CanJPsychiatry 2015;60(3):93–95

The Canadian Journal of Psychiatry Volume 60, Number 3

March 2015

Guest Editorial

A Valuable (and Ongoing) Study, the National Trajectory Project Addresses Many Myths About the Verdict of Not Criminally Responsible on Account of Mental Disorder Patrick Baillie, PhD, LLB1 1

Psychologist, Alberta Health Services, Calgary, Alberta; Consulting Psychologist, Calgary Police Service, Calgary, Alberta; Lawyer, Calgary, Alberta; [email protected].

Key Words: NCRMD, insanity, mental disorder, Criminal Code, Bill C-14, Bill C-54, criminal responsibility Received and accepted August 2014.

open access

W

ithout a doubt, politicians of whatever stripe should be permitted to determine public policy based on personal preferences and party positions. Shift tax burdens to different income groups? Change the legal age for purchase of alcohol (or marijuana)? Impose additional conditions on new, young drivers? People elected to make decisions about legislative interventions should feel free to do so based on whatever variables matter to them. What is particularly frustrating to at least some of us from a more scientific and less political background is when major policy changes occur in the absence of—and sometimes directly contrary to—what quality research has shown to be the current truth. For example, in early 2013, the federal government introduced what was then Bill C-14, amending the mental disorder provisions of the Criminal Code and the National Defence Act, specifically those provisions relating to people found not criminally responsible on account of a mental disorder (NCRMD). The changes included the introduction of a new high-risk accused category, which, when imposed by a court after a finding of NCRMD, limits that person’s access to community treatment supports and a review board’s (RB’s) discharge options. One factor, among several, to be considered by the court is the brutal nature of the act perpetrated by the accused person in the alleged offence. Passed and proclaimed (as Bill C-54 when reintroduced later in 2013), the new rules came into effect on July 11, 2014.

In some ways, this legislation played into certain beliefs about NCRMD, among them the notions that most NCRMD cases involve serious personal violence, that the verdict is used far too frequently (and conveniently, as when someone wishes to fake a mental illness to avoid punishment), and that, after a brief period of hospitalization, those found NCRMD are released back to the community where they promptly reoffend. What stood out most in the debate about the bills was the nearcomplete lack of discussion of any data addressing the key elements of the legislation. Certainly, Latimer and Lawrence1 had, in 2006, told us that the verdict of NCRMD is actually quite rare (occurring, they said, in 1.8 per thousand criminal cases per year in Canada). Nonetheless, little was known about the types of cases in which the verdict is found, the characteristics of people found NCRMD (for example, prior mental health histories, prior criminal histories, primary diagnosis, relationship and housing status, sex, and Aboriginal status), the lengths of hospitalization and treatment in the community, and the occurrence of recidivism. Then, along came the results of the National Trajectory Project (NTP), which provided the data that underscore 5 of the papers included in this issue of The Canadian www.TheCJP.ca

The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 93

Guest Editorial

Journal of Psychiatry.2–7 Described by the thoroughly dedicated Dr Anne G Crocker and her brilliant colleagues (particularly Dr Tonia L Nicholls, Dr Michael C Seto, and Dr Gilles Côté, ably accompanied by Yanick Charette, Dr Catherine M Wilson, Leila Salem, and Dr Malijai Caulet) as the “first longitudinal cohort study comparing provincially representative samples of NCRMD–accused people”3, p 103 to have been undertaken since the 1992 changes to the mental disorder provisions of the Criminal Code, the NTP gave us (and the government, which, through Justice Canada, sought early access to the data) a detailed picture of the verdict, its people, their histories, and their outcomes. For example, we now know, from this comprehensive review of 1800 patient files in Quebec, Ontario, and British Columbia, that marked provincial differences exist in the overall rates of NCRMD cases (Quebec having proportionately many more) and in changes to those rates (with Quebec increasing and British Columbia decreasing). Additionally, we now know that a person found NCRMD in Ontario is more likely to be under RB supervision for a longer period than in Quebec and British Columbia, and is more likely to remain in hospital while under supervision. Moreover, we now also know that no statistically significant differences exist between provinces regarding the proportion of NCRMD–accused people who had a history of prior mental health hospitalizations and regarding sex distributions of NCRMD–accused people. We now know that 51% of this large sample had no prior criminal convictions before the incident giving rise to the finding of NCRMD, but that 72% had at least 1 prior mental health hospitalization (and an average of 3 hospitalizations when looking only at people who had a mental health history). We now know that while most (65%) of the underlying index offences involved acts against a person, family members of the accused person (and often the parents of the accused person) were the most common target, followed by police and mental health workers. Strangers were a relatively infrequent target (being the victims in 22.7% of those offences against a person). We now know that 3.2% of the index offences resulted in the death of the victim. Further, we now know that women accounted for 15.6% of the NCRMD population, and that Aboriginal heritage was identified in just 2.9% of cases. (In the parliamentary debates, no politician ever mentioned the potentially different needs of women and Aboriginal NCRMD–accused people.) Three-quarters of the sample group was on government assistance at the time of the index offence and 1 in 10 was homeless. We now know that the most common primary diagnosis was a psychotic spectrum disorder, with one-third of the sample having a co-occurring substance abuse problem. We now also know that there are some key sex differences that may inform treatment choices, with women being more likely (than men) to be diagnosed with a mood disorder or a personality disorder, but also being less likely to have a prior criminal history, less likely to offend against strangers, and more likely to be older at their first offence against a person. 94 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015

Regarding gender differences, then, women show fewer of the identified risk factors for recidivism, thus they may be at lower risk of reoffending when back in the community. However, we know that formal risk assessments occur in only a small minority (17%) of cases. And, finally, regarding recidivism, the NTP found a reconviction rate of 16.7% during a 3-year follow-up period, with the time frame starting at the date of the NCRMD verdict. Quebec, with the lowest median offence severity, had a higher recidivism rate than the 9.5% and 9.3% figures found in British Columbia and Ontario, respectively. During the entire follow-up period, ranging up to 8 years in some cases, a total of 13 cases of severe violent reoffence were identified from the 1800-patient sample (0.7%). People whose verdict of NCRMD stemmed from a serious, violent offence actually had the lowest 3-year recidivism rate—for any type of reoffence—(6.0%) of all groups. The primary diagnosis was not found to significantly influence risk of reoffending, but substance abuse, the presence of a cooccurring personality disorder (seen in 10% of the sample), and a prior conviction or finding of NCRMD were relevant factors that enhanced risk. In short, an informed debate about the legislation would have considered that most people who are NCRMDaccused have not committed offences involving serious violence, that the brutal nature of the offence tells us nothing about the risk of recidivism, that most people found NCRMD are already known to the civil mental system and are on government financial assistance (which easily could see other forms of assistance being added on), and that, measured by recidivism rates that are lower than those seen for people being released from jails and prisons, RBs (relying on the evidence put before them by dedicated mental health professionals working with people who are NCRMD-accused) seem to be doing a very good job of determining when conditions should be altered. Given the observed differences across the 3 study provinces, we should be cautious about assuming that national statistics accurately measure local circumstances. Adding information from the Prairie and Maritime provinces could enhance our understanding of the Canadian realities around people found NCRMD. Following up to see the impact of the new legislation could be another fruitful avenue of future study. Further research is already under way with the NCRMD population, looking at positive outcomes (for example, family reunification) and protective factors, such as social support. Since time immemorial, criminal law systems have considered the simple idea that an accused person should not be convicted when their illegal behaviour stemmed from a disease of the mind. A truly safe society does not change that established principle by incarcerating people with mental disorders—or by further stigmatizing them— but, rather, ensures that procedures are in place to protect both the individual and the public. What these papers2–7 and the NTP give us is an exceptionally valuable picture of how www.LaRCP.ca

A Valuable (and Ongoing) Study, the National Trajectory Project Addresses Many Myths About the Verdict of Not Criminally Responsible on Account of Mental Disorder

the processes surrounding NCRMD have been working. The answers are very much worth reading.

Acknowledgements

A significant portion of the financial support for the National Trajectory Project came through the Mental Health Commission of Canada (MHCC), with the Project having been endorsed by the Mental Health and the Law Advisory Committee of the MHCC. Dr Baillie served on that Advisory Committee and continues to serve on the MHCC’s Advisory Council. He acknowledges the support of the MHCC in this important research endeavour.

References

1. Latimer J, Lawrence A. The review board systems in Canada: overview of results from the Mentally Disordered Accused Data Collection Study. Ottawa (ON): Department of Justice Canada; 2006.

