The man in the North Side park used to think the community nurse was “Becky from the Planning Department,” happily retaining the delusion despite her perennial questions about his stability.
“Becky” had no good reason to disabuse her patient of a harmless belief, and so Dympna Carten, one of two community psychiatric nurses who tour Grand Cayman in pursuit of their “clients,” did not belabor the point.
“Nurse Carten” – her preferred form of address – has been at the Health Services Authority for 19 years, working with a host of government units: the Department of Children and Family Services, the Department of Community Rehabilitation, the Health Services Authority, parole officers, psychiatrists and psychologists, a rehabilitation team and the courts.
Also a member of the Mental Health Commission, she is a frequent presence in the mental health court, sharing her time between Summary Court in general and the still-developing “diversionary court,” started in 2010 by Magistrate Margaret Ramsay-Hale to address mental disability issues.
Despite seven years and well-established operations modeled on its drug court predecessor, the mental health court is still finding its feet. In January, launching Cayman’s “legal year,” Attorney General Sam Bulgin said “a working group” was likely to be established to look at “a legislative framework that would underpin the court.”
What that means is simply that proper legislation would “mandate that various agencies provide support and facilities,” and that “funds would be allocated for that purpose,” according to Court Administrator Suzanne Bothwell, formalizing the largely voluntary services government now provides.
Magistrate Ramsay-Hale created the Metal Health Court following the success of its Drug Court twin, also founded by magistrates and also an informal operation, supported by such agencies as Drug Counseling, the Probation Department, the Office of the Director of Public Prosecutions, the Criminal Defence Bar Association, the Royal Cayman Islands Police Service and the Health Services Authority laboratory for drug testing.
At the time, more than 600 drug courts – many in the U.S. – operated worldwide. The local judiciary asked Toronto Judge Paul Bentley, who founded Canada’s first drug treatment court in 1998, to conduct two local workshops, resulting in formal proposals to create Cayman’s own treatment court, ultimately established through court rules and regulations by the Legislative Drafting department, magistrates and “all other stakeholders,” Ms. Bothwell said.
“Following the approach used for setting up the Drug Court, the responsible agencies were approached by the courts through then-Chief Magistrate Ramsey-Hale, and they agreed to participate,” Ms. Bothwell said.
Bail conditions in both the drug and mental-health “diversionary courts” are used to gain a defendant’s compliance with treatment and rehabilitation programs. Breaches can mean revocation of bail. Those habitually breaching the conditions may land in a Summary Court criminal trial.
“I’ve been working on the [mental health] court since 2008 or 2009,” says Dr. Marc Lockhart, chairman of the Mental Health Commission and longtime advocate for Cayman’s mentally ill, a population he pegs at 4,000, afflicted in one degree or another.
Mental Health Court defendants often also appear in Drug Court because the problems are often intimately linked.
Dr. Lockhart said 50 percent or more of the 4,000 have “serious chronic mental health issues,” such as schizophrenia or bipolar problems and many “deal with drug issues.”
Nurse Carten said many are “self-medicating,” yielding a “high rate of people using cannabis or cocaine,” seeking to dampen the relentless stress of mental disability.
“We see a wide range of disorders from depression to anxiety, to bipolar, to personality and developmental disorders,” she said.
“Our role is to keep people out of inpatient care in the hospital and in the community, and to do monitoring so they do not have to go to psychiatric care.… Maybe they can go in another direction,” she said.
“The mental health court,” Nurse Carten said, tries “to improve the well-being of people with mental illness and involved with the judiciary.”
She acknowledges the sometimes-circular nature of the endeavor, however: “It can be a chicken-and-egg [situation]. Every time someone stops using [drugs], the underlying anxiety can re-emerge.”
The court designs treatment programs tailored to each defendant, involving assessment, counseling, random drug screening and follow-up.
“Psychiatric and psychological assessment can be ordered,” Nurse Carten said. “The magistrate, community psychiatric nurses, parole officers and client counselors meet pre-court to discuss individual cases.”
Calling it a collaborative process, she said the magistrates – Valdis Foldats, Nova Hall and Kirsty-Ann Gunn – have a “very serious say” in the resulting recommendations. “They’re very good and it’s a very caring court.”
Dr. Lockhart says counselors examine the impact of each client’s condition on such things as “decision-making, compliance with treatment programs and general functioning in society.”
Like Nurse Carten, he acknowledges the downward spiral that can afflict “clients.” Homelessness and unemployment breed more of the same, meaning “the risk of them being charged, of coming into contact with police, is greater.”
Community psychiatric nurses deal with a host of persistent questions, including compliance and follow-up as ordered – with doctors and the courts.
“Sometimes they fall out and just can’t keep up with the meds,” said Dr. Lockhart, describing the most basic issues. “They have difficulties with time and with [court] appearances, but they still have to show up.”
Nurse Carten and the nurses literally go out to find and interview them, although she indicates that her clients are not hard to locate – once you know where to look.
“You learn to work with them. I do home visits and district clinics five days per week. Sometimes I go to police cells. Out in the community, we meet in cabanas, under shady trees. I once met a patient in a graveyard,” she said.
One consultant to the courts is Cayman Islands Hospital psychologist Dr. Clement von Kirchenheim. He interviews and tests two to three patients per week, determining if they are “intellectually cognitive,” perhaps neurologically impaired or present a recidivism risk.
“Some people are so low-functioning, they cannot be held responsible for their actions,” he said, and his subsequent written reports identify issues for the court.
Ms. Bothwell said the number of defendants in court at any given time “varies throughout the year, but is “currently approximately 16 persons.”
Nurse Carten’s case load is between 12 and 17 clients per month, most of them recurring. Court-mandated treatment periods range “from six months to 12 months, maybe 14 months.” Follow-ups depend on the problem: Schizophrenia and bipolar disorders require more sustained efforts while lesser difficulties may need as little as one month.
“I have had some patients for 19 years, but who are well-managed,” she said. Most have stayed out of court and in the community – and been consistently employed.
“I have seen some massive changes since establishment of the mental health court by frequent users of the court system. They have maintained mental-health stability and employment,” Nurse Carten said.
Treatments can change as clients improve, she observed, and “can be done at the request of a patient. They may say they’re feeling better, and so we can set up a review and after a period of reduction the meds can be stopped.
“Sometimes it’s all right, and sometimes there’s a relapse and the patient is stabilized again.”
Often, she said, “people with insight as to their own problems can identify their own needs. Mental health is manageable.”
The court convenes on the third Wednesday of each month at 2 p.m.
Both Nurse Carten and Dr. Lockhart hope the questions around long-term care will be addressed by the recently announced residential mental health facility, scheduled to open in 2019 on 15 acres in East End. The 42-bed home will be Cayman’s first permanent care unit for those with chronic mental disabilities.