Ui Wr;:;;:;:;J~Tt, . ;: f "ORT,· '""A~'\J BRITE~+~ c '}ltMBIA I uz::~if. ...N Prince George, BC Community Referrals: The Experiences Of Youth Forensic Mental Health Therapists In Prince George Jennifer Elizabeth Broughton H.B.S.W., Lakehead University, 2004 Practicum Report Submitted In Partial Fulfillment Of The Requirements For The Degree Of Master Of Social Work The University ofNorthem British Columbia August 2008 ©Jennifer Elizabeth Broughton, 2008 Abstract u Abstract Youth Forensic Psychiatric Services (YFPS) outpatient clinic in Prince George is the focus of this Master of Social Work practicum report. The following pages outline practicum learning goals and objectives and how goals and objectives were met. YFPS is described in detail including the mandate of the agency along with the clinical services provided by the clinic. The staff ofYFPS are the subjects ofthe research component of this practicum report. Participants were interviewed and asked to comment on their experiences in making or suggesting community referrals for their clients. The data provided by participants was evaluated using thematic analysis. The results yielded an understanding of the community resources youth most commonly require in the Prince George area. Also, participants identified the areas where additional services are required. Table of Contents m Table of Contents Abstract.______________________________________________________ 11 T l1l f t ~ Acknowledgments_________________________________________________ Vl Inroduction - ---------------------------------------------------- 1 Chapter 1: Literature Review____________________________________ 3 Forensic Social Work and Psychiatry___________________ 3 Definition of forensic social work -- -------------------- 4 Forensic psychiatry________________________________ 6 International Forensic Psychiatric Services__ __________________ 7 United States of America --------------------------------- 7 DenmMk__________________________ 9 Austria ------------------------------------------- 10 Australia --------------------------------------------- 11 History of Forensic Psychiatric Services_______________________ 11 International history of forensic services__________________ 12 Canadian history of forensic services_____________________ 13 British Columbia's history of forensic services___________ 14 Deinstitutionalization ~ 15 Federal Legislation Pertaining to Forensic Psychiatry__________ 17 Charter of Rights and Freedoms_______________ 17 Bill C- 30 an Act to Amend the Criminal Code of Canada- - - - - - - 19 Provincial Legislation Pertaining to Forensic Psychiatry The Mental Health Act 20 20 Table of Contents 1v Forensic Psychiatry Act 22 Forensic Psychiatric Services for Youth 23 International forensic services 23 Youth forensic psychiatric service in British Columbia 25 Forensic Psychiatric Services Current Services and Programs for Youth 27 Inpatient assessment unit 27 Maples adolescent treatment centre 27 Outpatient clinics 28 Gaps in the Literature Chapter 2: Practicum Placement 30 31 Youth forensic psychiatric services 31 Summary ofpracticum activities 33 Chapter 3: Practicum Research Component 38 Significance, Sample and Ethical Issues 38 Significance of the study 38 Sampling and data collection 38 Ethical issues 40 Thematic Analysis 40 The nature of thematic analysis 41 How to conduct thematic analysis 41 Threats to effective analysis 43 Chapter 4: Data Analysis and Results 44 Thematic Analysis 44 Professional Experience with Community Referrals 45 Table of Contents v Determining if referral is appropriate 45 Familiarity with community services 46 Professional responsibility in referral making 47 Skills professionals utilize in making referrals to community agencies_ 49 Community Referrals and Youth 50 Community services commonly referred to by mental health therapists _ 51 Matching community referrals and the need of the youth 53 Feedback regarding community referrals._ _ _ _ _ _ _ _ _ __ 55 Community services gaps and needs in the north region_ _ _ _ __ 56 Chapter 5: Implications for Policy and Practice_ _ _ _ _ _ _ _ _ _ _ _ __ 60 Policy_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 60 Practice------------------------------ 62 Recommendations for further research'----------------- 64 '--------------------------------- 65 Conclusion - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 67 References Appendix A._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 73 AppenruxB_____________________________ 74 AppenruxC_____________________________ 75 AppendixD_____________________________ 76 Acknowledgments v1 Acknowledgments I would like to extend great thanks to the following people for their support and encouragement throughout my academic journey. My supervisor Glen Schmidt, my practicum supervisor and committee member Judith Hayes, and committee member Dawn Hemingway; your participation is very much appreciated. I would also like to thank the members of my cohort for their emotional support (and occasional glass of wine) throughout this adventure. This academic journey has had its share of frustrations and triumphs and it has been a privilege to share all of it with such a fantastic group of men and women. One of my greatest thanks goes out to my teacher and friend Jennifer Roukkula for helping me find confidence as a social work student. To all of the people whom I have had the privilege to encounter in my work, you are my greatest teachers, I thank and wish everyone well. And finally, the ultimate thanks to my family and friends for loving me, listening to me rant, and supporting me through the frustrations and triumphs (bet you are all glad this is over!!). I Introduction 1 Introduction Youth Forensic Psychiatric Services (YFPS) in British Columbia has existed for over twenty years. During this time YFPS has evolved and expanded and currently provides comprehensive court ordered and court related assessment and psychiatric treatment to youth throughout British Columbia who have committed criminal offences (Ministry of Children and Family Development, 2004). There were two main objectives of the practicum. The first was to further increase this author' s knowledge and experience working with youth in conflict with the law and the mental health field. The second was to understand the experiences of mental health therapists who are employed at YFPS in Prince George. These two objectives were achieved and will be illustrated in the following five chapters. The first chapter of this practicum report examines the relevant literature that pertains to Youth Forensic Psychiatric Services including a brief overview of international youth and adult forensic services, history of forensic psychiatry in British Columbia, and the relevant legislation pertaining to the delivery of youth forensic psychiatric services in British Columbia. The second chapter illustrates the practicum setting which is the Youth Forensic Services Outpatient Clinic in Prince George. This includes the various staff positions and the clinical responsibilities of YFPS clinical staff. This chapter also includes an overview of practicum activities this author completed. Chapter three provides a detailed description of the research design used in the research component of the practicum report. The research question, sample, and data Introduction collection are identified. Information regarding thematic analysis is provided along with the step by step process used in completing the thematic analysis. The fourth chapter illustrates the results of the thematic analysis. The chapter examines two main themes and under each main theme sub themes are identified and explained. Also included in this chapter are direct quotes from participants which further illustrate themes that emerged from the data. Chapter five is the final chapter in which implications for policy and practice are addressed. This chapter provides suggestions on how to incorporate the results of this study in the YFPS agency's policy and professional practice. Also included are suggestions for further study. 2 Chapter 1 Literature Review 3 Chapter 1 Literature Review The following chapter includes a review of the literature relevant to this practicum report. This chapter includes discussion on eight areas pertaining to forensic psychiatric services. First, forensic social work and psychiatry will be discussed; second, international forensic psychiatric services will be reviewed; third, the history of forensic psychiatric services will be illustrated; fourth, the federal legislation pertaining to forensic psychiatric services will be examined; fifth, the provincial legislation pertaining to forensic psychiatric services will be described; sixth, forensic psychiatric services for youth will be addressed; seventh, the current services offered for youth through Youth Forensic Psychiatric Services will be identified; and the eighth area addressed in this literature review will be gaps in the literature. Forensic Social Work and Psychiatry Forensic social work is a specialization within the field of social work. The definition and roles of forensic social work will be identified and discussed within this section. Understanding the role and responsibilities of forensic social work and forensic psychiatry was an aspect of my practical experience at Youth Forensic Psychiatric Services. It is essential to discuss the roles and responsibilities of forensic social work and forensic psychiatry, as the majority of individuals who participated in the qualitative study discussed later in this report were employed as forensic psychiatric social workers and worked along side forensic psychiatrists and psychologists. Chapter 1 Literature Review 4 Definition offorensic social work In order to effectively defme forensic social work, first the term forensic must be examined. Barber, Fitzgerald, Howell, and Pontisso (2006) state that forensic refers to "connection with courts oflaw"(p.372). Alone the word is somewhat ambiguous but when attached to professional fields it describes the nature of the work within that particular area. Forensic social work based on Barber, Fitzgerald, Howell, and Pontisso's (2006) definition, would simply be social work "in connection with courts oflaw" (p.372). However, this simple definition lacks clarity and does not address differences in forensic social work roles. The following section will identify the various defmitions, roles, and responsibilities of forensic social work. There are a number of defmitions of forensic social work within the literature. Although most defmitions are somewhat similar, there are differences depending on the origin of the literature. The first definition identifies that forensic social work is " the practice ~ i t in social work that focuses on the law, legal issues, and litigation" (Barker, 2003, p.166). Neighbors (2002) states that forensic social work is "a new specialty area of professional social work practice" (p. xvii). And Broyles (2002) notes that forensic social workers are "highly trained professionals with specialized skills, stated values and a unique knowledge base" (p. 91). These definitions are valuable as they recognize forensic social work as a new specialty within the field of social work. Gothard (2002) says that forensic social work is " the interface of social work with questions and issues relating to the law and the legal system"(p.xv). Gothard (2002) continues by noting that a forensic social worker should have a familiarity with the law and Chapter 1 Literature Review 5 legal system, as well must be able to carefully evaluate clients and their situations. He reports that forensic social workers should provide diagnosis, treatment, and recommendations to court. He also identifies that the forensic social worker needs to be prepared to provide expert testimony to court. Barker and Branson (2000) provide an interesting perspective regarding forensic social work in the United States in a book they produced entirely dedicated to the subject. They define forensic social work as a "professional specialty that focuses on the interface between society's legal and human service systems" (p. 1). They identified interfaces as including child custody disputes, non-payment of child support disputes, mediation between divorcing couples, or any other dispute that could possibly go to court if not resolved through mediation. Throughout their work they pay particular attention to the role of the forensic social worker as an expert witness in court as well as legalities within the profession of social work. Barker and Branson (2000) outline the qualifications an expert forensic witness should possess, such as knowledge of court proceedings and how laws are made and changed. The authors also identify what incentives are offered for forensic social work witnesses and what motivates individuals to provide expert testimony. Barker and Branson (2000) also dedicated much time in this work to discuss how forensic social workers can avoid malpractice lawsuits and the importance of registration within the professional field of social work. What made this particular work stand out for this author was that assessment and treatment of clients was given little attention throughout the text. Roberts and Brownell (1999) operationally defme forensic social work as "policies, practices, and social work roles with juvenile and adult offenders and victims of crimes" (p. 360). This particular defmition provides a narrower explanation of who the consumers of Chapter 1 Literature Review 6 forensic social work services are. Gibelman (1995) discusses in her work the role of social workers in corrections. In her definition, social workers employed in correctional facilities are not forensic social workers. Gibelman (1995) regards forensic social work as specific to criminal offenders with mental health concerns (p. 289). This particular explanation of forensic social work is not unlike the role of a mental health therapist employed at Youth Forensic Psychiatric Services (YFPS) within the Ministry of Children and Family Development (MCFD) in British Columbia. Forensic psychiatry Forensic psychiatry is a different approach to psychiatric care in comparison to general psychiatry. Individuals involved in the forensic system are identified during their encounter with the justice system and often require longer periods of treatment. Forensic psychiatric service consumers often find that they require practical follow-up interventions that are not offered through community based mental health services. Forensic psychiatry also relies a great deal on a multidisciplinary team approach as mental health services and representatives of the justice system require communication with regard to the treatment of clients (Buchanan, 2001). Within forensic psychiatry the court is also considered the client. Forensic psychiatry will provide information to the court regarding an individual's risk to the community. Decisions regarding an individual's treatment plan may be established without collaboration or agreement of the forensic psychiatric service consumer. The relationship between the forensic psychiatric service consumer and the forensic psychiatrist is significantly different from that of a mainstream psychiatrist and client. Forensic psychiatry consumers do not have the same degree of confidentially. Treatment is part of a court order, Chapter 1 Literature Review 7 which requires the forensic psychiatrist to provide regular updates to Probation Officers regarding the client's progress (British Columbia Review Board, 2008). International Forensic Psychiatric Services As noted above forensic psychiatric services have numerous definitions and can provide numerous services. Laws vary between countries as well as between territories within countries. Forensic psychiatric practice differs considerably from country to country. For example, forensic psychiatrists in the United States generally do not facilitate specialized treatment programs for offenders, while this practice is an expectation of a forensic psychiatrist in the United Kingdom (Gunn, 2004).The following section provides a glimpse of international forensic psychiatric services. United States ofAmerica Jenelka et al. (1993) report that at any given time 10% to 15% of the state prison populations in the United States of America (USA) live with a serious mental