Le Bulletin de l’ACPD – juillet 2018

Le Bulletin de l’ACPD
Volume 1, numéro 1

Dans ce numéro

Surspécialité

PPC et formation

Psychiatrie légale civile

Psychiatrie correctionnelle

Psychiatrie légale au criminel

Demandez aux experts

Pratique professionnelle

L’ACPD vue de l’intérieur

Nouvelles des membres

Le mot des corédacteurs en chef

Jeff Waldman, MD, FRCPC et Todd Tomita, MD, FRCPC

En tant que nouveaux corédacteurs en chef du bulletin de l’ACPD, nous sommes très heureux de lancer le tout premier numéro du volume 1 de la nouvelle ère du bulletin. Comme plusieurs d’entre vous le savent, la responsabilité du bulletin de l’ACPD était auparavant confiée au président de l’ACPD, mais, la psychiatrie légale étant en voie de devenir une surspécialité officielle, le conseil d’administration a décidé que le bulletin devait être dirigé par des rédacteurs en chef qui se consacreraient précisément à cette tâche. Nous nous sommes proposés comme rédacteurs en chef et comme membres du conseil d’administration, et notre objectif est d’augmenter la visibilité du bulletin de l’ACPD et d’en développer le lectorat.

Le format du bulletin n’est pas encore terminé, et nous espérons que les membres nous feront part de leurs commentaires et proposerons du contenu. Nous voulons que ce bulletin devienne une tribune de communication, dont profiteront les membres du pays en entier pour discuter de cas intéressants et de dilemmes éthiques, et qu’il permette au petit nombre de psychiatres judiciaires dispersés partout au pays de sentir qu’ils font partie d’une communauté qui est là pour les soutenir.

Nous voulons tout particulièrement offrir la possibilité aux boursiers, aux résidents de 6e année et aux psychiatres judiciaires en début de carrière d’écrire sur des sujets qui les intéressent; leur contribution au bulletin enrichira du même coup leur curriculum vitæ et attestera de leur expertise auprès des tribunaux et d’autres décideurs.

Le succès du bulletin repose, en fin de compte, sur la participation des membres de l’ACPD, comme lecteurs et comme auteurs. Nous espérons que le tout premier numéro du bulletin remplira cette mission et que vous répondrez à notre invitation, en nous faisant part de vos commentaires et de vos suggestions, et en nous proposant des articles pour les prochains numéros.

Le mot du président

Joel Watts, MD, FRCPC, DABPN (psychiatrie légale)

La publication de notre dernier bulletin remonte à presque un an, et j’ai l’impression que cela fait des siècles! Avec les premiers signes de l’été, il semble tout indiqué de lancer la publication régulière d’un nouveau bulletin repensé et amélioré, et surtout, plus intéressant, pour faire connaître les activités de l’ACPD et faire participer nos membres aux discussions importantes qui touchent notre domaine. Je tiens à remercier chaleureusement les Drs Todd Tomita et Jeff Waldman d’avoir accepté d’être les corédacteurs en chef du nouveau bulletin de l’ACPD. N’hésitez pas à faire part à ces derniers et au conseil d’administration de vos idées de contenu pour le bulletin d’information en écrivant à capl@cpa-apc.org.

Le congrès annuel de l’ACPD, qui s’est tenu à Victoria, vient tout juste de s’achever et, une fois de plus, je suis honoré d’être à la tête d’un groupe de psychiatres aussi réputés et joyeux. Merci à toutes les personnes qui ont participé au congrès (en particulier celles qui sont venues à la séance de travail et ont participé aux élections) et y ont fait une présentation. Une fois de plus, il convient de souligner l’excellent travail du comité organisateur, du comité scientifique et de Mme Chantal Goddard. Les présentations données par les membres et les conférenciers étaient extrêmement intéressantes. C’était un plaisir d’entendre le lauréat de la bourse annuelle de l’ACPD, le Dr Achal Mishra, et un honneur de présenter le prix Bruno Cormier à un collaborateur de longue de l’ACPD, le Dr Johann Brink. La véritable surprise de ce candidat aussi méritant faisait plaisir à voir. Notre congrès continue d’aller de succès en succès, et l’ajout de la soirée au pub a été franchement une réussite. J’ai vraiment hâte de savoir ce que nous réserve le congrès de l’année prochaine, qui se tiendra à Montréal!

La composition de notre conseil d’administration a considérablement changé après les élections tenues lors de notre assemblée générale annuelle (AGA). Le mandat de plusieurs administrateurs prenait fin cette année, et nous remercions ceux-ci de l’appui qu’ils ont apporté à l’ACPD au fil des années : Drs Sandy Simpson, Paul Fedoroff et Johann Brink. C’était un plaisir de travailler avec eux, et leurs nombreuses contributions aux activités de représentation et à la gouvernance de l’ACPD sont inestimables. Nous souhaitons la bienvenue aux Drs Louis Morrisette, Todd Tomita et Jeff Waldman, qui les remplacent au conseil d’administration. Les Drs Brad Booth, Phil Klassen, Vicki Roth et moi-même avons été réélus pour notre troisième et ultime mandat de deux ans. Avec des administrateurs du Québec, de l’Ontario, du Manitoba et de la Colombie-Britannique, notre objectif d’avoir une meilleure représentation géographique au conseil d’administration est atteint. En vertu de nos règlements actuels, c’est le conseil d’administration qui désigne les membres du bureau de direction, à savoir le président, le vice-président, le secrétaire et le trésorier, qui assumeront leur fonction pendant la prochaine année; le Dr Brink, président du Comité des mises en candidature, a accepté de présider la première réunion du nouveau conseil d’administration afin de nous aider dans ce processus.

Nous étions heureux d’annoncer lors de l’AGA que l’adoption des nouvelles lignes directrices éthiques a été approuvée par les membres. Dix-neuf des 22 personnes qui ont voté étaient en faveur de la proposition; celle-ci a donc obtenu le nombre minimum de voix requis (15). Les lignes directrices éthiques sont enfin publiées sur le site Web après des années de travail acharné de la part de nombreux membres de l’ACPD, y compris : les Drs Graham Glancy et Padraig Darby, qui ont travaillé aux versions initiales du document, le conseil d’administration de l’ACPD et les Drs Renée Fugère et Sébastien Proulx, qui en ont révisé la traduction en français.

Encore cette année, le conseil d’administration a un programme chargé, et nous continuerons de nous réunir régulièrement pour faire avancer les activités prévues. Nos règlements étant désormais à jour, nous avons commencé à rédiger nos procédures et nos politiques de fonctionnement. Nous nous sommes rencontrés peu de temps avant le congrès de l’AAPL, qui s’est tenu à Denver, au Colorado, en octobre 2017, et nous avons réussi à abattre beaucoup de besogne pendant une réunion de quatre heures. Dans les prochains mois, nous allons tenir une autre réunion pour travailler à l’élaboration de ces documents. Cela permettra également de renforcer l’efficience opérationnelle de l’ACPD, de veiller à ce que le processus décisionnel soit plus efficace et de renforcer la mémoire institutionnelle de notre organisation. À l’AGA, le Dr Roth a dressé un portrait des fonds excédentaires accumulés par l’ACPD, et présenté quelques options quant à leur utilisation. Nous continuerons de faire un bon usage de cet argent en tenant compte des souhaits exprimés par consensus par les membres de l’ACPD, tout en assurant la stabilité financière future de l’organisation.

Comme ce fut le cas dans la dernière année, l’ACPD continuera de travailler en étroite collaboration avec l’Association des psychiatres du Canada (APC), notamment en parlant, de concert, aux différents intervenants et en répondant aux demandes des médias. En prenant la relève du Dr Brink, je siège dorénavant, en ma qualité de président de l’ACPD, au conseil d’administration de l’APC et au Conseil des académies canadiennes. L’ACPD a été invitée à donner une conférence dans le cadre de la Série des experts psychiatres lors du congrès annuel de l’APC, qui aura lieu du 27 au 29 septembre 2018, à Toronto. Pour donner suite à une évaluation des besoins effectuée par nos collègues psychiatres de l’APC, un groupe de membres de l’ACPD présentera une conférence sur l’évaluation de différentes capacités et fournira des conseils d’expert sur la façon de préparer la documentation et de se préparer à témoigner.

Je vous souhaite à tous un été chaud, et j’ai hâte de vous redonner des nouvelles dans le prochain bulletin!

Surspécialité

Rapport des directeurs de programmes de résidence de 6e année en psychiatrie légale

Lenka Zedkova, MD, PhD, FRCPC
Directrice de programme, programme de résidence en psychiatrie légale, Université de l’Alberta

Il y a sept programmes agréés de formation postdoctorale de surspécialité en psychiatrie légale (R-6) au Canada :

  1. Université de l’Alberta
  2. Université McMaster
  3. Université de Montréal
  4. Université d’Ottawa
  5. Université de la Saskatchewan
  6. Université de Toronto
  7. Université de la Colombie-Britannique

En ce moment, 11 résidents effectuent leur 6e année de résidence en psychiatrie légale auprès d’un programme de formation postdoctorale au Canada, et cinq autres sont censés s’inscrire pour l’année scolaire 2018-2019.

Les directeurs de programme feront des rapports réguliers aux membres de l’ACPD au sujet de la formation. Dans cette nouvelle rubrique, nous nous concentrerons sur un programme de résidence en psychiatrie légale particulier et donnerons de l’information sur la formation. Dans le présent numéro, nous vous présentons le programme de formation en psychiatrie légale de l’Université de l’Alberta. Chaque année, le programme de formation de l’Université de l’Alberta finance un poste de résident de 6e année en psychiatrie légale.

Programme de résidence en psychiatrie légale de l’Université de l’Alberta

Le programme de l’Université de l’Alberta a été agréé en 2013 par le Collège royal des médecins et chirurgiens du Canada. Comme c’est le cas des autres programmes, le résident doit, pour être admissible, avoir réussi l’examen du Collège royal en psychiatrie légale. À ce jour, jusqu’à deux postes de résident ont été financés chaque année.

Dans notre programme, les résidents sont exposés à un large éventail d’expériences d’apprentissage. Nos services aux patients hospitalisés, le plus grand de l’Alberta, sont situés à l’Alberta Hospital Edmonton (AHE), qui compte plus de 100 lits de psychiatrie légale. À l’AHE, les résidents développent des compétences en évaluation de l’aptitude à subir un procès et de la responsabilité pénale, ordonnée par le tribunal, et en rédaction de rapports (notamment, sur des cas complexes ou très médiatisés). Lorsqu’ils ont acquis plus d’expérience, les résidents fournissent des témoignages devant le tribunal, si l’occasion se présente. Avec leur équipe, les résidents participent également à l’établissement d’un plan de réhabilitation fondé sur un modèle de rétablissement et à la gestion des risques chez les patients jugés inaptes à subir leur procès ou non criminellement responsables. Les résidents doivent effectuer des évaluations officielles des risques, rédiger des rapports pour l’Alberta Review Board (ARB) et fournir des témoignages aux audiences de la commission d’examen.

