#60 Forensic Psychiatry: Mental Health Meets the Law

Mashup Clip 1 [0:03] My dark passenger is like a trapped coal miner, always tapping, always letting me know it's still in there. Still alive. Tonight's the night, and it's going to happen again and again. He goes on crazier than usual. A census taker once tried to test me. Mommy gets the knifes and fingers off. He doesn't like that. I ate his liver, but some fava beans. Not one bed. Nice candy. He takes the knife to her, laughing while he does it. He turns to me and says, "Why so serious?"

Max Strauss [0:53] Hi, everyone, I'm Max.

Eryn Tong [0:54] And I'm Eryn.

Max Strauss [0:55] We're gonna jump right into it as we have a lot of excellent content lined up for you. Today's episode covers a theme that is often sensationalized in the media, and is currently experiencing a bit of a high on entertainment platforms like Netflix, TV, podcast channels, etc.

Eryn Tong [1:10] We will be talking about the space in which serious crime, the law, and mental illness intersect. In other words, we'll be talking about forensic psychiatry. Stay with us for some thought-provoking and eye-opening conversations with the people who play a crucial role in this space, and really see it all, forensic psychiatrists and sex psychologists. Welcome to Episode 60 of Raw Talk.

Dr. Hy Bloom [1:42] Forensic is really just that joining point of law and another discipline. For example, forensic accounting, forensic engineering, and, in my case, forensic psychiatry. It's the application of psychiatry to the legal context. The people that I see are generally referred to me by the legal or employment sectors, with questions like, "Did this fellow have some kind of mental health problem when A, B, or C happened?" or "Does some mental health problem explain his behavior?" So, that's all forensic really is, the joining point of law and psychiatry.

Max Strauss [2:19] You just heard from Dr. Hy Bloom. He's a forensic psychiatrist, and a lawyer who is the Director and CEO of Workplace.Calm Inc, that is dot c-a-l-m incorporated. He consults in workplace conflict and violence prevention and management. Dr. Bloom is also an Assistant Professor in the Department of Medicine at the University of Toronto, and part-time staff in the complex mental illness/forensic services program at CAMH.

Eryn Tong [2:44] Dr. Bloom makes an important distinction between forensic psychiatry and the rest of psychiatry, such as community based psychiatrists who see patients for therapeutic intent. Most psychiatrists, as you may know, have a doctor-patient relationship and are there to advocate for their patients interest and well-being.

Dr. Hy Bloom [3:00] When you get referred to a forensic psychiatrist, whether it's for a criminal or civil matter, I'm not there to advocate for anyone's interest. I don't take sides, no matter which side hires me, and no matter which side pays me. So I'm there to do an objective evaluation. That's where my dedication is to objectivity and truth finding, because I'm involved in some way and the truth finding process, even though I'm not the finder of truth, the judge or jury or arbitrator is. So when a person is referred to me for a criminal matter, either by the crown or the defense, because I'll work any side that it's on the other side of the phone, calling me first, I will usually hear from the lawyer, what the charges are, and what it is that they want me to address. Very commonly, it's things like, was this fellow, and I'm just giving an example here, was this fellow suffering from a mental disorder at the time that he committed this act of, let's say, violence or a homicide? And if so, what do you think the connection is between the mental disorder and what he did? Is that the explanation from a psychiatric perspective for that behavior? So I have to consider whether or not, one, if he has a mental health problem; two, what symptoms was it exerting at the time that he committed the, let's say, homicide? And was there any other motivations at play? And was the mental disorder the instrumental reason for why he did what he did? And if it is, if I can give an opinion like that, and defend that opinion, and it gets accepted by the court, the person may get a psychiatric defense like not criminally responsible or diminished responsibility. So on the sentencing side, where responsibility for the act isn't the issue, the question usually his diagnosis, risk, risk reduction, treatability.

Max Strauss [4:53] The challenge in a forensic psychiatry job lies in the fact that there are many different factors that may lead someone toward committing a crime in the first place. So let's backtrack a bit. What do some of these contributing factors look like?

Dr. Hy Bloom [5:07] There's usually a number of factors operating in concert to bring that about. So I tend when I give an opinion about what was going on with someone at the time, generally not to pin someone's behavior on one factor only. And I often use the pie chart analogy. I've used it in court reports. And when I've testified, sometimes I will say that I've dug around this guy's history and his mental health and assess them. And I've come up with 5, 6, 7 factors that I think I can implicate as playing a causative role in the behavior. I did that once, in the case of a terrorist, an evaluation of a guy charged with a terrorist act and needed to sort of think about, as an example, was it radical ideology that is the only slice in the pie, or are there other slices in the pie that made this guy do these things that he got arrested for and convicted for? And in his case, I just thought it was a poignant example, years ago. And in any case, I've always found that because a bunch of slices in the pie. In order to get an NCR defense, you need the biggest slice, or more than half the pie. This is just a crude way of looking at it to really be occupied by some driving mental for some psychotic phenomenon, like voices, which he couldn't resist, may have resisted them before. In this case, he credibly couldn't resist them, made him do that. Delusions, believing the guy was Hitler, and not the actual victim caused them to do that. So you got to find that some psychotic explanation really occupies more of the pie chart. But then you're probably going to assign some slice to maybe he was undergoing stress, maybe the effects of some drugs, not enough drugs on board to explain the loss of control, but some drugs on board to explain impairment of judgment, disinhibition, things like that. Then there is maybe there's some pre existing animosity towards the victim. Never acted on before but in this particular case, maybe it found some expression in the act towards that victim. Maybe it's childhood factors. Maybe, you see an awful lot of this, by the way, in the forensic arena, you see a lot of people who themselves have been victimized earlier in life. Physical, psychological, sexual abuse, and neglect, and witnessing violence between the parents and all kinds of things. That's a factor sometimes, because it becomes ingrained in the person. They respond to precarious situations in a patterned way. That might be a factor or the factor. It may be something very instrumental, like, needing to do something to the victim because it gets you something. So I have to think about all these motivations, deciding what exactly what motivated an accused to do something is really the judge's job but I can weigh in psychiatrically and may or may not help the court out. If it's an NCR scenario, and they buy my opinion, so they've accepted the view that the psychotic disorder was the instrumental explanation for the behavior.