2. Crocker AG, Nicholls TL, Seto MC, et al. The National Trajectory Project of individuals found not criminally responsible on account of mental disorder in Canada. Can J Psychiatry. 2015;60(3):96–97. 3. Crocker AG, Nicholls TL, Seto MC, et al. The National Trajectory Project of individuals found not criminally responsible on account of mental disorder in Canada. Part 1: context and methods. Can J Psychiatry. 2015;60(3):98–105. 4. Crocker AG, Nicholls TL, Seto MC, et al. The National Trajectory Project of individuals found not criminally responsible on account of mental disorder in Canada. Part 2: the people behind the label. Can J Psychiatry. 2015;60(3):106–116. 5. Crocker AG, Charette Y, Seto MC, et al. The National Trajectory Project of individuals found not criminally responsible on account of mental disorder in Canada. Part 3: trajectories and outcomes through the forensic system. Can J Psychiatry. 2015;60(3):117–126. 6. Charette Y, Crocker AG, Seto MC, et al. The National Trajectory Project of individuals found not criminally responsible on account of mental disorder in Canada. Part 4: criminal recidivism. Can J Psychiatry. 2015;60(3):127–134. 7. Nicholls TL, Crocker AG, Seto MC, et al. National Trajectory Project of individuals found not criminally responsible on account of mental disorder. Part 5: how essential are gender-specific forensic psychiatric services? Can J Psychiatry. 2015;60(3):135–145.

Erratum Patten SB, Williams JVA, Lavorato DH, et al. Descriptive epidemiology of major depressive disorder in Canada in 2012. Can J Psychiatry. 2015;60(1):23–30. It has come to the authors’ attention that their article included an error in the lower bound of the confidence interval on page 27, line 12, of the January 2015 issue. The text should have read: “Therefore, this variable was initially removed from the models. In a model simultaneously adjusting for each of the remaining variables, the PR for female sex was 1.7 (95% CI 1.4 to 2.0, P < 0.001).” The Canadian Journal of Psychiatry regrets the error and any inconvenience it may have caused.

www.TheCJP.ca

The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 95

CanJPsychiatry 2015;60(3):96–97

Guest Editorial

The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada Anne G Crocker, PhD1; Tonia L Nicholls, PhD2; Michael C Seto, PhD3; Gilles Côté, PhD4 Associate Professor, Department of Psychiatry, McGill University, Montreal, Quebec; Associate Director, Policy and Knowledge Exchange, Douglas Mental Health University Institute Research Centre, Montreal, Quebec. Correspondence: Douglas Mental Health University Institute Research Centre, 6875 LaSalle Boulevard, Montreal, QC H4H 1R3; [email protected].

1

2

Associate Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia; Senior Research Fellow, Forensic Psychiatric Services Commission, BC Mental Health & Substance Use Services, Coquitlam, British Columbia.

3

Director of Forensic Rehabilitation Research, Royal Ottawa Health Care Group, Brockville, Ontario.

4

Professor, Department of Psychology, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec; Director, Philippe-Pinel Institute Research Centre, Montreal, Quebec.

Key Words: not criminally responsible, legislation, media, mental illness, criminality, mental health services, forensic mental health, Review Board Received November 2013 and accepted December 2013.

open access

W

hen the topic of mental illness is raised, few issues stir public and media interest, and generate as much controversy, as the verdict of not criminally responsible on account of mental disorder (NCRMD). Rare but sensational cases make the news, such as Vincent Li,1 found NCRMD for killing a fellow Greyhound bus passenger, and Allan Schoenborn,2 found NCRMD for killing his children. However, there is a firmly established legal doctrine in criminal justice systems around the world that recognizes that it is inappropriate to punish people who do not have the capacity to form criminal intent at the time of an offence. In Canada, section 16 of the Criminal Code defines the verdict of NCRMD as No person is criminally responsible for an act committed or an omission made while suffering from a mental disorder that rendered the person incapable of appreciating the nature and quality of the act or omission or of knowing that it was wrong.3

The increase in the number of people found NCRMD during the past 20 years,4 some recent high-profile cases, and the increasing voice of victim advocacy groups has brought to the forefront issues around processing and dispositions of people found NCRMD. The prominence of these types of cases has supported the current tough on crime approach to legislative reforms in Canada, including the trend toward longer detentions.5–7 The foundation of this approach is its appeal to the public desire for safer communities and decreased violence and crime. However, recent crime statistics have continued to show trends of decreasing criminality, and in particular violent criminality, in Canada.8 As our colleagues very eloquently demonstrated, current tough on crime policies are not supported by the current scientific evidence.6,7 In fact, theory (Risk-Need-Responsivity)9 and research firmly demonstrate that excessive intervention disproportionate to risk can actually increase the rate of adverse events, such as criminal recidivism, suggesting that the platform on which tough on crime laws are stationed are unstable and lacking an evidence base. Recently, the federal government introduced Bill C-54, which then became Bill C-14,5 now known as the Not Criminally Responsible Reform Act, which took effect on July 11, 2014. This legislative amendment to Part XX.1 of the Criminal Code on Mental Disorders consists of 3 main components, namely the explicit recognition that public safety is the paramount consideration in the decision-making process related to accused people found NCRMD, the creation of a new category of high-risk NCRMD accused, and the involvement of victims in the decision-making process related to people found NCRMD. Some elements of the act, particularly the high-risk designation and dispositions, run counter to the most recent scientific evidence on the trajectories of Canadian individuals found NCRMD. This legislative controversy in addition to the recent tough on crime policy trends6 are

96 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015

www.LaRCP.ca

The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada

likely to have significant effects on vulnerable populations, such as people living with a mental illness,7 and highlight the disconnect between evidence, public discontent, and current legislative policies in Canada.10 In this special section of The Canadian Journal of Psychiatry, we present the initial results of the National Trajectory Project.11 The National Trajectory Project investigated the trajectories of people found NCRMD in the 3 most-populated Canadian provinces (British Columbia, Ontario, and Quebec), each of which has a distinct organizational structure of forensic mental health services and varying general crime statistics. The goal of the study was to examine the operation of current criminal justice provisions for people declared NCRMD by the courts, and made subject to the jurisdiction of a provincial or territorial review board. This special feature addresses some of the current beliefs and perceptions about the NCRMD population and contextualizes some of the observed profiles and trends through 4 empirical papers following a detailed description of the methodology used to conduct the study across provinces (see Part 112). Part 213 provides a cross-provincial overview of the sociopsycho-criminological characteristics of people found NCRMD between 2000 and 2005. Part 314 addresses the processing of people found NCRMD through the review board system and the criminological outcomes among this cohort, followed until 2008. Part 415 examines the criminal recidivism rates and associated factors among NCRMD–accused people. Finally, Part 516 focuses on examining gender differences and similarities in the characteristics and processing of NCRMD–accused people.

Acknowledgements

This research was consecutively supported by grant #6356-2004 from Fonds de recherche Québec—Santé (FRQ-S) and by the Mental Health Commission of Canada. Dr Crocker received consecutive salary awards from the Canadian Institutes of Health Research (CIHR), FRQ-S, and a William Dawson Scholar award from McGill University while conducting this research. Dr Nicholls acknowledges the support of the Michael Smith Foundation for Health Research and the CIHR for consecutive salary awards.

www.TheCJP.ca

References

1. The Vince Li homicide case. Winnipeg Free Press. 2012 May 17. Available from: http://www.winnipegfreepress.com/local/ Timeline-The-Vince-Li-homicide-case-151941555.html. 2. Canadian Press. Schoenborn ‘not criminally responsible’ for murders. Father was insane when he killed 3 children, judge finds. Canadian Broadcasting Corporation. 2010 Feb 22. Available from: http://www.cbc.ca/news/canada/british-columbia/ schoenborn-not-criminally-responsible-for-murders-1.899491. 3. Criminal Code, R.S.C., 1985, c. C-46. 4. Latimer J, Lawrence A. The review board systems in Canada: overview of results from the Mentally Disordered Accused Data Collection Study. Ottawa (ON): Department of Justice Canada; 2006. 5. Bill C-54: an Act to amend the Criminal Code and the National Defence Act (mental disorder). 1st session ed. Ottawa (ON): House of Commons of Canada; 2013. Now known as the Not Criminally Responsible Reform Act. 6. Cook AN, Roesch R. “Tough on crime” reforms: what psychology has to say about the recent and proposed justice policy in Canada. Can Psychol. 2012;53(3):217–225. 7. Barbaree HE, Cook AN, Douglas KS, et al. Canadian Psychological Association Submission to the Senate Standing Committee on Legal and Constitutional Affairs. Ottawa (ON): Canadian Psychological Association; 2012. 8. Brennan S. Police reported crime statistics in Canada, 2011. Juristat (Catalogue no 85-002-X). Ottawa (ON): Statistics Canada; 2012 9. Andrews DA. The Risk-Need-Responsivity (RNR) model of correctional assessment and treatment. In: Dvoskin JA, Skeem JL, Novaco RW, et al, editors. Using social science to reduce violent offending. New York (NY): Oxford University Press; 2012. 10. Bousfield N, Cook A, Roesch R. Evidence-based criminal justice policy for Canada: an exploratory study of public opinion and the perspective of mental health and legal professionals. Can Psychol. 2014;55(3):204–215. 11. Crocker AG, Nicholls TL, Seto MC, et al. The National Trajectory Project (NTP) [Internet]. Montreal (QC): NTP; [year of publication unknown; cited 2015 Jan 1]. Available from: https://ntp-ptn.org. 12. Crocker AG, Nicholls TL, Seto MC, et al. The National Trajectory Project of individuals found not criminally responsible on account of mental disorder in Canada. Part 1: context and methods. Can J Psychiatry. 2015;60(3):98–105. 13. Crocker AG, Nicholls TL, Seto MC, et al. The National Trajectory Project of individuals found not criminally responsible on account of mental disorder in Canada. Part 2: the people behind the label. Can J Psychiatry. 2015;60(3):106–116. 14. Crocker AG, Charette Y, Seto MC, et al. The National Trajectory Project of individuals found not criminally responsible on account of mental disorder in Canada. Part 3: trajectories and outcomes through the forensic system. Can J Psychiatry. 2015;60(3):117–126. 15. Charette Y, Crocker AG, Seto MC, et al. The National Trajectory Project of individuals found not criminally responsible on account of mental disorder in Canada. Part 4: criminal recidivism. Can J Psychiatry. 2015;60(3):127–134. 16. Nicholls TL, Crocker AG, Seto MC, et al. National Trajectory Project of individuals found not criminally responsible on account of mental disorder. Part 5: how essential are gender-specific forensic psychiatric services? Can J Psychiatry. 2015;60(3):135–145.

