian health system makes planning for prison mental health services complex. It was only in 2007 that the government of Canada mandated that the Mental Health Commission develop a national strategy for mental health care.3 This document was released in 2012. It included recommendations to reduce the overrepresentation of persons living with mental health needs in the criminal justice system and to provide appropriate services, treatment, and support to those who are in the system. Although progress has been made in meeting the mental health care needs of Canadian prisoners, further resources and planning are necessary. For example, a proposal to create dedicated intermediate care units on a regional basis to support specialist psychiatric care units has not been funded. These units fall between care provided at a mainstream correctional institutions and acute inpatient care offered at the specialist psychiatric units.46 Further, barriers to providing mental health care in the correctional system include poor recruitment and retention of mental health professionals, inadequate bed space at specialist psychiatric care units, lack of funding, underutilization of clinical management plans to treat high-needs mentally disordered offenders, and over-reliance on segregation to manage offenders with mental health problems.46,76 Wait times for psychiatric assessment have been increasing in the past decade because the increasing number of persons to be assessed is outstripping the forensic mental health services’ ability to respond.77

Discussion

This review touches on some key points in the large and expanding area of public policy, clinical need, and research. Persons with SMI in the criminal justice system are some of the most marginalized, disenfranchised, and underserved patients in need of mental health care. Their increasing number appears to be a result of both tougher criminal justice policies and limited community mental health services. They are hard to engage, frequently receive few or no services, and can rapidly drop out of care after release into the community. The lack of continued care leads to problems of disability, social instability, substance misuse, illness, and criminality. These problems are not insurmountable. Inmates with SMI respond to treatment and benefit from well coordinated services. These services must be run in partnership between health and correctional systems. Given current government policies that cause an increase in the number of prisoners, the need for service development is becoming more acute and demands a coherent service and policy response. We know too little about the trends, needs, and service models for persons with SMI in prisons. We also have limited understanding of the effects of incarceration on persons with SMI.

We cannot assume that the problems will be the same for male and female inmates, for pretrial and sentenced populations, and for aboriginal groups. However, as most people are cycling through prison for short periods, imprisonment represents a vital opportunity for detecting the need for mental health treatment and attempting to link people with local community mental health services in concert with probation services after release. The successful FACT models point to a way of doing this more effectively than simply expecting mainstream community mental health services to provide care.

This article has focused on in-prison and point-of-release concerns, but comprehensive services in this area must include diverting minor offenders before incarceration through court and jail diversion programs and liaison with police services. Further, substance misuse treatment must be included along with the package of care that inmates receive during incarceration and on release.52 This is a challenging but very important area of service development. Unfortunately, too often the health and correctional sectors place the blame on each other for these problems. Corrections attribute the increased prevalence of mental illness in prisons to a failure of the health care system. Health says that it is a result of criminal justice policy and poor social environments. Regardless of the explanation, prison inmates with SMI require integrated health and correctional responses. This problem is not the responsibility of one sector or another; it is a human challenge for both.

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29. Reflections on Chad and Sudan – The Rule of Law

December 29, 2013 By StevenCohen-CAMH

I get parking tickets now and again. It happens. Here’s how the conversation went semi-recently:

I got a ticket

Oh, that sucks.

Kind of.

You’re just saying that, of course you’re pissed.

Nope, not pissed at all. In fact, I get a slight rush of happiness when I get a ticket.

uh… wha?

Growing up in Thornhill, Ontario was a standard, Canadian, secular-cloistered environment. When I started driving, at around 16/17, I would occasionally get parking tickets and feel hard-done-by. When I was driving and heard sirens behind me, my stomach would drop. Thankfully I never got a speeding ticket, but still, I recall the quasi-instinctive fear of the law. This feeling more or less diminished throughout my life, but the residues remained; tickets are a bad thing.

In Chad, there is no rule of law that is worth mentioning. There was a local administrator in Farchana, and often I was trotted along to negotiations now and again as it was viewed as a sign of respect to bring medical team members to meetings. The fellow could be abrasive and accusatory, and other times could be downright pleasant. He could do whatever he wanted. He had a type of power that is unknown in other parts of the world. He could set the truth conditions for the world around him, if only a small chunk of the world. That which he said was wrong was wrong, and his word was generally unquestionable. Negotiations were delicate, to say the least.

This fellow casually stated one afternoon, during a meeting, that he allowed MSF to maintain its medical mission with relative safety. Nobody doubted this.