Eryn Tong [8:23] Across individuals who have a mental illness. Are there factors or impacts either genetic or environmental, that may differentiate those who commit crimes from those who do not?

Dr. Sandy Simpson [8:32] All the things that drive any sensuality in the general population also increased risk of antisocial behavior, and the population of people who have a psychotic illness. So if you look at studies of people with psychotic illness, who are criminal justice involved, you see all of the factors that increase criminality generally occurring in their lives, unsurprisingly. Regrettably that's sometimes when the conversation ends. So the genetic factors that are there, there's some evidence around the low activity 5-HT allele as being a vulnerability factor for anti sociality. It's also a protective factor if you grow up in a supportive household. If you have that allele and you grow up in a neglectful or abusive setting, then that somewhat increases your risk of manifest and conduct disorder. There are no determinants of genes but there are gene environment interaction stuff going on.

Max Strauss [9:33] That was Dr. Sandy Simpson. He is the chief of forensic psychiatry and a clinician scientist at CAMH. Dr. Simpson is also an associate professor at the University of Toronto, and recently completed his term as the head of forensic psychiatry division at the university. Let's continue listening.

Dr. Sandy Simpson [9:50] The things that contribute to poor educational achievement to poverty to broken homes to being a victim of abuse or seeing abusive behavior occurring around, you developing an antisocial network, all of those patterns of personal or social vulnerability, or adult criminal behavior, oppositional disorders and conduct disorders and adolescents predict antisocial involvement and early onset drug misuse. Well, as well. A number of those things may also increase your risk of developing a psychotic disorder. If you also have the biological risk of developing a psychotic disorder, you start using cannabis in your early teens, you're probably increasing your antisocial risk, you're also increasing your onset of psychosis risk. Some people who have risk of psychotic illness have learning disabilities that may result in educational non achievement. There may be overlapping factors for those some forms of abuse may increase sight some the experience of some psychotic experiences as well. So there are there's this duo causation going on in some of those areas. So that produces a group of people who we see or it seems to be what we call the early status. So the people who have antisocial problems before they become unwell, before they develop their psychosis. Snd then the psychosis may further increase that, because when they get on well, it may exaggerate or further disinhibit aggressive behavior. Now some of the early status will be some of the prison population with people who also have serious mental illness. So they have both of those things going on in their lives, substance misuse, their risk factors for antisociality and illness factors and they may have fewer personal assets are strong relationships or community supports or other things to help you cope with the onset of a of a serious mental health problem as well. So you're further burdened. Those people have got complex interactions with those things. The second group, people who we refer to as the late starters, who do not have criminal justice involvement, or conduct disorder and their developmental histories before their psychosis develops, but the violence emerges largely or completely as a complication of the illness. Violence is a complication of acute psychosis. The way arrhythmia is a complication of an acute heart attack. It is a direct manifestation of certain delusional and hallucinatory experiences combined with disturbed, usually frightened and fearful affect. So certain sorts of command hallucinations, certain sorts of delusional sets, largely persecutory and grandiose, rarely the delusion of doubles have been called Capgras syndrome is that dangerous ideas and experiences to have, especially when it's combined incongruent with one's mood state because mood is the drive to action. It's usually fear, less commonly anger, or entitlement, but mostly most of psychotic related violence is fear driven, self protective, that largely manifests closely amongst the people, often with close family members or people who are in your close circle of relationships, especially the more serious. So there may be the particular types of symptoms and the syndrome that you happen to have. We don't know enough yet about why it happens to be those things that matter, but very broadly, sorts the shape and form of the illness itself. And where that sits broadly across your developmental lifespan that seemed to be relevant.

Eryn Tong [13:55] At this point, you might be curious, because we definitely were, what exactly does the process look like when someone who is suspected to have a mental illness commits a criminal offense from the point of arrest, and at which points do forensic psychiatrists come in? We asked Dr. Simpson and Dr. Bloom to walk us through this.