health disorder (as cited in Lurigio, 2001). Lurigio (2001) identifies that individuals with serious mental health disorders are often released on parole; however, with the current parole system in the United States, there are few services offered through parole services for individuals with serious mental health disorders. Harding (1993) states that in the USA an individual must be mentally competent to stand trial. Similarly, in Canada a person must be fit to stand trial (Department of Justice, 2008). If an individual is found incompetent to stand trial the court proceedings are delayed while the defendant's mental health is restored. Restoration of mental health may occur with a period of hospitalization. Legal standards for competency to stand trial vary from jurisdiction to jurisdiction and assessments can be paid for privately by the defendant or may Chapter 1 Literature Review 8 be provided by criminal court clinics at no cost. In the USA the insanity verdict is available in all federal jurisdictions and all states but three. A verdict of guilty but mentally ill is available in 13 states in the USA. This verdict identifies that the defendant was mentally ill at the time of the offence but offers no benefit to the defendant in terms of outcome following conviction. The individual receives the identical punishment a mentally well offender would receive. Treatment of a mentally disordered offender in the USA is provided in the state or federal jurisdiction where the offence occurred. A range of treatment facilities are available from specialized maximum security to secure units in general psychiatric hospitals. The placement of mentally ill offenders depends on the nature of the crime committed, the diagnosis of the individual, and history of violence. Admission and discharge from these hospitals is done through the criminal courts. In the case of Canada, the Review Board is responsible for altering disposition orders for forensic offenders. Harding ( 1993) identified that in the USA courts are reluctant to release patients who are at risk of future violence. The use of the death penalty is an issue in the forensic psychiatric community in some states in the USA. Often inmates spend many years on death row awaiting execution and it is not uncommon for death row inmates to develop mental illnesses while on death row. Forensic psychiatrists are called upon to restore inmates' mental health as execution cannot occur until mental health is restored. This presents an ethical dilemma as providing forensic psychiatric services will ultimately lead to the inmates' execution. It is also unethical to withhold services to an individual in need of psychiatric care (Harding, 1993). Chapter 1 Literature Review 9 Denmark Over time there has been a move away from the treatment philosophy for 'criminal psychopaths'. Mental health professionals have been increasing opposition to this approach and are not convinced of the effectiveness and ethical basis of indeterminate sentences and mandated treatment. In Denmark the verdict of irresponsibility means that the individual did not have the capacity to understand the unlawful nature of an act and the capacity to control behaviour. The Criminal Code of Canada also contains two criteria an individual must meet if they are to be found not criminally responsible due to mental disorder. The frrst criterion is similar to Denmark; the accused must be incapable of appreciating the nature of the act. The second criterion states that the accused must not understand that the act was wrong. In Denmark, if found irresponsible the individual is found not guilty and is not subject to punishment; however, the court may determine a mental health case management plan which concentrates on the prevention of further crimes. Currently in Denmark, psychiatric sentenced offenders receive treatment in the general mental health system and only the most dangerous offenders are placed in a special high security institution called Herstedvester. The medicolegal council is an advisory board under the Ministry of Justice. This advisory board is comprised of mental health and general health professionals and they provide treatment recommendations for mentally ill offenders to the court (Harding, 1993). In British Columbia, the Forensic Psychiatric Services Commission is responsible for arranging court related psychiatric assessment, case management, and treatment to mentally disordered individuals who are in conflict with the law through hospitals and clinics located throughout the province (BC Mental Health and Addictions, 2008). Chapter 1 Literature Review 10 Austria In Austria, the verdict of irresponsible is similar to that of Denmark. The individual does not receive punishment and will not stand trial when mental state improves, however an individual may be hospitalized. If an irresponsible person is hospitalized, discharge is the responsibility of the psychiatrist. Often the psychiatrist' s assessment focuses less on mental illness and more on risk to the community, which is not unlike psychiatric assessment in Canada. When an individual is found by the psychiatrist to be a risk, the offender may be held in hospital until no longer considered dangerous (Harding, 1993). In Canada in each province and territory there exist Review Boards. These Review Boards are responsible for making and reviewing dispositions for individuals found not criminally responsible on account of mental disorder and unfit to stand trial. The importance of public safety is an issue that is of great concern to Review Boards in Canada and is taken into consideration when reviewing and making dispositions (British Columbia Review Board, 2008). The concern for public safety is not unlike Denmark. There are a number of forensic facilities for male offenders in Austria; the high security facility can hold up to 130 patients and is operated by the Ministry of Justice. In addition to forensic hospitals, there are special units in prisons that treat patients when they can be allocated to hospitals. One criticism of the Austrian forensic system is that the system provides services in prison or in forensic hospital operated similar to prisons. This creates therapeutic barriers such as patient motivation and compliance. Forensic patients may have distrust for forensic professionals as the forensic mental health system closely resembles the penal system (Harding, 1993). Chapter 1 Literature Review 11 Australia Australia, which derives its penal system from the English legal system, has increased legislative development in some states bridging mental health and the penal system. Although there has been development with regard to forensic psychiatric services, there is concern in Australia with regard to housing and treatment of forensic psychiatric patients within institutions. In addition to concern for forensic patients in facilities, there is concern that deinstitutionalization is occurring without the establishment of adequate community based services. Defendants found unfit to stand trial are admitted to hospitals as restricted patients. In New South Wales, provisions exist to ensure that a person found unfit to stand trial will not be detained longer than the sentence they would have received if found fit. However, in Southern and Western Australia this provision is not in place and forensic patients can be held for an indeterminate period of time. The forensic psychiatric system in Australia is guided by state and federal Tribunals that determine fitness to stand trial and treatment for forensic offenders. Each Tribunal will serve a slightly different function, the responsibilities of the Tribunal are determined in their respective jurisdiction (Harding, 1993). As stated earlier, Review Boards exist in each province and territory in Canada. The review boards are similar to Australian Tribunals, however the mandates of all Review Boards in Canada are established by the Criminal Code of Canada in an effort to ensure consistency throughout the country (British Columbia Review Board, 2008). History of Forensic Psychiatric Services The development of forensic services throughout the world is varied. For example, Britain identified the need for forensic psychiatric services in the early 1800s (Gunn, 2004). Chapter 1 Literature Review 12 Japan on the other hand passed their first forensic mental health legislation in 2003 (Yoshikawa & Taylor, 2003). The following section of this literature review will examine the history of forensic psychiatric services internationally, within Canada, and British Columbia. International history offorensic services Gunn (2004) identifies that forensic psychiatry in Britain dates back to 1812 as the British government identified the need for separate housing for offenders who were mentally ill. Funding was provided to open a new wing in an existing hospital; however, it was found that there was considerably more need than a wing in a hospital could accommodate. The first forensic hospital was built in an effort to meet the need of forensic patients in 1863. By the 1930s deinstitutionalization began with the removal of power of compulsory admission away from the courts. This power was given to a collection of doctors, social workers, and relatives of patients. Roberts and Brownell (1999) discuss the beginning of forensic social work in the United States. The frrstjuvenile court was opened in 1899 as a result of the work of Jane Addams and Julia Lathrop, the founders of the settlement house movement and two of the earliest forensic social workers. Biggins and Oss (2003) identify that the establishment of youth courts was to separate youth or underage offenders from adults. Once separated from adult offenders, youth would receive the guidance and treatment needed to correct behaviour. The initial objective of youth justice was not to punish youth but to provide youth with the tools necessary to function in society (Biggins & Oss, 2003). Forensic social work emerged in the United States around 1800 and has evolved into a specialized field of social work. Barker and Branson (2000) recognized the work of Jane Chapter 1 Literature Review 13 Addams as an early forensic social worker who worked in settlement houses in underprivileged urban areas in the United States. Canadian history offorensic services The development of institutions for individuals with mental illness in Canada has a similar history as Great Britain. Sussman (1998) identifies that the development of institutions for the mentally ill in Canada in the 19th and 20th centuries was an attempt to alleviate the suffering of the mentally ill detained in jails and poorhouses. However, Kendall (1999) identifies that the interest in housing the mentally ill separately came from overcrowded jails and less from concern with the well being ofthe mentally ill. The emergence of institutions for the mentally ill in Canada occurred province by province with Quebec and New Brunswick opening lunatic asylums in the mid to late 1840s. The 1850s saw the opening of asylums in Ontario, Newfoundland, and Nova Scotia. British Columbia and Prince Edward Island opened asylums in the 1870s and Manitoba's asylum became operational in late 1880. The fmal two provinces to open asylums were Saskatchewan and Alberta in 1911 and 1914 respectively. Prior to opening asylums in both provinces mentally ill individuals were sent to Manitoba for treatment (Sussman, 1998). The first asylum specifically for "criminal lunatics" was built in Kingston Ontario (Foulkes, 1961). Criminal lunatics provided a particular challenge with regard to appropriate housing as they were both mentally ill and criminal and therefore belonged in both asylums and penitentiary. In 1855 a temporary criminal lunatic asylum was built for men within the Kingston penitentiary. Horse stables served as the temporary criminal lunatic asylum for women at the Kingston penitentiary. Women resided in the stables from 1857 to 1868 while awaiting the new asylum building to be completed. Temporary asylums were common while Chapter 1 Literature Review 14 permanent accommodations were being built. For example in Ontario, the old York Jail was used to temporarily house the mentally ill. In Newfoundland and Nova Scotia, old hospitals were used as temporary asylums and in Manitoba the mentally ill were temporarily housed in jails and during periods of respite from the jail they were housed in a storehouse of the Hudson's Bay Company (Sussman, 1998). British Columbia 's history offorensic services Menzies (2002) profiles eight decades worth of British Columbia's mental health system. In his work, he examines the evolution in mental health services in British Columbia between 1874 and 1950. The first asylum established in British Columbia was the Victoria Lunatic Asylum which was opened in 1872 and closed in 1878. After the closure of the Victoria Lunatic Asylum, three institutions were opened and remained the main facilities for the care ofthe mentally disordered until the 1960s. These facilities included the New Westminster Asylum (later named the Public Hospital for the Insane), Provincial Mental Home Essondale (later named Riverview Hospital) and Coquitz Mental Home which was responsible for housing of the criminally insane. Coquitz is located 10 kilometres northwest of Victoria and was originally constructed in 1912 to serve as the Saanich prison. The property served a number of purposes before 1919, which is when the facility reopened as Coquitz Mental Home and became the second institution in Canada to house "criminal lunatics" (Menzies, 1999). A study conducted by Menzies (1999) reviewed the files from 100 patients or inmates from Coquitz between 1919 and 1933 . This work examines the conditions and routine of inmates as well as the leadership role of Gamby Farrant, Coquitz's first supervisor. Farrant was responsible for the day to day operations of Coquitz. A number of these responsibilities included attending to administrative Chapter 1 Literature Review 15 administrative details such as hiring and dismissing staff; inmate ward assignments; and daily rounds to check on inmates. Once a former patient of British Columbia' s Public Hospital for the Insane, Garnby Farrant had no medical training and was directed by superiors in Victoria and psychiatrists on the lower mainland (Menzies, 1999). At Coquitz, security was of primary concern to staff. Inmates included individuals who were found not criminally responsible for reason of insanity, individuals who became insane while incarcerated, and patients from two of the other mental hospitals who displayed behavioural problems or were hard to manage. According to Menzies' (1999) writings, work was the treatment option preferred at Coquitz from 1919 to 1933. Inmates were encouraged to work on the property' s farm and grounds. Inmate labour was also responsible for the upkeep of the buildings, the laundry, and food preparation. De institutionalization As identified earlier, the original treatment response to mentally ill offenders was to house them in hospitals or various temporary institutions when hospitals were not available. Over time the cost of inpatient facilities along with legislation regarding individual rights and freedoms challenged the institutional model of treating mental illness. The following section provides a brief summary of literature found regarding the shift from inpatient treatment to outpatient treatment. Markowitz (2006) conducted a study on the relationship between available mental health services, homelessness, and crime. His research examined if there was a relationship between greater inpatient hospital services and crime and arrest rates in the United States. Markowitz (2006) reports that deinstitutionalization of mental health patients has over time created a phenomenon, which is referred to as the "criminalization of the mentally ill" (p. 2). Chapter 1 Literature Review 16 From the 1960s to the 1990s the availability of long term hospital beds in the USA decreased drastically. Markowitz (2006) reports that this drop was due to the advancement in medication to control serious mental illness such as schizophrenia and a more liberal position on confinement of mentally ill patients. Markowitz (2006) found that mentally ill offenders were overrepresented among inmates incarcerated for violent crimes. His fmdings also concluded that