The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 97

CanJPsychiatry 2015;60(3):98–105

National Trajectory Project

The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 1: Context and Methods Anne G Crocker, PhD1; Tonia L Nicholls, PhD2; Michael C Seto, PhD3; Gilles Côté, PhD4; Yanick Charette, MSc (PhD Candidate)5; Malijai Caulet, PhD6 1

Associate Professor, Department of Psychiatry, McGill University, Montreal, Quebec; Associate Director, Policy and Knowledge Exchange, Douglas Mental Health University Institute Research Centre, Montreal, Quebec. Correspondence: Douglas Mental Health University Institute Research Centre, 6875 LaSalle Boulevard, Montreal, QC H4H 1R3; [email protected].

2

Associate Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia; Senior Research Fellow, Forensic Psychiatric Services Commission, BC Mental Health & Substance Use Services, Coquitlam, British Columbia.

3

Director of Forensic Rehabilitation Research, Royal Ottawa Health Care Group, Brockville, Ontario.

4

Professor, Department of Psychology, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec; Director, Philippe-Pinel Institute Research Centre, Montreal, Quebec.

5

Post-doctoral Fellow, Department of Sociology, Yale University, New Haven, Connecticut; Student, Department of Criminology, Université de Montréal, Montreal, Quebec.

6

National Coordinator, National Trajectory Project, Douglas Mental Health University Institute Research Centre, Montreal, Quebec.

Key Words: forensic, mental health, National Trajectory Project, not criminally responsible on account of mental disorder, mental disorder, criminality, violence, review board Received November 2013, revised, and accepted February 2014.

The National Trajectory Project examined longitudinal data from a large sample of people found not criminally responsible on account of mental disorder (NCRMD) to assess the presence of provincial differences in the application of the law, to examine the characteristics of people with serious mental illness who come into conflict with the law and receive this verdict, and to investigate the trajectories of NCRMD–accused people as they traverse the mental health and criminal justice systems. Our paper describes the rationale for the National Trajectory Project and the methods used to collect data in Quebec, Ontario, and British Columbia, the 3 most populous provinces in Canada and the 3 provinces with the most people found NCRMD. WWW

Le Projet national des trajectoires des personnes déclarées non criminellement responsables pour cause de troubles mentaux au Canada. Partie 1 : Contexte et méthodes open access

Les membres du Projet national des trajectoires ont examiné les données longitudinales d’un vaste échantillon de personnes déclarées non criminellement responsables pour cause de troubles mentaux (NCRTM) afin d’évaluer la présence de différences provinciales en matière d’application de la loi, d’étudier les caractéristiques de personnes ayant une maladie mentale grave qui, ayant des démêlés avec la justice, sont déclarées non criminellement responsables, et d’examiner les trajectoires des accusés NCRTM à travers les systèmes de santé mentale et de justice pénale. Le présent document décrit la raison d’être du Projet national des trajectoires et les méthodes utilisées pour recueillir des données au Québec, en Ontario et en Colombie-Britannique, les 3 provinces les plus populeuses du Canada et celles où se trouve la majorité des personnes déclarées NCRTM.

98 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015

www.LaRCP.ca

The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 1: Context and Methods

T

here has been a dramatic growth in the rates of admissions to forensic mental health services in Europe and North America.1 In Europe, there has been a significant increase in the number of hospital beds and other resources dedicated to the forensic population.2 Seto et al3 reported similar findings in Ontario, and described data from the United States showing that an increasing number of psychiatric hospital beds were being occupied by forensic clients, a trend they called forensication of people with SMI. In short, research demonstrates it is increasingly easier to hospitalize someone with SMI, and access other mental health resources, after a criminal charge has been laid than it is to access mental health services through the civil psychiatric system.

The Canadian Context

In Canada, people find themselves in forensic institutions as a result of having been found unfit to stand trial (unable to participate in a criminal proceeding as a result of SMI or other mental disability) or following a verdict of NCRMD.4,5 In line with the common-law principle that it is inappropriate to punish people who did not have criminal intent at the time of the offence, section 16 of the Criminal Code defines the verdict of NCRMD as: No person is criminally responsible for an act committed or an omission made while suffering from a mental disorder that rendered the person incapable of appreciating the nature and quality of the act or omission or of knowing that it was wrong.6

Review Boards

RBs are independent tribunals established to determine dispositions of accused found unfit to stand trial or NCRMD. At the time the study was conducted, the criteria that governed the RBs’ dispositions in section 672.54 of the Criminal Code required the following: Where a court or Review board makes a disposition . . . it shall, taking into consideration the need to protect the public from dangerous persons, the mental condition of the accused, the reintegration of the accused into society and the other needs of the accused, make one of the following dispositions that is the least onerous and least restrictive to the accused.6

Abbreviations CPIC

Canadian Police Information Centre

FPSC

Forensic Psychiatric Services Commission

HCR-20 Historical-Clinical-Risk Management-20 NCRMD not criminally responsible on account of mental disorder NTP

National Trajectory Project

RB

review board

SMI

serious mental illness

UCR2

Uniform Crime Reporting Survey (1988)

VRAG

Violence Risk Appraisal Guide

www.TheCJP.ca

Highlights •

Significant interprovincial differences are observed in the number of people found NCRMD per criminal court verdict annually.

•

Different trends over time are observed across each province in the number of NCRMD–accused people entering the provincial RB systems.

These dispositions are as follows: 1) absolute discharge; 2) conditional discharge (typically living in the community under conditions set by the RB); or 3) detention in hospital. Although there has been an overall national increase in the number of people found NCRMD in Canada,4 there are some interprovincial differences. In Quebec, there were more than twice as many NCRMD findings in 2005 (n = 407) as in 1992 (n = 177).7 In fiscal year 2011/12, there were 540 new verdicts of NCRMD in Quebec (Carmelle Beaulieu, May 9, 2013, personal communication). There also has been a steady increase in Ontario, with 170 new NCRMD–accused cases diverted to the RB in 2010–2011.5,8 However, some provinces, such as British Columbia, have seen smaller increases.5 After an initial increase in the early 1990s,9 the annual number of new NCRMD findings has been on a steady gradual decline in British Columbia since 1999. This suggests there are potentially important differences in the way that the law is being applied across provinces.

Organization of Forensic Mental Health Services

In Quebec, in addition to the provincial forensic psychiatric hospital, there are over 50 mental health settings designated to receive NCRMD–accused people. Thus many NCRMD– accused people are in custody of civil psychiatric hospitals that are not specialized for risk assessment and risk management. There is one interregional forensic services group and one Montreal intersectoral services group who meet regularly to ensure interagency communication and training. British Columbia has a highly integrated network of forensic services. The BC FPSC is a multi-site organization that provides and coordinates specialized clinical services at the BC Forensic Psychiatric Hospital and 6 regional clinics across the province. All people sent for NCRMD or fitness assessments, as well as all people found unfit or NCRMD by the courts, are treated and managed by the FPSC. The forensic mental health system in Ontario is different from British Columbia and Quebec. People found NCRMD are treated and managed by 1 of 10 designated forensic facilities for adults. These facilities operate independently, but the staff and services are specialized and their directors meet regularly through a forensic directors group, thereby informally coordinating services. Ontario represents a middle ground between forensic systems in Quebec (highly distributed, with many nonforensic professionals involved) and British Columbia (specialized and centrally coordinated by a single organization). The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 99

Figure 1 Number of annual not criminally responsible on account of mental disorder

National Trajectory Project

verdicts diverted to review boards Figure 1 Number of annual not criminally responsible on account of mental

disorderPlease verdicts diverted to “to”; review boards [Layout: replace hyphens or close up space and insert an en dash]

450 400 350 300 250

QC BC

200

ON

150 100 50 0

May 2000April 2001

May 2001April 2002

May 2002April 2003

The National Trajectory Project

The main goals of the NTP10 were to provide a representative portrait of people found NCRMD during an extended period of time, and to examine their trajectories through the RB system. This study was conducted in the 3 most populated Canadian provinces: Ontario (39%), Quebec (23%), and British Columbia (13%),11 which also encompass most NCRMD cases4 and operate under different provincial forensic mental health service models.12,13 The primary objectives of the NTP were as follows: 1) Describe the demographic, psychosocial, and criminological profiles of NCRMD accused in Canada. 2) Evaluate the reporting of violence risk factors and assessments presented to the RBs. 3) Distinguish the rationales for RB dispositions. 4) Examine rehospitalization and recidivism outcomes. 5) Track the migration patterns of people found NCRMD. 6) Identify the individual and organizational factors associated with these geographic and processing trajectories. 7) Examine the use of mental health services by the accused people prior to the NCRMD verdict, under the RB, and following discharge. 100 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015

May 2003April 2004

May 2004April 2005

8) Examine each of these findings with respect to culture and gender. 9) Learn how the Criminal Code and the RB process are perceived and experienced by people adjudicated NCRMD, their families, and professionals across Canada.

