An Ontario court acquitted The Royal on four out of five charges related to the stabbing of a nurse by a patient, but fined it $75,000 on the fifth. Dr. AG Ahmed, the forensic psychiatrist who treated Marlene Carter, responds.
"What do we do with people who pose a risk due to their illness? Do we lock them up forever or do we treat them? These are our options as a society."
She thwacks her head on the concrete until she sees blood. Thwack. Thwack. Thwack. Thwack.
If she doesn’t see blood, her children won’t be safe.
Anyone trying to stop her may as well be harming her children themselves. So, when a well-meaning prison worker intervenes, she strikes out.
“In her mind, she’s protecting her kids like any mother would,” says Dr. AG Ahmed, The Royal’ associate chief of forensic psychiatry.
“She’s not bad. She’s ill.”
But in a correctional setting, the focus is on security and stopping behaviour perceived as deliberate offending, not on understanding its psychopathological underpinnings. The philosophies behind punishment and therapeutic environments are very different.
So, inmates with severe and complex mental illnesses are often put in segregation or restraints. They’re kept solitary. They spiral deeper into their illnesses.
This is the plight of Marlene Carter. In the penitentiary, before coming to The Royal, Carter was kept in restraints for two and a half years. Her muscles atrophied. She was confined alone. Her severe and complex mental illness, compounded by brain injury, only became more severe and complex.
She came to The Royal for treatment, where she successfully stabilized, but now she’s back in the penitentiary.
Marlene
Her history is well-documented in court records and news stories. It’s a long history of abuse, intergenerational trauma, mental illness, substance use, suicide attempts, and not receiving the care she so desperately needed.
In the summer of 2014, Carter came to The Royal’s Brockville site from a correctional facility in Saskatoon in very poor mental health.
On October 10, 2014, in a state of psychosis, Carter stabbed a nurse repeatedly with a pen, severely injuring her. Thankfully, the nurse recovered and returned to her job until her recent retirement.
Carter’s behaviours, including aggression and impulsivity, were part of why she needed care at a specialized, secure mental health care centre. When this incident happened, she was still undergoing assessment and stabilization to begin treating her extremely complex illness.
The Royal’s ability to treat Carter was severely limited by the lack of a dedicated unit for treating female offenders; the funding for a pilot program of only two beds wasn’t enough to adapt the environment and bring in the interdisciplinary team that someone with extremely complex needs requires.
Even so, Carter was improving.
In April 2016, Carter returned to a facility in Saskatchewan, and is now again in a correctional rather than therapeutic setting.
“We as a society failed Marlene,” says Dr. Ahmed, who was treating Carter.
“We sent her back to the environment she came from. Every good thing she had here, the hope we had for her recovery, was taken away.”
When Carter stabbed one of our nurses, it led to court proceedings through the Ministry of Labour. The ministry brought forward five charges, and The Royal was acquitted on four of them. One, the charge of failing to re-assess risk, resulted in a $75,000 fine.
The judge acknowledged that The Royal’s training programs and risk assessment procedures were excellent, but even with all this, a violent incident resulting in the severe injury of a valued staff member still happened.
“Health care is not like every other sector,” says Dr. Ahmed. “We are always working to manage the risks, especially with high-risk, high-need clients such as Marlene, but there’s always risk in caring for them.”
"Our society fails people living with mental illness, especially women, by locking them up instead of getting them the care they need."
To argue there should be no risk in a health care environment is to argue that there should be no place to treat people like Carter, he says. There will always be risks involved — risks that dedicated staff work tirelessly to mitigate — but risks, nonetheless.
“There are many more Marlene Carters,” says Dr. Ahmed. “Our society fails people living with mental illness, especially women, by locking them up instead of getting them the care they need.”
Women in corrections
Experts estimate that about one third of incarcerated women are living with complex mental illness and more than two thirds also have substance use issues. Most have a history of trauma.
“How is a correctional environment supposed to manage these complex issues?” Dr. Ahmed says.
Those who treat mental illness know that progress only comes through consistency, and these women typically have lives characterized by inconsistency and mistrust.
The Royal’s cost—benefit analysis for creating a secure unit to treat women estimates that every dollar invested would save at least three dollars of taxpayer money that now goes to resources such as corrections and policing.
Many experts in public safety and health care support this analysis, including Howard Sapers, independent advisor on corrections reform to the Ontario provincial government.
“The solution certainly isn’t to respond to illness in the criminal system. I can’t think of anything more expensive than that,” Sapers told the CBC.
One of the things standing in the way of getting proper mental health treatment to the people who need it most? Risk.
“But what do we do with people who pose a risk due to their illness?” Dr. Ahmed asks. “Do we lock them up forever or do we treat them? These are our options as a society. I for one believe that every human being living with mental illness deserves to be treated.”