Dr. Sandy Simpson [14:12] If somebody is arrested for behavior that's cause rise to public concern and may be a criminal offense, if you go through to charge being laid against you. The first issue when the person appears in quarters, are they able to defend themselves properly. So that's what fitness to stand trial is about. The justice system needs that any defendant coming before it is able to defend themselves Otherwise, the moral and ethical basis of law collapses. So if you're into civilians, disabled or acutely unwell, and you cannot instruct counsel about what's going on in court. You can understand the charge against you or the evidence that's coming or you can instruct a lawyer to act on your behalf, then you should not be made subject to criminal proceedings, and we're the people are coming to help with it. So the crown or the defense or the judge may raise have concerns about somebody's presentation before the court and they will ask us to give a report on that. If someone's acutely unwell, it may then be recommending coming to the hospital under treatment order to for the point of restoring their ability to defend themselves in court.

Dr. Hy Bloom [15:26] Unfit people kind of still belong to the court in a way. They're on loan, funny way to put it, but they're on loan to the review board, until they get well enough with medications or anything else to be fit to stand trial. Once they're fit, they go back to court. They return to the court of origin.

Dr. Sandy Simpson [15:44] Being unfit doesn't stay the proceedings, it's just suspends them for a period until you fit once again to defend yourself. Then the next question is, so was the person responsible or what they did at the time of the events? That's what criminal responsibility is about. If you're so unwell, that you don't know what's called either the nature or quality, so you don't know what it is you're doing or you don't know that it's morally wrong. So that if you're acting violently, believing it's that you're about to be attacked mortally by the devil who will kill you and kill the world and you fight back, then you don't know the moral wrongfulness of your action that feels morally right for you as you do it. But in terms of external moral right or wrong, you're doing the wrong thing. And that's what criminal responsibility is about. So then they will ask for expert testimony from one or two or three, depending on how contentious or serious the cases, forensic psychiatrists to give evidence to court about that.

Max Strauss [16:52] So their role isn't to determine whether or not a person is criminally irresponsible. That is the duty of the court, who are the "finders of fact". Rather, forensic psychiatrists are there to present their expert testimony to the court based on all of the prior assessments that they've conducted. But throughout all of these assessments, how do they discern whether or not mental illness was the primary explanation for the behavior and for the committing of the criminal offense, which is what is needed for an NCR?

Dr. Hy Bloom [17:20] So that's a great question. And that's really the central challenging task, along with deciding whether or not the guy is faking in some way or exaggerating, that's another big problem. But in figuring out whether or not the mental disorder is the responsible agent for the behavior, you do that kind of history, and you try to get as much information as you can. No doubt about it, mental state is invariably analyzed retrospectively. I wasn't there at the time. Most of the time, nobody else is exactly there, if there's a victim, he or she was there, but they may have passed because of the act. So there's all kinds of bits of information that provide clues part of the jigsaw puzzle of this guy's mental state at the time. I try to put the pieces in, and some pieces come from him, his mental state currently. His medical records are really important, like he's had certain ideas that have put them on the precipice of violent behavior and resulted in a number of hospitalizations before. But this time, he went further and actually did the act, seen that a number of times, that kind of past records, at least tell me that he's had these symptoms, they've come up before, he never acted on them, but at least they're in medical records and appear to be genuine. There is my take on on whether or not his symptoms are genuine. In my assessment of him based on all kinds of information, I don't rely on him entirely. In fact, he's only one component of it. I'll have documents but I'll also interview other people. If I don't read witness statements from the police, which are almost always provided, I may choose to interview a bunch of people, whether interviewed by the police or not, to kind of get a sense of what this guy was like through their eyes in the last year, month, week, day, hour or minutes before this thing. Putting all those pieces together, I can get some kind of take on whether or not the mental disorder was the reason. I also consider other motives of just like the courts and the lawyers do. If there was pre existing animosity between the parties, I have to consider whether that was the reason that the killing happened, instead of this guy's mental disorder even if he had one. It may not be the explanation, or it may be a composite of motives. When somebody is found not criminally responsible, they kind of more or less get owned by the Ontario Review Board, or the provincial review board meaning total jurisdiction over them is that of the board. Until such time, and here's the magic words from the Criminal Code, until such time is no longer a significant threat to the safety of the public. That's the test. The very common pathway for people who have committed marked violence and ended up in NCR is to come under the jurisdiction of the board to be in a psychiatric hospital at a level of security that they need. It's necessary to protect the public and them. And then to cascade from higher levels of security to lower levels of security with greater privileges as they get better and as their dangerousness diminishes to a point where they no longer can be said to be a significant threat, then they must be absolutely discharged. But until that happens, they're restricted. And sometimes you hear about this stuff, in highly publicized cases, about people committing atrocious acts while they're mentally ill. And then the press might report the person has been given privileges to wander on the hospital campus, or to go into the community and do different things. And some people might be outraged by this. But usually these things don't happen until such time as the clinical team has decided that this person's risk management plan allows for this. In other words, it's safe enough for them to do it. There's enough checks and balances in place. And they're well enough. He's been tested enough to have that those extra privileges. Eventually, as I said, no longer a significant threat, out they go into the community, hopefully to remain in some form of psychiatric follow up, which while highly recommended at that point wouldn't be mandated anymore.