Methods Design and Study Period

The NTP used a longitudinal design to study a cohort of people found NCRMD in British Columbia, Ontario, and Quebec, retrospectively. The sample selection start date considered the Winko decision,14 which could have influenced the characteristics of NCRMD–accused people and RB decisions about absolute discharges.15 The study end date allowed for a minimum of a 3-year follow-up for all cases, up to a maximum of 8 years. Note, the Winko decision clarified that the verdict of NCRMD is neither one of guilt nor acquittal and further elaborated on the notion of significant threat to public safety and underlined the importance of the least restrictive and least onerous disposition.16,17

Sample Selection

The sample selection period spanned May 1, 2000, to April 30, 2005. Quebec had a significantly higher number of www.LaRCP.ca

The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 1: Context and Methods

NCRMD verdicts per year than both Ontario and British Columbia (Figure 1). Averaged across 5 years, NCRMD verdicts accounted for 6.08 per 1000 decisions in Quebec criminal courts, compared with 0.95 in Ontario and 1.34 in British Columbia. No significant changes in the number of general criminal court cases were observed during this 5-year period.18 The number of NCRMD–accused people by province was also stable. For every person found NCRMD and under an RB, the first NCRMD verdict within the province’s time frame was identified as the index verdict. Owing to time and budgetary constraints, time frames varied across provinces. In Quebec, there were a total of 2389 NCRMD verdicts between May 1, 2000, and April 30, 2005, corresponding to 1964 people. To obtain a geographically representative sample of all 17 justice administrative regions of Quebec, a random sampling procedure was applied for each region using a finite population correction factor. Therefore, the descriptive analyses are weighted. The Ontario sample was comprised of all adults with an NCRMD verdict between January 1, 2002, and April 30, 2005 (n = 484). Data collection started with the same end date as Quebec and then files were coded backwards in time. Coding was completed to January 1, 2002. The British Columbia sample was comprised of 222 NCRMD–accused people registered with the BC RB between May 1, 2001, and April 30, 2005. For the Quebec sample, preliminary analyses were conducted to ensure that potential differences between provinces would not be attributable to different data collection time frames. No statistically significant differences in the psychosocio-criminal characteristics of people found NCRMD in Quebec for the 2000 to 2002 and the 2002 to 2005 time frames were observed. Thus the full Quebec sample was used for all analyses. In summary, the full population of people found NCRMD is represented for British Columbia and Ontario, whereas for Quebec, a random sample of people was selected, stratified by region. Normalized weights are attributed to the Quebec sample and the total sample when presenting total population rates. This normalized weighting may result in a slightly different number (±2) of valid cases in the various descriptive analyses because cell counts are rounded. The final national sample size was 1800.

Procedures

For each case, RB files 5 years prior to the index verdict were reviewed and then coded forward until December 31, 2008. In British Columbia, RB files dated before November 2001 had been destroyed; thus the 7 cases from May 2000 until October 31, 2001, were accessed from files kept at the British Columbia Forensic Psychiatric Hospital. The hospital files generally contain the same reports and documents found in RB files. Research assistants were instructed to code only from the file content that would have been generally found in RB files, to maintain comparability with other cases and the other provinces. www.TheCJP.ca

Trained research assistants coded and entered RB data into a bilingual computerized database to ensure standardization of data collection across study sites. Throughout the study, quality checks included meetings to discuss data collection issues. A password-protected blog was maintained on the NTP website to allow discussions between research assistants, project coordinators, and investigators about challenging or unusual cases.

Measures and Sources of Information

Five categories of information were coded: sociodemographic information (for example, age at verdict, gender, and marital status); clinical information (for example, age at first psychiatric hospitalization, diagnosis at NCRMD verdict); criminal history (for example, offences leading to the index NCRMD verdict, past convictions, or NCRMD verdicts); details of the risk assessments presented at each RB hearing; contextual factors and processing through the RB system (for example, RB dispositions and associated reasons). Psychopathology Diagnoses were coded from court-ordered psychiatric evaluations for the index verdict and annual reports submitted to the RBs. Diagnoses were rarely identified using standard codes from the Diagnostic and Statistical Manual19 or the International Classification of Diseases20 and often included nonstandard descriptors. Eight broad diagnostic categories were coded: psychosis; mood; organic (for example, dementia); anxiety; substance use; personality; other (for example, intellectual disabilities and autism); and none (the reports specify there is no diagnosis). Percentages add up to more than 100% because people could have more than 1 diagnosis. In 8.1% (n = 153) of NCRMD assessments presented to the courts, no psychiatric diagnosis was mentioned. Therefore, we used psychiatric diagnoses from the 3 hearings following the verdict on the assumption that there would be less missing information at subsequent hearings; further clinical evaluation could clarify the primary diagnosis(es); and diagnosis would be stable over time. In 13 cases, no diagnostic information was available because no psychiatric evaluations were found in the RB files. Therefore, the distribution of diagnoses for this report was calculated on 1787 instead of 1800 people. Police reports and other documents were also coded for psychiatric symptoms during the commission of the offence: unspecified psychotic symptoms, hallucinations, delusions, suicidal ideation, attempted suicide, self-harming behaviour, homicidal ideation, and substance use. Risk Assessments Research assistants coded the presence or absence of items from 2 widely used violence risk assessment tools (VRAG21 and HCR-2022) to ascertain the extent to which risk assessment measures were used and reported by clinicians to inform the RB dispositions and conditions. The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 101

National Trajectory Project

Table 1 Categories of offences Causing death or attempting to cause death Sex offences Assaults Deprivation of freedom (for example, forcible confinement) Threats, and other offences against the person Property offences (for example, theft) Prostitution and (or) gambling Offensive weapons Administration of justice (for example, failure to attend court and breach of probation) Disturbing the peace Drug possession and (or) trafficking Dangerous driving and (or) operation of a motor vehicle Other federal and (or) provincial statutes

Table 2 Categories of victims Stranger Professionals (that is, police or security officer, mental health professional, and landlord) Family (that is, offspring, parents, current and ex-partner or spouse, and other family members) Roommate or co-resident Friend and acquaintance Other

Historical-Clinical-Risk Management-20. The HCR-2022 was used to structure coding of risk factors presented by clinicians to RBs. It has strong psychometric properties and has been studied and used internationally.23–27 It has also been validated in French.28 The 20 items on the HCR20 are divided into 3 sections: H for 10 historical or static variables that do not or seldom change with time; C for 5 clinical variables that are amenable to intervention; and R for 5 risk management variables that should be the focus of attention to reduce violence. For our study, coding was modified to the following: present, absent, mentioned but uncodable, or not mentioned. Violence Risk Appraisal Guide. The VRAG29–30 is a 12-item actuarial measure that uses historical information, such as offence history and victim characteristics, to estimate longterm risk of violence.21 The measure has very good interrater reliability, been validated in both forensic and correctional populations, and very good predictive accuracy.29–31 Though the VRAG items are usually weighted, they were coded as present, absent, mentioned but uncodable, or not mentioned for this study. Research assistants coded whether HCR-20 or VRAG items were mentioned in clinical reports submitted to the RB. The intention of this approach was to examine what information clinicians brought as explicit evidence to the RBs. A limitation to this coding approach is that items 102 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015