police arrest individuals whose behaviour is troublesome or disturbing when hospitalization is not an option. Lurigio (200 1) identifies that deinstitutionalization occurred when the care for individuals with serious mental illness was shifted from psychiatric hospitals to community mental health centres. Lurigio (200 1) reports that deinstitutionalization was not properly implemented in the United States and as a result has not succeeded in providing adequate outpatient treatment for large percentages of patients with serious mental health disorders. Lurigio (200 1) identifies individuals with serious mental health disorders as those with schizophrenia, bipolar disorder, or major depression. The unsuccessful transition of patients from institutions to community services has resulted in many individuals with serious mental illness becoming in conflict with the law (Lurigio, 2001). Kahila, Kilkku, and Kaltiala-Heino (2004) note that deinstitutionalization occurred in Finland later than in the United States and the United Kingdom. The number of mental health institutional beds reduced significantly over 1980 to 1990. Ward and Jackson (2004) report that lack of appropriate outpatient services in the community to accommodate individuals being released from inpatient facilities led to difficulties for patient reintegration into the community. Kahila, Kilkku and Kaltiala-Heino (2004) report that during this period, inpatient mental health services for children and adolescents became unavailable but were replaced Chapter 1 Literature Review 17 with independent service providers. These specialized child and adolescent outpatient services often involved lengthy waitlists. A study examining a number of outpatient services for forensic patients was conducted by Hodgins et al. (2007). The authors suggest that there is considerable stigma associated with individuals with major mental illness who are involved with crime. There is a misconception that community safety cannot be ensured unless individuals with major mental illness are housed in hospitals or incarcerated. However, Hodgins et al. (2007) identify that institutionalization and incarceration are considerably more costly to operate than community based services. Community based programs prevent the loss of skills that individuals who have been institutionalized for long periods experience. Community programs may promote the development of new skills and encourage prosocial behaviours. Federal Legislation Pertaining to Forensic Psychiatry There are two important pieces of legislation that changed the way in which the criminal justice system in Canada addresses individuals with mental illness in conflict with the law. The first is the Charter of Rights and Freedoms and the second is 1992 Bill C-30 an Act to Amend the Criminal Code of Canada. Charter ofRights and Freedoms Concern for the protection of human rights appeared to gain global attention after World War IT. In 1960, Canada expressed concern for human rights by enacting the Canadian Bill of Rights, the first federal law designed to protect human rights (Department of Justice Canada, 2005). The Charter of Rights and Freedoms was established in 1982 and became an important part of Canada' s constitution. The Charter "protects Canadians' rights and freedoms by limiting the ability of governments to pass laws or take actions that discriminate Chapter 1 Literature Review 18 or infringe on human rights" (Department of Justice Canada, 2005). Issues addressed within the charter include democratic rights, legal rights, equality rights, official languages rights, minority language education rights, and enforcement (Department of Justice Canada, 1982). In 1983, Owen Lloyd Swain was charged with assault causing bodily harm after attacking his wife and children. Swain displayed bizarre behaviour at the time of the offence, reported believing that his family was being attacked by devils, and his actions were an attempt to protect them (Stuart, Arboleda-Florez & Crisanti, 2001). Swain was treated with anti psychotic drugs while residing in the community for a year prior to his trial. At trial the issue of mental illness was raised in court by the Crown Counsel although Swain objected (Stuart, Arboleda-Florez & Crisanti, 2001). The Crown Counsel was successful in convincing the court that Swain was insane at the time of the offence and Swain was found not guilty by reason of insanity (Eaves, Lamb & Tien, 2000). At the time of the trial the court "did not provide a mechanism for taking his mental condition at the time of the trial" as Swain had been undergoing treatment and was able to live in the community without concern (Stuart, Arboleda-Florez & Crisanti, 2001, p. 528). Swain appealed the ruling arguing that his rights under the Charter of Rights and Freedoms sections 7 and 9 were violated (Livingston, Wilson, Tien & Bond, 2003). In 1991 the Supreme Court of Canada found the Criminal Code of Canada pertaining to mentally ill offenders was in fact unconstitutional under the new Charter (Stuart, Arboleda-Florez, & Crisanti, 2001). The Supreme Court identified that Crown counsel could not raise the issue of mental capacity before the crown proved that the crime had been committed; but that the individual accused could raise the issue of mental capacity at any point during the trial (Canadian Centre for Justice Statistics, 2003). Chapter 1 Literature Review 19 Bill C- 30 an Act to Amend the Criminal Code ofCanada The first criminal code in Canada was created in 1892. This original code made insanity defence available to individuals of "natural imbecility" or those with "disease of the mind" (Raaflaub, 2004). The code regarding mentally ill offenders went unchanged until the Swain case prompted the development of new legislation. Bill C-30 was enacted on February 4, 1992. Prior to 1992, if a person was found not guilty by reason of insanity then detention (hospitalization) was at the pleasure of the Lieutenant Governor for an unspecified period of time. It was possible that an individual could spend more time detained if found not guilty by reason of insanity than if the person were found guilty and sentenced (Canadian Centre for Justice Statistics, 2003). Bill C-30 changed a number of aspects to the forensic system in Canada such as the duration of remand assessment orders. Prior to Bill C-30 an individual could be remanded for an assessment to determine fitness for 30 days. The Act requires that an individual remanded be assessed within 5 days, however there are opportunities for extensions up to 30 days (Zapf & Roesch, 1998). Some studies have found that the length of time individuals are remanded to assess fitness has not been reduced to the ideal period of 5 days (Livingston, Wilson, Tien, & Bond, 2003; Stuart, Arboleda-Florez, & Crisanti, 2001). Another important change that occurred as a result of Bill C-30 was the replacement of the Lieutenant Governor Advisory Board with Review Boards. This change extended jurisdiction to Review Boards in making dispositions regarding accused (Livingston, Wilson, Tien, & Bond, 2003). The Criminal Code of Canada (CCC) identifies that the: Review Board shall be established or designated for each province to make or review dispositions concerning any accused in respect ofwhom a verdict ofnot Chapter 1 Literature Review 20 criminally responsible by reason ofmental disorder or unfit to stand trial is rendered, and shall consist ofnot fewer than jive members appointed by the lieutenant governor in council of the province. The CCC identifies that the review boards are responsible to make a disposition (no later than 45 days after the verdict is rendered) when regarding an individual found not criminally responsible on account of mental disorder or unfit to stand trial. The review board is also responsible to determine fitness to stand trial of individuals identified through the court and review previous unfit individuals to determine mental health status. The review board has the power to keep an individual detained in hospital until the accused is fit to stand trial or if there is reason to believe that the accused would become unfit to stand trial if released (Department of Justice Canada, 2008). Provincial Legislation Pertaining to Forensic Psychiatry The section above outlined two important pieces of legislation that have had a direct impact on the way the judicial system views mentally disordered offenders in Canada. However, the delivery of forensic psychiatric services, like all health services, is the responsibility of individual provinces and territories. The following section will examine two pieces of provincial legislation that have an impact on forensic psychiatric services in British Columbia. The Mental Health Act The Mental Health Act came into effect in British Columbia in 1964 and has undergone updates since the original publication. The Mental Health Act "helps provide people with mental disorders the treatment and care they need when they are not willing to accept it" (Ministry of Health, 2005, p.l). The Mental Health Act outlines criteria and Chapter 1 Literature Review 21 procedures for involuntary admission and treatment of individuals with serious mental disorders and also contains protections to ensure that involuntary admissions occur in an appropriate and lawful manner (Ministry of Heath, 2005). For an individual to be admitted involuntarily for treatment, a physician must examine the individual and complete a medical certificate. There are four criteria the physician must use to evaluate an individual and the individual must meet all four criteria to be involuntarily admitted under the Mental Health Act. The four criteria are that a person must be suffering from a mental disorder that impairs the person' s ability to react to that environment or associate with others; require psychiatric treatment; require care to prevent the person's substantial mental or physical deterioration or for the person's protection or the protection of others; and fmally the person is considered not suitable as a voluntary patient (Government of British Columbia, 1996b). After the first certificate is issued, the individual is taken to a hospital designated under the Mental Health Act for an assessment; a second certificate completed by a different physician is required 48 hours after the first is issued. If the second certificate is completed and it is found that the individual requires continued hospitalization the certificate is renewed for one month. However if the individual requires continued care after one month, the certificate is renewed for three months and after that period has ended the renewal is extended for six months (Ministry of Heath, 2005). This author notes that the literature does not identify if there is a maximum period an individual can be involuntarily hospitalized under the Mental Health Act. In the event that an individual commits a crime and is found at the time of the offence to meet the criteria for medical certification, the Crown Counsel may ask for a stay of Chapter 1 Literature Review 22 proceedings to allow the individual to be taken for involuntary treatment to a designated facility. However if the individual is detained in custody under the Criminal Code of Canada and the individual is certified under the Mental Health Act, the person may be transferred to the Forensic Psychiatric Institute for treatment. If an individual appears in court and it is unclear at that time if the individual is fit to stand trial, the court may request that the individual be assessed at the Forensic Psychiatric Hospital in Port Coquitlam or the individual can be released on bail with the condition of attending an outpatient forensic or non-forensic mental health clinic (Ministry of Health, 2005). Forensic Psychiatry Act The provincial government in power in the 1970s identified the special circumstance of offenders with mental health disorders and established the Forensic Psychiatry Act in 1974. As a result of the new legislation the Forensic Psychiatric Services Commission (FPSC) was created (Eaves, Lamb, & Tien, 2000). The FPSC consists of five members who are appointed by the Lieutenant Governor. The function of the FPSC is to arrange for the provision of forensic psychiatric services to the courts in British Columbia who will give expert psychiatric evidence (Government of British Columbia, 1996a). The FPSC is responsible for arranging forensic psychiatric assessment for accused individuals remanded for psychiatric evaluation, the provision of services for individuals in need of psychiatric care while in custody, providing services for individuals held under court order, and individuals held under the criminal code or Mental Health Act (Government of British Columbia, 1996a). The objective in creating the Forensic Psychiatric Act was to have an independent body that works "at arms length from the Government" (Eaves, Lamb, & Tien, 2000, p. 621 ). This allows the commission to be impartial regarding mental health status and treatment of Chapter 1 Literature Review 23 individuals who appear before the court and the Review Board. Eaves, Lamb, and Tien, (2000) identify that the commission can express objective professional opinions regarding the balance between the accused's right to treatment and the need to protect the public. The FPSC is also mandated to organize and conduct "research respecting the diagnosis, treatment and care of forensic psychiatric cases" as well conduct "educational programs respecting the diagnosis, treatment and care of forensic psychiatric cases" (Government of British Columbia, 1996a, p. 2). More recently the commission has expanded services to all regions of the province with the establishment of outpatient clinics. Forensic Psychiatric Services for Youth Thus far, the content of this literature review has focused primarily on the adult forensic psychiatric systems internationally and locally. The purpose of this section is to provide an overview of youth forensic services internationally, within Canada and British Columbia. International forensic services Ward and Jackson (2004) conducted a study on youth forensic services in Finland and found that the first adolescent forensic unit opened in 2003. This unit offers a multidisciplinary approach to care and is the only facility of its kind in Finland. This unit provides assessment for criminal responsibility or for treatment in the event that an adolescent is deemed not criminally responsible due to mental disorder. The forensic unit also admits youth who present a challenge for treatment because they have a long-term history of suicidal behaviour, difficulties with impulse control, have severe conduct disorder, have severe antisocial behaviour, and have serious substance abuse disorders. Youth do not have to Chapter 1 Literature Review 24 be in conflict with the law in order to access forensic services in Finland (Ward & Jackson, 2004). Apler (2000) discusses his experience in both Australia and the United Kingdom working in forensic mental health. Apler (2000) notes that there are distinct differences in services between the two countries. In Australia forensic mental health services were provided by the correctional system while young offenders were in custody. Apler (2000) identifies that forensic services in Australia are in the early stages of development. Throughout his practice in Australia, Apler (2000) noticed that a large portion of the youth population in custody were Aboriginal. He reports that through his experience working with youth in Australia he identified that many clients' issues stemmed from environmental and social factors that psychiatry could do little to alleviate. In the United Kingdom, the focus of forensic services has been directed to youth in secure custody and community based followup is often reluctantly the responsibility of local psychiatric services. It is also important to note that adolescent forensic services are not as well developed in the southern part of England as compared to the north. Apler (2000) identifies that there are no forensic services for youth in Scotland. Apler (2000) states that the United Kingdom offers specialized training in youth forensic psychiatry. The training identified is for psychiatrists and at the time the article was published only I 0 people had completed the program. Australia, however, does not have