The lived experience of paroled offenders with fetal alcohol spectrum disorder and comorbid psychiatric disorder

Introduction

Our overall research project focuses on an ethnically diverse forensic population of adult men who attend the Saskatoon Health Region’s Forensic Psychiatric Outpatient Clinic in Saskatoon, Saskatchewan. We present a case study of two patients, Garth, ¹ a 61-year-old Caucasian man living with borderline personality disorder with antisocial personality traits and schizoaffective disorder, and Arnold, a 66-year-old Métis man living with chronic depression and schizophrenia. Both men were recently diagnosed with fetal alcohol spectrum disorder (FASD). The men met and became friends in prison and years after their release, from June 2013 to December 2014, lived together as roommates. Despite the documented challenges faced by male offenders living with comorbid psychiatric illness and FASD, the two men achieved and sustained a notable period of stability during which time they reported living meaningful and happy lives, including successful management of their mental illness.

An examination of the 18 months that Arnold and Garth lived together illustrates the importance of the supports provided to the men by their health care team. However, with their continued stability and growing independence, the level of support provided to the men was gradually scaled back. Unfortunately as services were decreased, important vulnerabilities arose for the men that neither the health care team nor the men identified prior to a serious crisis occurring; one that ended Garth and Arnold’s cohabitation and resulted in Arnold’s hospitalization.

Understanding the scope of patient vulnerability is a key challenge for health care teams who provide support to mentally ill patients living in the community. In this paper we argue that this is particularly true for mentally ill paroled offenders who have been institutionalized for several years and have complex life histories. In our study, the life history narratives of Garth and Arnold provide a deeper understanding of their life long vulnerabilities including undiagnosed mental illness and FASD, risk of suicide, and the limited opportunities throughout their lives to build healthy family and social support networks. As importantly, the life history narratives draw attention to the strengths and resilience of Arnold and Garth despite the adversity they experienced as children and into adulthood. From a policy perspective the linking of life histories to the present day circumstances and experiences of mentally ill offenders better illustrates the intersection of psychosocial factors that contribute to postincarceration success as well as to offender and system vulnerabilities that directly and indirectly contribute to relapse, criminal behavior, and recidivism.

Fetal alcohol spectrum disorder and comorbid mental illness

Fetal alcohol spectrum disorder is an umbrella term encompassing a range of birth defects associated with prenatal alcohol exposure. The most severe presentation of the spectrum, fetal alcohol syndrome, describes a set of anomalies including pre and/or postnatal growth deficiency (low birth weight and height), central nervous system (CNS) dysfunction, and characteristic cranio-facial malformations (Clarke & Gibbard, 2003; Jones & Smith, 1973; Riley, Infante, & Warren, 2011). Damage to the CNS is the most disabling effect and the severity and manifestation of disability varies, existing along a spectrum of cognitive deficits and maladaptive behavior (Chudley et al., 2005). CNS dysfunction can be worsened over the lifespan by negative socioenvironmental conditions; however, early diagnosis, a stable and nurturing home environment, and access to treatment and disability services greatly reduce dysfunction (Streissguth, Barr, Kogan, & Bookstein, 1996).

The presence of comorbid psychiatric illness and FASD greatly impacts patient care, including the added complexity for clinicians when assessing patients and assigning a diagnosis, and for health care providers to deliver adequate treatments and supports (Fast & Conry, 2011). The risk of poor health and social outcomes for patients also increases when comorbidity is present (Grant, Huggins, Connor, & Streissguth, 2005; Pei, Denys, Hughes, & Rasmussen, 2011). Rates of psychiatric disorders such as attention deficit hyperactivity, bipolar, conduct, oppositional defiant, personality, and psychotic disorders, along with depression, anxiety, and substance abuse are all found to be elevated among patients with FASD as compared to the general population (Brown, Long-McGie et al., 2014; Fast & Conry, 2004, 2011; Pei et al., 2011). Neurocognitive problems experienced by individuals living with FASD, such as impulsivity, difficulty with attention, and maladaptive functioning, also overlap with other learning and behavior disorders, adding to the diagnostic challenges of distinguishing FASD from other disorders (Fast & Conry, 2011; Jonsson, Dennett, & Littlejohn, 2009).