Nos services de médecine légale pour les patients non hospitalisés (Forensic Assessment and Community Services [FACS]) offrent des évaluations, des traitements ultraspécialisés et des services de proximité. Pendant leur stage aux FACS, il arrive que les résidents continuent d’effectuer des évaluations ordonnées par le tribunal, y compris des évaluations présentencielles. L’accent est mis dans ce cas sur le traitement des patients externes jugés non criminellement responsables et sur la gestion des risques chez cette clientèle. Les résidents prennent part également à l’évaluation et au traitement des délinquants qui participent au programme pour les délinquants sexuels et au programme pour les auteurs de violence conjugale.

Nos programmes s’adressant aux jeunes contrevenants comportent à la fois des services aux patients hospitalisés et des services aux patients non hospitalisés. L’unité de psychiatrie légale pour les adolescents de l’AHE (le Turningpoint Program) donne une occasion vraiment unique aux stagiaires d’être en contact avec des jeunes délinquants admis sur la base d’un éventail d’évaluations ordonnées par le tribunal, y compris des évaluations au titre de l’article 34 de la Loi sur le système de justice pénale pour les adolescents, des évaluations de la surveillance dans le cadre d’un programme intensif de réadaptation, ainsi que des évaluations de l’aptitude à subir un procès et de la responsabilité pénale. Dans le programme pour les malades externes Centrepoint, nos résidents ont accès aux évaluations présentencielles et aux cas de traitement recommandés par les tribunaux, les agences de probation et les organismes communautaires.

Nous venons d’ajouter récemment une autre expérience d’apprentissage aux résidents, à savoir le tout nouveau tribunal en santé mentale, auquel est affecté un psychiatre judiciaire. Ce tribunal vise à accélérer la procédure par l’intermédiaire d’évaluations en temps réel et à mettre les clients en relation avec diverses ressources communautaires.

L’établissement de détention provisoire, l’Edmonton Remand Centre, fournit à nos résidents encore plus d’occasions de participer aux évaluations ordonnées par le tribunal, y compris les évaluations des délinquants à risque élevé. Dans nos établissements correctionnels provinciaux et fédéraux, les stagiaires se familiarisent avec le fonctionnement des cliniques et avec les particularités de l’environnement correctionnel.

Notre programme offre une variété de possibilités de stages facultatifs, y compris l’évaluation et le traitement des individus qui participent aux programmes pour les délinquants sexuels et les auteurs de violence conjugale, aux programmes pour les jeunes contrevenants, à la psychiatrie légale en matière civile ou à la recherche en criminalistique, dont il est question ci-dessus. Les stages facultatifs à l’extérieur de la province sont encouragés.

Les résidents sont tenus de participer à des activités éducatives, notamment des séminaires judiciaires hebdomadaires, des séances scientifiques et des clubs de lecture mensuels sur la criminalistique, ainsi qu’un procès simulé annuel.

Le processus de demande et de sélection est décrit sur le site Web de l’Université de l’Alberta. Nous attendons avec impatience les demandes des futurs candidats!

Atelier sur la Compétence par conception en psychiatrie légale, 3 mai 2017
Étapes des activités professionnelles confiables

© Le Collège royal des médecins et chirurgiens du Canada, 2018. Cité et reproduit avec permission.

Étape 1 – Progression vers la discipline

  1. Effectuer une évaluation psychiatrique générale, élaborer une formulation de la problématique du patient et établir un plan de prise en charge, y compris le risque grave de violence et/ou de suicide
  2. Obtenir le consentement éclairé du patient à l’examen médico-légal
  3. Travailler efficacement au sein de l’équipe interprofessionnelle
  4. Documenter l’entretien clinique

Étape 2 – Acquisition des fondements de la discipline

  1. Effectuer les évaluations de l’aptitude à subir un procès et rédiger des rapports lorsqu’il s’agit d’adultes dont le cas est simple
  2. Effectuer les évaluations de la non-responsabilité criminelle et remplir le rapport lorsqu’il s’agit d’adultes dont le cas est simple
  3. Effectuer des évaluations des risques lorsqu’il s’agit d’adultes dont le cas est simple
  4. Évaluer et effectuer une prise en charge continue des patients évalués par la commission d’examen

Étape 3 – Maîtrise de la discipline

  1. Réaliser des évaluations psychiatriques ciblées complexes et juridiquement défendables
  2. Remplir des rapports écrits clairs et juridiquement défendables
  3. Témoigner devant la cour et les tribunaux
  4. Fournir une prise en charge continue des patients complexes
  5. Diriger une équipe de psychiatrie légale dans les soins aux patients et la gestion des risques
  6. Interagir professionnellement avec les avocats, la Couronne et les organismes de soutien

Étape 4 – Progression vers la discipline

  1. Gérer la charge professionnelle d’un psychiatre judiciaire
  2. Contribuer au domaine (séances scientifiques, résumés, administration, etc.)
  3. Développer et actualiser son curriculum vitæ
  4. Élaborer un plan de carrière et d’apprentissage pour les trois à cinq premières années de pratique

PPC et formation

Congrès annuel de l’ACPD de 2019

Phil Klassen, MD, FRCPC

Le comité organisateur du congrès est heureux d’annoncer que le prochain congrès annuel de l’ACPD aura lieu du 28 avril au 1er mai 2019 à Montréal, au Québec, à l’hôtel Le Westin Montréal. Pour donner suite aux résultats du sondage auprès des membres, qui révèle que les membres préfèrent que le congrès se tienne plus tard au printemps, contrairement à ce qui se fait depuis toujours, nous tiendrons la réunion à Montréal à des dates plus propices aux activités extérieures. En accord avec les résultats du sondage et avec notre tradition d’alterner le congrès à l’Est et à l’Ouest, le comité compte organiser le congrès de 2020 à Banff, sensiblement aux mêmes dates que cette année; ainsi, les participants auront la possibilité de faire un éventail d’activités de plein air, comme le vélo, la randonnée, le golf et le ski de printemps. N’hésitez pas à donner aux membres du comité votre avis sur nos suggestions. Nous avons hâte de vous voir!

Prochains événements dans le domaine de la psychiatrie légale

Événements internationaux

49e réunion annuelle de l’American Academy of Psychiatry and the Law (AAPL)
Du 25 au 28 octobre 2018
Austin, Texas
http://www.aapl.org/annual-meeting

Événements nationaux

24e congrès annuel de l’ACPD
Du 28 avril au 1er mai 2019
Montréal, Québec
http://www.capl-acpd.org/fr/congres-de-lacpd/

Alberta

The Calgary Annual Forensic Conference: Vicarious Trauma in Forensic Settings.
Conférenciers : Dr John Bradford, Dr Julian Gojer, la juge à la cour provinciale Michele Collinson et Dr Sergio Santana
12 octobre 2018
Contact : Dr Oluyemisi Ajeh : oluyemisi.ajeh@ahs.ca

Colombie-Britannique

Journée de formation sur la psychiatrie légale, 9e édition
Division de la psychiatrie légale de l’Université de la Colombie-Britannique et section régionale de la Colombie-Britannique
UBC Robson Square, Vancouver
9 novembre 2018
Contact : lchivers2@phsa.ca

Psychiatrie légale civile

Westerhof v Gee Estate and McCallum v Baker: A Warning to Guard Against the Perception of Being a “Hired Gun”

Jeffrey C. Waldman, MD, FRCPC
Forensic Psychiatrist

I have worked in forensic psychiatry since I completed my residency training program in 2003. For the first 10 years of that practice I also worked in correctional psychiatry, and for approximately seven years, I was the only psychiatrist who worked in the psychiatric intensive care unit. I provide clinics to clients with low IQ, have a history of violence and criminal sexual behaviour, as well as provide ongoing community-based psychiatric care for some of the more complex, high-risk, psychiatric patients with a history of involvement with the criminal justice system in the province.

Winnipeg is a relatively small community with only a few psychiatrists willing to provide expert testimony to the courts. As such, either out of habit, out of convenience, or out of pragmatism, the relationship between the courts and its experts has been an informal one. Although I remain cognizant of some of the issues related to how I communicate to the court in my various roles, that informal relationship allowed me to give recommendations to the court and successfully advocate for my patients, and for my clients’ and patients’ interests.

In early 2013, all of my colleagues left the hospital-based forensic program. I took over as the medical director and I began studying for my subspecialty examination in forensic psychiatry. Although the lack of formality of communication between the courts and my program in Winnipeg provided me with more power than I was likely entitled to, and more influence on the outcome of court proceedings for my patients or the accused, I decided that it was essential for our program to provide information to decision-makers in an ethical and standardized fashion. As such, I took steps to formalize the processes within forensic psychiatry to provide training to residents specifically on the role of providing testimony as an expert as opposed to a fact witness, and the responsibility that we have to a decision-maker to provide all of the relevant information in an unbiased fashion without usurping the role of the decision-maker in that process. Even after providing grand rounds to the department, speaking to the judiciary, providing information about the role of the expert at a defence – Crown conference, and speaking to members of the Law Society, I am still struck by the kinds of questions posed to me that are unrelated to the assessment question, the court’s use of information provided by some of my colleagues and my colleagues’ lack of awareness regarding issues raised when they are asked to answer questions unrelated to their role as a treatment provider.

Approximately three years ago, a Winnipeg man who had attempted to strangle the passenger he was sitting next to on a Greyhound bus was admitted to hospital in Vancouver. He was then transitioned back to Winnipeg to follow up with the Schizophrenia Program here. Within a couple of months he had attempted to drive his vehicle into oncoming traffic. When his vehicle finally lost control and left the road, he removed all of his clothes and ran into the woods screaming a religious monologue. Although the outcome may not have been different were the courts to order an assessment from our department, he was found Not Criminally Responsible (NCR) based on a one-paragraph letter by his treating psychiatrist, simply indicating that the man has schizophrenia, he was sick at the time, and providing the opinion that “he should be found NCR.”

Another case that I presented at a previous CAPL conference on sexsomnia involved a man who was referred by his family physician to a sleep specialist in Ontario as part of his family doctor’s efforts to respond to concerns that the man may be engaging in sexual behaviour in his sleep. In the context of that medical consult, the sleep expert indicated that it was his opinion that the reason the patient had been sexually assaulting his wife during the night was because of a condition that the sleep specialist called sexsomnia. With that report, and no forensic assessment, the individual was found NCR. He later acknowledged that he misled the medical specialist and that he was not asleep for any of the assaults.