training available for professionals interested in specializing in youth forensic services. The role social workers play in the forensic treatment of youth in both Australia and the United Kingdom was absent in the literature reviewed. Chapter 1 Literature Review 25 Biggins and Oss (2003) report that 50% to 75% of incarcerated youth in the United States are estimated to have a mental health disorder. The demand for mental health services for adolescents and children is on the rise and, due to decreased funding and lack of health benefits plans, many youth are being referred to mental health services through the child welfare and justice systems. Youth forensic psychiatric service in British Columbia In British Columbia forensic psychiatric services for youth have been in existence since 1982. Prior to 1982 an organized service that provided youth who were in conflict with the law with mental health assessment or treatment did not exist (Ministry of Children and Family Development, 2004). Forensic Psychiatric Services (FPS) which provided adult offenders with mental health treatment and assessment derived its mandate from the Forensic Psychiatry Act which, as stated earlier, was enacted in 1974. Two members ofthe FPS, Dr. Roy O'Shaughnessy and Mr. Alex Ryan identified the need for forensic psychiatric services for youth and were responsible for the development of Juvenile Services to the Court (JSC). Originally JSC offered assessment services to primarily the Vancouver area and was under the umbrella of the Forensic Services Commission. The Young Offenders Act (YOA) was enacted in 1984. This act provided legal mandate for ''the provision of medical, psychiatric and psychological assessment for young persons who committed criminal offences" (Ministry of Children and Family Development, 2004, p. G2). Youth Forensic Psychiatric Services (YFPS) was established with two separate programs, Juvenile Services to the Courts (JSC) and Maples Adolescent Treatment Services (MATC). JSC was the "central agency through which FPS met its responsibility of providing all court-ordered and court-related assessment and treatment under the YOA" (Ministry of Chapter 1 Literature Review 26 Children and Family Development, 2004, p.G3). The role of the MATC was to provide assessment and treatment to mentally ill and conduct disordered adolescents. JCS expanded services over time to include outpatient clinics in Victoria, Kamloops, Prince George, Kelowna, Langley, Nanaimo, and Vancouver. There is a network of contracted individuals who provide services in communities outside regional outpatient clinics to address gaps in service (Ministry of Children and Family Development, 2004). In 1996 the Gove Commission report was released and with it came numerous recommendations to improve the quality of services children and youth receive in British Columbia. The Honourable Judge Thomas J. Gove conducted an inquiry into the child welfare system in British Columbia after the death of a 5 year old boy, Mathew Vaudreuil. The young boy had an open file with child welfare and his home situation was reported to child welfare on a number of occasions throughout his short life (Government of British Columbia, 1995). The Gove Commission yielded recommendations to improve services to children and youth in British Columbia. One of these recommendations was to bring all services pertaining to youth from the Ministry ofWomen' s Equality, Ministry of Health, Ministry of Education, Ministry of Social Services, and the Ministry of Attorney General together under one ministry (Government of British Columbia, 1995). As a result of these recommendations, the Ministry of Children and Families was developed and YFPS was integrated into the new ministry. This integration led to the connection between YFPS and the Forensic Services Commission to be severed (Ministry of Children and Family Development, 2004). At this time JSC officially became Youth Forensic Psychiatric services and MATC no longer came under the umbrella of YFPS but was a distinct provincial Chapter 1 Literature Review 27 program. In 2001, Ministry of Children and Families was renamed the Ministry of Children and Family Development (Ministry of Children and Family Development, 2004). Forensic Psychiatric Services Current Services and Programs for Youth Inpatient assessment unit Youth Forensic Psychiatric Services (YFPS) offers both inpatient and outpatient services for youth. The Inpatient Assessment Unit (IAU) is the only YFPS inpatient service for youth in British Columbia. The Maples Adolescent Treatment Centre, which will be discussed later in this chapter, also provides forensic services for youth and both facilities are designated youth mental hospitals by the British Columbia Review Board (Ministry of Children and Family Development, 2008d). The IAU is mandated to provide inpatient hospitalization to British Columbia Review Board youth. The services offered at the IAU include psychiatric and psychological assessment of youth remanded into custody by the Court, assessments prior to sentencing as well as short-term transitional care and custody of youth found not criminally responsible by reason of mental disorder. The IAU also provides mental health services to youth remanded to Youth Custody Centres (Ministry of Children and Family Development, 2008d). Admission to this facility for youth in custody must be authorized by a YFPS psychiatrist (Ministry of Children and Family Development, 2008d). It is essential to note that the IAU is not responsible for long-term treatment of youth; the primary focus is on assessment (J. Hayes personal communication, February 28, 2008). Maples Adolescent Treatment Centre As mentioned earlier in this report YFPS and the Maples Adolescent Treatment Centre (MATC) have a strong relationship with one another; however MATC is independent from YFPS. MATC provides residential, outpatient, and outreach services to youth and r - - - - - - - - - - - - - - - - - - - - - - - - - - - ------- Chapter 1 Literature Review 28 families. This agency serves youth between the ages of 12-17 who have psychiatric and behavioural difficulties. As well, MATC provides services for youth found unfit to stand trial and not criminally responsible by reason of mental disorder. MATC offers a number of different programs; however the program of particular interest to this literature review is the Crossroads Program (Ministry of Children and Family Development, 2008c). The Crossroads Program can accommodate eight adolescents and provides assistance to youth, caregivers and communities when care in the community is difficult. Youth who attend this program often have severe conduct disorder or psychiatric disorders that require a secure setting. The Crossroads Program is the designated inpatient facility in British Columbia that provides treatment to youth who are found unfit to stand trial or not criminally responsible by reason of mental disorder. Services and length of stay for youth who are either found unfit to stand trial or not criminally responsible by reason of mental disorder are determined by the British Columbia Review Board. Youth are discharged from the program after the British Columbia Review Board determines that the youth no longer requires a custodial disposition (J. Hayes personal communication, June 4, 2008). Outpatient clinics There are eight Youth Forensic Psychiatric Outpatient Clinics in British Columbia. Three are located in the Lower Mainland in Burnaby, Vancouver, and Langley. Vancouver Island has two outpatient clinics, one in Victoria and one in Nanaimo. The interior region, has two clinics, one in Kelowna and one in Kamloops. Prince George is the location of the outpatient clinic in the north region. Contractors provide YFPS assessment and treatment in communities outside of Prince George. These contracts are supervised by the Regional Chapter 1 Literature Review 29 Manager; contractors complete psychosocial assessments and provide counselling for youth (Ministry of Children and Family Development, 2008b). Outpatient services include assessment and treatment services for youth in conflict with the law. Assessments are regularly requested from the court for youth within the region where the clinic is situated. YFPS staff completes comprehensive psycho-social assessments which include collecting collateral material regarding the youth and often interviews with family members. Treatment includes specialized group and individual counselling for youth who may have committed violent or sexual offences. Individual counselling is provided for youth experiencing symptoms of mental illness and dependency on drugs and alcohol. Outpatient clinics also provide assessment and treatment to youth who are in correctional facilities. Another aspect of treatment provided by staff of YFPS outpatient clinics is participation in integrative case management which involves liaison with other professionals who are also involved with youth (Ministry of Children and Family Development, 2005). Participation in Youth Forensic Psychiatric Outpatient services can be mandated by the court. Youth must be referred to YFPS by a probation officer and have a condition in their court order or extra judicial sanctions. A youth can access YFPS services without court ordered counselling; they are referred as a voluntary client. Clients include youth in the custody centre, in the community on bail, or probation order. Mandated clients are required by the court to participate in specific treatment as identified by the court. Mandated youth may discontinue participation in YFPS programming, however with repercussions (J. Hayes personal communication, June 25, 2007). Chapter 1 Literature Review 30 Gaps in the Literature A great deal of the literature reviewed regarding forensic services examined psychiatric care provided by psychiatrists and psychologists. There was limited discussion in the literature regarding the role of social workers in forensic psychiatric services. There was information discussing mental health services and the role of social workers, however, the literature was not specific to forensic social work services. Literature regarding actual forensic psychiatric services for youth within Canada is sparse. In Canada each province or territory is responsible for providing forensic psychiatric services. This created a challenge in locating information on each individual service. British Columbia has a unique forensic psychiatry system and research in the field of forensic psychiatric services is part of the adult and youth forensic psychiatric services mandate. Therefore a great deal of the information available on Canadian forensic psychiatric services originates from this province. Chapter 2 Practicum Placement 31 Chapter 2 Practicum Placement The previous chapter provided a review of the literature that is relevant to this practicum report. This chapter will examine two specific topics. First, information about YFPS with respect to the agency mandate, vision, mission, referral process, and services offered will be discussed. The second section of this chapter will explore my participation in the practicum setting; outlining specifically the activities that I had the opportunity to observe and actively engage in. Youth forensic psychiatric services As identified in the previous chapter, forensic psychiatric services for youth have been in existence in British Columbia since 1982. It is currently a provincial program of the Ministry of Children and Family Development (Ministry of Children and Family Development, 2004). The services ofYFPS are mandated under the authority of "the Youth Criminal Justice Act, the Criminal Code of Canada, the Mental Health Act and other provincial legislation" (Ministry of Children and Family Development, 2004, p. G 6). YFPS is committed to provide high quality assessment and treatment based on best practices. YFPS is also invested in furthering the knowledge of youth forensic psychiatry through ongoing program evaluation and research. This vision is carried out by the dedicated professionals employed at YFPS; these professionals include "psychiatrists, psychologists, social workers, community nurses and health care workers" (Ministry of Children and Family Development, 2004, p. G7). Chapter 2 Practicum Placement 32 Prince George YFPS clinic is located in downtown Prince George and is responsible for providing assessment and treatment for the North Region which begins north of 100 Mile house. Youth who access services through YFPS are between 12 and 17 and have been adjudicated in accordance with the Youth Criminal Justice Act or have been mandated by youth court for assessment or treatment. Youth are referred to YFPS by youth court, youth probation and youth custody centres (Ministry of Children and Family Development, 2004) The YFPS clinic in Prince George is an outpatient clinic; youth who access services reside in the community or at Prince George Youth Custody Centre. Staff at YFPS in Prince George complete court ordered assessments and provide group and individual treatment for youth in the north region. Psychosocial assessments and bail assessments are completed by psychiatric social workers and psychiatric nurses upon request of the court. Depending on what is ordered by the court, psychosocial assessments may also be accompanied by psychiatric assessments and psychological assessment, which are completed by a psychiatrist and psychologist who come to Prince George monthly from the lower mainland. Treatment offered at the outpatient clinic in Prince George includes the Youth Sexual Offence Treatment Program which is offered in the community and involves both group and individual therapy. The Violent Offender Treatment program is offered at the Prince George Youth Custody Centre and also involves group and individual therapy. This group is also offered in the community for youth on an individual basis. General mental health referrals are treated primarily through individual therapy sessions. YFPS offers the Choices group which is a program examining substance abuse, and the Steps group which is a social skills building group offered in the Youth Custody Centre. Chapter 2 Practicum Placement 33 Summary ofpracticum activities Throughout the practicum experience I had the opportunity to participate in a variety of activities; these opportunities gave me greater insight into the responsibilities and roles of mental health therapist who are the focus of the research component of this report. Participation in the following activities also encouraged me to advance and develop social work skills. 1. Weekly participation in team meetings provided me with an understanding of how youth are referred to services. Team meetings also provided the opportunity to observe YFPS staff share information regarding current, new or upcoming services that youth could access in the community. I had the opportunity to observe staff approach the team with concerns regarding follow-up services for youth upon the return of a youth to their home community. When issues regarding youth were brought to the team, the members of the team pooled their collective knowledge to provide suggestions and ideas for the team member presenting the concern. As part of a multidisciplinary team, each person brought with them experience that was beneficial to the entire team. 2. Attending Integrative Case Management meetings for youth. These meetings were of particular interest to me due to the direction of my research interests. Early on in my practicum experience I made my research intentions known to staff of YFPS and upon their suggestion, I sat in on numerous Integrative Case Management meetings at the Youth Custody Centre as well as in the community. The meetings were attended by YFPS staff; usually the primary therapist and the secondary therapist when possible, the youth, the youth's caregiver in the community, the probation officer and the ---------- - - - - - - - - - - - - - - · - - - Chapter 2 Practicum Placement 34 youth's biological parents if possible. Integrative Case Management meetings provided an excellent opportunity to observe professionals and families come together to create a plan and communicate any concerns or advances regarding the youth's progress towards identified goals. Integrative Case Management meetings at the youth custody centre often involved the coordination of release plans for youth. Release plans often consisted of referrals being made to services for the youth in their home communities, as well in Prince George. 