Believing in 2 nd chances: Social Work Services under the Mandatory Treatment Order in Singapore

1. Believing in 2nd chances: Social Work Services under the Mandatory Treatment Order in Singapore 26 July 2014

3. Singapore General Quick Facts 2010 • Total land area: 712.4 sqkm or 275 sq mile • Total GDP: $257,640.4 million • Total population: 5,076m • Population profile by race: • Chinese 74.1% • Malays 13.4% • Indians 9.2% • Others 3.3% • Four official languages: English, Malay, Chinese and Tamil. English is used administratively and as medium of instruction in education and at work

4. Outline • Forensic Psychiatry Services in Singapore • Community based sentencing orders in Singapore • What is Mandatory Treatment Order (MTO) • Case example: Role of social work in the MTO • Issues faced in MTO • Future directions

5. Forensic Mental Health Services provided by IMH Serving sentence Released from sentence Court hearing Police arrest Psychiatric Assessment Report (including PACP) Court Appearance Forensic Psychiatry Community Service PACP Psychiatric Housing Unit Mandatory Treatment Order CPC Diversion Programme Other services MHCTA (Form 3 & 5) Preparation for step-down care

6. Community Based Sentencing in Singapore • Community-Based Sentencing (CBS) • Introduced in the Criminal Procedure Code 2010 to provide greater flexibility in sentencing. • Implemented in January 2011. • CBS includes: • Mandatory Treatment Order (MTO) • Community Service Order (CSO) • Day Reporting Order (DRO) • Short Detention Order (SDO)

7. MTO Programme Characteristics Definition: A sentencing option that allows the Courts to order an offender to undergo compulsory psychiatric treatment for a period not exceeding 24 months. (Section 339 of Criminal Procedure Code) • Objectives: • Effective and targeted approach to rehabilitating mentally ill offenders • Better utilization of resources which would otherwise be allocated to incarceration • “Second chance” for mentally ill persons charged with (relatively) minor offences

8. Eligibility Criteria 1. Offenders with recognizable and treatable psychiatric illnesses 2. A causal, or substantive link between the psychiatric condition and the offending behaviour 3. Must be willing to undergo monthly psychiatric appointments for up to a 2 year period 4. Willing to be compliant to prescribed treatment in any form 5. Be prepared to be contacted/home-visited regularly by clinical staff 6. Adequate family/social support (preferred) MTO Programme Characteristics

9. Suitable for MTO & upon approval by Courts • Processes • Appointment of bailer • Treatment program • Submission of 6-monthly progress report • Funding & payment MTO Treatment Framework Court CWO, DRO etc. Potential for community based sentencing options Sentencing Potential for MTO No potential for community based sentencing Psychiatrists to assess by MTO service provider (IMH) Not suitable for MTO Jail/Fine etc Completes treatment Defaults treatment / does not improve Refer to Court for follow-up action

10. FY2014: 1 Program Director (Senior Consultant Psychiatrist) 1 Program Executive 4 Case Managers 3 Medical Social Workers 1 Administrative Assistant 1 Clinic Coordinator 1 OT 1 Psychologist MTO Team

11. Illness Inclusion & Exclusion Criteria • Generally, diagnoses which are included (DSM-IV-TR/ICD-10) • Psychotic Disorders – Schizophrenia, delusional disorder • Mood Disorders – Depression, bipolar disorder • Anxiety Disorders – GAD, phobic disorders, panic disorder, anxiety disorders (e.g. OCD), PTSD • Generally, diagnoses which are excluded: • Purely Personality Disorders, Substance abuse & addictive disorders, Intellectual disability

12. Operations Flow for MTO assessment

13. Operations Flow for MTO assessment

14. MTO Dashboard as of 11 July 2014 Assessments since January 2011 N = 523

15. MTO Duration (by months)

16. Age at time of MTO assessment

17. Gender N = 297

18. Index offences

19. Diagnosis

20. MTO status

21. Case Example • Kat (not her real name) • Demographics: • 44 year old female / Malay / Muslim / Married • Employment status: Unemployed. Previously helped mother in her stall. • Education: Primary 5 • Diagnosis: Depression (1st treated in 2008, irregular) • Suicidal history: Attempted suicide in 2010 with 6 tablets of panadol • Substance use history: Nil reported • Forensic History: Nil reported • Accommodation: 4 room purchased apartment

22. Family Genogram 55yo M. 2000 M. 1987, D. 1992

23. Case Example Index offence: • Voluntarily causing hurt to a domestic helper by slapping her cheek, pushing her, burning both her arms with heated iron and injuring her with a knife at her stomach area. Court outcome: Kat was granted MTO for 24 months

24. Case Example • Social Work Services under the MTO • Financial Assistance • Applied for assistance for treatment fees • Referral for financial assistance schemes • Family Work • Referred Kat to therapy services: work on her coping with divorce proceedings (3 sessions) • Family conflict • Employment assistance • Contacts for child care services given • Kat set up a food stall in a school • In other cases, referral to Job Club or employment placement services

25. Case Example • Family Violence Intervention • Home visit was conducted: Eldest son and 2 youngest sons seen • Bedroom doors were removed, door knob was missing • Worked out safety plans for family – stay in a cheap hostel till court hearing • 3 days later, Kat informed that family moved to stay in a park • After returning to the flat, Bob hit the 2 youngest children (with a belt and torchlight) and the children were admitted to a hospital • Kat decided to apply for protection order for her children • Family stayed at the hospital for the time being • Therapy was closed due to crisis management

26. Case Example • Referral to/Liaise with external services • Referred Kat to a Family Service Centre (FSC) for safety monitoring • Case conference: Clarification of roles of agencies • Accommodation assistance • Referred Kat to a crisis shelter • Kat stayed at friends place, moved to stayed in school but was warned by the police, then shifted to a rental place (Daughter stayed separately) • In other cases, social worker refers patients to psychiatric residential centres, halfway houses

27. Case Example • Child Risk management • 11 year old son reported to a school counselor that Kat wanted to throw her 5 year old son from an 11th floor, and was stopped by her other children • When questioned, Kat admitted having such thoughts, saying she felt very stressed then as the family had no place to stay • Referred Kat to Child Protection Services • Kat received emergency funds, which • addressed her stressors • No further risk was assessed towards children

28. Case Example • Updates: • Completed her MTO • No longer given any appointments in IMH • Kat had divorced and was selling the matrimonial flat • Working as a cook in a childcare • FSC will continue to explore alternative housing and assist her in parenting her children

29. Issues faced in MTO • Assessor vs Treating role – Need for role clarity • What is defined as treatment? – Need for engagement • Managing expectations of family members/service providers – Being aware of limitations and powers • Role of rehabilitation vs role of supervision - Firmness with flexibility

30. Future Directions • Research • Review on effectiveness of MTO • Focus on criminogenicfactors • Expansion of criteria?