could be considered by clinicians without being specifically mentioned. Moreover, there is an asymmetry of information because it is easier to code the presence of a factor than its absence, because the natural tendency is to mention presence (for example, “He has a history of substance use problems.”) rather than to specifically mention absences (for example, “There is no evidence he ever had substance use problems.”). Interrater Reliability A total of 1835 RB reports associated with 573 NCRMD– accused people were submitted to interrater reliability testing for the HCR-20 and the VRAG regarding the expert reports to the RBs and RB justifications for their decisions. For the expert reports to the RBs, the average kappa for the HCR-20 was 0.78 (0.84 for the H factor, 0.75 for the C factor, and 0.69 for the R factor) and 0.68 for the VRAG. For the RB justification for their decisions, the total HCR-20 yielded an average kappa coefficient of 0.76 (0.83 for the H factor, 0.73 for the C factor, and 0.67 for the R factor) and 0.72 for the VRAG. Criminal Behaviour Criminal History. Information on lifetime criminal convictions was obtained from the CPIC. Given that NCRMD verdicts are not recorded in CPIC records in a systematic fashion, we also coded NCRMD verdicts from RB files. Index Offence. In many instances, an accused person had been charged with more than one offence leading to the index NCRMD verdict. All charges were coded, but only the most serious charge was selected as the index offence for the purpose of this study, ensuring consistency across provinces. Index offences were aggregated into 13 categories (Table 1) corresponding to the UCR2.32 Categories 1 to 5 are offences against the person, category 6 are crimes against property, and the remaining categories fall under other Criminal Code violations. Victims. For offences against the person, the relation between the accused and the victim was assigned to 1 of 6 categories (Table 2). Severity of Offences. Descriptions of the offences were coded using the UCR2.32 A severity score was also assigned to each index offence using the Crime Severity Index, which is based on average sentence lengths.33 Recidivism. New charges and convictions were also coded from the CPIC records and the RB files. There is generally a significant time lapse owing to administrative delays between the date an offence is committed and the final verdict. This has important implications for our analysis of prior criminal offences and future criminality. For example, a verdict for offence X might occur after a verdict for offence Y, despite offence X actually being perpetrated before offence Y. Therefore, what may be identified as recidivism may be an artefact of delayed processing. Given that criminal records provide Court dispositions and do www.LaRCP.ca

The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 1: Context and Methods

not provide offence dates, the following algorithm was applied to paint an accurate portrait of criminal history and recidivism: for each Court decision, we subtracted the median justice processing delay by province and matched for most severe offence; this is measured using the median time between the first and last hearing of a Court case.18

Ethics

Ethics approval was obtained from the investigators’ primary institutions and renewed annually according to TriCouncil Guidelines.34,35

Discussion

To our knowledge, this is the first longitudinal cohort study comparing provincially representative samples of NCRMD–accused people since the 1992 changes to the Criminal Code. It is clear there are differences across provinces in the likelihood of an NCRMD verdict; using data from Statistics Canada and the number of people found NCRMD, Quebec had 6.4 times the number of cases diverted to the RB system than Ontario, and 5 times that of British Columbia. British Columbia had 1.5 times the number of cases of Ontario when considering all criminal court decisions. Historically, Quebec courts have always yielded higher rates of NCRMD verdicts (or previously, Not Guilty by Reason of Insanity)36,37 and the gap appears to be increasing. As of 2012, the annual rate of NCRMD cases had increased in Quebec and stands at 9.27 per 1000 cases, it has stabilized in Ontario at 1.07 cases per 1000, and has decreased in British Columbia to 0.8 per 1000 criminal court cases.18 These differences may be due to differences in prosecutorial discretion, legal aid, and civil mental health resources and legislation, and Quebec may be using the NCRMD defence as a criminal justice diversion option.

Strengths and Limitations

Our study has the advantage of a large sample, allowing us to examine interesting subgroups (for example, gender and diagnosis), low base rate characteristics, and recidivism rates. To our knowledge, the NTP is the first study to analyze detailed RB file content and the information on which RBs make their decisions. It also comprises one of the largest samples of people found NCRMD studied to date. The NTP entails a lengthy follow-up period and integrates official criminal records in addition to RB files to assess recidivism rates and predictors. Finally, this is also the only study to systematically examine provincial differences in the extent to which clinicians in forensic psychiatric practice have embedded evidence-based risk assessment measures into their clinical decision making.38 In terms of limitations, some information was not available in RB files in this archival study. This limited our ability to obtain details about symptoms at the time of the index offence, recovery while under the RBs, detailed diagnostic information, and violence risk assessments. In some cases, missing information could be interpreted as the absence of a factor. For example, one would not expect mention www.TheCJP.ca

of someone’s non-Aboriginal status, thus no mention of Aboriginal status was coded as non-Aboriginal status. This results in a conservative estimate of missing data, as it is possible information was truly missing in some cases that were coded as factor absence. Variables with more than 10% missing data were dropped from multivariate analyses.39 Further, file data quality and quantity differed within and across provinces, over time and between RB hearings.

Conclusion

Given there are no current indications of increased criminality and court cases in Canada that could help explain the increased number of NCRMD cases over time,4 the profile of the NCRMD population is increasingly diversified. This increasing heterogeneity is evident regarding both criminal behaviour and clinical profile. The next 4 NTP papers, published in this special issue, examine the psychosocio-criminological profiles of NCRMD people, their processing across provinces, outcomes, as well as gender differences, in NCRMD profiles.40–43

Acknowledgements

This research was consecutively supported by grant #6356-2004 from Fonds de recherche Québec—Santé (FRQ-S) and by the Mental Health Commission of Canada (MHCC). Dr Crocker received consecutive salary awards from the Canadian Institutes of Health Research (CIHR), FRQ-S, and a William Dawson Scholar award from McGill University while conducting this research. Dr Nicholls acknowledges the support of the Michael Smith Foundation for Health Research and the CIHR for consecutive salary awards. Yanick Charette acknowledges the support of the Social Sciences and Humanities Research Council of Canada in the form of a doctoral fellowship. This study could not have been possible without the full collaboration of the Quebec, British Columbia, and Ontario Review Boards (RBs), and their respective registrars and chairs. We are especially grateful to attorney Mathieu Proulx, Bernd Walter, and Justice Douglas H Carruthers and Justice Richard Schneider, the Quebec, British Columbia, and consecutive Ontario RB chairs, respectively. We thank Carmelle Beaulieu from the Quebec RB for providing recent annual statistics. Ms Beaulieu has provided written permission to publish the information she sent to us at our request. The authors sincerely thank Erika Jansman-Hart and Dr Cathy Wilson, Ontario and British Columbia coordinators, respectively, as well as our dedicated research assistants who coded RB files and Royal Canadian Mounted Police criminal records: Erika Braithwaite, Dominique Laferrière, Catherine Patenaude, Jean-François Morin, Florence Bonneau, Marlène David, Amanda Stevens, Stephanie Thai, Christian Richter, Duncan Greig, Nancy Monteiro, and Fiona Dyshniku. Finally, the authors extend their appreciation to the members of the Mental Health and the Law Advisory Committee The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 103

National Trajectory Project

of the MHCC, in particular Justice Edward Ormston and Dr Patrick Baillie, consecutive chairs of the committee as well as the NTP advisory committee for their continued support, advice, and guidance throughout this study and the interpretation of results.

References

1. Jansman-Hart EM, Seto MC, Crocker AG, et al. International trends in demand for forensic mental health services. Int J Forensic Ment Health. 2011;10:326–336. 2. Priebe S, Badesconyi A, Fioritti A, et al. Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries. BMJ. 2005;330:123–126. 3. Seto MC, Lalumière ML, Harris GT, et al. Demands on forensic mental health services in the province of Ontario. Toronto (ON): [publisher unknown]; 2001. Report prepared for the Ontario Ministry of Health and Long-Term Care. 4. Latimer J, Lawrence A. The review board systems in Canada: overview of results from the Mentally Disordered Accused Data Collection Study. Ottawa (ON): Department of Justice Canada; 2006. 5. Schneider RD, Forestell M, MacGarvie S. Statistical survey of provincial and territorial review boards. Ottawa (ON): Department of Justice Canada; 2002. 6. Criminal Code, R.S.C., 1985, c. C-46. 7. Tribunal Administratif du Québec. Rapport annuel de gestion 2006 – 2007 [Internet]. Quebec (QC): Tribunal Administratif du Québec; 2008 [cited 2005 Jan 3]. Available from: http://www.taq.gouv.qc.ca/fr/publications-documentation/ publications/depliants-guides-et-rapports2007. 8. Ontario Review Board. Annual report, fiscal year: 2010–2011 [Internet]. Toronto (ON): Ontario Review Board; 2011 [cited 2005 Jan 3]. Available from: http://www.orb.on.ca/scripts/en/ annualreports.asp2011. 9. Livingston JD, Wilson D, Tien G, et al. A follow-up study of persons found not criminally responsible on account of mental disorder in British Columbia. Can J Psychiatry. 2003;48(6):408–415. 10. Crocker AG, Nicholls TL, Seto MC, et al. The National Trajectory Project (NTP) [Internet]. Montreal (QC): NTP; [year of publication unknown; cited 2015 Jan 1]. Available from: https://ntp-ptn.org. 11. Statistics Canada. Population and dwelling counts, for Canada, provinces and territories, 2006 and 2001 censuses—100% data (table). Population and Dwelling Count Highlight Tables. 2006 Census. Ottawa (ON): Statistics Canada; 2007. 12. Crocker AG, Braithwaite E, Nicholls TL, et al. To detain or to discharge? Predicting dispositions regarding individuals declared not criminally responsible on account of mental disorder. Oral presentation at the 10th Annual conference of the International Association of Forensic Mental Health Services, Vancouver, BC, 2010 May 25–27. 13. Livingston JD. A statistical survey of Canadian forensic mental health inpatient programs. Health Q. 2006;9(2):56–61. 14. Winko v. British Columbia (Forensic Psychiatric Institute). 2 S.C.R. 6251999. 15. Balachandra K, Swaminath S, Litman LC. Impact of Winko on absolute discharges. J Am Acad Psychiatry Law. 2004;32(2):173–177. 16. Desmarais S, Hucker S. Multi-site follow-up study of mentally disordered accused: an examination of individuals found not criminally responsible and unfit to stand trial. Ottawa (ON): Research and Statistics Divisions, Department of Justice Canada; 2005. 40 p. 17. Schneider RD, Glancy GD, Bradford JM, et al. Canadian landmark case, Winko v. British Columbia: revisiting the conundrum of the mentally disordered accused. J Am Acad Psychiatry Law. 2000;28(2):206–212.