3. I was permitted to observe a number Youth Sexual Offence Treatment Group programs. The groups that I observed focused on teaching youth about boundaries and appropriate interactions with the people in their home environments. Also, groups reinforced with the youth the skills and strategies they were taught in order to reduce risk of recidivism. The treatment groups I participated in occurred at the end of the treatment process which is roughly a year long in duration. Through involvement with these groups, I became more familiar with the youth in need of this specialized program and the importance of relapse prevention planning. I also became aware that the youth enrolled in this program come from all areas of the North Region and have to relocate to Prince George for the program. I had the opportunity to discuss with the facilitator what follow-up services youth access in their home communities to assist youth in preventing relapse. YFPS has contracts with a number of service providers in communities surrounding Prince George. 4. I attended a Violent Offender Treatment group. These particular youth have a history of offences that are violent in nature. These offences may include assaults, assaults with weapons, or threat of violence. This group provided me with the opportunity to Chapter 2 Practicum Placement 35 observe two additional members of YFPS staff and gain a better understanding of how mental health therapists establish rapport with youth. 5. Participation in the YFPS new contractor training, which was held in Prince George, increased my knowledge of surrounding communities and the role contractors have in the provision of services through YFPS to areas ofthe North Region outside ofPrince George. Contractors are often employed by local social service agencies and are contracted to provide services to YFPS youth on a part-time basis. Contractors are responsible for a number of tasks which include, but are not limited to, completing psychosocial assessment, individual general mental health counselling, Violent Offender Treatment follow up, Sexual Offender Treatment follow up, maintaining progress notes, completing client needs assessments, progress evaluations and the use of risk assessment tools. Contractors play an important role in the delivery of YFPS services to a large geographical area. 6. Composing documents for the court was an excellent learning opportunity. Court reports require the writer to be concise, clear and objective. I had the task of coauthoring a number of psychosocial histories. Psychosocial histories provide a picture of a youth from birth to present day. I also co-authored a bail assessment which focused on the youth's current situation. The psychosocial history is compiled through collateral material from numerous sources including information provided by caregivers of the youth. A bail assessment requires less research regarding the youth's early years and focuses on the youth' s current living situation, associations, and supports. Both types of court documents require liaison with the YFPS psychologist and psychiatrist who complete their own reports for the court. Often a conference is Chapter 2 Practicum Placement 36 held in order to discuss the youth and potential recommendations that will be made to the court concerning the youth. 7. Participation in individual counselling sessions provided valuable experience in understanding the needs of the youth YFPS serve. 1brough contact with the youth, various topics were discussed. By observing counselling sessions, it became apparent that youth presented with complex treatment needs. Often counselling sessions explored issues such as family of origin issues, substance abuse, interpersonal relationship problems, home life stress, and financial problems. I had the opportunity to observe a number of mental health therapists in counselling sessions with youth. This allowed me the opportunity to watch how mental health therapists engage and establish rapport with a challenging population. Youth who receive services from YFPS are mandated to attend, with legal repercussions as a consequence if they do not participate. 8. I had the opportunity to co-facilitate a program called Choices which was delivered at the Prince George Youth Custody Centre once a week for 8 weeks. I co-facilitated this group with two mental health therapists from YFPS. The Choices program was designed by YFPS staff for clients who identify as having a substance abuse problem. This closed group is psycho-educational and provides members with information regarding the impact of drugs on the body and central nervous system. The group also addressed the link between substance abuse and crime, relapse strategies, positive and negative consequences of substance abuse, and provided youth the opportunity to ask for additional information on topics of their choice. A guest presentation was also given by Positive Living North regarding sexually transmitted infections, hepatitis, Chapter 2 Practicum Placement 37 and AIDS. This group provided me with the opportunity to practice my group facilitation skills. My role as co-facilitator was to ensure that the youth were following the group rules, on task when completing work sheets, on topic in group discussion, and to challenge youth on thought distortions. Overall YFPS provided me with an excellent learning experience as I had the opportunity to observe how a multidisciplinary team operates effectively. The practicum provided me with an environment to practice and improve my clinical skills with guidance from my clinical supervisor and also support from the entire staff. The clinical staff at YFPS played an active role in my learning experience as they are the subjects of the research component, which will be discussed in the following chapters. Chapter 3 Practicum Research Component 38 Chapter 3 Practicum Research Component Significance, Sample and Ethical Issues The previous chapter identified the practicum setting and experience at Youth Forensic Psychiatric Services. In addition to practical experience, the requirements for completion of the Master of Social Work practicum route necessitate a research component. This author completed a qualitative study with staff ofYFPS; the following chapter will illustrate the significance of the study, research question, sample, ethical issues, and method with respect to the research conducted. Significance of the study The concept for this particular study was developed from referral dynamics observed through this writer's experience as a social worker. Referral making is an essential aspect of social work practice. It is the intention of this research component to gain greater knowledge regarding professionals' experience in making referrals; as well as to gain better knowledge regarding what services are available and referred to by mental health therapists employed at YFPS in Prince George. The research question is as follows: What are the experiences of mental health therapists, employed by Youth Forensic Psychiatric Services, in identifying and suggesting referrals for youth to community based services in Prince George and surrounding area? Sampling and data collection Clinical staff employed at YFPS are either psychiatric social workers or psychiatric nurses and provide direct mental health counselling services to youth. These individuals Chapter 3 Practicum Research Component 39 make up the sample of mental health therapists from which participants for the research component were asked to volunteer their time. Participation in this study was voluntary, therefore staff was informed in advance of the purpose of the research in an effort to generate interest in the study. With the approval of the Clinic Manager (Judith Hayes) an interoffice memo was drafted by this writer and distributed to all seven eligible participants asking for expression of interest with regard to the research. All interested participants were encouraged to email this writer expressing their interest and potential interview appointments. Approximately two weeks after the interoffice memo was distributed, this writer presented the research intentions at a weekly team meeting. Again staff was encouraged to email this writer to set up an interview time and day if they were interested in participating. Data was collected for this study between September 29, 2007 and October 3, 2007. A total of seven mental health therapists were employed at YFPS at the time of data collection. Six of the seven individuals who met the eligibility criteria for participation in this study participated. Participants were provided with an information sheet (see appendix A) which outlined the purpose of the study and what the participant would be required to do. They were also required to sign an informed consent document (see appendix B). Data was collected during face to face interviews which took place at the YFPS office. Interviews took place in staff's personal offices. Each interview took approximately 60 minutes and was recorded on a digital voice recorder. Due to malfunction of the digital voice recorder, three interviews were not recorded correctly and had to be re-conducted and re-recorded. Semi structured interviews were conducted using an interview guide. Structured interviews were considered for this study but did not provide the flexibility needed to ensure the participants were able to express their experiences (Bryman, 2004). The interview guide Chapter 3 Practicum Research Component 40 was pre-tested with a YFPS contractor in a community outside of Prince George (see appendix C). The interview guide contains specific questions for the participants, however if a question was unclear or misunderstood efforts were made by the interviewer to clarify. This study seeks to understand the experiences of mental health therapists employed at YFPS specifically in Prince George. It should be noted that this study is not representative of the experiences of all mental health therapists employed at YFPS in British Columbia. Ethical issues As noted earlier the sample size consisted of seven eligible YFPS staff members. Staff was informed in advance that interviews would begin September 29, 2007. Interviews were conducted at the YFPS office in each staff member's personal office. Due to the small sample size and location of interviews anonymity proved to be challenging to ensure. Each participant was advised about anonymity prior to participation in the study (see appendix A). Thematic Analysis The research component of this practicum report relies on qualitative data derived from interviews. The interviews were conducted using an interview guide consisting of 13 questions (see appendix C). Participants' responses to these questions made up the data that was analysed using thematic analysis. It is essential to note that the research question and the interview guide were designed with the objective of extracting from participants their experiences as mental health therapists. The thematic analysis was conducted to determine if patterns exist among participants' experiences. The following section will provide a clear understanding of how thematic analysis is applied to this study. Chapter 3 Practicum Research Component 41 The nature of thematic analysis Thematic analysis is a common method of interpreting qualitative data. However, the literature identifies that there is no clear agreement about what thematic analysis is and the process in conducting thematic analysis. Thematic analysis is a "method of identifying, analyzing and reporting patterns within data" (Braun & Clarke, 2006, p.79). Boyatzis (1998) identifies that thematic analysis is a process for encoding qualitative information involving the generation and evaluation of themes. A theme is a pattern that emerges from the data that "at minimum describes and organizes the possible observation and at maximum interprets aspects ofthe phenomenon" (Boyatzis, 1998, p.4). Braun and Clarke (2006) identify two types of thematic analysis, inductive and theoretical. Inductive thematic analysis occurs with data that has been collected specifically for the research of interest. The themes generated from the data are created without trying to place codes into a predetermined coding frame. Inductive analysis is data driven. Theoretical thematic analysis is driven by the researcher's theoretical interest in a particular area. The results of this type of analysis yield detailed analysis of some aspect of the data but do not provide the rich description of the data of an inductive approach. The approach applied to this practicum report is inductive and therefore the themes identified in chapter four are data driven. How to conduct thematic analysis There are four key skills a thematic researcher must develop in order to complete an effective analysis. First the researcher must be able to sense themes or recognize a codeable moment. Second, the researcher must train themselves to use themes or codes reliably. Chapter 3 Practicum Research Component 42 Consistency in the researchers' own judgments is important. Third, the researcher must develop a code to process and analyze or capture the essence of their observations. The fourth and final objective thematic researchers must reach is to interpret the information and themes in a way that contributes to the development of knowledge (Boyatzis, 1998). Braun and Clarke (2006) identify 6 phases of thematic analysis. The first phase is becoming familiar with the data. Becoming familiar with the data involves transcribing audio or video taped data, reading and re-reading the written transcriptions and keeping a record of initial ideas regarding the data as the researcher becomes immersed in the text. The second phase is generating initial codes. This phase requires the researcher to code interesting or relevant features of the data in a systematic fashion. The researcher will apply this to the entire data set by collecting information that is relevant to each code. The third phase involves searching for themes. The researcher must collate codes into potential themes. This involves reviewing all codes and allocating them under the most appropriate themes. Phase four involves reviewing themes. After codes have been placed under appropriate potential themes, the researcher must ensure that themes work in relation to coded items and the entire data set. Phase five involves defining and naming themes. In order to define and name themes ongoing analysis must occur. The themes are refined throughout ongoing analysis. Phase 6 requires the researcher to write the report. Writing the report requires the researcher to look at all aspects of the study, the research question, and the literature review. This phase offers the researcher the final opportunity for analysis through the selection of direct quotes from participants that illustrate themes. Chapter 3 Practicum Research Component 43 Threats to effective analysis There are two noteworthy threats to accuracy in conducting thematic analysis. One particular threat is projection; this occurs when the researcher reads their own characteristics, thoughts, or values in the data. Boyatzis (1998) states the stronger the researcher' s ideology, the more they will be tempted to impose their values onto the participants in the research. The second threat is the mood of the researcher; the researcher' s level of frustration, fatigue, and sensory overload can impact the analysis. Boyatzis (1998) recommends that the analyst be well rested when analysing and be able to stop analysis if preoccupied or otherwise distracted from the research. This chapter presented the research question, the significance of the study, the method of participant recruitment, ethical issues, and the steps used to conduct the thematic analysis. The following chapter will reveal the results of the data analysis and provide direct quotes from the participants to further illustrate the themes that were uncovered throughout the analysis. Chapter 4 Data Analysis Results and Discussion 44 Chapter4 Data Analysis Results and Discussion The previous chapter provided a description of the methodology and method used in the research component of this practicum report. This