At the most recent CAPL conference there was a talk of great interest to all forensic psychiatrists that was presented by two law students under the supervision of Dr. Glancy who spoke on the role of the expert in the courts, and how it has been further clarified in the Ontario Appeals Court. Although the emphasis was on White Burgess,1 I found the cases of Westerhof v Gee Estate and McCallum v Baker2 that were also referenced most interesting. By my reading, those cases seemed to allow treatment providers to be questioned as experts without any consideration for the ethical obligations or professional obligations of the treatment provider to their patient. The courts also seem to assume that the issues relevant for the courts should be available to treatment providers who are completing basic diagnostic assessments or are seeing their patients in order to simply provide treatment.

Are the decisions in Westerhof and McCallum reflective of a lack of understanding or an inherent truth? It appears that the court and the average person make two general assumptions. First, they believe that a treating psychiatrist or treatment provider who has known a patient over time will ultimately have the most relevant information for the courts or any other decision-maker. Second, that the expert is simply a hired gun and is being paid to provide a predetermined opinion. In response to this and the cases that have spoken to this issue, forensic psychiatrists need to be very careful to explain the processes that occur in the context of their assessment and do everything they can to ensure that the courts understand the steps taken to remain objective.

I expect that there is significant cross-Canada variability in understanding the role of the expert in general, and of the forensic psychiatrist in particular. I expect that all forensic psychiatrists are comfortable educating the courts and other decision-makers on issues relevant to decisions that are being made. But in my opinion these cases highlight the importance of educating the courts and other decision-makers, as well as our psychiatry colleagues on the role of the expert and the processes involved in arriving at our opinions. I expect that most would be comfortable with this and might even be of the opinion that this is already the case. If so, what is at the root of the judges involved in the cases who appear to value the opinion of the treatment provider as opposed to the expert? You might all agree with the first step required to remedy the apparent misperception of the layperson and the courts that the expert is to educate them on the processes that occur in the context of a forensic assessment. A forensic psychiatrist is not simply providing a bought opinion, but rather an opinion based on sound methodology, specific to the issues relevant for the decision-maker.

Would you be willing to take more decisive steps? Given that we are a self-regulated profession, what is the obligation of the forensic psychiatrist when we believe a colleague is providing unsubstantiated opinion, or opinion that they could not have arrived at in the course of a routine clinical assessment or during the course of treatment? Is the integrity of forensic psychiatry as a subspecialty worth encouraging our regulating body to censure colleagues who undermine what we do? There is an article that describes a process for communicating with expert colleagues when appropriate practice processes are not followed.3 The authors provide a useful process for “polite” email or letter communication to a colleague with templates for “confronting colleagues.” This process is an excellent first step. If this process does not result in a change in practice, a report to our regulating body is necessary.

The integrity of the forensic psychiatry profession depends on maintaining high ethical standards. The revised Canadian ethical standards for forensic psychiatry that were approved at the last CAPL conference, highlight the importance of careful attention to practising forensic psychiatry with a high ethical standard. In my opinion, the integrity of our profession requires us to hold each

other and our colleagues to that ethical standard, and that may require that we as a profession be willing to take more decisive steps to address unsubstantiated opinions based on misguided methodology as one additional remedy to counter the courts’ assumptions that a treating physician is the most objective expert and that a forensic psychiatrist may simply be a hired gun.

References

  1. White Burgess Langile Inman v Abbott and Haliburton Co. [2015[ SCC 23.
  2. Westerhof v Gee Estate; and McCallum v. Baker [2015] ONCA 206.
  3. Brodsky SL, McKinzey RK. The ethical confrontation of the unethical forensic colleague. Prof Psychol. 2002;33(3):307–309.

Forensic Psychiatric Evaluation of Mild Traumatic Brain Injury

Todd Tomita, MD, FRCPC

“Follow the data…” – Dr. Roy O’Shaughnessy

Introduction

I often hear Dr. O’Shaughnessy’s admonition to follow the data which I have always found to be a guiding maxim in my approach to forensic psychiatric evaluation, particularly in personal injury cases. To those uninitiated to the civil medical-legal arena in which personal injury cases are assessed and adjudicated, it can be an eye-opening experience to observe how opinions based on a paucity of data can influence the outcome of cases. In British Columbia, and I suspect in most jurisdictions, forensic psychiatrists do not provide the bulk of psychiatric personal injury evaluations; however, in my admittedly biased view, the quality of forensic psychiatric assessments and written reports does much to moderate some of the extreme, “hired-gun” type opinions that stray far from the available data in particular cases.

Mild traumatic brain injury is one of those troublesome areas in which there can be considerable variability in opinions based on limited or questionable data sources. In this article, I propose to comment on the strengths of a forensic psychiatric methodology in the approach to personal injury cases involving mild traumatic brain injury. I will touch briefly on relevant research findings, then highlight the vexing forensic psychiatric assessment issues that need to be explicitly addressed in a written report and testimony.

Forensic Psychiatric Methodology

In the civil legal arena, lawyers will often inquire as to the differences between a clinical and a forensic approach to the psychiatric evaluation. Perhaps the simplest way to explain this is to emphasize that a forensic psychiatrist routinely juggles two different roles—forensic and treater—and the approach adopted differs depending on the one being used. In contrast, non-forensic psychiatrist evaluators may have difficulty stepping out of the treater role as the forensic role is not a routine part of their work. A treater role is ill-suited to a forensic psychiatric evaluation.

There are several ways to unpack the forensic psychiatric approach but one generally accepted model is Heilbrun’s four step model:1,2

  1. Preparation
  2. Data Collection
  3. Data Analysis
  4. Report Writing and Testimony

I do not propose to go through each step, but suffice to say that preparation involves understanding the legal questions at hand in a personal injury case that typically focus on diagnosis, causation and psychiatric functional impairment.

The data collection step is critical in mild traumatic brain injury cases, as it provides the foundation for opinions. Lovejoy and Oakes describe data lying along a subjective-objective continuum.4 They emphasize that all data needs to be clinically weighted in terms of reliability and degree of applicability to the questions at hand in data analysis.

Data can range from the most subjective to a mix of subjective/objective to the most objective. The most subjective data are in individual statements or medical records submitted by treaters that offer a recapitulation of self-report without any formulations related to diagnosis, impairment or documentation of observed behaviours.

The subjective/objective level of data typically relates to procedures that serve to quantify and organize subjective symptoms in reports, and offer a cross-sectional view in an individual’s functioning. This is typically where the forensic psychiatric interview will take place.

The most objective evidence includes things such as academic records, formal work performance evaluations, neuroimaging, psychometric testing with norms and provisions for validity testing and surveillance data. Establishing the clinical weight to assign to these sources of data is critical as sometimes less objective and more subjective data is emphasized in opinions involving mild traumatic brain injury cases which can have a marked influence on the conclusions. Furthermore, it can distort opinions away from what appears to be the most objective picture based on the data.

Relevant Research Findings

There is an extensive literature on mild traumatic brain injury. Examination of the details and nuances of the literature is beyond the scope of this paper. Instead, a selective review of the key findings related to the typical course after mild traumatic brain injury and some of the competing clinical conditions and factors that can complicate assessment will be reviewed.

The typical course after mild traumatic brain injury is full recovery. The research literature is reasonably settled in this regard. Within the first week after a mild traumatic brain injury, there are objective cognitive sequalae. Measures of attention, memory and speed of information processing show abnormalities. There is rapid recovery within weeks. The majority are fully recovered by three months. There is a persistent minority who deviate from the typical recovery trajectory with numbers ranging from five per cent to 15 per cent cited. Commentators caution that the number needs to be interpreted carefully as persisting symptoms, typically attributed to a post-concussion syndrome, are primarily subjective in nature.

There is a typical constellation of symptoms attributed to post-concussive syndrome including cognitive, physical and emotional symptoms. Cognitive symptoms include loss of concentration and memory problems. Physical symptoms include headaches, dizziness, fatigue, insomnia, tinnitus, and sensitivity to light and noise. Emotional symptoms include depression, irritability and anxiety.

It is critical to recognize that the post-concussive syndrome is not synonymous with mild traumatic brain injury. The literature shows that individuals who have not suffered any traumatic brain injury can manifest similar symptoms. Consequently, the persistent post-concussion syndrome is non-specific and of questionable utility in forensic evaluations. This is for at least three reasons that may be used in rebuttal or testimony. First, the underlying pathophysiology is undefined. Second, the severity of traumatic brain injury does not clearly correlate with the risk of post-concussion syndrome. Third, the symptoms are subjective and common in other clinical populations and, in fact, in the general population.

The literature and expert commentary would suggest that the informed treater position would be to avoid lumping cognitive, physical and emotional symptoms into a single syndrome of post-concussion syndrome. This approach can create iatrogenic difficulties with implied causation and it also obscures rather than helps clarify some of the vexing independent medical examination (IME) assessment issues when the clinical data are undifferentiated.

Conditions that can present with post-concussion syndrome symptoms in the absence of traumatic brain injury include depression, chronic pain, posttraumatic stress disorder, non-traumatic brain injury trauma and normal populations. Ultimately, whether it is called post-concussion syndrome or simply persisting symptoms attributable to a mild traumatic brain injury, this conclusion is most reasonably considered a diagnosis of exclusion after other conditions that can produce comparable symptoms are excluded.

There are some predictors of incomplete recovery from mild traumatic brain injury: these include prior head injury, presence of psychiatric conditions, Glasgow Coma Scale (GCS) of 13 rather than 15 following head injury, and involvement in litigation and compensation proceedings. It is important to emphasize that given the state of our science, these are correlational and not causal predictors.

For the purposes of a forensic psychiatric evaluation, based on the available literature, there are four reasonable assumptions to make:

  1. mild traumatic brain injury is a highly individualized injury;
  2. the typical course is full recovery by three months;
  3. an atypical course is most likely due to preexisting and comorbid conditions; and
  4. long-term problems attributable to a mild traumatic brain injury should be reserved as a diagnosis of exclusion.

Forensic Psychiatric Assessment Challenges

I will turn to the psychiatric assessment challenges in the forensic evaluation of mild traumatic brain injury cases. There is a reasonable consensus on the challenging issues in the assessment of mild traumatic brain injury but no standardized assessment approach. My contention is that a forensic psychiatric methodology is well-suited to these types of evaluations.

Part of the difficulty in mild traumatic brain injury cases is that they lie at the intersection between multiple specialties including neurology, neurosurgery, physical medicine and rehabilitation, and neuropsychology. No specialist can make the determinative finding; however, psychiatry may be particularly well-situated as the comorbid conditions which lead to a persistence of emotional and cognitive symptoms are often attributable to psychiatric disorder.

