The Forensic Early Intervention Service A New Facility, A New Approach

1. The Forensic Early Intervention ServiceA New Facility, A New Approach Forensic Early Intervention Service, Centre for Addiction and Mental Health Andrea Monteiro, Deputy Superintendent Treatment & Programs, Toronto South Detention Centre Provincial HSJCC Meeting - November 18, 2015

2. The Toronto South Detention Centre • The TSDC became operational in January 2014. • The TSDC replaced the Toronto Jail, Mimico Correctional Centre and Toronto West Detention Centre. • When fully operational the TSDC will have the capacity to house: • 1650 adult male remand inmates • 320 intermittent offenders (weekend only)

3. TSDC Security • The design of the TSDC provides internal safety and public safety through state-of-the-art security and is one of the most environmentally friendly facilities in the province. • The TSDC is a maximum security facility which refers to the physical security design of the facility. • The facility’s state of the art security system is supported by using the latest security applications - closed circuit television, touch screen technology, metal detection and scanner systems.

4. Inmate Population & Statistics • The majority of the inmates at TSDC are remanded – awaiting court dispositions, a small portion are serving provincial sentences. • The average length of say for a remanded inmate is 34 days. • Majority of the inmates are from the Greater Toronto Area. • The TSDC’s inmate population presents with diversity that reflects the diverse GTA community. • Although the facility is running at an average capacity of 890 inmates, we currently have approximately 160 releases a week: • 100 at Court • 30 via TSDC • 30 via TIC (Weekend Only)

5. TSDC Unit Configuration:November 12, 2015

6. Direct Supervision • Direct Supervision is a progressive, proactive correctional management system that places Correctional Officers in a more normalized housing unit, in direct contact with inmates. • This method of supervision is premised on managing inmate behaviour through personal interaction/communication. • Direct Supervision was first developed by the American Federal Bureau of Prisons in the 1970’s. • The Vancouver Pre-Trial Centre opened in 1983 as the first Canadian Direct Supervision jail. • Today, Direct Supervision facilities can be found on all five continents.

7. Toronto South Detention Centre - Toronto Intermittent Centre

8. TSDC Direct Supervision Living Unit

9. Direct Supervision & Internal Classification • The success of the Direct Supervision model and one of the most critical tools for staff to effectively supervise inmates at TSDC is the internal classification and placement of inmates.

10. Direct Supervision & Internal Classification • The classification of inmates at the TSDC begins at A&D and enables the proper internal placement of inmates in order to: • Separate violent inmates from those who display more pro-social behaviour; • Identify inmates who have special needs; • Identify inmates with specific programming needs; • Ensure that inmates are placed in the least intrusive level of security based on their individualized needs; • At any given time, it is expected that approximately 5-7% of the TSDC inmate population will not be suitable for placement on a Direct Supervision Unit.

11. TSDC Indirect Supervision Unit

12. TSDC Special Needs Beds

13. Mental Health Assessment Unit

14. Forensic Early Intervention Service (FEIS) An Introduction and Early Findings Provincial HSJCC Conference: Mobilizing Community: Promoting Resiliency, Sustaining Recovery and Restoring Justice. November 18, 2015 Dr. Kiran Patel, Forensic Psychiatrist, Complex Mental Illness Program Kiren Sandhu, MSW, RSW, Advanced Practice Clinician, Complex Mental Illness Program Katy, Konyk, MSW, RSW, Forensic Early Intervention Service Elissa Aknay, MSW, RSW, Forensic Early Intervention Service Seby Joseph, MSW, RSW, Forensic Early Intervention Service

15. Overview Forensic Early Intervention Service (FEIS) CAMH Integrated Care Pathway Brief Jail Mental Health Screen (BJMHS) Jail Screening Assessment Tool (JSAT) Roles and Responsibilities: Toronto South Detention Centre (TSDC) and FEIS Program Data Challenges Case Study: John Future Directions Discussion/Questions

16. Forensic Early Intervention Service (FEIS) • A collaboration between: • Centre for Addiction and Mental Health (CAMH) • Ministry of Community Safety and Correctional Services (MCSCS) • Ministry of Health & Long-Term Care (MOHLTC) • Partially operational at TSDC since January 15, 2015. • Multidisciplinary team

17. Forensic Early Intervention Service (FEIS) The FEIS program compliments the mental health services provided by TSDC The goal is to enhance timely access to acute forensic services for individuals identified with specific forensic mental health needs or at risk of falling under the mental disorder provisions as defined by the Criminal Code of Canada (CCC)

18. FEIS Inclusion Criteria The inmate/client has been found unfit to stand trial The inmate/client is experiencing a condition or illness such that their fitness to stand trial may be in question The inmate/client is at risk of becoming unfit to stand trial The inmate/client is undergoing a criminal responsibility assessment The inmate/client has been ordered to CAMH under the CCC and is awaiting admission to hospital

19. Screening STAIR MODEL Triage Assessment Intervention Re-Integration Release into community Admission Period of Incarceration Dr. Alexander(Sandy) Simpson, March 2015. Prison mental health care: Issues and questions. Faculty of Forensic Psychiatry Annual Conference 2015, Budapest.

20. FEIS Intake Pathway

21. FEIS: Integrated Care Pathway (ICP) What is an ICP? “ …a multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes”. (Middleton, Barnett, & Reeves, 2001). Provides detailed guidance for each stage in the management of care for a patient with a specific condition over a given period of time. Focused on improving the overall spectrum of clinical practice in a measurable way.