In the practice of psychiatry, a lack of diagnostic clarity and approved treatment protocols has led to FASD being marginalized by psychiatrists as a viable diagnostic consideration (O’Malley & Rich, 2013). Management of psychiatric patients with undiagnosed FASD can result in patients not responding to psychiatric treatment as expected, lower levels of patient compliance to medication and treatment regimes, and ongoing patient instability (Brown, Long-McGie et al., 2014; Fast & Conry, 2011; Jonsson et al., 2009). This can also negatively impact the ability of families and caregivers to successfully provide appropriate home and environmental supports. The failure in recognition and inadequate management contribute to negative outcomes dubbed “secondary disabilities” and include, for example, disrupted school experience, unemployment, trouble with the law, confinement, alcohol and drug problems, increased mental distress, and inappropriate sexual behavior (Streissguth et al., 1996). Due to the multiple factors that underlie the manifestations of FASD and complicated psychiatric disorder management, an increased consideration by psychiatrists to the presence of FASD and new ways of understanding the relationship of FASD to comorbid psychiatric illness is required (Pei et al., 2011).

FASD and the criminal justice system

FASD is overrepresented in forensic populations; however, precise prevalence rates in Canada and elsewhere are unknown (Burd, Selfridge, Klug, & Juelson, 2003; Fast, Conry, & Loock, 1999; Popova, Lange, Bekmuradov, Mihic, & Rehm, 2011). Former inmates living with FASD are identified as a high-risk population to reoffend and for those with psychiatric comorbidities, risk of committing impulse-related violent offenses is elevated (Brown, Herrick, & Long-McGie, 2014; Fast & Conry, 2011; McLachlan, 2012).

The Canadian criminal justice system has long struggled with identifying offenders who are living with FASD and experts believe most have gone undiagnosed (Boulding & Brooks, 2010; Brown, Long-McGie et al., 2014). This presents a number of problems. For example, as individuals living with FASD move through the justice system, they can appear to understand the reasons why they have been arrested, what they are being charged with, their rights while in custody, details of their defense and trial, and why they may go to prison. However, these individuals’ ability to understand, process, and remember details may be significantly impaired (Boulding & Brooks, 2010; Fast & Conry, 2011). This also holds true postincarceration, where keeping appointments with parole officers and adherence to conditions of their release can be difficult due to their illness. For offenders in Canada from Indigenous and ethnic groups where English or French is a second language, the challenge is even greater.

Undiagnosed FASD with comorbid psychiatric illness, along with a lack of supports such as stable housing and transportation, and effective treatment options, exacerbates the problem and increases the risk of recidivism. In cases where FASD is undiagnosed, behaviors can easily be misinterpreted as deviant or noncompliant and result in increased sentencing and incarceration (Brown, Long-McGie et al., 2014; Fast & Conry, 2004, 2009).

There is consensus that rates of FASD among inmates are highest in subpopulations where elevated rates of prenatal alcohol exposure are confirmed and other significant maternal risk factors for FASD exist (Burd et al., 2003; Fast et al., 1999; Popova et al., 2011). In Canada, compounding historical factors such as the impacts of the residential school and the child welfare systems, loss of land and dislocation, elevated rates of substance abuse, and health and social disparities experienced across generations of Indigenous peoples, suggest FASD and comorbid mental illness are most likely elevated in the Indigenous forensic population (Mann, 2009; Public Safety Canada, 2010). However, prior to involvement with the criminal justice system, most Indigenous offenders living with mental illness or FASD have limited or no access to prevention, diagnostic, and treatment services and it is assumed most enter prison without a diagnosis. This is due in part to social (racism, stigma, poverty) and geographical (limited health services in remote, northern, and rural communities) barriers, and to gaps in diagnostic services (Tait, 2003a). Important to note is that unlike in other cultural/ethnic groups, a practice of nonmedical labeling of Indigenous offenders with FASD by professionals such as social workers, lawyers, judges, and prison advocates commonly occurs in Canada (Tait, 2003b). This further confuses the use of the FASD label in prison populations and perceptions of prevalence rates generally, including limited consideration of the presence of FASD in non-Indigenous prisoner populations.