Five psychiatric assessment challenges arising in the forensic psychiatric assessment of mild traumatic brain injury revolve around: 1) clinical discernment and bias, 2) different diagnostic thresholds, 3) atypicality and persistence of symptoms, 4) multifactorial causation and 5) proportionate attribution.

1. Clinical discernment and bias

Employing a high degree of clinical discernment and maintaining an awareness of bias are critical in evaluating mild traumatic brain injury cases. As already mentioned, data must be weighed, and the key question is to consider whether the data being relied upon to form a picture of the outcome of mild traumatic brain injury are clinically credible.

Iverson and Lange review potential biases in the assessment of mild traumatic brain injuries.3 There are potential plaintiff biases including expectancy bias, “good old days” bias and iatrogenesis. Expectancy bias refers to symptoms being caused by expecting to have them after an event occurs. People can experience a head injury and expect to have some adverse outcome: this can create symptoms. “Good old days” bias refers to a tendency to recall one’s condition before a traumatic brain injury in an overly positive way. Iatrogenesis refers to a medically-induced adverse outcome. In mild traumatic brain injury cases, iatrogenesis is often introduced when treating clinicians keep telling people that their persisting symptoms are related to mild traumatic brain injury. This causes difficulties as the underlying assumption is often that little can be done as the changes are permanent.

There are potential expert biases. They include treater bias, partisan bias, as well as anchoring and confirmation bias. Treater bias arises in the context of a treating physician taking on a dual role in provisioning an IME report. Treaters are aligned with patients, advocate for them and do not want to impugn them or cause harm as this is typically against the treater’s ethics. This creates the potential for bias if the direction of opinions is not aligned in a favourable way for the plaintiff/patient. Partisan bias refers to alignment with the retaining side. In extreme cases, this leads to the “hired gun” phenomenon. Anchoring bias refers to the tendency to focus on a single event in mild traumatic brain injury cases—the injuring incident. Confirmation bias refers to a search for the presence of symptoms, in this case post-concussion syndrome, to affirm the presence of a mild traumatic brain injury with persisting symptoms.

2. Different diagnostic thresholds

Although diagnostic thresholds are not always explicitly applied, it is important to emphasize that there is variability. The classification of traumatic brain injury severity involves three factors: 1) duration of loss of consciousness, if any, 2) the duration of memory disturbance and 3) GCS score.

Three generally used mild traumatic brain injury diagnostic criteria are the American Congress of Rehabilitation Medicine (ACRM), Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and International Classification of Disease (ICD-10). Depending on which diagnostic criterion is employed, the threshold to establish a diagnosis changes.

The lowest threshold is the ACRM, which requires, “…a traumatically induced physiological disruption of brain function” that is manifested by one or more of the following: any period of loss of consciousness for up to 30 minutes, any loss of memory for events immediately before or after the accident for as much as 24 hours, or, any alteration of mental state at the time of the accident (e.g., feeling dazed, disoriented or confused).

A higher threshold for diagnosis is found in the DSM-5 criteria for mild neurocognitive disorder due to traumatic brain injury. The DSM-5 has an emphasis on the need for evidence of a traumatic brain injury, and sets out a requirement that there has been an impact to the head or other mechanisms of rapid movement or displacement of the brain within the skull. There is also a temporal criteria that symptom onset occurs immediately after the traumatic brain injury or after recovery of consciousness.

The DSM-5 also has a comparatively higher threshold as it does not use the “any” criteria that is found in the ACRM criteria. Instead, there are definitive findings that must be present including one or more of the following: loss of consciousness, posttraumatic amnesia, disorientation and confusion, or neurological signs (e.g., neuroimaging demonstrating injury, a new onset of seizures, a marked worsening of preexisting seizure disorders, visual field cuts, anosmia (loss of smell), hemiparesis).

The ICD-10 post-concussion syndrome criteria are the highest threshold by virtue of the defining criteria for injury that requires a history of head trauma with a loss of consciousness preceding symptom onset by a maximum of four weeks. The presence of multiple symptoms including physical, cognitive and emotional are required.

The most common challenge in forensic psychiatric evaluations is the need to carefully consider whether a mild traumatic brain injury diagnosis established using the ACRM also crosses the DSM-5. If not, then a more extended analysis of other causal conditions and factors is required. It is often in this specific scenario that the strength of a forensic psychiatric methodology is demonstrated in parsing, weighting and analysing the case data.

3. Atypicality and persistence of symptoms

Usually by the time a forensic psychiatrist evaluating a case of mild traumatic brain injury sees the plaintiff, the clinical course has become atypical as the individual has failed to recover and has persisting symptoms, hence the reason for the evaluation.

Addressing atypicality requires: 1) identifying predictors of incomplete recovery, 2) identifying any of the common co-occurring conditions that are present, 3) identifying contemporaneous factors clouding the causation question and 4) addressing the issue of malingering.

As Dr. O’Shaughnessy’s admonition indicates, following the data is critical. Initial injury data must be reviewed, including first responder reports such as ambulance crew, witness statements and hospital records. A survey of the medical records often reveals symptom patterns. It is important, in particular, to look for a pattern of increasing complaints or symptoms over time, which would typically militate against attribution to a traumatic brain injury in which, absent other clinical conditions, one would expect a pattern of decreasing symptoms and recovery. The issue of “chart creep” needs to be examined carefully. For example, finding evidence of altered reporting about the severity of the initial trauma, or any indications of misdiagnosis or misinformation provided to the patient by various health care providers or others.

One must also examine for possible biases and assess the person’s beliefs and expectations regarding their injury and their understanding of the mechanism, damages and outcomes. In particular, one must be careful to identify mixed messages that a plaintiff may have received and the issue of iatrogenesis in which the notion of persisting mild traumatic brain injury, typically in the form of post-concussion syndrome, is introduced and endorsed by treatment providers.

4. Multifactorial causation

Single factor causation is rare in mild traumatic brain injury cases. Instead, the most common scenario is multiple causal factors lead to persistence of symptoms; in other words, multifactorial causation is the rule rather than the exception. In contrast, in moderate to severe brain injury, it is more clinically plausible to expect that traumatic brain injury is the single causal factor. A guiding maxim, grounded in the available literature, is that persistent mild traumatic brain injury symptoms and related impairment need to be reserved as a diagnosis of exclusion while one considers factors that may be leading to atypicality of outcome.3

There are sometimes contemporaneous issues which cloud the assessment that are often difficult to express in the psychiatric IME. These include the role of the litigation context. Involvement in litigation can be stressful and it is unsurprising that involvement in litigation is one of the predictors of persisting symptoms. There is also the role of personality. Sometimes this is obvious as in the case of someone with an obsessional personality who has great difficulty accepting and adjusting to some degree of residual difficulties, whether it be physical or emotional as a consequence of a traumatic injury. At other times, it can be more subtle and difficult to pin down with available data. Finally, clinical misattribution, reinforcement and iatrogenesis can sometimes be important factors, but they may be difficult to address explicitly in the assessment.

5. Proportionate attribution

The final area is in the data analysis section in ensuring that proportionate attribution of causal conditions and factors is explained. The psychiatric expert’s analysis needs to reflect the realities that single factor causation is the exception rather than the rule.

If one approaches these cases with a “multifactorial maxim” in mind, a clinical weighting of contributing conditions and factors must follow. Clinical judgment is required in weighing the data along the subjective-objective data continuum because this can be a source of significant variability in both diagnosis and opinions around attribution of persisting symptoms and related functional impairment. One must be careful to select data which are the most credible to use as a foundation for opinions. The analysis that is set out should reflect evidence of a search for symptom patterns, both of symptoms that might be attributable to mild traumatic brain injury and for common co-occurring conditions in mild traumatic brain injury. That is, there should be some type of “ruling out” process in evidence in the analysis.

Clinical judgment is critical in evaluating mild traumatic brain injury cases because of the need to decide on the causal weight to place on a remote mild traumatic brain injury when contemporaneous causal factors such as depression, insomnia or chronic pain, are present.

Clinical judgment is required in determining the scope and limits of psychiatric expertise. Mild traumatic brain injuries typically involve multiple evaluators from different specialties including neurology, neurosurgery, physical medicine and rehabilitation, and neuropsychology. Depending on the presence of comorbid conditions, a psychiatrist may not be best-placed to provide opinions. For example, if posttraumatic headaches have been diagnosed and these are the main source of clinical distress and impairment, then this may be deferred to a neurologist.

Conclusion

Forensic psychiatrists are well-placed to conduct forensic evaluations in personal injury cases. In my jurisdiction, when two forensic psychiatrists, retained by opposing counsel, evaluate the same case, opinions typically fall into the same ballpark. When major divergences in opinions occur, it is often when a non-forensic evaluator and a forensic psychiatric evaluator provide opinions. Although there are many factors in play, I submit that one recurring finding is that divergence in opinions is often because the non-forensic opinion has strayed too far from the data. From my perspective, promoting and demonstrating the utility of a forensic psychiatric methodology could do much to reduce the “battle of the experts” phenomenon that often transpires in the civil legal arena.

Forensic psychiatrists have a well-defined skill set employing a forensic assessment methodology that can assist in making a unique contribution to psychiatric evaluations in the civil legal arena. This paper has been an attempt to highlight the strengths of forensic psychiatric methodology in the approach to mild traumatic brain injury cases.

References

  1. Heilbrun K, Grisso T, Goldstein AM. Foundations of forensic mental health assessment. New York: Oxford University Press; 2009.
  2. Heilbrun K. Principles of forensic mental health assessment. New York: Kluwer Academic /Plenum Publishers; 2001.
  3. Iverson G, Lange R. Traumatic brain injury in the workplace. In: Bush SS, Iverson GL, editors. Neuropsychological assessment of work-related injuries. New York: Guilford Press; 2012.
  4. Lovejoy DW, Oakes HJ. The behavioural health provider as a participant in the disability determination process: Evaluations, terminology and systems. In: Bush SS, Iverson GL, editors. Neuropsychological assessment of work-related injuries. New York: Guilford Press; 2012.

Psychiatrie correctionnelle

Ethical and Therapeutic Questions About the Use of Seclusion and Restraint in Patients With Severe Borderline Personality Disorder in Forensic and Correctional Settings

Gabrielle Provost, MD, FRCPC
Forensic Psychiatrist, Institut Philippe Pinel de Montréal

This article is a complement to the CAPL 2018 complex case presentation describing issues with the use of restrictive measures with a patient presenting a severe borderline personality disorder. It highlights multiple challenges associated with the use of seclusion and restraint measures and the specificities of working in a forensic environment while facing such challenges. The specific demographic of patients with a borderline personality disorder within the forensic milieu is specifically discussed. Finally, remaining unanswered questions within the existing literature are highlighted and lead to reflection on current practices.