104 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015

18. Statistics Canada. CANSIM Table 252-0055. Adult criminal courts, cases by median elapsed time in days, annual (number unless otherwise noted) [Internet]. Ottawa (ON): Statistics Canada; 2013 Jun 12 [cited 2015 Jan 7]. Available from: http://www5.statcan.gc.ca/cansim/a26;jsessionid=059C768E01 E654D5F8C079EBE190D890?id=2520055&pattern= &p2=31&p1=1&tabMode=dataTable&stByVal=1&paSer= &csid=&retrLang=eng&lang=eng2012. 19. American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders. 4th ed, text rev. Washington (DC): APA; 2000. 20. World Health Organization (WHO). ICD-10 international statistical classification of diseases and related health problems. Geneva (CH): WHO; 2005. 21. Harris GT, Rice ME, Quinsey VL. Violent recidivism of mentally disordered offenders. Crim Justice Behav. 1993;20(4):315–335. 22. Webster CD, Douglas KS, Eaves D, et al. HCR-20: assessing risk for violence, version 2. Vancouver (BC): Mental Health Law and Policy Institute, Simon Fraser University; 1997. 23. Grann M, Belfrage H, Tengström A. Actuarial assessment of risk for violence: predictive validity of the VRAG and the historical part of the HCR-20. Crim Justice Behav. 2000;27(1):97–114. 24. Tengström A. Long-term predictive validity of historical factors in two risk assessment instruments in a group of violent offenders with schizophrenia. Nord J Psychiatry. 2001;55(4):243–249. 25. Kroner DG, Mills JF. The accuracy of five risk appraisal instruments in predicting institutional misconduct and new convictions. Crim Just Behav. 2001;28(4):471–489. 26. Douglas KS, Webster CD. The HCR-20 violence risk assessment scheme: concurrent validity in a sample of incarcerated offenders. Crim Just Behav. 1999;26(1):3–19. 27. Douglas KS, Reeves KA. Historical-Clinical-Risk Management-20 (HCR-20) Violence risk assessment scheme: rationale, application, and empirical overview. In: Otto RK, Douglas KS, editors. Handbook of violence risk assessment. New York (NY): Routledge/Taylor & Francis Group; 2010. p 147–186. 28. Côté G, Hodgins S. Les troubles mentaux et le comportement criminel. In: Leblanc M, Ouimet M, Szabo D, editors. Traité de criminologie. 3ième ed. Montreal (QC): Les Presses de l’Université de Montréal; 2003. p 501–546. 29. Quinsey VL, Harris GT, Rice ME, et al. Violent offenders: appraising and managing risk. Washington (DC): American Psychological Association; 2006. 30. Quinsey VL, Harris GT, Rice ME, et al. Violent offenders: appraising and managing risk. Washington (DC): American Psychological Association; 1998. 31. Rice ME, Harris GT, Hilton NZ. The Violence Risk Assessment Guide and Sex Offender Risk Appraisal Guide for violence risk assessment and the Ontario Domestic Assault Risk Assessment and Domestic Violence Risk Appraisal Guide for wife assault risk assessment. In: Otto RK, Douglas KS, editors. Handbook of violence risk assessment. New York (NY): Routledge/Taylor & Francis Group; 2010. 32. Canadian Centre for Justice Statistics Policing Services Program. Uniform Crime Reporting Incident-Based Survey, reporting manual. Ottawa (ON): Statistics Canada; 2008. 33. Wallace M, Turner J, Matarazzo A, et al. Measuring crime in Canada: introducing the Crime Severity Index and improvements to the Uniform Crime Reporting Survey. Ottawa (ON): Canadian Centre for Justice Statistics; 2009. 34. Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, Social Sciences and Humanities Research Council of Canada. Tri-council policy statement: ethical conduct for research involving humans. Ottawa (ON): Interagency Secretariat on Research Ethics, Government of Canada; 2005. www.LaRCP.ca

The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 1: Context and Methods 35. Canadian Institutes of Health Research Natural Sciences and Engineering Research Council of Canada and Social Sciences and Humanities. Tri-council policy statement: ethical conduct for research involving humans. Ottawa (ON): Research Council of Canada; 2010. 36. Hodgins S, Webster CD. The Canadian database: patients held on lieutenant-governors’ warrants. Ottawa (ON): Research and Statistics Divisions, Department of Justice Canada; 1992. 37. Hodgins S, Webster CD, Paquet J. Canadian database: patients held on lieutenant-governors’ warrants. Ottawa (ON): Research and Statistics Divisions, Department of Justice Canada; 1990. 38. Côté G, Crocker AG, Nicholls TL, et al. Risk assessment instruments in clinical practice. Can J Psychiatry. 2012;57(4):238–244. 39. Langkamp DL, Lehman A, Lemeshow S. Techniques for handling missing data in secondary analyses of large surveys. Acad Pediatr. 2010;10(3):205–210.

40. Crocker AG, Nicholls TL, Seto MC, et al. The National Trajectory Project of individuals found not criminally responsible on account of mental disorder in Canada. Part 2: the people behind the label. Can J Psychiatry. 2015;60(3):106–116. 41. Crocker AG, Charette Y, Seto MC, et al. The National Trajectory Project of individuals found not criminally responsible on account of mental disorder in Canada. Part 3: trajectories and outcomes through the forensic system. Can J Psychiatry. 2015;60(3):117–126. 42. Charette Y, Crocker AG, Seto MC, et al. The National Trajectory Project of individuals found not criminally responsible on account of mental disorder in Canada. Part 4: criminal recidivism. Can J Psychiatry. 2015;60(3):127–134. 43. Nicholls TL, Crocker AG, Seto MC, et al. The National Trajectory Project of individuals found not criminally responsible on account of mental disorder in Canada. Part 5: how essential are gender-specific forensic psychiatric services? Can J Psychiatry. 2015;60(3):135–146.

1956 to 2015

of Medical Publishing Excellence

For 60 years, Canadian psychiatrists have turned to The Canadian Journal of Psychiatry for reliable research they can use in their clinical practices to improve patient care.

d’excellence en publication médicale

Depuis 60 ans, les psychiatres canadiens consultent La Revue canadienne de psychiatrie pour des études fiables qu’ils peuvent utiliser dans leurs pratiques cliniques afin d’améliorer les soins des patients.

www.TheCJP.ca

Dr. F. Rhodes Chalke Editor, 1955 to 1971

The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 105

CanJPsychiatry 2015;60(3)106–116

National Trajectory Project

The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 2: The People Behind the Label Anne G Crocker, PhD1; Tonia L Nicholls, PhD2; Michael C Seto, PhD3; Yanick Charette, MSc (PhD Candidate)4; Gilles Côté, PhD5; Malijai Caulet, PhD6 1

Associate Professor, Department of Psychiatry, McGill University, Montreal, Quebec; Associate Director, Policy and Knowledge Exchange, Douglas Mental Health University Institute Research Centre, Montreal, Quebec. Correspondence: Douglas Mental Health University Institute Research Centre, 6875 LaSalle Boulevard, Montreal, QC H4H 1R3; [email protected].

2

Associate Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia; Senior Research Fellow, Forensic Psychiatric Services Commission, BC Mental Health & Substance Use Services, Coquitlam, British Columbia.

3

Director of Forensic Rehabilitation Research, Royal Ottawa Health Care Group, Brockville, Ontario.

4

Post-doctoral Fellow, Department of Sociology, Yale University, New Haven, Connecticut; Student, Department of Criminology, Université de Montréal, Montreal, Quebec.

5

Professor, Department of Psychology, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec; Director, Philippe-Pinel Institute Research Centre, Montreal, Quebec.