The complexity of behavioral profiles of prisoners living with FASD is a factor in determining whether an assessment for FASD adds information that will help in rehabilitation and reduction of recidivism. Screening and diagnosing FASD in adolescent and adult offenders is not only challenging given this complexity, but it is also costly (Chudley, Kilgour, Cranston, & Edwards, 2007; Popova et al., 2013). Therefore, on the one hand, it could be argued that a therapeutic approach that forgoes the cost of a FASD assessment and instead targets prisoners generally who are struggling with cognitive and mental health challenges may free up health care resources that could be used to tailor rehabilitation and reintegration services to individual offenders. On the other hand, it can be argued that a diagnosis of FASD supported by evidence-based treatment and interventions during and postincarceration can provide specialized supports that result in better patient outcomes. The high cost of screening and diagnosis in this context could be offset if identification of FASD plays a protective role by linking offenders with appropriate support, structure, and supervision. Unfortunately, neither option has been fully implemented and researched to determine which approach provides the optimal outcomes for prisoners, public safety, and reduction of criminal justice costs associated with recidivism.

Transition to community

The transition from incarceration to reentry into society is a vulnerable period for individuals living with FASD and is further compounded when comorbid psychiatric illness is present (Brown, Long-McGie et al., 2014; Conry & Fast, 2000). Without proper services, supports, and treatment options that take into account the complexity of their needs, these individuals are at elevated risk of breaching their conditions of release and/or reoffending (Brown, Long-McGie et al., 2014). When the person’s FASD or mental illness is not diagnosed and is unrecognized by them and their parole officer, this compounds the risk significantly. Typically in Canada, offenders living with mental illness and FASD are provided some level of support during the postincarceration supervision. Paroled offenders receive supports from either the federal and/or provincial systems, depending on whether they served their prison sentence in a provincial (less than 2 years) or federal institution (over 2 years). In many cases they receive supports from both systems, which can create confusion if communication between the systems is inadequate. Depending on the conditions of their release, paroled offenders may live in halfway houses or group homes for offenders living with mental illness. While these options provide safe shelter, the support and the structure of the environment may not meet the specific needs of the individual. In Canada, having a diagnosis of FASD with or without an additional psychiatric disorder does not guarantee a comprehensive set of supports beyond those offered in the context of parole conditions, despite growing clinical evidence that the integration of specialized supports such as a mentor and a coordinated health care team can greatly reduce rates of recidivism or hospitalization among this population (Brown, Herrick, et al., 2014; Gerger, 2011; Radford-Paz, 2013).

Parolees are required by the justice system to follow a set of conditions and to meet regularly with their parole officer; however, breaches of conditions of release are common for paroled offenders living with FASD (Brown, Long-McGie et al., 2014; Conry & Fast, 2000; Fast & Conry, 2009; Mela & Luther, 2013; Roach & Bailey, 2009). For example, their ability to understand and follow their conditions of release can be impaired because of memory deficits (e.g., forgetting about appointments or agreements with their parole officer), difficulties with time management, and problems avoiding substance abuse (Brown, Long-McGie et al., 2014; Mela & Luther, 2013; Roach & Bailey, 2009). Living with comorbid mental illness can exaggerate risk in some offenders living with FASD, while for others the recognized need for professionals to manage the offender’s mental illness, such as is the case of Garth and Arnold, places these offenders in regular contact with a psychiatrist and other health and social service supports, indirectly helping them to manage their FASD whether it is diagnosed or not. Arnold and Garth’s case study is generated out of a specialized clinic in Saskatoon, Saskatchewan that is dedicated to addressing the gap in FASD assessment for paroled offenders living with mental illness. The case study draws attention to the added complexity of integrated patient management required for this group of offenders postincarceration and provides much needed direction for health care and corrections leaders tasked with increasing patient/offender success.

Methods

The case study focuses on two male psychiatric patients living in Saskatoon, Saskatchewan who were enrolled in a diagnostic and case management study. The Saskatoon Forensic Psychiatric Outpatient Clinic identified five areas ² that contribute to the success of parolees living with FASD and comorbid psychiatric illness: (a) a stable, consistent, and trusting relationship with a psychiatrist; (b) a medication regime that provides optimal satisfaction (e.g., fewest side effects while successfully regulating symptoms); (c) living in a stable, safe home environment; (d) consistent family and social support networks; and, (e) constant and reliable mentors trained in the skills required for hands on mentoring with individuals with FASD (Mela, 2013; Mela & Tait, 2014). The life history project sought to explore these findings from the perspective of Garth and Arnold, particularly to identify the level of importance given by the men to the five areas, including how the supports figured into the broader life context of the men.