chapter will illustrate the application of thematic analysis, the results of the analysis, and discussion regarding the results of the analysis. Thematic Analysis Data analysis for this practicum report was conducted using Braun and Clarke's (2006) six phase guide to completing thematic analysis. The data set included six transcribed interviews with Mental Health Therapists employed at YFPS. The audio recordings were transcribed by this author as recommended by Braun and Clarke (2006). After the data was transcribed, the text was read and reread to ensure familiarity was achieved. The data analysis began using Taylor and Bogdan's (1984) instructions on conducting coding effectively. These authors recommend refining the coding scheme while coding the data which includes adding, collapsing, and expanding categories. The data analysis yielded over 120 codes. The initial list of codes generated were topics and concepts that appeared in the text more than once. Themes were identified by reading and rereading the data to determine the number of participants who identified each coded item. In addition to how many participants identified certain coded items, the number of times participants brought up a coded item was recorded. Each individual code was placed on an index card and all index cards were laid out to provide a better visual in the first stage of theme identification. Common codes were collapsed and the coded items were examined and re-examined for themes. Taylor and Bogdan (1984) identify that researchers must ensure that the code fits the Chapter 4 Data Analysis Results and Discussion 45 data and not vice versa. They caution that researchers must allow codes to emerge naturally from the data. Themes were created and collapsed and two main themes emerged from the data. The first theme is professional experience in referral process and the second is community services and youth. Working from these two main themes, coded material was examined and organized based on relevance to each of the two themes which are discussed in greater detail in the following section. Professional Experience with Community Referrals The first theme to emerge from the data analysis is professional experience with community referrals. Within this theme four sub themes emerged. The first sub theme is determining if referral is appropriate; the second discusses the professional's familiarity with community services; the third addresses professionals' responsibility in referral making; and the fourth examines the skills professionals utilized in referral making. Determining if referral is appropriate Participants discussed four main methods of determining when and if a referral is appropriate for youth. The first is the use of file information which included the youth's current and previous criminal charges, previous psychosocial assessments, and previous psychiatric and psychological assessments. The second method discussed by participants was the use of a treatment needs assessment. Treatment needs assessments are completed with new referrals to YFPS. This assessment provides the mental health therapist with information in a variety of areas of the youth's life. The third method of determining if a referral is needed or appropriate for a youth is to collaborate with other professionals involved with the youth. A number of participants identified that integrative case management meetings are a Chapter 4 Data Analysis Results and Discussion 46 particularly useful environment for discussion regarding the youth's needs. Finally the fourth method in determining if a referral is appropriate is the relationship mental health therapists establish with the youth. Mental health therapists identified that they were able to establish effective therapeutic relationships with youth. Through that relationship the youth would express needs that may be better met by community services. Familiarity with community services Mental health therapists identify that knowledge regarding where local community services are located and what services they offer is an essential component of the service they provide youth. Word of mouth was identified as a means of becoming more familiar with community services by all participants. However a number of participants identified that they were not originally from Prince George and had not been residing in Prince George for a significantly long period. These participants expressed that they were willing to ask other colleagues and service providers who had experience with various community services for youth in Prince George. Participants who had been in the community for a significant period of time identified that their familiarity with available community services for youth was a result of the years spent in the helping field in Prince George. This was the response from participant 5 when asked how he/she learns about community services "/guess for myself it's just been through.. umm.. having lived in the community for 18 years ". However all participants expressed the value of word of mouth in becoming familiar with community services. Participants identified that it is the responsibility of the practitioner to keep abreast of the changes with regard to community service agencies. The community resource handbook was identified by participants as a very useful tool for remaining aware of what services are Chapter 4 Data Analysis Results and Discussion 47 available. The community resource handbook is distributed by The Crisis Prevention, Intervention and Information Centre for Northern BC ( 2007). Participant 6 reports: The Prince George crisis centre has a community resource book that they put out once a year with a list ofevery service and support in this community. So it 's excellent; it's like a bible ofall the services and supports and of course other services and supports pop up here and there and so once again as a professional person we should make ourselves aware ofwhat resources are available so we can pass that information on to the people we work with. Integrative case management meetings were identified as an effective area to find out about new agencies and ask other service providers about possible community services for youth. YFPS in Prince George ascribes to a team philosophy and as such holds weekly team meetings. These meetings provide opportunity for YFPS staff to advise colleagues about new services that are available in the community. Another method of becoming familiar with a particular resource was to attend functions at agencies, or visit youth at agencies such as group homes and residential treatment facilities. By going to the agency and becoming familiar with the environment and the staff, participants expressed that they received a complete picture of the agency and services. Volunteering on committees was another avenue through which participants identified they became familiar with services for youth. There is one particular committee that focuses on youth services in Prince George. Professional responsibility in referral making Throughout discussion generated during interviews regarding the referral process participants identified that Youth Forensic Psychiatric Services does not have specific Chapter 4 Data Analysis Results and Discussion 48 guidelines for staff in making a referral to a community agency. Mental health therapists employed at Youth Forensic Psychiatric Services interviewed for this study each identified their own personal process in making referrals. Although the process of making community referrals is individual, there are a number of common steps among participants. Participants identified that they would assess the client's needs. From there, mental health therapists identified that they would contact the community agency prior to discussing the possibility of referral with the youth. Contact with the potential referral is made to ensure that the community agency is still in operation, providing the service required, and that new referrals were being accepted. The potential referral would be discussed with the youth and if the youth was interested in participating, a referral would be made. Two forms of referral were identified throughout the interviews. The first is formal referral which was described as involving paperwork and possibly supporting documents from a medical professional. It was identified that referrals to alcohol and drug treatment centres were formal referrals often recommended by mental health therapists employed by YFPS. However YFPS staff cannot make this referral but they can refer youth to an agency that is responsible for making referrals to addictions services. Informal referrals were identified as being a simple process such as phone call to a community agency to inform them of the youth and the need. Participants were asked to comment on when they identified that they made community referrals most commonly. A number of participants reported that referrals are made when the need arises. The need could be at the beginning of the therapeutic relationship within the first few meetings. The referrals made early on were identified as referrals that were known to mental health therapists as taking considerable time to process and consisted Chapter 4 Data Analysis Results and Discussion 49 of long wait lists or that would meet an immediate basic need. Referrals made near the middle of the therapeutic relationship were identified as needs that became evident after establishing rapport with the client. Participants emphasised the importance of ensuring referrals are in place at the end of the counselling relationship. They reported referring youth to a YFPS contractor or clinic in a different region if a youth was leaving the community or to community based counselling if the client was no longer eligible for services through YFPS. Participant 3 said: Addiction residential treatment program, there's typically a long wait so even though I am not really sure they're still going to be bought in 6 months from now I am going to do the referral now hoping that by then we are going to have them prepared and ready to go. Skills professionals utilize in making referrals to community agencies Referral making is an aspect of human service work that requires various skills. Participants were asked to provide two lists. First they were asked to identify skills mental health therapists in general required in order to make community referrals; then they were asked to provide a list of skills they felt they possessed. Communication skills was one of the most commonly identified skills in both lists. Communication skills include listening to the client to ensure that their needs are clearly identified. The ability to talk to community service providers and establish professional relationships is another aspect of communication skills. Participants identified using humour and conducting oneself in a professional manner as methods of establishing rapport with community service providers. Familiarity with available community services was identified as a skill that is utilized in making community referrals for youth. As noted above, there is a link to familiarity with Chapter 4 Data Analysis Results and Discussion 50 available community services and length of time in the community. Those participants who identified familiarity with community services were long time members of the community. Willingness to ask questions and seek out services is a skill that participants identified as being particularly important. Participants reported that they would ask colleagues and other service providers for information regarding community services. For participants who are newer to Prince George asking about and researching community services was a skill that is highly valued. An understanding of psychiatric illness and medication used to treat psychiatric disorders is a skill identified by participants. In order to make appropriate referrals, the mental health therapist must have knowledge regarding the youth' s mental health diagnosis and medication in order to evaluate if a community service is appropriate for that youth or if the youth is appropriate for the service. The following is an excerpt from participant 4 regarding skills required to make appropriate referrals: Communication skills, the ability to relate to people and maintain positive professional relationships so that they know what's going on. Maintain contact, know the referrals, what the resources are in case they have to make a referral. The relationship with the kids too so that ifyou make the referral they will trust you that that referral will probably be helpful and will increase their chances offollowing through and actually using the services from the referral. So yeah I think communication skills. Community Referrals and Youth The first theme examined professional responsibilities in referral making and decisions that professionals have to make in the referral making process. The second main Chapter 4 Data Analysis Results and Discussion 51 theme focused on youth services. This section includes discussion on the services that YFPS staff commonly refer clients to, assessing the needs of youth, and locating and linking them with community referrals, feedback regarding community referrals, and the gaps with regard to community service in the north region. This second theme is unlike the first as participants provided information regarding the youth they work with. They provided their professional experiences, however the focus was centred on the service needs of the youth. Community services commonly referred to by mental health therapists Housing was discussed by a number of participants. Participants noted that youth require not only referrals to emergency housing such as the local youth shelter, but also youth required housing resources though the Ministry of Children and Family Development (MCFD) child welfare branch. It was discussed in a number of interviews that it is common for youth who were in the child welfare system and were detained in the Youth Custody Centre to lose their group home placement while they were in custody. As a result, housing would have to be arranged for the youth while in custody prior to their release back into the community. What was also revealed through the discussions regarding housing was that it was often difficult to find an MCFD residential resource for the youth. Drug and alcohol treatment was a referral that was brought up as another area of concern for the youth that participants serve. Drug and alcohol treatment referrals must be completed by specific agencies within the region. YFPS does not commonly make the official referral, however participants report strongly advocating on behalf of their clients for drug and alcohol treatment referrals. Employment and school programs were identified as referrals that mental health therapists commonly make. This included employment programs that offer youth an Chapter 4 Data Analysis Results and Discussion 52 opportunity to gain job skills and acquire equipment to better prepare them for the work force. Employment services are available in the community, as well the Youth Custody Centre offers a program for youth in custody. Mental health therapists report recommending alternative education programs for their clients. There are a number of alternative education programs in the community that provide youth with the opportunity to complete courses at their own pace. Psychiatric and counselling follow-up services are common referrals made by mental health therapists. Participants identified that when youth are not originally from Prince George, they would refer them to a contractor who is employed by YFPS located in their home community. When contractors are not available in the community, participants said that they would try to link their clients to a local community counsellor. Locating and linking youth with a professional in the community that could monitor psychiatric medication was expressed as a common referral made by participants. Many youth involved in services with YFPS have a mental health diagnosis and take various medications to treat their mental health symptoms. It is essential that youth be linked with an individual in their home community or in Prince George who can renew prescriptions and monitor medication. Participants identified that many youth that they serve are transitioning