6

National Coordinator, National Trajectory Project, Douglas Mental Health University Institute Research Centre, Montreal, Quebec.

Key Words: forensic mental health, National Trajectory Project, not criminally responsible on account of mental disorder, mental disorder, criminality, violence, review board Received November 2013, revised, and accepted February 2014.

open access

Objective: To examine the psychosocio-criminological characteristics of not criminally responsible on account of mental disorder (NCRMD)–accused people and compare them across the 3 most populous provinces. In Canada, the number of people found NCRMD has risen during the past 20 years. The Criminal Code is federally legislated but provincially administered, and mental health services are provincially governed. Our study offers a rare opportunity to observe the characteristics and trajectories of NCRMD–accused people. Method: The National Trajectory Project examined 1800 men and women found NCRMD in British Columbia (n = 222), Quebec (n = 1094), and Ontario (n = 484) between May 2000 to April 2005, followed until December 2008. Results: The most common primary diagnosis was a psychotic spectrum disorder. One-third of NCRMD–accused people had a severe mental illness and a concomitant substance use disorder, with British Columbia having the highest rate of dually diagnosed NCRMD–accused people. Most accused people (72.4%) had at least 1 prior psychiatric hospitalization. Two-thirds of index NCRMD offences were against the person, with a wide range of severity. Family members, followed by professionals, such as police and mental health care workers, were the most frequent victims. Quebec had the highest proportion of people with a mood disorder and the lowest median offence severity. There were both interprovincial differences and similarities in the characteristics of NCRMD–accused people. Conclusions: Contrary to public perception, severe violent offenses such as murder, attempted murder or sexual offences represent a small proportion of all NCRMD verdict offences. The results reveal a heterogeneous population regarding mental health and criminological characteristics in need of hierarchically organized forensic mental health services and levels of security. NCRMD–accused people were well known to civil psychiatric services prior to being found NCRMD. Risk assessment training and interventions to reduce violence and criminality should be a priority in civil mental health services. WWW

Projet national des trajectoires des personnes déclarées non criminellement responsables pour cause de troubles mentaux au Canada. Partie 2 : Les personnes derrière l’étiquette Objectif : Examiner les caractéristiques psychologiques, sociales et criminologiques des accusés déclarés non criminellement responsables pour cause de troubles mentaux (NCRTM) et les comparer dans les 3 provinces les plus peuplées. Au Canada, le nombre de personnes déclarées NCRTM a augmenté ces 20 dernières années. Le Code criminel relève de la compétence du gouvernement fédéral mais son application relève des provinces, et les services de santé mentale sont régis par les provinces. Cette étude offre l’occasion unique d’observer les caractéristiques et la trajectoire des accusés NCRTM. 106 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015

www.LaRCP.ca

The National Trajectory Project of Individuals Found Not Criminally Responsible on Account of Mental Disorder in Canada. Part 2: The People Behind the Label

Méthode : Le Projet national des trajectoires a permis d’examiner 1800 hommes et femmes déclarés NCRTM en Colombie-Britannique (n = 222), au Québec (n = 1094) et en Ontario (n = 484) de mai 2000 à avril 2005, et de les suivre jusqu’en décembre 2008. Résultats : Le diagnostic principal le plus courant était un trouble du spectre de la psychose. Un tiers des accusés NCRTM souffraient d’une maladie mentale grave et d’un trouble concomitant lié à l’utilisation de substances, la Colombie-Britannique ayant le taux le plus élevé d’accusés NCRTM ayant ces troubles concommitants. La plupart des accusés (72,4 %) avaient déjà été hospitalisés au moins une fois dans un établissement psychiatrique. Les deux tiers des infractions répertoriées des accusés NCRTM étaient des infractions contre la personne, de niveaux de gravité variables. Les membres de la famille, puis des intervenants comme les agents de police et les travailleurs de la santé mentale, étaient les victimes les plus fréquentes. C’est au Québec que la proportion de personnes souffrant d’un trouble de l’humeur était la plus élevée et que la gravité médiane des infractions était la plus basse. Les caractéristiques des accusés NCRTM entre les provinces présentent à la fois des différences et des similarités. Conclusions : Contrairement à la perception publique, les infractions graves avec violence comme le meurtre, les tentatives de meurtre ou les agressions sexuelles représentent une faible proportion de tous les verdicts NCRTM. Les résultats révèlent une population hétérogène en termes de santé mentale et de caractéristiques criminologiques ayant besoin de services hiérarchisés et des niveaux de sécurités variables. Les personnes déclarées NCRTM étaient bien connues des services de psychiatrie générale avant d’être trouvées NCRTM. La formation et les interventions en évaluation du risque, afin de réduire la violence et la criminalité, devraient être une priorité dans les services de santé mentale civils.

I

nstitutional mental health services are more difficult to access following the deinstitutionalization movement and a subsequent shortfall in community-based services,1 often compelling families to report criminal acts to police to access services for their relatives with SMI, even for relatively minor offences, such as uttering threats or causing a disturbance. The criminal justice system has become a major gateway to mental health services for people with SMI.2,3

International research suggests that people with SMI find themselves in forensic facilities at increasing rates.4 In Canada, the number of forensic clients entering the system has been growing.5–7 This so-called forensication transforms mental health systems into de facto forensic systems.8

Criminal Responsibility Legislation

A fundamental principle of Canadian law is that an accused person must possess the capacity to understand their behaviour was wrong to be found guilty of an offence. According to the Criminal Code, section 6, people can be found NCRMD for an act committed or an omission made while suffering from a mental disorder that rendered the person incapable of appreciating the nature and quality of the act or omission or of knowing that it was wrong.9 People found NCRMD are then under the jurisdiction of provincial or territorial RBs that must review NCRMD dispositions (that is, detention in hospital, conditional discharge, Abbreviations K-W Kruskal–Wallis

or absolute discharge) on a minimum yearly basis. In Part 1 of this special issue,7 we described the main components of the NCRMD legislation and the role of review boards. The forensic population seems more heterogeneous today in terms of criminological and psychosocial characteristics5,10 as a reflection of the 1992 legislative changes making the defence of NCRMD more attractive for some (for example, to people charged with minor offences).11 Forensic mental health systems must thus adjust their services to address diverse patient needs regarding mental health problems, substance use, independent living, and risk for future violence and criminality.12

Clinical Implications •

The mental health and criminal heterogeneity of the NCRMD population reinforces the importance of targeted evidence-based risk and need assessments to inform treatment planning.

•

Given NCRMD legislation is federal and there are differences in availability of information in the review board systems, we encourage review boards and forensic mental health services to align their data and assessment protocols.

•

Families are among the most common victims of crimes committed by NCRMD–accused people; further education, support, and research is needed to better understand the needs of families and how best to support them.

Limitations •

This was an archival study and thus is more likely to have missing information than a prospective design.

•

We were limited to the 3 most populous provinces (Quebec, Ontario, and British Columbia), which might reduce and (or) restrict generalizability to other provinces (and internationally).

•

The data reflect the population entering the review board system from the year 2000 to 2005. It is possible that the characteristics of the population may have changed.

NCRMD not criminally responsible on account of mental disorder NTP

National Trajectory Project

RB

review board

SMI

serious mental illness

SUD

substance use disorder

www.TheCJP.ca

The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 107

National Trajectory Project

Interprovincial Differences

In Canada, all provinces and territories operate under the same Criminal Code. In previous papers, we13 and others14 reviewed some of the important interprovincial differences regarding the organization of mental health civil and forensic services in Canada. Our results indicated significant interprovincial differences in the use of the NCRMD verdict, with Quebec having a higher rate of NCRMD findings per criminal court decision than Ontario or British Columbia, and that this gap continues to grow.7 Evidence of continued criminalization of people with mental illness and interprovincial differences in the application of federal law suggests the need to explore the characteristics and needs of the NCRMD population across the country. In turn, this can help program planning and organization of services.

Current Study

The objective of the NTP was to provide an accurate portrait of people found NCRMD and to examine the operation of current criminal justice provisions for people under the authority of an RB (pursuant to section 672.38, Criminal Code).9 In this study, we examined psychosociocriminological characteristics of the NCRMD population and compared them across 3 provinces.

Methods

The full NTP design and procedures are described in more detail in Crocker et al.7 The sample was comprised of 1800 men and women found NCRMD in British Columbia (n = 222), Quebec (n = 1094), and Ontario (n = 484) between May 2000 and April 2005 and followed until December 2008. This archival retrospective cohort study included information on sociodemographic, clinical, contextual, and criminological characteristics of the sample. Sources of information were RB files and national criminal records.