Both Arnold and Garth attended the clinic and were diagnosed with FASD according to the Canadian guidelines (Chudley et al., 2005). At the time of their assessment, they had each been paroled for more than 5 years. After discussing the goals and scope of the life history project with the two men, their psychiatrist (MM) referred them to the principal researcher (CLT). Garth and Arnold attended introductory meetings with the researcher to receive details about the objectives and scope of the study and to confirm their interest. They met individually and together with the researcher several times over a 1-year period. The interviews (60–90 minutes) were audio recorded, transcribed, and reviewed by the participants for accuracy. Garth and Arnold were also asked to take photographs representing their everyday lives and during the interviews discussed the photographs with the researcher, explaining the importance of the images. The photo-voice method (Wang & Burris, 1997) of interviewing was particularly important for generating new lines of discussion and for the researcher to gain a deeper understanding of their roommate relationship, everyday activities, and the importance of supports such as stable housing. After the completion of the interviews, Garth stayed involved with the project for the writing of this manuscript. The project was approved by the University of Saskatchewan Research Ethics Board (BEH# 13-124).

Case study

As young men, Garth and Arnold were convicted of serious violent crimes and served lengthy sentences primarily in the Prince Albert Federal Penitentiary (PAFP). Garth is 61 years old, Caucasian, and is diagnosed with borderline personality disorder, antisocial personality traits, and schizoaffective disorder. He was physically healthy until 5 years ago when he became more fragile and required a walking cane. Garth reports a high level of satisfaction with his current treatment and monitors his mood for when he feels “too up or too down.” During periods when he feels he is becoming mentally unwell, Garth seeks help from his psychiatrist or community health worker. He has good relationships with his health care team and parole officer.

Garth describes a turbulent childhood including being abandoned at the age of 2 in a rooming house with his infant brother by his mother; the children were not discovered for 4 days. While in a long-term foster home Garth was regularly spanked, tied to his bed at night, and forced to eat bars of soap as punishment for “bad” behavior. At the age of 10, he was placed in a group home after he and his brother ran away from the foster home. Because Garth and his brother frequently fought, Garth was moved to the building that housed the older children. Shortly after being moved, he was raped by one of the older youths.

Over his childhood, Garth experienced behavioral problems and found it difficult to concentrate and learn. At school he was in and out of trouble, commonly fighting with other children, stealing, and running away. Garth describes not having close friends and while he was close to his younger brother he felt his brother was favored in school and at their foster home. Participating in sports was the only time he felt connected socially with other children and it helped him to cope with his built up energy, anxiety, and anger.

After Garth was raped, his behavioral problems escalated and he withdrew from everyone at school and the group home. He did not tell anyone about the rape out of fear of retribution from his rapist and despite a counselor being assigned to him Garth kept the rape a secret. The shame Garth felt about the rape continued for many years and it was only much later while in prison that he disclosed the rape to a counselor.

Garth had a strong bond with his father throughout his childhood. His father visited his sons while they were in the foster and group homes and at the age of 14, Garth and his brother went to live with their father and new stepmother. This was an important time for Garth as he deeply loved his father and had always dreamt of living with him. His father and stepmother also had a child, a girl, and Garth quickly formed a close bond with her. An argument with his stepmother led to Garth leaving the family home a year after he had moved in. He lived on the streets for a few months before being arrested and convicted of a minor crime. Because of his aggressive behavior, Garth’s stepmother would not allow him to return to the family home and he was placed in foster care until he was 16 years of age.