Eryn Tong [21:29] If you are a fan of true crime, you've probably heard the term psychopath thrown around a lot. Psychopathy, although not an official clinical diagnosis under the DSM-V, but is classified under antisocial personality disorder, is commonly considered to be a personality disorder characterized by a range of traits and behaviors such as deceptiveness, lack of empathy and guilt, shallow affect and impulsive behavior. New developments in science suggests that their brain differences in people with psychopathic tendencies. Could or should they be considered NCR as well?

Dr. Hy Bloom [22:00] It shouldn't, is the short answer, but I'll just give you a little bit of reasoning behind that. I sometimes, when I'm when I'm doing a talk to trainees, I'll say forensic psychiatry is kind of easy in a way. At the end of the evaluation, all you have to do is say one of three things: [the] person is a bad apple, a sick apple or a troubled apple. Troubled apples, and up with rehabilitative outcomes. They're given maybe some better sentences with a rehabilitative outcome, like you have to go into therapy. Bad apples end up in jail and sick apples end up in a mental hospital. That's just the very crude outline I use when I'm kind of describing it. Psychopath would would not fall into the sick apple kind of category ordinarily. It's been tried. For example, I guess the argument would be psychopaths come by their problems honestly, strange as that sound, they haven't picked them off the shelf, they didn't choose to be a psychopath. They had environmental and genetic factors that kind of took them down that pathway, and consequently, there's even been some work that suggests in conclusively that their brains are a bit different through imaging studies, which is very big right now in my field. Even if that's true, and we're still inconclusive about whether or not the differences in brain structure and function in psychopaths are severe enough to limit their ability around their knowledge of their criminal acts and their impact to justify an NCR defense, our current understanding is that it's a matter of choice, as opposed to a matter of the fact. They choose not to abide by the same moral standards that everyone else does, rather than they can't abide by the same moral standards. And that's because our test in the Criminal Code is relatively straightforward, in the sense that street knowledge that this act is legally wrong in this country, and that most people would condemn it, meaning you understand the legalities moralities involved. If you do, you don't get an NCR defense. And psychopaths understand that just as well as you and I do. They don't like it, don't want to apply it to themselves, but they get it.

Max Strauss [24:11] Let's pause for a second. It's important to note that all of what we've discussed so far assumes that the defendant has been flagged or picked up to be referred for clinical assessment. But as Dr. Simpson explains, this may not always happen.

Dr. Sandy Simpson [24:25] There's a lot of serendipity in your criminal justice pathway where you may get picked up at court that you're suffering from an illness, maybe your lawyer will flag it and you get an NCR assessment, or maybe for all sorts of reasons you don't qualify for either of those or you don't want to tell anybody about what's going on inside, or you you know, you've offended criminally that's got nothing to do with your mental illness, but you also have mental health problems. For all of those reasons, serious mental illnesses greatly over represented and present. So about 15 to 20% are caught by the International Epidemiology, of which I've contributed to over the years, of a standing prison population have schizophrenia, bipolar disorder, or current major depression. Health services have a duty of care to those people. So regardless of whether you wind up on a bigger forensic pathway, that's in CI, there's a whole large number of people who are in with serious mental illness who are encountering the criminal justice system, who need care, and seeing that as a health opportunity. Health duty has been one of the major things that I've been dedicated to. So prison epidemiology, the development of assessments of needs, developing of clinical tools to help with that, developing models of care of what a prison mental health service should look like, piloting that, rolling it out, publishing on it has been a sort of half of my academic productivity. And we've been very successful with that. We're now in the woman's prison, as well as throughout a South detention center. We get referred to us about three and a half thousand people a year through those programs. We see about two and a half thousand of those each year, and Toronto's South detention center and in the center for women. And we try and get care rapidly wrapped around those people as quickly as possible. But there are unmanned people. So they're turning over quickly, their average length of stay is less than four weeks in the prison. So we have to move rapidly to detect the need, get referred to treatment services and try to get them linked up to community services as quickly as we can. So if we fail that group, then people, people suffer and die at their own hand. If we don't treat people with serious mental illness, then other people in the community can suffer and die because we're not treating the people with acute psychosis.

Eryn Tong [27:00] Dr. Simpson also points out that too much of our resources are institution based. And there's not enough community based follow up to promote education and skills for reintegration into society. And a potential result of this is that people end up becoming repeat offenders. In general, there's a lack of research and evidence based program creation to better serve and support this vulnerable population, both within the correctional institutions and out in the community.