Challenges in Seclusion and Restraints Use

The ethical and professional challenges associated with the use of seclusion and restraint measures in psychiatric and correctional settings are widely acknowledged. This issue has been the subject of much reflection and many publications. These include efforts aimed at decreasing the use of seclusion and the discussions about the efficacy of such measures, within general psychiatry units and in forensic settings.1,2 It appears to be an important time for forensic psychiatrists to reflect on their clinical practice around the use of seclusion and restraints given the the increasing scrutiny on the use of segregation and solitary confinement. Although clinical seclusion is arguably different than these non-clinical practices, this may not be a view shared in all quarters of society.

Practical experience using clinical seclusion in a forensic environment with particularly challenging patients highlights how such issues can take up a major place in daily clinical decisions. These challenges are even more complex when they involve the management of patients with not only aggressive behaviour towards others, but also (and sometimes mainly) towards self. Caring for patients with borderline personality disorder, especially those with severe presentations, represents a good example of this specific type of challenge. Indeed, discussing such patients can, and should, lead to further reflection on the challenges in balancing the risks to self and others posed by the patient, between safety for all and the need to develop a therapeutic, positive alliance and rehabilitation-oriented approach.

The Specificities of the Forensic Milieu

The forensic environment presents particularities which render the management of such patients more complex. There is a paradoxical dual role of care and custody, incorporating dynamics of power, protection and containment, that can often present as significantly coercive. This specific dynamic can, by itself, be described as a factor leading to the development of self-harm behaviour in patients within forensic settings.3,4,5 Self-harm also presents, in and of itself, as a dynamic risk factor for aggression.6 Forensic settings are also risky environments, leading to specific safety concerns associated with the distinctive characteristics of their populations. Forensic environments tend to care for a clientele presenting with self-harm behaviour as these patients are specifically referred to secure settings because of previous aggressive behaviours, unmanageable self-harm or need for a high secure environment of care. The need to prevent and manage violence and the parallel need to achieve therapeutic and rehabilitative goals are both paramount. Additional challenges can include flights and security breaches, which are heightened in forensic/correctional settings and must be considered in decision-making. The legalistic framework can sometimes lead to an oppositional position from the patient, to more secret self-harming or plain refusal to be helped. Finally, the risk of assaults on staff by patients when they try to prevent or manage self-harm can have a significant negative impact on staff morale and capacity to care.4,7,8

Patients With Borderline Personality Disorders: Tackling an Additional Challenge

The ethical and therapeutic questions associated with use of seclusion and restraints measures are of paramount importance when addressing the care of patients with borderline characteristics in forensic settings. A key question is the impact these measures may have on the clinical trajectory of patients with severe borderline personality presentation, which are overrepresented within the female population in forensic settings,9 and whether iatrogenic effects can arise from the use of such measures. Indeed, these issues have been increasingly highlighted around the use of seclusion in the context of self-harm or suicidal intention. In 2016, the National Commission on Correctional Health Care deemed prolonged seclusion as inhumane and harmful to health. In the literature on segregation in correctional settings, some authors can make quite definitive statements (for example, segregation measures being described as torture) although recent research questions whether these definitive statements are realistic or generalizable. (For example, Chadick et al describing segregation as a “barrier to opportunities for continued growth” rather than causing significant psychological damage.)10

What Do We Know?

A review of the literature reveals a lack of consistent findings. A Cochrane review from 2000, updated in 2012, notes a lack of well designed and controlled studies showing the effectiveness of using seclusion measures in patients with serious mental illness.11 This review highlights the important difficulty in carrying out controlled trials in people with challenging behaviour, and, hence, no recommendation was provided regarding the effectiveness, benefit or harmfulness of seclusion or restraint. Nevertheless, the perspective is mostly pessimistic about seclusion measures in qualitative studies addressing more specifically staff and patient perceptions throughout their trajectories and about the use of restrictive measures. As described by Tulley et al, “Patient perspectives include anger with a sense of injustice, and feelings of being rendered powerless and of being degraded.”12 Anxiety and trauma are described as possible long-term effects of seclusion measures. The use of such seclusion and restraint have been described as not only detrimental to the therapeutic relationship, but also as potentially resulting in physical injury to patients and staff.13,14,15,16,17

Being Cautious in the Face of Uncertainty

In conclusion, the literature is quite sparse in regard to the specific use of seclusion measures with patients presenting with borderline personality disorders within forensic settings. Nevertheless, the ethical and therapeutic questions must be responded to in our day-to-day clinical decisions. The current knowledge about the personality structure, reactions and trajectories of borderline personality disordered patients compel the conclusion that using seclusion and restraints in forensic and correctional settings must be done with caution and a firm clinical rationale. Avoiding harm and iatrogenic effects is critical. This patient population can be described as “severely traumatized and challenging patient group,”18 and the issues are complex and involve avoiding reenactment of traumatic experiences, maintaining a fragile treatment alliance and recognizing the adverse effects given the ease with which these patients can feel vulnerable and powerless. Although there is no prescriptive approach, guidelines that address the particularities of treating these patients in forensic and correctional settings would help clinicians manage these challenging, resource-intensive, patients.

References

  1. Goulet MH, Larue C, Dumais A. Evaluation of seclusion and restraint reduction programs in mental health: a systematic review. Aggress Violent Behav. 2017;34:139-146.
  2. Long CG, West R, Afford M, et al. Reducing the use of seclusion in a secure service for women. Journal of Psychiatric Intensive Care. 2015;11(2):84-94.
  3. Jade Lovell L, Hardy G. (2014). Having a diagnosis of borderline personality disorder in a forensic setting: a qualitative exploration. Journal of Forensic Practice. 2014;16(3):228-240.
  4. Baker A, Wright K, Hansen E. A qualitative study exploring female patients’ experiences of self‐harm in a medium secure unit. J Psychiatr Ment Health Nurs. 2013;20(9):821-829.
  5. Shaw S. Shifting conversations on girls and women’s self injury: an analysis of the clinical literature in historical context. Feminism and Psychology. 2002;12:191–291.
  6. Selenius H, Leppänen Östman S, Strand S. Self-harm as a risk factor for inpatient aggression among women admitted to forensic psychiatric care. Nord J Psychiatry. 2016;70(7):554-560.
  7. Sarkar J. Short-term management of repeated self-harm in secure institutions. Adv Psychiatr Treat. 2011;17(6):435-446.
  8. Uppal G, McMurran M. Recorded incidents in a high‐secure hospital: a descriptive analysis. Crim Behav Ment Health. 2009;19(4):265-276.
  9. Conn C, Warden R, Stuewig J, et al. Borderline personality disorder among jail inmates: how common and how distinct? Correct Compend. 2010;35(4):6.
  10. Chadick CD, Batastini AB, Levulis SJ, et al. The psychological impact of solitary: A longitudinal comparison of general population and long‐term administratively segregated male inmates. Leg Crim Psychol. 22 Feb 2018. doi:10.1111/lcrp.12125.
  11. Sailas EE, Fenton M. Seclusion and restraint for people with serious mental illnesses. Cochrane Database Syst Rev. 2000;(2):CD001163.
  12. Tully J, McSweeney L, Harfield KL, et al. Innovation and pragmatism required to reduce seclusion practices. CNS Spectr. 2016;21(6):424-429.
  13. Bonner G, Lowe T, Rawcliffe D, et al. Trauma for all: a pilot study of the subjective experience of physical restraint for mental health inpatients and staff in the UK. J Psychiatr Ment Health Nurs. 2002; 9(4): 465–473.
  14. Frueh BC, Knapp RG, Cusack KJ, et al. Patients’ reports of traumatic or harmful experiences within the psychiatric setting. Psychiatr Serv. 2005;56:1123-1133.
  15. Nelstrop L, Chandler-Oatts J, Bingley W, et al. A systematic review of the safety and effectiveness of restraint and seclusion as interventions for the short-term management of violence in adult psychiatric inpatient settings and emergency departments. Worldviews Evid Based Nurs. 2006;3(1):8–18.
  16. Hallett N, Huber JW, Dickens GL. Violence prevention in inpatient psychiatric settings: Systematic review of studies about the perceptions of care staff and patients. Aggress Violent Behav. 2014;19(5):502–514.
  17. Larue C, Dumais A, Boyer R, et al. The experience of seclusion and restraint in psychiatric settings: perspectives of patients. Issues Ment Health Nurs. 2013;34(5):317-324.
  18. Parkes JH, Freshwater DS. The journey from despair to hope: an exploration of the phenomenon of psychological distress in women residing in British secure mental health services. J Psychiatr Ment Health Nurs. 2012;19(7):618-628.

Psychiatrie légale au criminel

The Defence of Duress

David William Morgan, LLM, FRCPC
Forensic Psychiatrist, Northern British Columbia

The criminal law of England and Wales, from which Canadian law derives in large part, is based on the fundamental principle that only voluntary conduct – the product of a free will and controlled body, unhindered by external constraints – should attract criminal liability. Or, as the Latin phrase actus reus non facit reum nisi mens sit rea reminds us, that without a guilty mind, there is no crime.

The defence of duress is a complete common law defence whose history dates back many centuries; common law, also known as judicial precedent, is that body of law derived from courts, and is more malleable than statutory law. In common law, the ratio decidendi is a legal rule which refers to the way in which the court uses the legal, moral and social principles to arrive at a particular judgement, and are binding on lower courts through the legal doctrine of stare decisis.

Statutory defence: s17, Criminal Code of Canada

In current Canadian law, the defence of compulsion by threats is enunciated in s17 of the Criminal Code of Canada; this provides:

“17. A person who commits an offence under compulsion by threats of immediate death or bodily harm from a person who is present when the offence is committed is excused for committing the offence if the person believes that the threats will be carried out and if the person is not a party to a conspiracy or association whereby the person is subject to compulsion, but this section does not apply where the offence that is committed is high treason or treason, murder, piracy, attempted murder, sexual assault, sexual assault with a weapon, threats to a third party or causing bodily harm, aggravated sexual assault, forcible abduction, hostage taking, robbery, assault with a weapon or causing bodily harm, aggravated assault, unlawfully causing bodily harm, arson or an offence under sections 280 to 283 (abduction and detention of young persons)”.

The clinical utility of the statutory s17 defence is thus very limited indeed; it applies only to situations where there exists an imminent threat of death or bodily harm, and where the threatener is bodily present at the material time the threat is made. Further, it can be seen that the defence does not apply to a number of specific offences, particularly those involving more severe violent or sexually violent offences.

However, the common law defence of duress still exists, by virtue of s8(3), which provides:

“Common law principles continued
(3) Every rule and principle of the common law that renders any circumstance a justification or excuse for an act or a defence to a charge continues in force and applies in respect of proceedings for an offence under this Act or any other Act of Parliament except in so far as they are altered by or are inconsistent with this Act or any other Act of Parliament”.