After leaving foster care, Garth began working odd jobs, eventually moving to Calgary. He first attempted suicide a few months later and because the clinic did not identify the injury as the result of a failed suicide attempt, he was never referred to a mental health therapist. Garth’s second attempted suicide occurred a few years later when he was out of work and very depressed. His brother interrupted the attempt, they argued, and Garth stabbed his brother several times. The offence was judged as having a psychotic motive and Garth was found not guilty for reasons of insanity and spent a year in a psychiatric hospital. Three years later, Garth was convicted of the death of his infant son, an impulsive act that he describes as an accident precipitated by the difficulty he was experiencing coping with his mental illness, which was undiagnosed, and the stress he and his partner were experiencing caring for their infant son. Garth spent 21 years in prison, much of it in the PAFP Mental Health Unit. While he could have applied for parole earlier than he did, he did not feel he deserved to be released. It was while he was in prison that he was diagnosed with borderline personality disorder and antisocial personality traits.

Garth met Arnold in the PAFP Mental Health Unit in 1980. Arnold is from a northern Saskatchewan Métis settlement and has a strong Métis identity. He is currently 66 years old and in good physical health. Arnold’s childhood was characterized by poverty, parental alcohol abuse, and family dysfunction. He has a number of siblings and a large extended family; intergenerational alcohol abuse remains common in his extended family. Arnold found it difficult to talk about his childhood but spoke fondly of both his mother and father and growing up in his family home. As a child, Arnold was exposed to alcohol at an early age and began drinking heavily as a preteen. This continued into adulthood including after his son was born. Violence commonly accompanied his drinking episodes and at the age of 30, he murdered a woman in a drunken rage. Arnold was convicted of second-degree murder in 1978 and spent 21 years in prison before receiving day parole. Arnold had no access to mental health services prior to incarceration and it was not until he was in prison that his depression and schizophrenia were diagnosed. Today he remains connected to his extended family but chooses to live in Saskatoon because of the level of alcohol abuse in his family.

The friendship between Garth and Arnold grew over the years of their incarceration. While they both served the majority of their sentences in the PAFP Mental Health Unit, they also attended the Regional Psychiatric Centre in Saskatoon. Both Garth and Arnold attempted suicide several times while in prison, describing the attempts as being driven by the guilt and shame they felt about their crimes. The counseling support they received in prison from health care providers and clergy allowed both men to eventually reconcile within themselves the dreadfulness of their crime with their ability to move forward in life. Once this happened, they said they no longer felt compelled to turn to suicide to cope with their pain. Garth dedicated his life to the memory of his son and Arnold committed himself to a life of sobriety. Despite the progress the men made, both stated firmly that they would take their own life if they were faced with going back to prison.

Arnold was the first of the two to be paroled, receiving day parole in 1999 and full parole in 2001. He first moved into a highly structured and supervised mental health approved home. He then moved into a less structured home before living independently for a year. While Arnold was supported by regular contact with a community mental health worker, living alone proved challenging. Arnold found it difficult to manage his finances and at times difficult to manage his illness. Arnold’s community treatment program consisted of antipsychotic medications and regular meetings with his psychiatrist, caseworker, and other health professionals. Despite being on medication, Arnold experienced occasional symptoms of psychosis and depression. He participated in a number of educational programs on basic life skills and schizophrenia that were offered by a local mental health centre. Arnold also developed a social network through activities such as bingo and an exercise regime. After his release, he also became a contributing member of the community in a number of ways including conducting interviews for teaching group home operators and mentoring young offenders. Arnold receives social support from a small group of friends including Garth, some members of his family, and a long-term mentor. While Arnold does not practice traditional Indigenous or Métis spirituality, he has strong social connections both in the Indigenous community of Saskatoon and in his home community and because of this he experiences less social isolation than does Garth.

In 2001, Garth was released to a private care home with day parole and received full parole in 2005. He was sent back to prison in 2011 for a breach of parole; however, the Parole Board overturned the breach and he was placed back on day parole. Garth lived semi-independently until he moved in with Arnold in 2013. When living alone, he struggled with his finances and eventually was appointed a trustee to manage them. Garth does not have contact with his family but is supported by a small group of friends including Arnold, his long-term mentor, and health support team.

