Forensic Mental Health Services

National Trajectory Project

The National Trajectory Project (NTP) is the largest Canadian study (N = 1800) of persons found Not Criminally Responsible on Account of Mental Disorder (NCRMD, Canada’s insanity defence), led by Dr. A. Crocker. The project followed individuals within the forensic system who were found NCRMD between 2000-2005 in three Canadian provinces (Ontario, Quebec, and British Columbia). This study aimed to explore the trajectories of NCRMD individuals, as well as historical data prior to their NCRMD verdict (e.g., mental health history, history of criminal justice involvement). In addition, provincial differences across forensic systems were examined. The study was published as a special issue of the Canadian Journal of Psychiatry. The issues highlighted: (1) The methods (how this project was conducted); (2) An in-depth examination of the sample (diagnosis, index offence, etc.); (3) An examination of patients’ trajectories through forensic systems; (4) Re-offending outcomes for NCRMD patients; and (5) Gender differences across NCRMD patients. You can read these issues, as well as other related publications for the project, here. This project was funded by the Mental Health Commission of Canada.


Going Home Project

Conducted after NTP-1, the Going Home Project allowed for a prospective, longitudinal examination of the community reintegration process for individuals found NCRMD, one of the most marginalized and high needs groups. This project examined the positive and negative outcomes experienced by NCRMD patients as they were discharged into the community. At 6 months and 12 months post-release, interviews were conducted with patients and their families to assess patients’ experiences reintegrating into the community. This project was funded by the Canadian Institutes of Health Research (CIHR).


National Trajectory Project Community

Over the past two decades, Canada has witnessed an increase in the number of persons found NCRMD which has made re-examining a more current sample of NCRMD patients (i.e., building on NTP-1) a priority. The National Trajectory Project – Community (NTP-C), a longitudinal, multi-site study examining a large Canadian cohort of individuals found Not Criminally Responsible on account of Mental Disorder (NCRMD). Comprised of 1,468 individuals found NCRMD who were discharged between 2010 and 2015 from one of 18 hospitals across six provinces in Canada, the sample was followed until 2018 resulting in a 3-to-8-year follow-up period.

This national project is led byDr. A. Crocker, Dr. Nicholls is the BC lead. NTP-C is funded by the Canadian Institutes of Health Research (CIHR).


Aggression Management Project

The Aggression Management Study intended to gain an understanding of the nature and prevalence of aggression that is perpetrated against staff, with the intent of guiding the development of effective policies and crisis intervention strategies. This project was done to conduct a review of incidents of aggression and factors related to these incidents; both staff and patient perspectives on aggression and the non-violent crisis intervention model at the Forensic Psychiatric Hospital were also collected. The findings of this study were used to create a final report for the Forensic Psychiatric Hospital.  The results of this study were also presented at several conferences and publications (such as this one).


Guidelines for Improving Forensic Mental Health Services in Inpatient Psychiatric Settings

There have been notable gaps in the use of evidence-based practice within mental health care. Given this, Dr. Tonia Nicholls and her graduate student, Ilvy Goossens, sought to outline the characteristics of forensic patients, the objectives and responsibilities that forensic services have for providing patient care, and what principles are required for high-quality forensic services. The findings were presented in a chapter that serves as a template for forensic services and care providers to guide the implementation of responsive and evidence-based practice mental health care within various forensic services.


Staff-Supported Community Outings Project

The Staff-Supported Community Outings (SSCO) Project sought to explore the nature of SSCOs at the Forensic Psychiatric Hospital. SSCOs are staff-facilitated excursions into the community that are intended to support patients’ recovery. Previous research has indicated that community access has many benefits for the reintegration of correctional populations, but less research has been done for forensic patients. The project investigated the characteristics of the patients who participated in SSCOs over a one-year period. This project is currently ongoing. Preliminary data was presented during a conference poster session that can be viewed here.


Trauma-Informed Practice in Forensic Services

Research has highlighted the importance of implementing trauma-informed interventions within forensic services due to the high rates of trauma patients have often experienced. In order to raise awareness on the importance of trauma-informed practice within forensic inpatient settings, Dr. Tonia Nicholls has led several workshops and invited presentations on the implementation of trauma-informed practice (some of which have been in collaboration with her graduate student, Ilvy Goossens). These workshops/presentations have been delivered to various forensic institutes (Forensic Psychiatric Hospital, Philippe-Pinel National Institute of Legal Psychiatry), to the Forensic Forum in Vancouver, to the Forensic Psychiatric Service Commission Clinic Managers, and a variety of other organizations.


The VERDICT on Virtual Review Board Hearings for Forensic Psychiatric Patients: An examination of Virtual Engagement, its Remedial or Detrimental Influences since COVID-19, and Trajectories

COVID-19 forced the rapid implementation of adapted practices to safeguard public health. For Review Boards, this meant a transition to virtual hearings to fulfill their mandate and prevent undue restrictions on patients’ rights and progress through the Forensic Mental Health system. This study will evaluate the experiences of all stakeholders involved with virtual hearings (i.e., patients, patient family members or supports, hospital/agency staff, legal counsel, and Review Board members/experts) to assess their quality and efficacy in this unique context. Findings will have direct clinical/policy implications for patients and service agencies pertaining to quality improvement and future adoption of this practice in forensic mental health in BC. Moreover, the findings are anticipated to be of interest nationally and internationally given the widespread reliance on virtual health platforms due to COVID and long term interest due to resource implications. This study is funded by a CIHR grant to Dr. Nicholls. The project launched in late 2021!


COVID-19 and Plurality of Confinement Among People with Mental Health Disorders in an Institutional Setting: From Research to Action

Exploring the consequences of COVID-19 measures experienced by people with mental illness and justice involvement is important given their unique vulnerability to the virus and the unique experience of these populations with respect to coping with the typical limitations of being institutionalised and then also layering over the usual limitations to movement, etc., the additional requirements to keep patients, staff and the community safe from COVID. Across sites in Quebec (QC) and British Columbia (BC), the project produced knowledge on the impacts of COVID-19 measures in the inpatient forensic mental health setting to inform knowledge users about the implementation of best practices during a health emergency in a locked, long term facility. This was achieved through both a literature review covering major themes and semi-structured interviews with people receiving services from BCMHSUS in BC and Pinel Institution in QC, as well as with professionals, and patient family members/loved ones. Knowledge gained from this project will be disseminated in the hopes of guiding policy and practice in hospitals and prisons. This project is funded by a grant from the SSHRC to Dr. Anne Crocker and colleagues in QC and Dr. Nicholls in BC. The study was conducted in 2021, and the findings were presented at IAFMHS– read the paper here!


Unauthorised Leaves Project at BC’s Forensic Psychiatric Hospital

Community access is essential to a patient’s successful reintegration and recovery, and requires staff to weigh the needs of the patient, community and hospital. UALs whether from an approved leave (failure to return), or otherwise, are not widely studied. Through this project, we aim to develop a comprehensive picture of UAL incidents among forensic psychiatric patients to inform policies and practise (e.g., risk assessment, risk management). Consistent with prior research, we will define UALs as any unauthorised absence from the hospital. This will include breaching the security of an inpatient unit, accessing hospital grounds or the community without permission, or being absent for longer than permitted (e.g., see Simpson et al., 2015).
We will also test the validity of UAL-specific risk assessment tools (BEAT; Booth et al., 2021, WERS; Marshall & Usinger, 2016) while exploring how a UAL affects the trajectory of a patient compared to the trajectory of one who didn’t.
Data collection began in August 2023.