from youth service to the adult social service system. Participants identified that in preparation for the youth becoming an adult, referrals are niade to adult services. Services for Aboriginal youth were identified by participants as a referral that is made regularly. They identified a number of agencies within Prince George that offer services such as sweat lodges, artistic outlets, and mentorship. However, participants also identified that Chapter 4 Data Analysis Results and Discussion 53 they often referred to Aboriginal centred services as well such as residential treatment programs that are specifically for Aboriginal youth. Participant 4 identifies the following services that clients commonly require: Substance abuse treatment programs.. housing.. housing and foster placements so not just independent living but group homes foster placements.. employment.. older kids assistance with employment.. those are probably the main ones. Matching community referrals and the need of the youth Participants were asked to identify how they select what community agency to refer clients to and a number of ideas were generated and discussed. The need to match the needs of the youth to available services was identified. With regard to residential addiction treatment services, participants identified that long term programs are beneficial for their clients. However location of services was also identified as an issue that required attention; many participants were reluctant to recommend youth travel long distances to access services. By leaving the area for services youth would have less contact and support from family and would be at a disadvantage for continued ongoing support in the community. The client' s willingness to engage in service is also valuable in matching referral and youth. The client may have a number of needs that could be met by community services however the client may not be prepared at that time to engage in services or address certain aspects of treatment. Participants identified that they had to be aware of the youth's needs as well as their readiness to address issues in their lives. They identified that they would wait to make a referral until the youth was ready for the community services. Wait time to access community services is a concern expressed by participants. In the case where mental health therapists are working with youth who are residing in the Youth Chapter 4 Data Analysis Results and Discussion 54 Custody Centre, it is preferable to have residential services lined up for after the youth have completed their sentence, before they return to their home communities, or if they are from Prince George before they return to their living situations. Often youth require housing which is essential to establish prior to youth leaving custody. In the situation where there are specific services for Aboriginal youth, participants identified that they would prefer to refer youth to the service that provided a culturally appropriate approach to service. Participants shared their experiences with youth in exploring all of their community service options and assisting in the selection of the most appropriate service for that youth. Often if I am working with a First Nations client I will as a rule. I would probably refer them more to a First Nations agency. Usually I will run that by the youth as well and I have always found that.. they seem to be more willing to access say a First Nations' support. (participant 6). Feedback from other professionals regarding quality of service was discussed by a number of participants. Mental health therapists identified that they rely a great deal on word of mouth with regard to quality of services provided by community agencies. Participants identified that poor reports from other service providers regarding a community service may impact their referral. Participants identify that often there is only one available resource in the community and in the north region. In cases such as these there is less to consider when determining if the referral matches the need of the youth as there is only one option. Chapter 4 Data Analysis Results and Discussion 55 Feedback regarding community reforrals Participants identified that they received feedback regarding community referrals from youth and from other professionals. Youth provide mental health therapists with insight into their experience with community service providers. Participants identified that although they do not base future referrals on the feedback of youth alone, they do keep in consideration the experience of the youth with a particular service. As noted by participants, a youth's perception of unsatisfactory service may be skewed due to their position as involuntary clients. Professional feedback from other professionals is valued by mental health therapists. Participants said that they learn about services offered by various agencies through other service providers as well as co-workers. Some participants reported that they would be careful when suggesting a community service to a youth if a trusted colleague had reported having a poor experience with a resource. The participants commented that they would not rule that particular community service out as an option but they would follow up with the feedback and investigate the agency further and seek additional opinions and experiences from professionals. Positive feedback is accepted more readily and a number of participants report that they would likely not investigate positive feedback regarding a community agency. And that positive feedback from a professional regarding a community agency would make them more inclined to refer to that agency. Participants were asked to comment if they found that youth benefited from community services. Participants commented that the youth's willingness to engage and express interest in participating in the community service had an impact on whether the service was beneficial. As noted earlier, youth who are not engaging in Chapter 4 Data Analysis Results and Discussion 56 service may be less likely to gain from community services. An issue raised by a number of participants was that the term benefit is a relative term. They mentioned that each youth is different and therefore what benefit they receive from a particular service may not be the standard concept of success. There is no one way to measure benefit or success. Overall a number of mental health therapists identified that youth in general did benefit from community referrals. They said they knew that the youth had benefited by observing youth and their behaviours. Youth had also told mental health therapists how they had benefited. Other service providers had mentioned that they observed changes in attitude and behaviour of the youth. The knowledge that youth had benefited from community services did have an impact on referrals made by mental health therapists. As mentioned earlier in this section, positive feedback from youth regarding community services increased the likelihood that mental health therapists would refer to a particular community agency. The knowledge that youth found a particular service beneficial would also impact the likelihood that the mental health therapist would refer to that agency again. Community services gaps and needs in the north region Participants were asked to comment based on their practice with youth from the north region as identified by YFPS. Participants said that they became familiar with service gaps in surrounding communities in creating discharge plans for youth who were residing at the custody centre and about to return home. For example, youth involved in the Youth Sexual Offence Treatment Program are brought from communities all over the north region to Prince George to access specialized treatment. Once treatment is complete youth return to their home communities. Prior to the return of the youth, a plan is made so that the youth can Chapter 4 Data Analysis Results and Discussion 57 access follow-up services from a YFPS contractor or counsellor in the community. In creating plans like these, YFPS staff became familiar with the resources that are available in smaller communities in the north region. The first gap mentioned by participants is subsidised recreation for youth. Many youth who access services through YFPS do not have the financial means for various reasons to join athletic associations. Athletic equipment and fees for sports such as hockey and soccer are costly and many cannot afford all the expenses. Long term residential treatment programs focused on all areas of specialization are lacking in the north region. This includes addictions treatment programs. Prince George has a 28 day residential drug and alcohol treatment program; however participants identify that youth could benefit from a significantly longer program. Longer programs do exist in British Columbia, however they are not located in the north region. An issue that is of significant concern to mental health therapists employed at YFPS is psychiatric follow-up in Prince George and in smaller communities. Psychiatric follow-up in smaller communities is a concern as some communities do not have general practitioners who are willing to monitor and refill some psychiatric medications. Participants also noted that there was a lack of support services for youth in small communities with psychiatric illness, such as outreach workers. Participants noted that many communities do not have counsellors and the communities that do have counsellors may not have expertise in providing forensic services. Housing was discussed by the majority of respondents. Participants identified that housing is an ongoing issue temporarily relieved by the local youth shelter. The housing Chapter 4 Data Analysis Results and Discussion 58 shortage is identified by participants as being linked to MCFD' s lack of foster placement and group home resources. Participant 2 comments on the need for housing: Lacking agencies or lacking homes terribly. I mean having your kid come out of custody and go straight to reconnect because there is nothing there; I think there is something horribly wrong with that. I mean I know that 's outside the agency but I am just saying in general, absolutely not, there is not enough. There are a few things but there is just not enough to really keep them completely linked. Culturally specific services were identified by participants as lacking in Prince George and surrounding communities. Participants expressed that they wish youth had access to more Aboriginal programs and treatment options in the region. Participants were careful to identify that there are programs in Prince George available through various organizations, however more was required to meet the needs of the youth that access services through YFPS. In smaller communities participants identified that there was a lack of employment opportunities for youth. Youth who have been in conflict with the law in small communities are known to the community and often labelled as trouble makers. Participants identified that youth have a difficult time shedding that trouble maker label and struggle to find employment due to previous behaviours. As noted above the thematic analysis yielded many common codes that were then collapsed. Two main themes emerged from the collapsed codes: professional experience with community referrals and community referrals and youth. Under professional experience with community referrals four sub themes emerged: determining if referral is appropriate, familiarity with community services, professional responsibility in referral making, and skills professionals utilize in making referrals to community agencies. Four sub themes are also Chapter 4 Data Analysis Results and Discussion 59 found under the second main theme community referrals and youth. They include; community services commonly referred to by mental health therapists, matching community referrals and the need of the youth, feedback regarding community referrals, and community services gaps and needs in the north region. The following chapter includes implications for policy and practice as identified by this writer. Chapter 5 Implications for Policy and Practice 60 Chapter 5 Implications for Policy and Practice The previous chapter illustrated the results of the thematic analysis conducted on data received from mental health therapists employed at YFPS in Prince George. A number of common themes were identified. The purpose of this chapter is to examine what implications these common themes have on policy and practice within YFPS in Prince George and within the mental health therapist's personal practice. The first section will address links to the results ofthe analysis to YFPS policy. The second section will address the personal practice implications from the results of the data. Policy YFPS agency policy was addressed in both chapters one and two with respect to the purpose ofYFPS and the responsibilities of mental health therapists employed at YFPS. However, as identified through examining the policy manual and conducting interviews with staff of YFPS, there appears to be ambiguity regarding the role of mental health therapists and their role in referral making. A number of participants identified that referral making or suggestions are the responsibility of the case managers, who are within the youth justice system as probation officers. This ambiguity about the role and responsibility with regard to referral making could potentially lead to professional tension; however, it was identified by participants that there existed particularly good communication between YFPS and Youth Probation and that tension is rare. It may be beneficial to establish some form of agreement between the two agencies to prevent any conflicts regarding referral making between professionals. This agreement would ensure clear boundaries to ensure that YFPS mental health therapists do not take on the responsibilities of youth probation and that mental health therapists do not proceed with anything that youth probation is not aware of and supports. Chapter 5 Implications for Policy and Practice 61 There exists no formal procedure for suggesting or making referral to community agencies. There is a section within the discharge paperwork that asks the mental health therapist to identify additional services the youth requires and what possible referrals could be made. Perhaps a more detailed tracking form would be useful to identify what community resources are being referred to by mental health therapists also noting the frequency. A method of tracking common referrals would provide YFPS with a list of community partners with whom they may wish to encourage communication and professional relationships. The list of community agencies provides an idea regarding the types of services youth who access services through YFPS require. It could potentially provide YFPS with a better understanding of the demographics of their clients and identify areas for potential service expansiOn. A main component of the YFPS mandate is to conduct research (Ministry of Children and Family Development, 2004). Information generated from this research study reflected that mental health therapists employed at the Prince George outpatient clinic identify that practice is directly linked to geographical location within British Columbia. In the previous chapter it was identified that making referrals to community agencies for youth who reside in the north region (as identified by YFPS) in small rural communities can be particularly challenging due to the limited availability of medical, psychological, psychiatric, and counselling follow-up (Ministry of Children and Family Development, 2008a). A number of participants identified that YFPS outpatient clinics in more populated southern regions may not have similar experiences as the north region. Perhaps more research through YFPS could be conducted specifically regarding the north region to first identify if the experience of mental health therapists in the north region is in fact unlike practice in southern parts of the provmce. Chapter 5 Implications for Policy and Practice 62 As stated earlier in this paper, mental health therapists provide individual counselling and psychoeducational groups for youth who are in custody. While I was completing my practicum at YFPS, mental health