Garth and Arnold reconnected postincarceration at an outreach day program. They shared the same community support worker and parole officer, who suggested that because of increasing rent costs, the two men might consider a shared living arrangement. Arnold and Garth agreed and the Parole Board consented to the arrangement. The flexibility within the system that allowed them to live together contributed to the 18 months that the men successfully and happily lived together. In describing their home, both men highlighted the benefit of having another person around to talk to, share a home life with, who understood what it was like to live with mental illness, and whom they could rely on to help them if they were becoming sick again. Sharing expenses also meant they had extra money and their apartment, “their home,” was a great source of pride. While their long-term support worker eventually moved to another job, she chose to remain in the men’s lives, adding to their support network. Both men shared the same psychiatrist (MM), outreach worker, and parole officer.

The shared and coordinated supports in their lives provided a valuable added level of stability for Garth and Arnold because members of their support team were regularly checking in with both men and with each other. This support assisted the men to adhere to their parole conditions and to organize their daily routines. However, as time passed the frequency of contact with their care team decreased and therefore less information was available to the team. This included members of the health care team being unaware that Arnold’s father was dying and of the sudden death of his son—information that would have alerted them that Arnold’s mental illness might be triggered and he could experience a relapse.

After living together for 18 months, Garth and Arnold’s cohabitation came to an abrupt end when Arnold became very sick following the deaths of his 38-year-old son and his elderly father within 3 weeks of each other. The mother of Arnold’s son would not allow Arnold to go to his son’s funeral, despite Arnold’s request to attend. Arnold traveled to his home community for the funeral of his father (a 6-hour trip by bus) and was brought back to Saskatoon by one of his brothers. When he returned he was withdrawn and over a period of days Garth started to see signs that Arnold was losing touch with reality. Arnold’s mood became increasingly agitated, he was unable to sleep, stopped taking his medication, and started chain smoking. Two days before the weekend, Garth reached out for help from their new support worker, a community nurse. He was advised to keep an eye on Arnold and to take him to hospital emergency if he got worse. The worker also arranged for an appointment with Arnold’s psychiatrist the following Monday. Over the next day, Garth grew increasingly worried about Arnold’s behavior, however, he knew Arnold was sick enough that he would never agree to go to the hospital. Friday evening, Arnold became increasingly disordered and violently attacked Garth, resulting in a protracted period of involuntary psychiatric hospitalization. Arnold spent 2 months in the hospital and is now living in a group home.

Garth sustained acute injuries as a result of the attack and experienced psychological and emotional difficulties in the weeks following. He was able to remain living in the apartment and currently receives added support, counseling, and extra money to cover rent costs. At Garth’s request no charges were laid against Arnold, preventing him from being sent back to prison. Garth made this decision because he knew Arnold was very sick when he attacked him and because he knew that being sent back to prison would destroy the progress Arnold had made postincarceration. Both men have remained friends and in regular contact with each other. Arnold does not currently remember the attack.

In discussions about their mental illness and FASD, Garth and Arnold both stated their recent diagnosis of FASD did not hold much meaning for them because it did not provide new insight for their self-care nor did the diagnosis come with added supports. However, for the health care team, knowledge of the presence of FASD should have provided further insight into the behavioral profile of the men, the complexity of their illness, and the consistency of support required for their stability. Unfortunately, even with the added knowledge of the presence of FASD as a factor in patient care, Garth and Arnold’s health care team had limited access to additional training or resources that may have helped them in better supporting the men.

An important observation made by Garth about his mental illness came later in the research when he reported that he felt more stigmatized and feared by society because of his mental illness than he did as a man who had served a life sentence. Garth linked the “double jeopardy” of stigma experienced by mentally ill paroled offenders to barriers to employment, education, building healthy social networks, and difficulties in integrating fully into society. His observation of the level of stigma related to mental illness tells us a great deal about the fear and anxiety Canadian society has towards offenders with mental illness, a fear that has been recently fuelled by violent high profile cases, specifically that of Vince Li and Luka Rocca Magnotta.

Discussion

Most parolees living with FASD and comorbid psychiatric illness eventually face environmental and psychosocial risk factors similar to the ones that contributed to their incarceration. However, integrated postincarceration supports designed specifically for this population are shown to reduce recidivism and contribute to parolees transitioning successfully to life in the community (Gerger, 2011; Gustafsson, Holm, & Flensner, 2012; Radford-Paz, 2013). For example, an evaluation of a program in a small British Columbia community found that the provision of stable housing and positive supports to mentally ill parolees with a 10-year history in the criminal justice system reduced recidivism by 75% (MacPhail & Verdun-Jones, 2013).