During a car-jacking, as I mentioned in a previous post, an ex-pat humanitarian aid worker from France was shot in the head. His death may not have been entirely accidental, and the repercussions for the local community was effectively absent. This was a sanctioned occurrence, it appeared.

Harsh, arbitrary and radically discretionary punishments, meted out by the local warlord was the way of life. Human rights were negligible. Women’s rights were almost non-existent. This was the furthest thing from a meritocracy I had ever seen, and it made me sick to my stomach. It struck me for the first time how crucial the rule of law is to undergirding civilization. (I wondered what other fundamentals were necessary and sufficient, such as payment of living wages, adoption of the scientific method, etc.)

Back to modern day Toronto. The fact that one can leave their car for an extra 20 minutes for which payment was not made, and there is a surveillance system that is generally fair, universal, enforceable and contestable is a great achievement. A seemingly small thing, but flowing from an absolutely necessary, and in a way, a wonderful system. Even if I’m out $30 for tarrying a bit.

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15. The Marabou Picnic

April 18, 2008 By StevenCohen-CAMH Leave a Comment

One of the more conspicuous aspects of psychiatric work is that we deal with syndromes and diseases whose defining elements are often invisible. You can’t see a “depressive or anxiety disorder” in any definitive way, and would usually have no way of telling whether the person beside you on the bus or at the market has schizophrenia. You could say this for so many ailments, but few medical disciplines so completely lack genetic or physical markers, biochemical tests or imaging technologies that we can deploy to confirm or deny our suspicions. We listen, ask questions, and listen some more, and eventually fashion a clinical story that makes sense. And this brings us to Farchana camp, a veritable village of 20,000 Sudanese refugees who have for generations relied on “marabous” as the healers and vessels of a long history of orally transmitted knowledge. A marabou, of course, has his or her their own way of taking these empirical facts such as “feelings of sadness,” “decreased appetite,” “nightmares,” or “confusion” and making sense of them. About four or five years ago, when hundreds of thousands of Sudanese herders, farmers and nomads fled Darfur, they brought their practitioners and practices with them. Along came MSF, shortly there after, and the two healing systems have worked side-by-side, in a way, but with almost no contact. You gotta wonder, who are these people? What do they do and why? And what do they think of us? So I decided to ask.

After over a month of planning and a broad invitation, we received this week about 20 “healing” marabous to our mental health services. “Marabou” is the term given to Sudanese traditional healers, and could be translated into “teacher” in English, or maybe more accurately into the way the Japanese use the term “sensei.” It refers to someone who has attained mastery in a field, and uses that mastery to guide others. I wrote previously about three subtypes of marabous: 1) Imams, or scholarly religious leaders; 2) Faux marabous who have no real training, and practice their charlatanism on the credulous; and 3) Healing marabous, who have apprenticed in the therapeutic use of Koranic verse, botanicals, insects, small animals and their by-products for ingestion or ritual practices. When asking around, I found that these healing marabous are usually venerated by the Sudanese, although some scoff at them as well. Either way, well over half of our patients see marabous for the same symptoms for which they come to our mental health services, sometimes in parallel and sometimes after one or the other system has “failed” to meet expectations. Marabous were in this Sahelian region of sub-Saharan Africa well before MSF showed up, and’ll be here long after we’re gone so I figured that it would be clinically useful to sit around a table, munch on nuts, drink sugar-tea and start a dialogue. And, yeah, I thought it could be kinda trippy, too. This is what happened.

Pretty much everyone arrived at once, and I was giddy to have the opportunity to meet them. After some introductions and polities, they were informed of our “rule” in mental health services, that “anyone can say pretty much anything at any time, and nobody needs to put up a hand to request to talk… if people talk at the same time or disagree, it is like family.” For some reason, this seems to set the right tone here.

Who do you feel is best treated by marabous?

The room was silent for about ten seconds, which seemed like a long time. Most of the group, which consisted of men in white Jalabias (long shirts over a fair of pants), and one woman wearing a bright orange stole, were studiously avoiding eye contact; there was no “predetermined leader” here. I was going to paraphrase when one fellow in the corner promptly said that for every person that comes to him for treatment, he sends them to MSF’s Health Center for a first-pass assessment. And only if MSF’s shot at things is found ineffective, the marabou will then offer treatment. I double-checked to make sure that I’d heard correctly, and then polled the room to see if this was standard practice or a one-off thing. No dissent… nodding heads and few more statements indicated that this was the norm. Wow. It’s possible that we had a biased sample of marabous, and the ones who were less enthralled with our services did not stop by for tea, but again the group said that this was not the case; they liked the fact that we were there, and trusted our services. Marabous come to MSF all the time, they said, we’re “good for some things.”

