Richard Doan is a Psychiatrist with Inner City Health Associates and Assistant Professor of Psychiatry at the University of Toronto in Toronto, Ontario
On December 19, the Globe and Mail reported developments in the case of an unprovoked stabbing death of a vibrant young woman in a downtown Toronto drugstore by an also-young, and unknown, female assailant. As it turns out, the alleged assailant, though well-dressed and well-educated, was homeless and living on the street. It also appears that she was likely seriously mentally ill.
This story, as sad as it is, is naturally of interest to me, a psychiatrist who works with a street outreach team serving people who are homeless in Toronto. I never met the alleged assailant, but I wish I had. Then again, it is not certain that any involvement or intervention by our team would have made a difference.
The Globe and Mail reported that the alleged perpetrator habitually wore “an immaculate black suit and dress shirt” and had an MBA. She passed her days in a downtown Starbucks but she “spent her nights much like the panhandlers did, sleeping on subway trains and in the maze of tunnels and shops beneath the financial district, where she had once worked”. What the reporter described as "her charade” ended with the alleged stabbing.
“Charade”? Really? Since when is being homeless a charade? This is far, far more tragic than a parlour game.
The article also reports that the former MBA student had spent some time in hospital, presumably for mental health reasons, but she told friends that “she did not want to go back to the hospital”. She had broken up with her live-in partner and was alienated from her family, but still had the support of an elderly former professor, who said that “if she realized she was struggling with serous mental-health issues she never talked openly about it . . . 'She never brought it up and I never suspected a thing’.”
According to the article an email was sent to another newspaper from her e-mail address in which the writer “asked for help finding professionals in ‘artificial intelligence, biotechnology, nanotechnology, satellites’, military or government”. The writer “apologized for the stabbing . . . 'I felt the need to be extreme to see if it would work . . . Something has been happening to me and this is not my normal self . . .’”
We are shocked and fascinated by this case because of our stereotypes regarding those who are homeless and suffering from mental illness. We expect to them to be disheveled with poor hygiene, perhaps intoxicated, gesticulating to themselves or panhandling while sitting on a subway grate. They are manifestly not us, and we give them a wide berth. Why, this young woman could have been a relative, former colleague, or childhood friend! As if others on the street are not.
I wonder if our team would have been able to help her. Perhaps, if someone who had seen her on a daily basis would have gone beyond our stereotype of homeless individuals and had known to contact authorities or outreach services such as ours. Like other street outreach workers, we pride ourselves on engaging the most isolated, fearful, and marginalized folks. But our services are voluntary, and despite the obvious mental illness of some, the Ontario Mental Health Act does our society no favours.
The Harper government commissioned the Hon. Mr. Justice Richard Schneider, who long presided at Toronto’s Mental Health Court, to write a report about those with mental illness in the criminal justice system. The former federal government did not release the report but it is available under the freedom of information act. In his report, Justice Schneider writes of the shift from the law’s earlier parens patriae and “need to treat” approach to one based on civil rights and dangerousness as the grounds for involuntary confinement in hospital. With this way of thinking, “if an individual is not seen as dangerous to himself or others, he is free to roam the streets 'madder than a hatter'.” However, “the problem with this dangerousness-based legislation, some say, is that we are not able to determine with any accuracy who should be detained and who should not.” Consequently the mental health system “is simply unable to reliably capture many disordered individuals who are at risk of criminal activity . . . you will inevitably and unavoidably have mentally disordered individuals leaking through the ‘civil net’ and slipping downstream to be caught in the ‘forensic net’”. Judge Schneider proposes a federal mental health act with hospitalization “based upon illness and lack of insight (as well as, or perhaps instead of, dangerousness)”. He acknowledges that such a change “may not be accomplished easily”. I can already hear the enraged anti-psychiatry lawyers.
St. Francis de Sales said that “you can attract more bees with a spoonful of sugar than a cupful of vinegar”. Our team offers the “sugar” of practical support, genuine concern, and a willingness to support those who live with mental illness and homelessness on their own journeys toward housing and healing. Many are helped, but sometimes it’s not enough. So why does our mental health act see hospitalization as “vinegar”, a failure, or something to be avoided at all cost? And what does the law have to do with the care health professionals want to offer those who are mentally ill? Will our emphasis on civil rights and autonomy provide solace to two grieving families and a frightened and confused prisoner?