Due to the nature of their cognitive impairments, former inmates living with FASD, with or without a comorbid psychiatric illness, may actually require closer supervision than former inmates living only with a mental illness (Fast & Conry, 2011). Community mentors trained to work with this specific group play an important role in providing advice, direction, and structure that prevent recidivism (Brown, Long-McGie et al., 2014; Gerger, 2011). Also having knowledgeable, coordinated, and empowered decision makers across the human service sector who are in positions to make informed and flexible choices about the management of this high risk group increases the likelihood that sustained and meaningful community reintegration will be achieved (Brown, Long-McGie et al., 2014).

Achieving long-term stability for individuals living with FASD and comorbid mental illness does not equate well with rehabilitation models that gradually remove services as patients achieve greater independence. When FASD and comorbid mental illness are both present, the complexity of potential illness-related risk factors requires a continuous level of support once stability is achieved. In relation to FASD, while the process of diagnosis may adhere to the Canadian guidelines (Chudley et al., 2005), Canada lacks specific guidelines for long-term treatment and support. Currently, individual treatment plans that incorporate the provision of support, supervision, and structure as well as mentoring by support workers and referral to specialists including psychiatrists and psychologists, are believed to be the most effective; however, this model of care has not been adequately evaluated. Presently, specific services for mentally disordered offenders living with FASD, like Garth and Arnold, are piecemeal and depend on local health care managers successfully lobbying for the implementation of integrative models of long-term care.

The early childhood experiences of Garth and Arnold unfortunately are typical of inmates living with FASD and mental illness. Neurocognitive deficits coupled with family dysfunction and childhood adversity arguably prepared their path through the criminal justice system. Failure by the health care, child welfare, and criminal justice systems to recognize and respond appropriately to the level of distress and dysfunction expressed by Arnold and Garth early in life meant a delay in the provision of protective care and meaningful interventions for both men until later in their lives.

Life history work specifically points towards a complex interaction of factors over multiple generations that marks the lives of Arnold and Garth as well as those of their parents and children. These factors effectively solidified the social marginalization, involvement with the criminal justice system, and loss of full citizenship experienced by the two men. Their life narratives directly point to the need within our society to protect and nurture vulnerable children, best done by notable reductions in poverty, comprehensive and sustainable supports for vulnerable families, and revisions to the child welfare system (Tait, Henry, & Walker, 2013). Arnold and Garth’s life narratives also highlight their alienation from family members because of the violent nature of their crimes and their lengthy prison sentences. However, for Arnold, strong Métis kinship ties meant that despite being estranged from some family members, other members of his immediate and extended family remained in his life (some living in Saskatoon) and he continues to be accepted as a member of his home community.

The limitation to Arnold’s familial support is, however, in the high prevalence of alcohol abuse. Alcohol abuse was a central factor in the premature death of Arnold’s son and it is the main reason why Arnold chooses not to live in his home community. Garth, on the other hand, remains estranged from his immediate family members, even after having lived successfully outside of prison for more than a decade. Lacking familial support, Garth relies more heavily on the relationships he has with his health care team and parole officer. His friendship with Arnold is extremely important to him and to the people currently in his life; Arnold is the only person who has known Garth for a considerable length of time. The fostering of positive relationships such as the relationship the two men have is very important and helps to build social networks that bolster stability and happiness outside of prison.