The common law defence of duress

The defence applies in situations where an accused person has no reasonable means of escape, and the crime is committed in response to a threat; the accused is a victim of a scenario created by another person, and reacts to preserve themselves or others. The legal authority (precedent) on the common law defence of duress is R. v. Ruzic;1 as R. v Ruzic is a decision of the Supreme Court of Canada, per stare decisis it is binding on all lower courts. The judgement in R. v. Ruzic means, that when considering the common law defence of duress, one must consider (i) the particular circumstances of the accused, (ii) the ability of the accused to perceive a reasonable alternative to committing the crime, and (iii) the background and essential characteristics of the accused.

The common law defence of duress is thus far broader than that set out in s17 of the Criminal Code, and is commensurately more useful in clinical practice.

Case Example

I was recently retained by a defence lawyer regarding the defence of duress for a young female who had been involved in an RCMP standoff; this was the first time I had been involved in a case involving the defence of duress. The standoff had developed as a result of her father, who was probably suffering from a psychotic illness, believing that the world was about to end and taking steps to prepare for this. These preparations involved his hoarding firearms, ammunition, food, batteries and other items needed to survive in a post-apocalyptic world. The young female had lived with her father subsequent to the breakdown of her parents’ marriage some years earlier, and since that time had enjoyed very little contact with the outside world. As a result, she gradually came to take on some of her father’s beliefs – those that the world was ending, and that they needed to be prepared. Her father had physically and emotionally abused his daughter over many years; as a result the daughter had become very compliant, shy and withdrawn.

In the context of the father’s untreated psychotic illness, he and his daughter began, over the course of several years, to progressively live in more rural and remote areas. They eventually moved to a very isolated village in the foothills of the BC Rockies, and began to live off the grid. In addition to the firearms and stored supplies, they also had a number of German Shepherd dogs, which were trained to attack. The daughter had no contact with the outside world for a number of years during her late adolescence, a critically important developmental period.

After a situation arose at a cross-country ski facility between the father and members of the public, the RCMP were called and the father was charged and released on bail. The situation was resolved without incident. However, the father and daughter then moved further into the bush and began to live in a hunting cabin; the owner attended and found it occupied; after speaking with the father, the owner called the RCMP.

There then followed significant RCMP surveillance, the establishment of a secure perimeter and the deployment of an ERT team; ERT teams are highly trained RCMP officers who specialize in high risk situations. After a standoff, the incident commander decided to end the situation, and the ERT team was deployed. This resulted in the father being killed, and the daughter being shot three times. She survived after a lengthy stay in hospital.

The statutory defence of compulsion by threats was not available; there was no direct threat to the daughter from the father, and one of the offences she was charged with was assault with a weapon.

In ascertaining whether the criteria for the common law defence of duress was fulfilled, several factors were relevant: that her father exerted almost complete control over her, her having no contact with the external world and her father being far more powerful than her, in the context of a critically sensitive developmental period, led to the development of a Folie à Deux and her believing that the world was ending. There seemed to me to be a good case for the common law defence of duress, when the particular circumstances of the daughter, her ability to perceive a reasonable alternative to committing the crime, and her background characteristics.

Eventually, defence counsel elected not to run the common law defence of duress, as there were separate charges related to the earlier standoff and her jeopardy would be higher; offences involving circumstances where a shoot-out with RCMP members occur typically attract significant custodial sentences. However, a joint submission by Crown counsel and defence resulted in a conditional discharge. I am reliably informed by the defence counsel that she continues to live with her mother and do well, and is free of psychotic symptoms.

References

  1. R. v. Ruzic [2001] 1 SCR 687 SCC24.

Demandez aux experts

Rock and a Hard Place: Practice, Ethics and Dilemmas in Forensic Psychiatry

Susan is a 41-year-old single woman whom you have seen for the last 21 years, initially as an inpatient and then as an outpatient. She was charged with infanticide regarding the death of her 11-month-old daughter. She was diagnosed with psychotic depression and was found NCR-MD. You have followed her since she was admitted to your unit on a detention order, then when she was discharged with conditions, and finally you have seen her as an outpatient after she was discharged absolutely by the provincial review board. She has been stable as an outpatient. Recently she has been babysitting her daughter’s four-year-old daughter. You have received a letter from the Children’s Aid Society (CAS) legal department requesting an assessment of her risk to the child since they are concerned about her background. How should you respond?

Per Dr. Graham Glancy

In 1984, psychiatrist and professor of law, Alan Stone, challenged the field of forensic psychiatry, commenting that the field itself lacks sufficient intellectual and ethical boundaries. There has been much debate about this since that time, but one issue that most commentators have agreed upon is the problems inherent in psychiatrists « wearing two hats. »1 One of the issues that Dr. Stone raised was that a psychiatrist might bend the rules of justice to help the patient. Since 1984, forensic psychiatry and psychology have made significant efforts to develop ethics guidelines for the practice of forensic psychiatry, culminating in the most recent iterations, accepted in 2018.2 Inherent in this argument upon the above-noted dilemma is the issue that acting as a treating psychiatrist, one’s primary obligation is to the patient or the doctor-patient relationship. However, when one acts as a forensic psychiatrist, Appelbaum notes that we have an obligation to the justice system, nevertheless respecting the values of truth-telling and respect for persons.3 In the above influential paper by Strasburger and colleagues, it was noted that therapist who attempted to combine these roles faced especially treacherous waters, strongly advising against such efforts.

In the case above, the conflict between roles becomes especially clear. You have seen this patient through a number of difficult events, and to your great credit you have stuck by her and remained her doctor through thick and thin. Over the course of this time, you have empathized with her while she mourned her child, tried to get her life back together and have guided her recovery through a serious illness, with creditable success. It is clear that you have a good therapeutic alliance and your skills of empathy and identification have served both doctor and patient well in guiding her recovery. However, it is these very skills, and the issues encountered, that put you in the worst position to give an objective risk assessment. No doubt your patient will beg you and expect you to help her and be her advocate in this difficult situation. However, my advice to you would be to refuse and explain to her very clearly the reasons why you must refuse in order to be ethical. These reasons include the fact that everything she has told you has been in the setting of doctor-patient confidentiality. If you do this report, you may breach this confidentiality and therefore possibly harm the therapeutic alliance. You should explain to her that you are her advocate and you could not be independent or objective. You should also explain that in order to perform this assessment, you would have to get collateral information, for instance from the daughter and other people in her life, about how she was doing, and she may feel betrayed by this. Equally, you should explain these reasons to the CAS lawyer. It would be helpful if you gave the names of some colleagues, preferably in a different program, who might be able to do an objective risk assessment.

Per Dr. John Bradford

Despite the seminal articles and positions put forward by Dr. Glancy, there are alternative arguments. Some other medical academies, including surgical subspecialties, argue that as the treating physician and surgeon you are in the best position to advise whether the person has recovered from treatment and is stable moving forward. The argument is there is no magic in bringing in a qualified third party who sees the patient and reviews the record of treatment for the first time to give an opinion on the course of treatment and the level of recovery and stability of the patient at this single point in time. It is forensic psychiatry that seems to have this difficulty. I would argue that the foundation of this is a throwback to when psychodynamic psychotherapy was the hallmark of the psychiatrist-patient alliance as opposed to the competent use of psychopharmacology that is the norm today. In forensic psychiatry, the issue is often the evaluation of potential risk of future violence. The objective risk assessment model is violated everyday in Canada, the United Kingdom, Europe and the United States. This occurs specifically in the context of individuals who are found not criminally responsible on the basis of mental disorder or its equivalent in other countries. In fact, the tribunals responsible for the monitoring and decision-making with regard to granting further freedom to these individuals in the community rely heavily on the attending physician and treatment team to guide them in their decision-making. The low recidivism and positive outcome for persons under Criminal Code Review Boards in Canada shows the success of this approach.4

This then raises the question as to why this approach of Review Boards eliciting principal evidence from the treating physician and treatment team is so successful even when violating objective evaluation and possibly ethics guidelines. A systematic evaluation of work of these tribunals in three provinces in Canada showed that a variety of static and dynamic factors were considered by these Review Boards.4,5 The defined legal basis for the decision-making of these Criminal Code Review Boards is the “need to protect the public, the mental condition of the accused, and other needs of the accused,” especially with regard to decisions to reintegrate the accused into the community. In most cases, a structured risk assessment was not presented to these Review Boards.

The Review Boards were found to take into account empirically validated factors related to risk such as items from the HCR-20. Particular attention was paid to the patient’s behaviour between annual hearings, including acts of violence and compliance with medication and compliance with conditions or restrictions. Interestingly, historical factors such as the severity of the index offence had more influence on decisions to detain somebody in hospital, whereas clinical factors had more influence in community integration as well as the move towards an absolute discharge.

Large epidemiological-based studies tend to show that the factors being considered by Review Boards are intrinsically validated when considering psychotic patients committing a homicide within six months of discharge from hospital.6 Clinical factors on admission associated with a risk of homicide were a previous hospitalization for a violent incident, substance abuse and poor self-care. Inpatient factors were the presence of a severe mental disorder for at least one year before admission. Other factors associated with homicide were noncompliance with medication and substance abuse. The predictive validity of these factors related to homicide and schizophrenic patients was not strong but were clinical factors.6

A followup epidemiological study showed the importance of treatment with antipsychotic medications in reducing violent recidivism.7 Violent crime dropped by 45% in patients receiving antipsychotics and 24% in patients receiving mood stabilizers. Within the group receiving antipsychotic medications, those receiving higher doses compared with those receiving lower doses had lower rates of violent recidivism and those taking intramuscular antipsychotics had lower rates of violent recidivism compared to those receiving oral medications.7

These studies support the importance of having a therapeutic alliance with the patient and ensuring their compliance with treatment. This supports the argument for a strong clinical input into managing patients with a violent history and a serious mental disorder. Compliance with pharmacological treatment has an enormous effect on reducing violent recidivism.

Epidemiological studies of risk assessment instruments show that they are better geared towards identifying low-risk individuals, as opposed to high-risk individuals.8 This may mean that the success of Review Boards is based on a common sense approach to identifying low-risk individuals on their clinical presentation as monitored by the attending psychiatrist and treatment team.

Another significant exception to the objection to a dual role is when, for instance in rural communities, there is a profound lack of psychiatrists and forensic psychiatrists, claiming no alternative but to use the treating psychiatrist. In our experience come particularly in several cases, the courts tended to favour the opinions of treating psychiatrists, even though our own ethics guidelines caution us against this. Although this is an important legal and ethical concept, in my opinion (JB), this can be dealt with by a declaration of possible bias that you may have as a treating psychiatrist.