What ailments are the most common for which people seek their services?

“For invisible things” was the answer. The list includes joint pain, back pain, change in eyesight, bone pain, infertility, head-ache, insomnia, stomach troubles, malaise, and fast heart-rate (what I assume meant palpitations). This is basically a list of non-specific and chronic symptoms for which there is often no good diagnosis nor treatment in the allopathic Western medical system (e.g., a Canadian hospital). One fellow added that for “nightmares” he’ll just jump straight in and forego the “referral” to MSF.

So what does a marabou offer?

The first and by far most commonly used treatment is translated as “black water” or “sacred water.” A small object shaped like a star is placed in the Koran at a random page, and when the verse that it touches is read, it hints at both the diagnosis and treatment. On a wooden board, this verse is written alone or with a few others. The ink used to write the words is scraped off and put into some water, and mixed with a specially made concoction of herbal, animal or mineral elements, and is then drunk by the patient. The most common examples given were roots and ground-up insects, but the phrase “it’s complicated” came up a few times. The marabous wait two days and then adjust the concoction depending on the result of the first trial. One marabou suggested that if two trials do not work, or if the symptoms change, then the person is sent back to MSF, but others had a few other possibilities for treatment: A beaded necklace could be used to direct the prayers of many Imams, if need be; or concoctions could also be applied to various body parts, although I could not really understand which ailments routinely called for this approach. There is also another ritual whereby the tip of a ram’s horn is inserted under the skin of the chest of a man who has heart troubles, and some “bad blood” is removed. A specific ointment may be placed on the skin, and the quality of the scar indicates the success of the treatment and an indication of the quality of the remaining malady. These were some of the examples given, but there was not enough time to explore much more into their local significance, unfortunately.

What happens if the service is ineffective?

Success, I was told, is guaranteed or you get your money back. Initial payment can be cash, some food, or, if it’s a complicated ritual, a goat. One question that I’m still very interested in asking at a subsequent meeting is “what counts as a positive outcome?” But we were running out of time.

We finished the tea and nuts and asked at the end if there were any comments or questions that the marabous had for us at MSF. The only one that came was “how can you afford to do this?” MSF runs a big operation in Farchana. We have seven ex-pats, over 50 national staff, and over a hundred Sudanese employees (like the counselors and community health workers with whom I work most closely). Apart from the health center, there is a busy maternity center and nutritional center, and, of course, our mental health services, which has about 500 “patient visits” per month. Over 85% of all the births in the camp happen in our centers, which run 24 hours a day. And if the job is too big for us (we don’t do surgery here, for example), then ambulances are available at all hours to take patients to a nearby town where there is an MSF team with surgical services. And, of course, all of this is free. So how we pay for this is a fair question, but it still came as a surprise. I’m Canadian, and free health care is what we do… the idea of anyone paying for health care seems distasteful. But it’s not taxes that have subsidized the exporting of socialized medicine to the eastern border of Chad, and since I don’t know how to say “good will” in French, I told him the other commonly-used phrase in our mental health clinic: “we’re all in this together.”

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13. Trauma, Empathy and Counselling

April 2, 2008 By StevenCohen-CAMH Leave a Comment

(In the following story, names and minor details have been changed for confidentiality).

Ahmed, one of the national staff pulled me aside today. He hesitantly asked if he could speak with me about a member of his family who was “traumatized,” and specifically how he could help. This is the story that was told to me. Several weeks ago, Amane, his 32 year-old first cousin was fleeing violence in N’Djamena, the capital of Chad. Fighting had escalated quickly and within 24 hours parts of the city were destroyed and looting and random violence were rampant. Amane, her husband and their two children decided that it would be safer to flee at night, but she became separated from her husband and continued to the bridge to Cameroon with her two children, a 5 year-old daughter and a 9 year-old son. Many people left N’Djamena for the villages outside the capital or fled to neighbouring Cameroon (UNHCR registered over 30,000 Chadian refugees).

I imagine that the 500 metre-long bridge was a welcomed sight. There are three bridges across the Chari river, and the closest for Amane was single-laned, large enough for one truck and a few feet on either side. Enterprising boat-owners were cashing in on the chaos, charging people up to 10,000 CFA (CAN $24) for passage across the short channel, but few could afford this and opted for the walk. Stories tell of the flood of frantic people pushing to get by the abandoned vehicles to the other side. The walk that normally takes fifteen minutes took up to three hours. I’d like to think that it was to avoid the danger of her small children being trampled that Amane steered toward the side of the bridge, but it was probably bad luck and the madness of the crowd that pushed them against the rails. And it was in this same madness that her children fell over the edge, into the water about 20 feet down. There were no lights at all and when they fell, there was probably no way to see them in the dark water. Ahmed tells me that Amane tried to jump in after them but people held her back, and she finished crossing the bridge not knowing whether her children were dead or alive.

