Forensic psychiatry: out of mind, out of sight

Abstract

Out of Mind, Out of Sight: Inside the Brockville Psych is an intense film about forensic psychiatry that won best Canadian documentary at the 2014 Toronto Hot Docs Film Festival in Canada. It is set in the Brockville Mental Health Centre in Ontario, Canada, a secure hospital which provides psychiatric assessments for the courts, and treatment for people who have been charged with offences but found unfit to stand trial, or to lack criminal responsibility. Similar in design and intention to the network of forensic hospitals that now exist in many economically developed countries, Brockville's treatment is offered in wards that seem fairly stern and sparse. In the UK, similar hospitals are stratified into different levels of security (high, medium, and low), and accessed differently, with less emphasis on criminal responsibility as a deciding factor in the process of admission.The documentary follows four patients as some progress through treatment and recovery to community resettlement. Film, as a medium, comes into its own here, capturing nuance and complexity in a way that written clinical notes or academic papers can struggle to achieve. In telling the stories of these patients, whose individual institutional pathways have been characterised by violence to self, others, or both, four-time Emmy award-winner John Kastner opens a clear window into the day-to-day reality of forensic psychiatry.The story of Michael and his family is particularly poignant. He is a young man who developed schizophrenia and, driven by delusions of thought control, killed his mother by blunt trauma to the head as she returned home one day. His subsequent journey through secure hospital treatment is described, as is the battle to gain control of his symptoms in the face of advancing mental illness. The family's grief is still apparent, as is Michael's. Yet their struggle to understand, and then forgive, their son and brother, who killed their mother, is remarkable to watch: they take a robust stand against schizophrenia which is reminiscent of recent public anti-cancer campaigning in its vigour. In doing so, they offer support for Michael in the clearest possible terms. As his brother said, “There were two victims here”. As Michael moves closer to the relative freedom of absolute discharge back to the community, the need for checks and balances to prevent his illness from escalating again is debated, and, although it is not stated clearly, it is apparent that all involved are mindful of his potential for becoming dangerous, should his condition relapse.Out of Mind, Out of Sight offers an examination of the few people with severe mental illness who kill or seriously harm others, while carefully advising that most do not. In achieving a balanced perspective, the film opens a range of clinical and ethical issues to further discourse: the relationship between mental illness and offending behaviour; the nature of treatment and recovery in forensic psychiatry; the use of physical restraints in treatment (an area in which there are international variations in standards); and the reality of in-patient violence and behavioural disturbance.John Kastner's greatest success is in keeping humanity at the core of this film, while telling complicated, multi-faceted stories about victims, perpetrators, and families. Despite the coverage of some distressing deeds, which are confronted in their full reality, Kastner never loses his sympathetic touch. Although this is a documentary which could easily have slipped into voyeurism, the simplicity and honesty of the filming prevents this. The visceral struggle of Michael, and his family, to forgive and to move on is a story worth telling. John Kastner, in telling it well, has advanced the case of forensic psychiatry—a subject so easy to marginalise and to dismiss.Out of Mind, Out of Sight: Inside the Brockville PsychDirected by John Kastner, 2014 Canada Out of Mind, Out of Sight: Inside the Brockville Psych is an intense film about forensic psychiatry that won best Canadian documentary at the 2014 Toronto Hot Docs Film Festival in Canada. It is set in the Brockville Mental Health Centre in Ontario, Canada, a secure hospital which provides psychiatric assessments for the courts, and treatment for people who have been charged with offences but found unfit to stand trial, or to lack criminal responsibility. Similar in design and intention to the network of forensic hospitals that now exist in many economically developed countries, Brockville's treatment is offered in wards that seem fairly stern and sparse. In the UK, similar hospitals are stratified into different levels of security (high, medium, and low), and accessed differently, with less emphasis on criminal responsibility as a deciding factor in the process of admission. The documentary follows four patients as some progress through treatment and recovery to community resettlement. Film, as a medium, comes into its own here, capturing nuance and complexity in a way that written clinical notes or academic papers can struggle to achieve. In telling the stories of these patients, whose individual institutional pathways have been characterised by violence to self, others, or both, four-time Emmy award-winner John Kastner opens a clear window into the day-to-day reality of forensic psychiatry. The story of Michael and his family is particularly poignant. He is a young man who developed schizophrenia and, driven by delusions of thought control, killed his mother by blunt trauma to the head as she returned home one day. His subsequent journey through secure hospital treatment is described, as is the battle to gain control of his symptoms in the face of advancing mental illness. The family's grief is still apparent, as is Michael's. Yet their struggle to understand, and then forgive, their son and brother, who killed their mother, is remarkable to watch: they take a robust stand against schizophrenia which is reminiscent of recent public anti-cancer campaigning in its vigour. In doing so, they offer support for Michael in the clearest possible terms. As his brother said, “There were two victims here”. As Michael moves closer to the relative freedom of absolute discharge back to the community, the need for checks and balances to prevent his illness from escalating again is debated, and, although it is not stated clearly, it is apparent that all involved are mindful of his potential for becoming dangerous, should his condition relapse. Out of Mind, Out of Sight offers an examination of the few people with severe mental illness who kill or seriously harm others, while carefully advising that most do not. In achieving a balanced perspective, the film opens a range of clinical and ethical issues to further discourse: the relationship between mental illness and offending behaviour; the nature of treatment and recovery in forensic psychiatry; the use of physical restraints in treatment (an area in which there are international variations in standards); and the reality of in-patient violence and behavioural disturbance. John Kastner's greatest success is in keeping humanity at the core of this film, while telling complicated, multi-faceted stories about victims, perpetrators, and families. Despite the coverage of some distressing deeds, which are confronted in their full reality, Kastner never loses his sympathetic touch. Although this is a documentary which could easily have slipped into voyeurism, the simplicity and honesty of the filming prevents this. The visceral struggle of Michael, and his family, to forgive and to move on is a story worth telling. John Kastner, in telling it well, has advanced the case of forensic psychiatry—a subject so easy to marginalise and to dismiss. Out of Mind, Out of Sight: Inside the Brockville PsychDirected by John Kastner, 2014 Canada Out of Mind, Out of Sight: Inside the Brockville PsychDirected by John Kastner, 2014 Canada Out of Mind, Out of Sight: Inside the Brockville Psych Directed by John Kastner, 2014 Canada