Dr. Sandy Simpson [27:24] The area, and I use a quote from a New Zealand artist called Colum McCann who is a great New Zealand abstract expressionist, is always stuck with me on a landscape with too few lovers. Forensic is a landscape with too few lovers. We have, in the mid teens have endowed chairs and child and adolescent and suicide researchers in the U of T. We have four endowed chairs and forensic psychiatry in the world. So we have 2025 endowed chairs in U of T psychiatry, none of them forensic. People don't want to attach their name to this area. They don't want to think about what it's about. It's the other part, yet here where we're a third of the hospital. We have, frankly, in my view, putting too much into biological research, and not enough into social determinants and social responses. We could shift the dial in terms of outcomes with implementation science research on what we already know. What am I doing? We've got a suite of things going on in the area of prison mental health. We've coined and developed a model for that. We're looking to develop measurement tools to measure that care pathway through corrections to define staffing levels, throughput rates, and the care that we should be achieving an outcome measures of what mental health services should be receiving to use as a both a design measure an audit tool and a resource calculator internationally. So we've piloted it in four centers. We hope it will be rolled out soon and in other major parts of the world, so that we could have a measure of what should be happening in that area. So that's about half of what I do. The other part is better understanding the patterns of risk and recovery for people largely with psychosis and violent behavior. We studied that at epidemiological levels in terms of homicide epidemiology, both in New Zealand and here, trying to understand it at individual patient level and trying to understand motivation to violence, and trying to make sense of what recovery pathways, what packages of treatments work and how to help people recover from those risks, using recovery philosophies, doing that with shared formulations and understandings of risk to understanding that whole recovery pathway. The issues in here are tricky, because you will read that there's no relationship between mental illness and violence, that it's the same or less than the general population. That's not true. There is a three to four fold in some population seven to eight fold, depending on what your base rate of violence in the population is. An increased rate of violent behavior by people who have a psychotic illness. Said boldly like that. That's a very stigmatizing statement. The risk lies in acute psychosis. The risk is driven. So good care, given early reduces at risk at the same level or lower than the general population. So reducing the stigma or reducing the barriers to risk having very good services, starting at first episode, but right across the life course, for people with psychosis, is the answer to that problem, not raising stigma, not raising fear. In other words, the increased risk to the public that comes from people with psychotic illness is thoroughly treatable with good services. That's the message we have to give. If you wanted to reduce homicide by people with serious mental illness, they would contribute somewhere around about 5% of all societal homicides. So if you think that we're at profound risk to the general population, because of people with serious mental illness, whether it's the Vince Lee or the cash car, or the you know, the other co celebrities that the media focus on at times, that is only around about 5% of all of society's homicides. So locking up people with mental illness to make the world safer is not the answer. Providing good care for people, decreasing stigma making services acceptable, effective for people is the answer to the issues of addressing these these questions.

Max Strauss [31:53] Dr. Simpson emphasizes that there's a health duty towards all people with serious mental illness both within the forensics pathway as well as those who end up in the criminal justice system. It's important for us to appreciate the complexity of these pathways.

Eryn Tong [32:06] We are oftentimes exposed to high profile cases of extreme violence in the media and this can quickly lead us to categorize people and be polarized in our views. But in doing so we need to be aware of our own biases towards the relationship between mental health and crime.

Dr. Hy Bloom [32:21] The highly publicized cases do stir up a lot of public opinion. And usually they're centered on extreme violence committed by a guy with a mental health problem, It's important to really appreciate, and the public wouldn't because I don't think it comes out this way, in the media that these are outlier cases. And that extreme violence by mentally ill individuals is very uncommon. In fact, the more common statistic is that if you have a serious mental disorder, like schizophrenia, you're more likely to be a victim of violence than a victimizer. I'm oversimplifying other factors can come together and your mental disorder can turn out to be more dangerous. But at baseline, the mental disorder is really not synonymous with having violent tendencies, but that's portrayed that way sometimes in the media.

Max Strauss [33:07] We are often exposed to such extreme examples of violence in the media as Dr. Blum points out. Dr. Simpson gives us his take on some of these issues, including gun violence and mass killings.

Dr. Sandy Simpson [33:18] Most mass killing is done by guns. But as we saw in Sri Lanka, over the weekend, it's done in other ways as well. So hate-driven mass crimes, or it can be done with just the one year anniversary of North York van mass killing. We've seen that in Europe as well with people driving vans and trucks into crowds. So the they're not the same thing. Last year was a bad year for gun violence in Toronto. Almost none of that had anything to do with with mental illness. The only one that would that was raised significantly was the Danforth incident, and the the man probably had some mental health issues, but we don't know what amd he died as a part of that, I think, by his own hand. But we don't know anything further about that. He would not have done that, if we didn't have a problem with the availability of handguns amongst antisocial young men, because he got the gun from his brother. Let's see, that was the way it was reported. And that gun was part of an antisocial subculture. If we want to reduce gun related homicides, there is very good evidence based ways that that can be done. The best evidence for that comes out of the public health guided initiatives around knife crime in Scotland. And it was built on local neighborhood interventions and antisocial impoverished parts of the states where they developed public health strategies around reducing gun crime. The great thing about the states is that because the funding for those programs would come on and then come off. They can show when the services are on, gun crime goes down. Services come off, gun calm rises. So you get these obscene natural experiments. But Glasgow was the knife homicide capital of Europe in the early 2000s. They didn't have one knife homicide in Scotland last year. How did they do it? they targeted the antisocial gangs and got the leaders of those out. They brought in stiff penalties for carrying knives. The cops realized that they were never going to stop and search their way out of the problem. They had doctors against gun crime, they had the mothers of the victims, they had school-based initiatives and they put educational development in. So they identified the kids who were at-risk, and they got them into education, into job training, and they celebrated their successes. So you give kids a different line to go and you pass the messages as to how destructive knife crime is and you lead them in different ways. They've done that with gun crime in the US. We could do exactly the same here. The problem is generally in the US, gun control has been taken away as an issue of public policy. So if you think of that suite of things they did in Scotland, the gun control piece, it gets taken out. So the only bit you're left with is developing things for antisocially at-risk youth. We are not allowed to do that in America because of mass incarceration policies. The New Jim Crow, where these are all nasty guys who deserve to be locked up. So we were just pandering to the thugs if we do that. So no, we can't do that either. So the only group you're left with to target in terms of public safety of a people with mental illness, who as I said earlier, are a very small part of crime, generally, less than 5% of crime can you put at the mental health related piece. So could we comprehensively attack gun crime in the GTA by those methods? Yep, we can. Are some of those pieces in place? Yes. Is the whole of government commitment to that present here at the moment? No, it isn't. Mass killings are very rare, but important subset of that. And amongst those, there is a greater overrepresentation of people with mental illnesses, not 5%. It's more like 30 to 40. But the statement that you said is that you must be mentally unwell to do it, does not hold. And that has to be the lesson from terrorism. So all of the terrorist attacks in the US last year were right wing extremism, some of those people may have paranoid disorders or things of that sort. The overwhelming majority did not which creates and propagates hate. We probably need to think about that from a public health perspective if we're going to offer some of these things. So the messages are don't take the levers for change off the agenda and the way in which the US has think of it. The best interventions are complex and multi layered, and integrated in terms of how they're done things and issues like gun crime and local antisociality are soluble, not eliminated. But vastly reducible is what the Scottish message tells us.