For the last 30 years, various iterations of ethics guidelines in North American forensic psychiatry have cautioned us against being in the situation where we are the treating psychiatrist and the evaluating psychiatrist. There are a number of good reasons for this, including the possible breach of trust of fiduciary duty, possible harm to the therapeutic alliance, lack of objectivity, amongst others. There may be exceptions, such as when it is not possible to avoid the conflict, in review boards settings, and in areas where there is a shortage of psychiatrists. Declaring the conflict and the limitations inherent may be one way of dealing with the situation if no other solution arises.

Drs. Glancy and Bradford will answer questions from members related to practical issues in the real world of forensic psychiatry. Please send questions to graham.glancy@utoronto.ca

References

  1. Strasburger L, Gutheil TG, Brodsky A. On wearing two hats: role conflicts in serving as both psychotherapist and expert witness. Am J Psychiatry. 1997;154(4):448-456.
  2. Canadian Academy of Psychiatry and the Law (CAPL). Ethical guidelines for Canadian forensic psychiatrists. Ottawa (ON): CAPL; 2018. Available from: http://www.capl-acpd.org/wp-content/uploads/2018/05/2018-CAPL-Ethical-Guidelines-FIN-EN.pdf
  3. Appelbaum PS. A theory of ethics for forensic psychiatry. Am J Acad Psychiatry Law. 1997;25(3):233-247.
  4. 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.
  5. Crocker AG, Nicholls TL, Charette Y, et al. Dynamic and static factors associated with discharge dispositions: the national trajectory project of individuals found not criminally responsible on account of mental disorder (NCRMD) in Canada. Behav Sci Law. 2014;32(5):577-595.
  6. Fazel S, Buxrud P, Ruchkin V, et al. Homicide in discharged patients with schizophrenia and other psychoses: a national case-control study. Schizophr Res. 2010:123(2-3):263-269.
  7. Fazel S, Zetterqvist J, Larsson H, et al. Antipsychotics, mood stabilisers, and risk of violent crime. Lancet. 2014;384(9949):1206-1214.
  8. Fazel S, Sing JP, Doll H, et al. Use of risk assessment instruments to predict violence and antisocial behaviour in 73 samples involving 24 827 people: systematic review and meta-analysis. BMJ. 2012;345:e4692.

Pratique professionnelle

MAID and Forensic Psychiatry

Skye Rousseau, MD, FRCPC

With the recent passing of Bill C-14 in 2016, a response to the Carter v. Canada decision of the Supreme Court of Canada (SCC), medical assistance in dying (MAID) has become legal in Canada.1 There are a number of requirements that must be met in order for a person to access MAID, and these include: the person must suffer from a grievous and irremediable medical condition as defined within Bill C-14, and they must voluntarily provide informed consent. It is unlikely that many psychiatrists will be directly involved in the administering of lethal substances to patients for the purposes of causing their death. However, psychiatric assessment will sometimes be requested to assist the physicians and nurse practitioners involved in providing MAID.

A psychiatrist’s involvement in MAID is most likely to arise in two scenarios. The first is when a patient requests MAID for a terminal or progressive disease and there is concern that the patient lacks required decision-making capacity due to co-morbid mental illness. To my knowledge, most provincial colleges do not mandate psychiatric assessment for patients; however if there are concerns about a patient’s capacity, a psychiatrist’s opinion may be requested. The second scenario is when a patient requests MAID solely on the basis of mental illness. Though many such requests are certainly made in Canada, the eligibility criteria as presently legislated in Bill C-14 effectively exclude patients for whom mental illness is the primary reason they are requesting MAID.

Previous work has found that even among psychiatrists there is significant concern about the ability to assess capacity in a patient who has requested MAID, especially in a single assessment.4 Among psychiatrists, forensic psychiatrists might be considered to have the greatest expertise in assessment of decision-making capacity in different situations, and one of the earliest published surveys of psychiatrists’ views on assisted suicide is a survey of forensic psychiatrists specifically.4 Thus it is not unreasonable to anticipate that the opinion of forensic psychiatrists may occasionally be sought in particularly difficult assessments.

A recent national survey examined the attitudes of psychiatrists towards MAID2. The primary outcomes were to examine whether psychiatrists in general supported MAID for solely psychiatric illness, and the reasons that they either supported or did not support such a practice. Most respondents supported legalization of MAID for certain medical conditions (72%) nearly to the same degree that the general public supports MAID; however only a minority (24%) supported legalization of MAID on the basis of mental illness. Identified concerns about the legalization of MAID for mental illness included the concern that it could compromise a psychiatrist’s commitment to endure with patients through their times of greatest suffering, and concerns from professional experience of having patients who likely would have received MAID were it legal, but went on to recover from their illness. In a recent ethical and legal analysis, Simpson identified similar concerns about provision of MAID for reasons of mental illness. In his view, one of the fundamental roles of a psychiatrist is to help a patient find a life worth living, and participating in a decision to end a patient’s life is fundamentally in conflict with this role.3 Additionally, he suggests that hope of recovery from mental illness is never lost, and emphasizes our inability to predict recovery or whether the severity of an illness will remit in time. For these reasons and a host of others, he concludes that “acting as a partner in helping people recover as well as acting as an agent in a patient’s death is an impossible burden that is not ethically justifiable….”3

Perhaps a more important role for psychiatrists with forensic training and experience will involve the interpretation and application of case law with respect to MAID. With numerous challenges to Bill C-14 likely to arise, there may be need for expertise in a realm quite familiar to forensic psychiatrists, that of interpreting case law to guide assessment and opinion. Already there has been at least one instance in which the ambiguous language of the SCC Carter decision led to an interpretation that was unsupported by the legislation which followed; in the legislative vacuum that existed after the Carter decision but before Bill C-14, at least one person was found to be eligible for MAID based solely on mental illness, which would not have happened under Bill C-14. In the case of Canada v. EF (plaintiff)5, the Alberta Court of Appeal granted MAID due to severe pain and disability arising from a conversion disorder. EF received MAID when it was briefly permissible through a court ruling using the Carter criteria; however, she would now not be eligible for MAID.

In Simpson’s recent review of the topic, he points out that one of the key arguments made in the Carter decision does not extend to patients requesting MAID solely for mental illness.3 The SCC found that a prohibition is a violation of Section 7 of the Charter of Rights and Freedoms on the basis that a prohibition on MAID forces some individuals with progressive illness to take their lives early due to fear that they would be incapable of doing so when they were in a state of further decline. Simpson rightly points out that the arguments made in Carter do not hold for mental illness, since the decision is not an end-of-life decision, and the individual will not be robbed of their ability to take their own life due to progressive illness as they would in a progressive illness such as ALS.

Psychiatrists with an interest in the intersection between the law and psychiatry will have a role in public and academic discourse about MAID.2-4 Though regular input from forensic psychiatrists will not be requested for the provision of MAID, a psychiatrist with training in forensics may possess degree of comfort in understanding and providing relevant opinions that would be valuable for the courts and potentially for teams providing MAID. Challenges to the criteria of Bill C-14 are likely already in process and will certainly be forthcoming. There will be a need for expertise in interpretation and application of case law for the purpose of providing a psychiatric opinion, and forensic psychiatrists may be uniquely qualified to have input in such cases.

References

  1. Parliament of Canada. An act to amend the criminal code and to make related amendments to other acts (medical assistance in dying) [Internet]. Canada; 2016. [cited 2018 April 12]. Available from: http://www.parl.gc.ca/HousePublications/Publication.aspx?Language¼E&Mode¼1&DocId¼8384014.
  2. Rousseau S, Turner S, Chochinov HM, et al. A national survey of Canadian psychiatrists’ attitudes toward medical assistance in death. Can J Psychiatry. 2017;62(11):787-794.
  3. Simpson, A. Medical assistance in dying and mental health: a legal, ethical, and clinical analysis. Can J Psychiatry. 2018;63(2):80-84.
  4. Ganzini L, Leong G, Fenn D, et al. Evaluation of competence to consent to assisted suicide: views of forensic psychiatrists. Am J Psychiatry. 2000;157(4):595-600.
  5. Canada v EF, 2016 ABCA 155.

L’ACPD vue de l’intérieur

Rapport de la section régionale de la Colombie-Britannique

Todd Tomita, MD, FRCPC
Président, La section régionale de la C.-B.

La section régionale de la Colombie-Britannique continue de se concentrer sur l’organisation d’activités de formation, en collaboration avec la division de la psychiatrie légale de l’Université de la Colombie-Britannique (UBC). Ces activités, qui portent principalement sur la criminalistique, s’adressent aux membres de l’ACPD et aux stagiaires en psychiatrie. En outre, nous avons pour objectif de favoriser des relations collégiales avec d’autres groupes professionnels du domaine judiciaire et correctionnel.

Le comité de direction de la section régionale de la Colombie-Britannique est composé des personnes suivantes :

  • Président : Dr Todd Tomita
  • Vice-président : Dr Rakesh Lamba
  • Secrétaire : Dr David Morgan
  • Administratrice : Dre Jeanette Smith

Le comité de planification du programme de la section régionale de la Colombie-Britannique et de la division de la psychiatrie légale de la UBC est composé des personnes suivantes :

  • Dr Kulwant Riar, professeur de psychiatrie clinique, UBC
  • Dre Jeanette Smith, professeure agrégée de psychiatrie clinique, UBC
  • M. Lyle Hillaby, avocat principal de la Couronne
  • Hugues Herve, Ph. D., psychologue médico-légal
  • Dr David Morgan, professeur adjoint de psychiatrie clinique, UBC
  • Dr Andrew Kolchak, professeur adjoint de psychiatrie clinique, UBC
  • Dre Emlene Murphy, professeure de psychiatrie clinique, UBC
  • Anton Schweighofer, Ph. D., psychologue médico-légal
  • M Bernd Walter, président du British Columbia Review Board
  • Dr Johann Brink, professeur de psychiatrie clinique, UBC
  • Dre Todd Tomita, professeur agrégé de psychiatrie clinique, UBC

Nous continuons de tenir, au printemps et à l’automne, des journées de formation en psychiatrie légale au campus Robson Square de l’Université de la Colombie-Britannique, à Vancouver. En général, de 30 à 40 personnes, dont des psychiatres judiciaires, des psychologues médico-légaux, des stagiaires en psychiatrie et en psychologie, des procureurs de la Couronne et des avocats de la défense, ainsi que des membres du British Columbia Review Board, y participent.