therapists were encouraged to spend time in admitting and discharge at the Prince George Youth Custody Centre. They were encouraged to spend time getting to know the procedures and responsibilities of the individuals who are employed at an agency they regularly visit to provide services. Perhaps further encouragement and presentations at team meetings could be beneficial in continuing to be aware of services available within the community. This author would also suggest community agencies that may be known to YFPS, but may have undergone some form of agency change that may have altered or improved services, be invited to come in and update staff at YFPS as to the impact, if any, changes have had on services. Chapter four revealed that mental health therapists employed at YFPS in Prince George become familiar with community referrals through word of mouth as well though the community resource manual (The Crisis Prevention, Intervention and Information Centre for Northern BC, 2007). Although participants appear to know where to gain information regarding agencies in Prince George, what was not addressed by participants was knowledge of informal services. For example, informal services could include First Nation's elders and traditional healers. It was identified in the previous chapter that there is a lack of culturally specific services available for First Nations youth. Perhaps YFPS could become more familiar with informal supports for First Nations clients in Prince George and surrounding communities. Practice An intention of this study was to examine the individual experiences of YFPS mental health therapists and to identify common experiences or themes among participants. One Chapter 5 Implications for Policy and Practice 63 theme that was apparent among participants was the perception of referral making. Participants identified that making or suggesting referrals for clients was an aspect of professional practice which is not viewed as a skill. A number of participants identified not being from Prince George or the north region originally. They expressed that learning about community referrals and becoming familiar with community agencies was a challenge after arriving in the area. However it was noted that professional collaboration and a team approach to service provision was beneficial in learning about available resources. This author identifies that it is a personal professional choice to keep abreast of available community resources and is hopeful that this study reminded participants that there is value to remaining knowledgeable. Participants noted that referral making is an opportunity to create positive professional collaborations with community partners. Professional reputation was an area that most participants identified as being of particular interest when interacting or strongly advocating on a client's behalf. A number of participants recognized the need to remain professional while advocating passionately. Participants also remarked that as a referral maker they represent YFPS and identified the responsibility of representing the agency in a professional manner. The results of this study demonstrated that mental health therapists are knowledgeable regarding the youth they work with and that there are a number of common experiences among those who participated in the study. It is the intention of this study to provide participants with validation that what they are observing in the youth they serve is also being observed by colleagues. Participants identified numerous service gaps in Prince George and the north region. These gaps have prompted mental health therapists to be creative within their own practice to Chapter 5 Implications for Policy and Practice 64 attempt to fill service gaps such as subsidised recreation, drug and alcohol counselling, First Nations programming, and housing. Although the efforts of mental health therapists to meet these needs are beneficial to the client, meeting these needs takes time away from work with the youth regarding forensic therapy. Recommendations for further research The following recommendations for further research have been generated from the results of the data collected from mental health therapists. A number of participants compared their practice to that of mental health therapists in more populated southern regions of the province. However, the comparisons made by participants were speculation. Participants associated higher population with more access to resources. This author suggests some form of comparative analysis with respect to making referrals in the north region and in the lower mainland to examine issues such as referral waitlist length, distance to travel to resource, and follow-up services in the community. Another area of potential further study is to survey other agencies in the community regarding which community services they commonly refer youth to and any identified gaps in service. A study such as this would examine if the needs of youth are uniform across all services. Perhaps youth who access services from YFPS have different needs than youth who are not involved in crime and require mental health services. Conclusion 65 Conclusion Forensic Psychiatric Services in Canada has an intriguing history and the evolution of legislation and laws pertaining to mentally disordered offenders has been remarkable. The increased global interest in identifying and preserving human rights was marked in Canada by the implementation of the Charter of Rights and Freedoms in 1982. This legislation inadvertently initiated a change in the Criminal Code of Canada (CCC) in 1992 regarding the mentally disordered offenders. This change to the CCC ultimately provides mentally disordered offenders the right to have their case appear before a Review Board and be detained or hospitalized for only as long as necessary to ensure they no longer pose a risk to the community. Gunn (2004) acknowledges the amendments to the CCC in his work in forensic psychiatry. He recognizes British Columbia as the first province to revamp their mental health act after the 1992 Canadian Criminal Code amendments regarding mentally disordered offenders. Youth Forensic Psychiatric Services has also evolved along with changes in federal as well as provincial legislation. This agency provides forensic services to eligible youth in all regions of British Columbia through eight outpatient clinics such as the one located in Prince George, as well through contractors in areas outside of major centres where outpatient clinics are located. The Prince George outpatient clinic was the location of this author' s practicum experience and the location from which participants for this study were drawn. The Practicum provided this author with the opportunity to improve and refine clinical skills and the experience provided the opportunity to develop new clinical skills. Throughout the practicum and in preparing this report, this author became more familiar with the Criminal Code of Canada, the provincial and federal legislation regarding forensic psychiatric services, Conclusion 66 Youth Criminal Justice Act and Youth Forensic Psychiatric Services agency mandate, as well as the responsibilities of YFPS to the court and to youth. The research component of this practicurn report illustrated that participants clients often require referrals to community agencies. These services include housing, drug and alcohol treatment, employment and school programs, Aboriginal programming, community based psychiatric follow-up, and assistance with transitioning youth to adult mental health services. Participants were asked to identify gaps in service for youth in Prince George as well as the entire north region. Participants acknowledged that the following services are needed: subsidised recreation, long term residential programs (drug and alcohol), increased follow-up services in small communities within the north Region (counselling, medication), culturally specific services (Aboriginal), increased employment training opportunities, and housing. Participants also identified their thoughts on issues such as the importance of professionals to be aware of community services available to youth in the north region. They identified they become aware of services through word of mouth. They also identified their own personal process in referral making. The research component of this practicurn report offers a minute inspection of participants' experience in referral making. It is by no means representative of every mental health therapist's experience at Youth Forensic Psychiatric Services. 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John Wiley & Sons: New York The Crisis Prevention, Intervention and Information Centre for Northern BC. (2007). Community resource directory. Prince George: Ward, M., & Jackson, A. (2004). Psychiatric treatment and research unit for adolescent intensive care: The first adolescent forensic psychiatric service in Finland. Journal ofPsychiatric and Mental Health Nursing, 11, 240244. References Yoshikawa, K., & Taylor, P. (2003). Editorial: New forensic mental health law in Japan. Criminal Behaviour and Mental Health, 13, 225-228. Zapf, P., & Roesch, R. (1998). Fitness to stand trial: Characteristics of remands since the 1992 criminal code amendments. Journal of Canadian Psychiatry, 43, 287-293 72 Appendix A 73 Appendix A Information Sheet Practicum Report Community referrals: The experiences of youth forensic mental health therapists in Prince George. Jennifer Broughton Candidate for the Master of Social Work Degree Contact: broughtj@unbc.ca Supervisor: Glen Schmidt Contact: (250) 960-6519 schmidt@unbc.ca Greetings, Thank you for expressing an interest in participating in this study. The purpose of this research is to examine your experiences as Mental Health Therapists in making referrals for the youth that you work with. It is the intention of this study to examine what community resources you commonly refer clients to in Prince George, as well as the resources that you refer to in the youth's borne communities. All those who choose to participate in this study will be employees ofthe Youth Forensic Psychiatric Services Office in Prince George. As participation in this study is voluntary, you may withdraw from the study at anytime. If you choose to withdraw from this study the information that you provided to me will not be included in the analysis or in the final report. If you choose to participate in this study you will be invited to share your ideas and experiences in structured interviews. After the initial interviews you will be will be invited to a follow up interview to review your responses and have an opportunity to ensure that all information collected is accurate. Information that you share with this researcher will be kept confidential. This means that no one will have access to your responses to the interview question. I will keep all research material including interview transcripts locked securely in a file cabinet in my home for one year, after which time I will shred all material. It should be noted that maintaining anonymity will be a challenge as the study identifies that the research participants (you) are professionals employed as Mental Health Therapists at Youth Forensic Psychiatric Service. You should be advised that anonymity cannot be ensured, but that every measure will be taken to protect anonymity. To ensure confidentiality, pseudonyms will be used in the published results of the research so that you can not be identified. After the interviews have been conducted and the data bas been analysed I will present my findings to staff of Youth Forensic Psychiatric Services staff. A copy of the published results will be provided to your agency (Youth Forensic Psychiatric Services Clinic). For more information regarding this study please email myself (Jennifer Broughton) at brougbt@unbc.ca or contact my supervisor Glen Schmidt at 960-6519 or at scbmidt@unbc.ca. If you have any complaints regarding this research please contact the University of Northern British Columbia's Office of Research at 960-5820 or by email reb@unbc.ca. Thank you, Jennifer Broughton, HBSW, RSW Appendix B Appendix B Informed Consent Community referrals: The experiences of youth forensic mental health therapists in Prince George Do you understand that you have been asked to participate in a research study? Yes No Have you received and read a copy of the attached information sheet? Yes No Do you understand that the research interviews will be tape recorded? Yes No Have you had the opportunity to ask questions and discuss the study with the researcher? Yes No Do you understand that you are free to refuse to participate or withdraw from the study at any time? Yes No Has the issue of confidentiality been explained to you? Yes No Has the issue of anonymity been explained to you? Yes No Do you understand who will have access to the information you provide? Yes No Do you understand the potential risks and benefits from participating in this study? Yes No 0 0 0 0 0 0 0 0 0 This study was explained to me b y : - - - - - - - - - - - - - - Print name I agree to take part in this study: Signature of Research Participant Date Signed Printed name of Research Participant Signature of Witness Printed name of Witness Date signed 0 0 0 0 0 0 0 0 0 74 Appendix C 75 Appendix C Interview Guide Community referrals: The experiences of youth forensic mental health therapists in Prince George. I. What are the steps you (MHT) are required to take to make a referral or suggesting a referral for a youth to a service in the community? l(b) What are the benefits and disadvantages to this process? 2. What types of services do your clients commonly require in Prince George and the youth's home communities? 3. How do you (MHT) decide what other issues are relevant for a particular youth? (issues that can not be or are not addressed through youth forensic services ie housing) 4. How do you (MHT) learn about the community services that you refer or suggest a youth be referred to? 5. At what point in the treatment process do you most commonly make or suggest community referrals for youth? (during treatment at some point ... during discharge planning). 6. Have you (MHT) actually observed services from a community agency being delivered? a) If yes what services did the agency provide and describe the services being delivered. 7. Do you (MHT) know if referrals are actually made by case managers? b) If yes how? c) If no, why were services not used? 8. Do you (MHT) know if youth have benefited from referrals made to community services? b) How do you know this? c) How might this knowledge impact the likelihood of you making a similar referral in the future? 9. Do you (MHT) receive any feedback regarding community services (from case managers or youth) that might change the pattern of referrals in the future? b) If so, what feedback have you received? I 0. Are there specific factors that would influence your referral, or recommendation for referral, to one agency over another? 11. What are gaps and needs in Prince George that are not addressed with current community based services available for your clients? 12. What ar.e the gaps and needs in surrounding communities that are not addressed with current community based services available for your clients? 13. What skills do you believe mental health therapists in general require in order to make appropriate referrals for youth? a. What particular skills do you possess that you utilize when making referrals or suggesting referrals for youth? Appendix D 76 Appendix D UNIVERSITY OF NORTHERN BRITISH COLUMBIA RESEARCH ETHICS BOARD MEMORANDUM To: CC: Jennifer Broughton Glenn Schmidt From: Greg Halseth, Chair Research Ethics Board Date: July 9, 2007 Re: E2007.0614.066 Community referrals: The experiences of youth forensic mental health therapists in Prince George Thank you for submitting the above-noted research proposal and requested amendments to the Research Ethics Board. Your proposal has been approved. We are pleased to issue approval for the above named study for a period of 12 months from the date of this letter. Continuation beyond that date will require further review and renewal of REB approval. Any changes or amendments to the protocol or consent form must be approved by the Research Ethics Board. Good luck with your research. Sincerely, Greg Halseth