24. Triage & Assessment

26. Brief Jail Mental Health Screen (BJMHS) A brief screening tool used to determine the need for further mental health assessment and treatment 8-item tool Quick and easy to administer Validated tool in identifying individuals with mental health problems Screens for mental health symptoms, history of hospitalization, and current medication use (Steadman, Scott, Osher, Agneses, and Robbins, 2005).

28. Brief Jail Mental Health Screen (BJMHS)Items 1-6 Do you currently believe that someone can control your mind by putting thoughts into your head or taking thoughts out of your head? Do you currently feel that other people know your thoughts and can read your mind? Have you currently lost or gained as much as two pounds a week for several weeks without even trying? Have you or your family or friends noticed that you are currently much more active than you usually are? Do you currently feel like you have to talk or move more slowly than you usually do? Have there currently been a few weeks when you felt like you were useless or sinful?

29. Brief Jail Mental Health Screen (BJMHS)Items 7 & 8 7. Are you currently taking any medication prescribed to you by a physician for any emotional or mental health problems? 8. Have you ever been in a hospital for emotional or mental health problems? Positive Screen: Answers yes to item 7 or item 8 Answers yes to at least of 2 of the items 1 through 6 Further mental health assessment required

30. BJMHS RATINGS FEIS Clients (n=55) Item #7 (medication) – 50% Item #8 (history of hospitalization) – 59%

31. Jail Screening Assessment Tool (JSAT) Nicholls, Roesch, Olley, Ogloff, & Hemphill, 2005 FEIS triage tool Semi-structured assessment tool Utilizes structured professional judgment to make referrals and recommendations

34. Jail Screening Assessment Tool (JSAT) Legal situation Violence issues Mental health treatment Social background Substance use

35. TSDC Role and Responsibilities Regarding FEIS • Complete BJMHS on all new admissions • Refer inmates that screen positive on BJMHS to FEIS • Identify individuals at risk and refer to FEIS when appropriate • Review recommendations received from FEIS • Coordinate treatment plans with FEIS

36. FEIS Role and Responsibilities at TSDC Complete a full assessment on all referrals Develop an inter-professional service plan for all clients meeting the inclusion criteria Communicate assessment outcomes and recommendations to TSDC staff Collaborate with TSDC staff in the further development and refinement of treatment plans Remain engaged with clients who meet inclusion criteria

37. FEIS Role at Court Work with CAMH’s Court Liaison Team, bridging the gap between forensic hospitals, the courts, TSDC and other facilities in Ontario Coordinate admissions to forensic hospitals across Ontario where a Treatment Order or Assessment Order has been issued by a judge Communicate court outcomes for current and potential FEIS clients to TSDC and FEIS team Flag individuals returning to custody who could benefit from TSDC mental health services and potential FEIS involvement

38. FEIS Interventions Provide continuity of care (smooth transition/coordination of information between correctional facility, court and CAMH Assessment & Triage Unit). Help people in custody reconnect with families and community supports Brief therapeutic interventions (supportive counselling) Psycho-education Coordinate discharge plans to minimize re-incarceration

39. FEIS Referrals

42. Anticipated Impact of FEIS Reduction in the number of persons requiring fitness to stand trial assessments because of earlier treatment interventions Improved demand management into the forensic system because of earlier engagement and case detection Improved court efficiency through enhanced clinical coordination and communication regarding inmates presenting in court Reduction in number of treatment orders and keep fit orders issued

43. Challenges Environmental challenges Rapid turnover: (average stay 34 days) Client may be released from facility prior to initial assessment Inability to complete a thorough release plan due to rapid turnover Difficulty engaging certain clients due to high acuity, aggressive behaviour, and/or limited desire to engage with mental health professionals Limited community resources to make referrals (long waitlists)

44. Case Example: John TSDC Staff Reported: • Consent obtained from client to share case example • Client appears paranoid and delusional • Client is refusing to eat • Client is staring at the window and toilet paper in his cell TSDC Observations: • Actively suicidal • Engaging in self-harm • Spitting at staff • Assaultive towards staff • Eating soap & swallowing pencils • Throwing feces and urine at staff

45. Case Example: John Demographics: • 19 year old single male • Immigrated to Canada in 2011 (at age 15) From East Africa • Refugee status • No family in Canada Mental Health: • Schizophrenia • Anti Social Personality Traits Current Charges: • Attempted murder • Aggravated assault with a deadly weapon • Abandoned few days of his arrival in Canada • Ended up at Youth Shelter in GTA • Involvement with CAS until he turned 18 • Significant difficulties adapting to transition to Canada • Struggled to adjust with foster parents, CAS group homes • Arrested under Criminal Youth Justice Act

46. Case Example: John FEIS Interventions: FEIS physician made medication recommendations Provided education to the client and lawyer about the forensic mental health system Referred to TSDC services (chaplain) Encouraged client follow his treatment plan using motivational interviewing

47. Case Example: John Client Update: Over time client was compliant with medication Eating and sleeping well No behavioural issues reported by correctional officers Transferred to a less secure unit with increased privileges NCR Assessment (May 2015) Found NCR (September 2015) Transferred to a forensic hospital (October 2015)

48. Future Directions Model could be adopted in other correctional facilities Advocate for additional mental health supports for jails across Ontario Ongoing evaluation of FEIS Research opportunities Improved coordination between the court, correctional facility, and the mental health system Completed FEIS Integrated Care Pathway (ICP)

49. Questions? Andrea Monteiro Toronto South Detention Centre (p) 416-354-4030 ext. 1040 (e) andrea.monteiro@ontario.ca Tanya Connors MSW, RSW Centre For Addiction Mental Health (p) 416 535-8501 ext. 32252 (e) tanya.connors@camh.ca