Arguments that suggest the experiences of these two men are not relevant to the experiences of children today hold true only in a limited sense. It is true that at the time of their childhoods FASD was not yet described in the clinical literature and attention to childhood mental illness was limited. However, rates of childhood poverty in Canada have not decreased since the 1950s (Campaign 2000; Family Services Toronto, 2014; Statistics Canada, 2009), current waiting times to see a child psychiatrist are typically several months (Kowalewski, McLennan, & McGrath, 2011) and many children are never referred for assessment (Sayal, 2006; Waddell, McEwen, Shepherd, Offord, & Hua, 2005), child welfare systems are overburdened and underresourced (Blackstock, Cross, George, Brown, & Formsma, 2006), and the intergenerational impacts of colonization on Indigenous populations have not been properly addressed (Truth and Reconciliation Commission of Canada, 2015). Criminal justice systems across the country are repositories for individuals who come from disadvantaged childhoods (Corrado, Freedman, & Blatier, 2011; Corrado, Kuehn, & Margaritescu, 2014); prisoners living with mental illness and FASD make up a notable percentage of this population (Burd et al., 2003; Centre for Addiction and Mental Health, 2013; Fast et al., 1999; MacPhail & Verdun-Jones, 2013; Popova et al., 2011); and Indigenous peoples are overrepresented (Corrado et al., 2014; Cunneen, 2014). Canada lacks a national strategy aimed at improving prison and postincarceration supports and services for prisoners living with mental illness, addictions, and cognitive deficits, despite research indicating the substantial human, financial, and societal gains that can be made with better coordination of policies and services (Centre for Addiction and Mental Health, 2013).

Our case study indicates that despite shortfalls, we are moving in a positive direction, illustrated by a model of integrated services, flexibility, and rapid response that was set up for Arnold and Garth postincarceration. The 18 months of stability and happiness experienced by the men points to the level of success that is possible if proper clinical and mentorship supports are consistently in place (Brown, Herrick, et al., 2014; Conry & Fast, 2000; Gerger, 2011; Radford-Paz, 2013). The crisis experienced by the men, however, teaches us that consistent stability cannot be taken for granted by either the services supporting ex-offenders or by the individuals themselves.

In addition to housing, interim release conditions, and employment opportunities, the success of offenders is primarily influenced by the type and philosophy of support staff. Therapeutically oriented and trained staff is vital to the recognition of relapse signs, for motivating offenders towards treatment, to ensure cultural safety, and for serving as a guidepost to available services (Brown, Herrick, et al., 2014; Conry & Fast, 2000; Fast & Conry, 2009; Gerger, 2011; Radford-Paz, 2013). Such staff should be able to provide the coordinated strategy incumbent on case management. Any strategy short of this, as was the case during the relapse experienced by Arnold, defeats the purpose of community care. In this context, complacency brought on by a perception held by the health care/parole team, and by the men themselves, that risk of a serious relapse by either man was unlikely, contributed to the crisis occurring. This is indicated by the assumption on the part of the new health support worker that Arnold’s distress did not require an in-person home assessment and instead an overreliance on Garth to facilitate the needed intervention was evident.

The functions of mentors, who provide 24-hour coverage and hands on access to care, exceed any type of support that is limited in time and access. This points to a need for the criminal justice system to establish a mentoring service in its community mental health strategy to supervise those with both FASD and mental disorders. A philosophical change and staff/team training about the level of vulnerability of this patient population would prevent against the stripping away of services with increased client stability and ensure immediate assistance and correct recognition of levels of distress. Arguably this could prevent injury, death, and reincarceration. The case study points to the current vulnerabilities within our health care and parole system for mentally ill offenders. As the result of the breakdown in the support given to the men, a need arose for emergency response care, an extensive hospital stay, and other added costs that could have been avoided.

The factors that led to the crisis occurring for Arnold and Garth support the enhancement of relapse prevention strategies and postincarceration supervision. Ideally, release plans for this high-risk group of offenders should begin, and where possible be tested, when the offenders are still in custody. Our study participants spent over two decades each in correctional facilities and both described having periods of instability that were later followed by improvement of mental health. Identifying patient triggers for instability and interventions that assist them to recover while in prison can be valuable in the design of release plans. To ensure successful community reintegration and for the protection of the public, this early identification and provision of adequate specialized supports are essential and will lower risk of reincarceration.

During the transition to the community, complementary supports should be fortified and the relevant services maintained even in the face of continued stability. This is a form of intensive case management whose success lies in how coordinated, flexible, and patient centered it is. To foster independence, mental health services usually encourage reducing and withdrawing services when clients are doing well. It appears that with FASD and comorbid mental illness, when the patient is doing well, this may signal to the health care team that they have identified the right balance of supports and so these supports should be maintained. Our participants’ narratives and the existing literature suggest that this maintenance of appropriate supports may be essential to reducing recidivism and relapse in those offenders with FASD and comorbid mental disorder.