It’s been over a month and they have not been found, and Amane has been taken to live with her husband’s extended family in a quiet village far from the capital. I’m told that she sits with others at meal-times and looks as if she is “in a daze.” She doesn’t talk, eat, or make any emotional contact most of the time, and when children are playing nearby, she often breaks into tears and has to get up and leave. At night Amane is not able to sleep for longer than an hour; she wakes up crying, calling out the names of her children. In the early morning she often informs her family that she needs to go to the market “to see her kids,” but given that loud sounds and sudden movements cause her great distress, a trip to the market would be quite difficult; she has not been able to leave the house for weeks. Soon her sisters will visit, and the family hopes that this will help.

Steven Cohen CAMH door

Of course, one cannot make a diagnosis without a full in-person assessment. But it does appear that Amane may suffer from a constellation of symptoms that is labeled in the Western psychiatry manual, the DSM-IV-TR, posttraumatic stress disorder (PTSD). The label in-itself is not so helpful, and there have been other names of syndromes that collect and organize symptoms of re-experiencing, numbing, and hyper-arousal in other ways. The diagnosis is a bit of a misnomer, too, as in many situations the threat and actuality of trauma continues, so there is nothing “post” about it. But what is PTSD? And how does our understanding of its origins lead us to treat psychological trauma?

PTSD is a malady of memory. To function well, we need the capacity to remember some things and to forget (or dull) others. It is good to remember that touching a hot stove is dangerous, and in a near-literal way, this memory is seared into our minds by virtue of the pain—and emotional arousal—of the moment. But we need to dull this memory allowing us to attempt to use the stove again, albeit more cautiously. In PTSD, this natural dulling of the emotional tone of a bad incident is thrown off, and the smallest sound or sight takes you right back to the pain; in a real sense, every night since, Amane may be back on that bridge, with all the horror, helplessness, and loss. The adaptive “high-alert” vigilance that helps her keep safe when cooking on hot stoves has turned against her, like a disease of adaptation, and now exhausts her resources. Any loud sound or unexpected movement can be perceived as a threat, and it is this distorted threat-appraisal that must be unwound. In a manner of speaking, our sense of who we are (our “self”) is bounded by the ability to remember and to forget, and if one is compromised, we lose who we are.

The question of what can be done to help Amane and so many other people who continue to suffer in this way, must be split up into two questions: 1) How can we prepare ourselves for this type of calling, and 2) What can we do to help? The rest of this blog will answer the first question, and the second question will be the subject of the next entry.

1) Preparing to listen

In blog #11, I gave an account of the narratives of Fatna and Ibrahim, which were quite emotional for me. A few days later, a friend from Montreal wrote a comment asking what we do in our mental health team to protect against “vicarious traumatization,” which means in this case a counsellor being themselves traumatized by hearing such difficult stories. It’s a good question. One has to balance empathy with self-preservation, while doing honour and justice to the integrity of the patient, his or her narrative, and the attendant empathic emotions that they evoke. A therapist needs to be able to withstand the brutal side of empathy to simply bear witness to it. In psychiatric terms, the ability of a person to do this is their “negative capacity.” In my opinion, the role of a good therapist is to facilitate a surface upon which meaningful communication can flow. And we have to prepare ourselves for a torrent of words and emotions… whatever may come, a counsellor must be capable of simply letting the moment happen.

As you can imagine, discussion among our team of counsellors gets heavy at times. We go from laughing about small things to presenting difficult cases to the group and getting support and counsel from each other. We talk of our patients, and of our experience of being with them. Once a week, two hours are set aside for this exact purpose, and other “supervision” times are available, too. (Of note, 24-hour psychological support is available for MSF staff.)

It quickly becomes clear that fear and pity can be dangerous if they lead to a paralyzed empathy and inaction. Through these discussions, in a number of ways, we become more familiar with the pain of suffering, so that we can contain the harshness of it, rather than have to dissociate, isolate, or destroy within us that which resonates with it. This does not minimize the horror of the situations or stories that we witness and feel, but it increases our negative capacity, or ability to withstand it. And by doing so, we can attend more closely to our patients rather than to ourselves.