Max Strauss [38:33] Alongside act of gun and mass violence, child abuse is another mainstay in the media. Our society views sexual abuse of children as one of the most heinous crimes and rightly so. Lately, though, it seems as if there's been a barrage of media coverage of pedophilia, from the documentaries featuring the victims of R Kelly and Michael Jackson to the decades of headlines of the Catholic clergy.

Eryn Tong [38:54] Despite this uptick in attention, our next guest tells us that the rates of child sexual abuse has been on the decline for quite a while now. Dr. James Cantor is a psychologist and senior scientist at CAMH. His research focuses on the neurological basis of pedophilia, and paraphilias, or atypical sexual interest. While helping pedophiles might not be the first thing people think about when trying to address child abuse. His hope is that by understanding how this problem starts, we can figure out how it can end.

Max Strauss [39:20] In our conversation. We learned that for pedophilia, we have identified many many physiological markers by which we can say that there's something about the brain development that makes these individuals physiologically different from non-pedophiles. Here's Dr.Cantor.

Dr. James Cantor [39:34] When we first started these studies, we had already established by them that there were several neuro-psychological differences certain very minor, very mild behavioral differences or patterns of strengths and weaknesses that pedophiles showed. Some of them were just you know, small malformations on the skin like attached to your lobes, or they were much more likely to be left handed. Things that only happened before birth. These are thingsthat, one does not learn. They don't change after birth. So anything I could find that ultimately tells me what was going on at an early period of development, that gives me very strong evidence and the nature-nurture debate for whether this is a brain reflecting experiences, or whether these are behaviors reflecting brain anatomy. Now, in our first MRI studies, all we were expecting was stuff to be on the surface of the brain, that's where, you know, all the gray matter was, and in those days, you know, that's where everything interesting was. So that's what we were looking for. And when we started running the numbers in this series of analyses, and it was just page after page after page of nothing, after nothing after nothing, blank after blank. It was supposed to be just bright, colorful, you know, design showing you where the significant differences was, but everything was just black and white and gray. I was lucky, however, in that, I had very good research assistants who were chunking through the numbers at the time. And even though, I was essentially ready to just give up and just crawl under a rock, they continued running kinds of analyses and normally wouldn't be done, rather than just limiting themselves to the surface area of the brain to the cortex, which is where, as I say, everything hot always seemed to be. They were also running scans on subcortical stuff, which, again, I had no reason to think that the lizard brain stuff would be any different, but whatever, they were running it anyway. But on the way there, they also found that there were these dramatic deficits in white matter. White matter's the connective tissue. It doesn't do anything, it's just the axon tails that hang off, you know, the actual parts of the neuron cell that actually are active, what could connective tissue possibly have to do? It makes absolutely no sense to me. And then I just ran into this one other paper and meta-analysis by a [talented French] researcher and neuroscientist. It was a meta analysis of activations studies, which again, especially in those days was particularly advanced. Essentially, he took all of the brain activation studies of people who were shown porn while in EEG or fMRI to show which parts of the brains became more active when the person who was sexually aroused and he showed it was about you know, a dozen different regions. Fascinating. As I read through the list of regions that lit up when somebody is shown porn, I said, Wait a second. All those areas are the same areas that are connected through the same frickin chunk of connective tissue that we just found was deficient in the pedophiles. They weren't deficient in just any clump of connective tissue. They're deficient in the clump of tissue that's supposed to connect the various parts of the sex response system into one sex response network. It's like there was a cross wiring. But in the pedophiles viewing the kids seems to be triggering the sex response system, either in addition to war instead of the avuncular caring kind of instinct. All of a sudden, all of this bizarre stuff made sense.

Max Strauss [43:21] Dr. Cantor touched on some of the physiological changes that can happen before birth and paedophiles. We asked if sexual abuse experienced during childhood can also lead to perpetrating abuse as an adult.