Analytic Strategy

Descriptive information is provided for the total sample and for each province. Group comparisons were carried out using chi-square for categorical variables and K-W tests for continuous variables that were not normally distributed. Post hoc pairwise comparisons were conducted for significant omnibus results. A multinomial logistic regression with 3 pairwise comparisons was then used to define NCRMD– accused profiles by province. Only variables with less than 10% missing data were included in the overall model.15

Results Sociodemographic Characteristics

Women represented 15.6% of the sample. NCRMD–accused people were, on average, 36.56 years of age, one-half had a high school diploma, and more than three-quarters were single at the time of the index offence (Tables 1A and 1B). Two-thirds of NCRMD–accused people were Canadian born, with a slightly higher proportion of immigrants in Quebec than in British Columbia. At the time of the offence, slightly 108 W La Revue canadienne de psychiatrie, vol 60, no 3, mars 2015

more than one-third of the sample were living alone, less than one-half resided with family, friends, or a spouse, and 1 in 10 were homeless. Ontario had a higher proportion of people living with family and a lower proportion of homeless people than Quebec and British Columbia. Quebec had a higher proportion of accused people living independently than British Columbia and Ontario; British Columbia had fewer accused people living in supervised settings. Nearly threequarters of the NCRMD–accused people were under some form of governmental income support, whether it be welfare, pension, or disability; Quebec had the highest proportion. Aboriginal status (any or First Nations, Inuit, or Metis, specifically) was mentioned for 53 people (2.9%), with significant differences across provinces in the expected direction according to population base rates: 7.7% in British Columbia, 4.5% in Ontario, and 1.3% in Quebec [χ2 (n = 1800) = 32.21, df = 2, P  Quebec χ2 (n = 1316) = 64.23, df = 1, P < 0.001; Ontario > Quebec χ2 (n = 1578) = 19.91, df = 1, P < 0.001

g

Delusions: British Columbia > Ontario χ2 (n = 706) = 40.90, df = 1, P < 0.001; British Columbia > Quebec χ2 (n = 1318) = 131.84, df = 1, P < 0.001; Ontario > Quebec χ2 (n = 1578) = 38.19, df = 1, P < 0.001

h

Suicidal ideation: British Columbia > Ontario χ2 (n = 706) = 6.13, df = 1, P = 0.01; British Columbia > Quebec χ2 (n = 1316) = 3.95, df = 1, P = 0.047

i

Suicide attempt: British Columbia > Quebec χ2 (n = 1316) = 40.88, df = 1, P < 0.001; Ontario > Quebec χ2 (n = 1578) = 9.36, df = 1, P = 0.002

j

Self-harm: British Columbia > Ontario χ2 (n = 706) = 0.88, df = 1, P = 0.35; British Columbia > Quebec χ2 (n = 1318) = 13.35, df = 1, P < 0.001; Ontario > Quebec χ2 (n = 1577) = 31.75, df = 1, P < 0.001

Homicidal ideation: Ontario > British Columbia χ2 (n = 706) = 9.31, df = 1, P = 0.002; British Columbia > Quebec χ2 (n = 1316) = 22.68, df = 1, P < 0.001 PD = personality disorder; SMI = serious mental illness; SUD = substance use disorder k

www.TheCJP.ca

The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 111

National Trajectory Project

Table 3 Relationship of victim to NCRMD–accused people for offences against a person British Columbia n (%)

Ontario n (%)

Quebec n (%)

Total n (%)

Stranger

35 (23.8)

86 (26.6)

125 (20.4)

246 (22.7)

Professional

31 (21.1)

60 (18.5)

157 (25.6)

248 (22.9)

Victim

20 (13.6)

32 (9.9)

78 (12.7)

130 (12.0)

Mental health worker

9 (6.1)

27 (8.3)

56 (9.1)

92 (8.5)

Other authority figure

2 (1.4)

1 (0.3)

23 (3.8)

26 (2.4)

49 (33.3)

104 (32.1)

212 (34.6)

365 (33.7)

6 (4.1)

7 (2.2)

15 (2.5)

28 (2.6)

Police officer

Family Offspring Partner or spouse

13 (8.8)

41 (12.7)

75 (12.2)

129 (11.9)

Parent

18 (12.2)

40 (12.3)

86 (14.0)

144 (13.3)

Other family member Other known person Friend or acquaintance Roommate, coresident, or copatient Other Total

12 (8.2)

16 (4.9)

36 (5.9)

64 (5.9)

32 (21.8)

74 (22.8)

119 (19.4)

225 (20.7)

19 (12.9)

41 (12.7)

83 (13.5)

143 (13.2)

4 (2.7)

15 (4.6)

25 (4.1)

44 (4.1)

9 (6.1)

18 (5.6)

11 (1.8)

38 (3.5)

147 (100)

324 (100)

613 (100)

1084 (100)

Statistical test conducted on the 4 main categories, χ2 (n = 1084) = 10.21, df = 6, P = 0.12

(Table  4). More specifically, 46.6% had at least 1 past conviction. Less than 1 in 10 of our sample had a previous NCRMD finding (8.2%), with significant differences across provinces. Among the 148 people with a prior NCRMD verdict, a higher proportion were male (90.4%, compared with 83.9%) [χ2 (n = 1800) = 4.41, df = 1, P = 0.04] and had a diagnosis of SMI with comorbid SUD or personality disorder (9.2%, compared with 5.1%) [χ2 (n = 1787] = 4.42, df = 1, P = 0.04], a lower proportion were homeless (9.2%, compared with 17.3%) [χ2 (n = 1561) = 26.42, df = 1, P  British Columbia χ2 (n = 706) = 6.25, df = 1, P = 0.01

e

Any prior NCRMD finding: Quebec > British Columbia χ2 (n = 1316) = 6.51, df = 1, P = 0.01; Quebec > Ontario χ2 (n = 1578) = 5.67, df = 1, P = 0.02 NCRMD = not criminally responsible on account of mental disorder; PD = personality disorder

Table 5 Multinomial logistic regression for NCRMD provincial characteristics (n = 1575) Ontario, compared with Quebeca

British Columbia, compared with Quebeca

Ontario, compared with British Columbiaa

Predictor

OR

OR

OR

Female

1.29

(0.92 to 1.80)

1.04

(0.65 to 1.68)

1.23

(0.75 to 2.03)

Aboriginal status

3.15

(1.50 to 6.59)b

5.20

(2.30 to 11.76)c

0.61

(0.29 to 1.25)

Age at the index offence

0.99

(0.96 to 1.01)

0.99

(0.95 to 1.03)

1.00

(0.96 to 1.04)

(95% CI)

(95% CI)

(95% CI)

Diagnosis (nonexclusive) Psychosis

1.16

(0.71 to 1.92)

1.60

(0.75 to 3.40)

0.73

(0.33 to 1.61)

Mood

0.46

(0.26 to 0.80)b

0.56

(0.24 to 1.31)

0.81

(0.33 to 2.00)

SUD

1.21

(0.93 to 1.58)

1.87

(1.32 to 2.66)c

0.65

(0.44 to 0.94)d

PD

1.14

(0.79 to 1.66)

0.85

(0.49 to 1.47)

1.35

(0.76 to 2.40)

Presence of psychiatric history

1.05

(0.81 to 1.36)

1.18

(0.82 to 1.68)

0.89

(0.61 to 1.31)

Age at first offence against person

1.02

(0.99 to 1.05)

1.02

(0.98 to 1.06)

1.01

(0.96 to 1.05)

NCRMD

0.40

(0.25 to 0.64)c

0.33

(0.15 to 0.73)b

1.19

(0.51 to 2.77)

Criminal

0.91

(0.65 to 1.28)

0.81

(0.52 to 1.27)

1.13

(0.69 to 1.85)

Against person

2.01

(1.34 to 3.03)

b

1.07

(0.59 to 1.93)

1.88

(1.00 to 3.54)

Homicides or attempted

2.08

(1.25 to 3.41)b

1.89

(0.91 to 3.95)

1.10

(0.52 to 2.30)

Assault and sexual assaults

0.88

(0.61 to 1.27)

1.41

(0.82 to 2.42)

0.62

(0.36 to 1.10)

Other crimes against persono

0.74

(0.51 to 1.06)

0.97

(0.56 to 1.70)

0.76

(0.42 to 1.35)

Property crimes

0.41

(0.25 to 0.70)

0.70

(0.35 to 1.41)

0.59

(0.27 to 1.27)

Presence of criminal history

Index—most severe offence (others as reference)

c

–2 Log Likelihood = 2560.22; χ2 = 169.78; df = 32, P < 0.001; Nagelkerke pseudo-R² = 12.2%; proportional chance criteria = 47.8%; model accuracy rate = 61.5% a

Reference category; b P < 0.01;

c

P < 0.001; d P < 0.05

NCRMD = not criminally responosible on account of mental disorder

www.TheCJP.ca

The Canadian Journal of Psychiatry, Vol 60, No 3, March 2015 W 113

National Trajectory Project

murder or attempted murder, assaults and sexual assaults, other offences against a person, and property offences were included. All other offences were collapsed into an other category, which was used as the reference for this variable. This model resulted in an accuracy rate of 61.5%, that is 29% higher than expected by chance (47.8%; –2 Log likelihood = 2602.28) [χ² (n = 1575) = 163.83, df = 32, P