Sixième édition de la journée de formation en psychiatrie légale organisée par la section régionale de la Colombie-Britannique et la UBC – 12 mai 2017

Odd, Eccentric, and Erratic Participants in Civil & Criminal Courts (Les personnalités bizarres, excentriques et erratiques dans les tribunaux civils et criminels) :

Vexatious Litigants (Les plaideurs quérulents)
Dr Johann Brink

Eccentric Litigants: Challenges they pose for the Court (Les plaideurs excentriques : un défi pour les tribunaux)
Honorable madame la juge Duncan, Cour suprême de la Colombie-Britannique

Eccentric Litigants: Practical and Professional Challenges they pose for Crown Counsel (Les plaideurs excentriques : un défi pour les procureurs de la Couronne)
Christina Godlewska, procureure de la Couronne

Eccentric Litigants: Practical and Professional Challenges they pose for Defence and Plaintiff Counsel (Les plaideurs excentriques : défis pratiques et professionnels des avocats de la Couronne)
Janet Winteringham, Québec

Stalking of Professionals in the Criminal Justice System (Le harcèlement des professionnels dans le système de justice pénale)
Dr Randy Kropp

Psychological Aspects of Radicalization (Aspects psychologiques de la radicalisation)
M. David Marxsen

Septième édition de la journée de formation en psychiatrie légale organisée par la section régionale de la Colombie-Britannique et la UBC – 7 novembre 2017
Work Stress and Trauma: Managing Self-Care over a Forensic Career (Stress au travail et traumatisme chez les professionnels du domaine médico-légal : prendre soin de soi)
Dr Jeff Morley

Forensic Questions about Cannabis Use: A Practical Update (Questions médico-légales relatives à la consommation de cannabis : mise à jour pratique)
Dr Nick Mathew, UBC

Mr. Big Undercover Operations (Les opérations d’infiltration de type Mister Big)

Mr. Big Undercover Operations: Culpability, Confessions & Coercion (Les opérations d’infiltration de type Mister Big : culpabilité, confessions et contrainte)
Mark Jette, avocat de la défense, et Elliott Poll, avocat de la Couronne

A Psychotic Murder Confession to Mr. Big and a Trio of Experts:
Perspectives of the Defence, Crown, and Court-Appointed Experts (Confession de meurtre à caractère psychotique aux enquêteurs chargés des opérations d’infiltration et à un trio d’experts : le point de vue de la défense, de la Couronne et des experts nommés par le tribunal)

Dre Jeanette Smith, Dr George Wiehahn, Dr Todd Tomita

La huitième édition de la journée de formation en psychiatrie légale organisée par la section régionale de la C.-B. et la UBC a eu lieu le 1er juin 2018. Lors de cette journée, dont le thème était l’intoxication et l’aliénation mentale, des conférenciers ont abordé la question de la psychose induite par une substance.

Rapport de la section régionale du Québec

Joel Watts, MD, FRCPC, DABPN (psychiatrie légale)
Président, ACPD-Québec

Les membres de la section régionale du Québec continuent de se réunir tous les six mois au cours d’un repas afin d’échanger leurs expériences et leurs préoccupations, et de s’entendre sur les moyens qu’ils prendront pour défendre l’amélioration de la prestation des services de médecine légale dans la province. Qui plus est, ces rencontres sont d’excellentes occasions de profiter d’un bon repas et d’entretenir la grande amitié et la collégialité qui unissent nos membres. Nous avons tenu récemment notre rencontre de travail à un nouvel endroit, toujours dans la région de Shawinigan, au centre du Québec; nous nous assurons ainsi la participation du plus grand nombre de membres possible. Depuis quelques années, le nombre de membres de la section régionale du Québec est assez stable; notre comité exécutif n’a pas changé et compte sur une bonne représentation des grandes régions de la province.

Depuis juillet 2015, nos dirigeants sont les suivants :

  • Président – Joel Watts (représentant du conseil d’administration de l’ACPD)
  • Président sortant – Sébastien Proulx (Québec)
  • Vice-président – Fabien Gagnon (Québec)
  • Secrétaire – Louis Morissette (Montréal)
  • Administratrice – Marie-Frédérique Allard (Shawinigan)

La majorité des membres du Comité des affaires juridiques et médicolégales de l’Association des médecins psychiatres du Québec (l’AMPQ, notre association provinciale de psychiatres) sont toujours des membres de la section régionale du Québec. Nous continuons de défendre l’amélioration de la rémunération des psychiatres judiciaires (en particulier ceux qui travaillent avec les clients évalués par la commission d’examen dans les établissements de soins chroniques) afin de faciliter le recrutement de la prochaine génération de psychiatres judiciaires.

Depuis peu, nous aidons les psychiatres généralistes, qui sont confrontés à des changements importants touchant la mise en œuvre des procédures civiles d’internement à la suite de certaines décisions récentes prises par la Cour d’appel du Québec. Ces décisions ont pour effet de limiter la compétence parens patriae de l’État en compliquant encore davantage la procédure d’internement des personnes qui présentent un risque de préjudice pour elles-mêmes ou pour autrui sur la base d’un certificat d’admission non volontaire. En outre, il se peut que le degré d’imminence du risque requis pour l’hospitalisation involontaire ait été modifié en vertu de certaines autorités judiciaires, ce qui rend encore plus difficile l’hospitalisation de malades mentaux instables. Tout cela est très nouveau, et il est difficile de prévoir s’il y aura une augmentation des demandes d’ordonnances de traitement en matière civile ou une augmentation de la criminalisation des malades mentaux dans la province à la suite de ces décisions récentes de la cour.

Nous sommes ravis que le congrès annuel de l’ACPD se tienne de nouveau au Québec, cette fois à Montréal, du 28 avril au 1er mai 2019. Nous avons hâte de profiter avec vous tous de cette ville cosmopolite et animée. Vous ne serez pas déçus par le nombre et la qualité des excellents restaurants et des activités culturelles dans les deux langues officielles!

Nouvelles des membres

Le Dr Derek Eaves et les origines de l’Académie canadienne de psychiatrie et droit

John M. W. Bradford, MBChB, DPM, FFPsych, MRCPsych, DABPN, DABFP, FRCPC, CM
Professeur émérite, Université d’Ottawa; professeur titulaire (psychiatrie clinique), Université McMaster; scientifique, Institut de recherche en santé mentale du Royal; psychiatre, St. Joseph’s Healthcare Hamilton

Graham D. Glancy, MBChB, FRCPsych, FRCPC
Professeur agrégé et codirecteur de la division de psychiatrie légale, Université de Toronto

Remerciements : Dre Dominique Bourget et Dr Gary Chaimowitz

Le Dr Eaves est décédé le 16 juin 2017 à son domicile, à Vancouver, en Colombie-Britannique, entouré de sa famille. Né le 5 janvier 1942 à Nelson, au Lancashire, en Angleterre, le Dr Eaves a obtenu son diplôme de médecine à l’université de Liverpool en 1966 pour se spécialiser par la suite en psychiatrie. Il a immigré au Canada en 1973, et en 1979, il s’est joint à la Forensic Services Commission de la Colombie-Britannique. Le Dr Eaves est ensuite devenu commissaire exécutif de la Commission; il occupera ce poste pendant 20 ans. Le Dr Eaves était professeur de psychiatrie clinique à l’Université de la Colombie-Britannique, mais il a formé très tôt une forte alliance avec l’Université Simon Fraser. Au cours de sa carrière, il a travaillé avec un grand nombre de chercheurs en psychologie médico-légale de l’Université Simon Fraser. En guise de reconnaissance de l’excellent travail qu’il a effectué à l’Université Simon Fraser, il a obtenu le Chancellor’s Award. Il a terminé sa carrière professionnelle comme vice-président de la médecine et de la recherche du Riverview Hospital.

Le Dr Eaves a travaillé dès le début à la reconnaissance de la psychiatrie légale au Canada. En 1989, le Dr John Bradford a demandé au conseil exécutif de l’American Academy of Psychiatry and the Law (AAPL) de créer l’Académie canadienne de psychiatrie et de droit à titre de section de l’APPL1. Le Dr Bradford a ensuite travaillé avec le Dr Derek Eaves, qui était alors le directeur administratif de la Forensic Services Commission, et avec le Dr Lionel Béliveau, qui était le président de l’Institut Philippe-Pinel de Montréal, afin de faire accepter cette approche pour obtenir la reconnaissance de la psychiatrie légale au Canada à titre de surspécialité de la psychiatrie.

Le Dr Bradford a coprésidé la section canadienne avec le Dr Eaves pendant la première année de son existence1. Par la suite, le Dr Bradford a continué de présider la section avec le Dr Graham Glancy, qui en était également le vice-président. Le Dr Glancy a ensuite pris la relève comme président de la section canadienne. Le Dr Eaves a continué de collaborer avec la section canadienne, mais avec le temps, il a décidé de mettre ses efforts à l’International Academy of Forensic Mental Health Services.

De 1989 à 1997, les bourses canadiennes en psychiatrie légale ont été agréées par l’Accreditation Council on Fellowships in Forensic Psychiatry (ACFFP), qui faisait partie de l’AAPL. En 1997, l’Accreditation Council for Graduate Medical Education (ACGME) est devenue la responsable de l’agrément de tous les programmes d’enseignement médical universitaire aux États-Unis, ce qui signifiait que les programmes canadiens ne pouvaient plus être agréés de cette façon1. En 1997, l’Association des psychiatres du Canada (APC) a soutenu la formation de surspécialités au Canada. La structure administrative de l’ACP comprenait trois académies : l’Académie canadienne de psychiatrie et droit, l’Académie canadienne de psychiatrie de l’enfant et de l’adolescent et l’Académie canadienne de psychiatrie gériatrique. Avec l’aide de l’APC, les trois académies ont travaillé ensemble pour promouvoir et obtenir la reconnaissance officielle des surspécialités en psychiatrie du Collège royal des médecins et chirurgiens du Canada.

Cette brève histoire vise à honorer le Dr Derek Eaves et à reconnaître la contribution de ce dernier au développement de l’ACPD et à l’évolution de la psychiatrie légale au Canada à titre de surspécialité.

Bibliographie

  1. Bourget D, Chaimowitz G. Forensic psychiatry in Canada: a journey on the road to specialty. J Am Acad Psychiatry Law. 2010;38(2):158-162.

C’est le temps de renouveler votre adhésion

Les avis de cotisation ont été envoyés aux membres de l’ACPD le 7 juin : veuillez vérifier vos courriels, si vous ne l’avez pas déjà fait. L’ACPD accepte désormais les paiements par carte Visa ou MasterCard en plus des chèques personnels. Pour renouveler votre adhésion par téléphone, contactez Julie Lambert au 1-800-267-1555, poste 231; ayez en main votre numéro de carte de crédit et la date d’expiration.

Veuillez noter que, conformément à la législation à laquelle l’ACPD est soumise, seuls les membres en règle, les membres à vie et les membres en formation qui ont payé leur cotisation dans un délai de trois mois suivant la date de facturation (i.e., au plus tard le 7 septembre 2018) disposent du droit de vote à l’assemblée générale annuelle (AGA). Évitez toute déception à l’AGA et renouvelez aujourd’hui!