Dr. James Cantor [43:32] The thing that seems to affect the brain when it suffers abuse is not the kind of abusebut the stress the person was under. All of the research on how the brain responds long term to stress show the same thing whether it was sexual abuse, non-sexual, violent abuse, or even just neglect. Although sexual abuse does seem to predict several problematic outcomes in adulthood, it doesn't seem to be specific to sexual abuse. It's any kind of abuse, so it's really the stress that does it. One of the long term effects appears to be an inability to deal with stress. And so taking a kid with a vulnerability towards stress because of how we developed in the womb. Again, in these cases, they're mostly a kid who is abused in childhood and so again, doesn't have the opportunity to, for example, compensate for stresses that accumulated in the womb, now doesn't have the ability to deal with stresses or has a hampered ability to deal with stresses in adulthood. If he has a predilection towards pedophilia, if he has something you know, that he's not as interested in, when he is under stress in adulthood has no other way to deal with stress. Men often use sex to deal with stress. Men use sex and orgasm to relax to fall asleep. It's self-soothing. If the only thing that soothes him is the thing that you know, he doesn't have have as much impulse control to deal with no role models that ever taught him the skills to handle either the stress or his sexual interest pattern. This is the person more likely to actually act out and commit abuse. And so it seems to be that pattern that inability to inhibit ourselves seems to be the link between childhood abuse and adult abuse. It doesn't seem to be the kind of sexual abuse begets sexual abuse and that kind of learned "like makes like" kind of way. It seems to be chaotic. childhoods beget chaotic adulthoods. You know, a sexually abused child could just as easily end up being a physically abusing adult or a neglected child could end up as sexually abusing adult. There doesn't seem to be a one-to-one correspondence. It's chaos begets chaos. There doesn't seem to be a learning or genetic component, even though there does seem to be a intergenerational transmission of problems.

Eryn Tong [45:56] So what makes the difference between someone that has a sexual interest and acts on these thoughts versus another Who doesn't?

Dr. James Cantor [46:03] The most important thing about understanding pedophilia and the definition of pedophilia is [that] it's a standard Venn diagram between pedophilia and child abuse. Some pedophiles abuse children, some do not. Some child abusers are paedophilic, most of them are not. Roughly two thirds of people who commit sexual offenses against children are actually not paedophilic. They actually prefer adults as sex partners, but use the kid kind of as a surrogate. Now, the pedophiles who are not child molesters, and they call themselves at this point, virtuous pedophiles, and savage used to call them the goldstar pedophiles. These are people who realize, through no fault of their own, they're into kids, they didn't pick it, they figured it out as they were growing up. The rest of us when we're 10, 11, 12, 13, we get crushes on 10, 11, 12, 13. That's that. But these people by the time they start hitting 17, 18, 19, and they're still getting crushes on 11, 12, 13, they only just then start realizing something's up and they realize immediately they can't tell a soul. Now the best that they can do and what many of them do do is swear themselves essentially to a life of celibacy, completely unknown to anybody else. So as I say, there is also a group of pedophiles who are not child molesters, and they are invisible. So for understanding each of them, we need to remember that we're actually looking at two important psychological and neuroscientific factors. One is the sexual interest pattern. They're into children or into adults. And as best as we can tell, that's neurological. The other is antisociality and psychopathy. And again, as best as we can tell it, that also has very, very strong neuro-psychological correlates. Now a person can have one, the other, or both. A person who's psychopathic or anti social will steal whatever they want. They're the ones who will grab they will attack you know, and in the truly dangerous ones, they're the ones who abducted and really, really hurt people. They're fortunately rare. But the problem really is not pedophilia. Exactly. It's the anti sociality and the psychopathy. The difference between being a pedophile or not is really the difference of whom they are going to choose as a victim. It's not really a difference of whether they're going to have a victim. If a person is a psychopath, and they only get off on hurting somebody, they're gonna hurt whatever it is they're into. If they're into adults, that's who they will hurt. If they're into kids, that's whom they will hurt. Now, of course, we have a very natural, larger guarding instinct to the kids that are in danger, which is perfectly correct. But if we want to understand what's going on in the brain in order to detect and prevent it to figure out whatever way to make it less likely that a person will develop in the first place and so on. But we need to treat each of these as distinct phenomena.

Max Strauss [49:12] In order to fully understand this quite complex problem, sometimes helps to try and understand all of the perspectives.

Dr. James Cantor [49:19] The pedophiles themselves in general do not want to be pedophiles. Imagine what a curse it is to have to live an entire life with a sexual interest pattern you cannot express ever, once, zero tolerance, no exceptions, not so much as porn. Right? I couldn't imagine curse to wish on someone, but that's the situation they're in and if we could prevent them from being in that position, they would love for me to be able to find a way to treat this or prevent it from developing in the first place. And attempt to find a conversion therapy you know, is a very, very different ethical situation thenregular gays and lesbians, where [they can] have a good time get married enjoy.

Eryn Tong [50:05] Dr. Cantor tells us that there have been attempts to change pedophiles into non-pedophiles. But such claims haven't really been legitimate or successful thus far. Dr. Cantor also described a very stark climate for people who have these types of sexual desires. He often hears from clients he treats that they wish they didn't experience these feelings if these aren't things that they can necessarily just turn off. So in light of this, what kinds of supports are there for pedophiles? Are there resources they can access to help them avoid acting on their desires.

Dr. James Cantor [50:34] There's a group that I you know, cannot endorse enough and they call themselves the virtuous pedophiles. It took me a while to be able to say that phrase because it is such a counterintuitive phrase. But I've gotten used to it and it actually does fit. So these are people who recognize their sexual attractions to children. And because of course, they have no other place to turn, they support each other. Sometimes it's just reminding each other that they're not the only one in the world and it's just random chitchat with the only other people who know their deepest, darkest secrets so they feel like they have a greater attachment than they can, or a different but very important kind of attachment that they can't with their friends and their regular physical offline lives. Their website is vrpd.org, virtuous pedophiles.org. I would like to be able to send people in to therapists. Unfortunately, the mandatory reporting situation has made that very, very difficult. If we think that there's a child some someplace in need of protection, if they're being abused, for example, by somebody in their family, we find out about it, we have to report that to the Children's Aid Society and to anybody else as necessary to protect that child. That's perfectly fine. Unfortunately, the way things go and the way people behave is not exactly according to the letter of the regulation, but according to what they think will get them sued. We need to have some specific method, either anonymous or some statement that the mental health professionals can use really to give us the kind of confidentiality that other jurisdictions have. I can understand the idea, you know, oh, my God, somebody is being hurt. You want to report them to the police in order to stop the hurt. But really once you permit that all you're doing is stopping the person from telling the shrink the first place. You haven't protected anybody, the hysterical public, and the legislators are patting themselves on the back for being bad to the bad guys. But all they've done is driven the problem underground where we can't help anybody. It's insane.

Max Strauss [52:42] When a sex offender is convicted, what does the rehabilitation process look like?

Dr. James Cantor [52:47] Many programs have been put in place to treat sex offenders, but very few of them are based on any kind of science. I don't know what to call it. The closest term I have is when Stephen Colbert said truthiness. These treatments are filled with therapy-ishness. It borrows terms that are familiar. It uses terms like CBT, and it says learning it looks legit, but none of them have been tested. It's not like let's take 100 people put them in this program, another hundred people put them in that program and look up what happens in 10 years. Nobody's done that kind of stuff or at least to the extent that kind of thing has happened. The answer has been the treatment really doesn't matter. The primary thing that makes the difference between somebody who's going to commit another offense or not is exactly the thing that the public doesn't want to hear. Give these people a chance to reintegrate into society in a healthy way. Help them find a job, get an education, help them rehabilitate themselves, find a place to live, [and] find a place to work. When people have a life worth defending, they will do what they need to defend their life and keep on the straight and narrow. When people have nothing left to lose, they behave like people with nothing left to lose. But all we've done with these angry policies is make sure they have nothing to lose. We should help them but that requires a level of empathy, mercy, forgiveness and understanding that is unheard of today. One of the most wonderful phrases I heard to help people get past the unbridled anger that is really fueling this kind of hysterical legislation is to forgive people, not because they deserve forgiveness, but because you deserve peace. We have every reason, I understand it's hard and that the gut reaction is the anger, but that's not where the solution is going to be.

Eryn Tong [54:43] Taking in all that we've touched on in this episode, we can now deeply appreciate the work that professionals in the forensics field do on a daily basis.

Max Strauss [54:50] The popularity of true crime has skyrocketed from our beloved serial podcast to Netflix's Making a Murderer and recently Conversations with the Killer: The Ted Bundy tapes. Many of us really gravitate towards true crime. But have you ever wondered why?

Eryn Tong [55:04] Maybe because the subject matter itself is compelling. It's inherently intriguing. But at the root of it true crime stories are stories about the human condition. What drives someone to commit such extreme morbid acts? We want to understand human behavior and the forces behind something that we could only imagine to be inconceivable. We are curious about other people's stories. And it's also an opportunity for us to learn about the broader societal structures we live in that house issues like mental health, sexual and physical abuse and neglect.

Max Strauss [55:33] And I think today's episode helped us do just that. Our wonderful guests helped us open our eyes to an area in the population that our society may tend to turn away from. We would like to thank Dr. Bloom for your insights into the intersection of the criminal justice system and the practice of forensic psychiatry, to Dr. Simpson for your reminder that our society's health duty towards all individuals with serious mental illness, and to Dr. Cantor for your frank discussion on the science of paraphilia and pedophilia, and for creating a little empathy with regards to those phenomena.

Eryn Tong [56:04] Today's episode was hosted by Max and myself, Eryn. Help with content production by James and Alex. Production and Sound Design by Max.

Max Strauss [56:11] Until next time, keep it raw. Raw Talk Podcast is a student presentation of the Institute of Medical Science in the Faculty of Medicine at the University of Toronto. The opinions expressed on the show are not necessarily those of the IMS, the Faculty of Medicine, or the university. To learn more about the show, visit our website at rawtalkpodcast.com. Stay up to date by following us on Twitter, Instagram, and Facebook at Raw Talk Podcast. Support the show by using the affiliate link on our website when you shop on Amazon. Also, don't forget to subscribe on iTunes, Spotify, or wherever else you listen to podcasts and rate us five stars. Until next time, keep it raw.