Interview by Austin Lam, a medical student at the University of Toronto
Dr. Alexander (Sandy) Simpson, MBChB, BMedSci, FRANZCP, is Chief of Forensic Psychiatry at CAMH. Additionally, Dr. Simpson is Associate Professor and Head of the Forensic Psychiatry Division of the Department of Psychiatry at the University of Toronto.
Dr. Simpson has extensive experience in service development, recovery and cross-cultural forensic mental health care. He has provided advice to government agencies and services on law and policy. He published extensively on topics including homicide and the prevention and management of violence risk, to the issues of mental health needs of prison inmates. He is a member of the Editorial Board of Criminal Behaviour and Mental Health and The Canadian Journal of Psychiatry. He is an active member of a number of Australasian, Canadian, U.S. and international forensic mental health bodies.
I had the opportunity to interview Dr. Simpson in-person at CAMH. Prior to the interview, I had the privilege of shadowing Dr. Simpson at the Toronto South Detention Centre to learn about forensic psychiatry within a correctional setting, specifically, the Forensic Early Intervention Service (FEIS).
(Dr. Simpson’s biographical information is from the CAMH website: https://www.camh.ca/en/science-and-research/science-and-research-staff-directory/alexandersimpson)
What drew you to forensic psychiatry?
I come from a medical family, with doctors going back generations, although not within my immediate line in psychiatry. I thought I was going to be a physician, by which I mean a medical specialist or internist, as they call them in North America. I increasingly realized during my house surgeon years in New Zealand that the work didn’t involve repairing the bits of people in which I was interested; it was understanding and being with people that interested me more. I saw psychiatry as dealing with the essence of people rather than bits of people. That drew me into the area.
In my training, I knew that I wanted to work with the people of greatest need – I think that some of my Presbyterian mother and social duties from my father contributed to that. It was during my training that there was a major inquiry into the care of people with what we would now call forensic mental health need. It was a visionary document called the Mason Report of 1988. I knew the people who were involved in the inquiry as I helped set up its terms of reference. The blueprint they provided for what forensic mental health should be was visionary and frankly, is still followed largely unchanged. They talked of integrated services and interdisciplinary teams; they talked of the health sector’s responsibility to people with serious mental illness, wherever they were in the criminal justice system. And because half the people in the forensic mental health system were Maori, it necessarily demanded that the services were bicultural and clinical leaders had to be cross-culturally competent, including as much competence as possible with speaking the Maori language (i.e., Te Reo).
When those services were established toward the end of my training, all the most interesting people in the area were going into forensics, so I thought I would go there too. Professor Paul Mullen set up for me a senior registrar attachment to the Maudsley Hospital in London, and I spent eight months there at the end of my residency. Afterwards, I came back to New Zealand to set up and help run forensic services while also being the clinical director of the Maori mental health service in Wellington. I had one day a week in monocultural services, namely the Maori mental health service, and four days a week in bicultural services, namely the forensic service. That helped ground us in those areas very strongly.
The foundations of forensic, which were about looking after the people at highest risk to others and highest risk to themselves, who had much neglected needs and were multiply stigmatized against, and to do it comprehensively and with strong interdisciplinary and cultural commitment, ticked all the boxes of the work that I wanted to do and I never regretted that decision.
What do you enjoy most about being a forensic psychiatrist?
Because the risks are high and because we are at the interface of meaning systems – of health, of personal meaning, and of legal systems and social accountability – those complex and different currents is a very fertile area for understanding. We have to do things thoroughly; we have to understand behaviour and all the complexities that give rise to it, and then translate that into something that is meaningful in terms of legal and wider social understandings – and of course, meaningful for the person, so that they can make the changes in their lives that mean that the risk that they pose when they’re unwell does not repeat again. That comprehensiveness of understanding, and how that feeds both that person’s therapeutic needs and societal demands for accountability and safety, is an incredibly rich and valuable process. It means that we have to do general psychiatry at great complexity and depth.
It’s not only that we have to understand disorders and their treatment, addictions and the way we treat them, we have to put all of that together across the trajectory of somebody’s life, their personal and social meaning. We have to write that coherently and comprehensively to courts who have great power for punishment, for detention, and for facilitating recovery. That’s pretty special. That complexity of systems is never boring and always important. Of course, it’s a privilege to know people that well to help them recover and it’s of vital societal importance that forensic psychiatry does its job well. All of those bits matter greatly. I also love the ability to think, research, teach, and help develop services and advance care agendas.
You were previously the Clinical Director and Director of Area Mental Health Services of the Auckland Regional Forensic Psychiatry Service – can you tell us more about your journey to Canada, as Chief of Forensic Psychiatry at CAMH?
I’ve been clinical director for nine years in Auckland and we had achieved a lot: developed services and grown the program, developed by Maori and for Maori services there. I’ve always thought those sorts of roles are ten year jobs. I was lucky that I had academic time as well as clinical leadership time. During that period, I had also done some senior bureaucratic work as well. So, it was a point of working out what to do next: do I move more into academia, do I move into senior management? I enjoy the combination of clinical leadership and academic leadership and contribution.
There aren’t many places in the world that still value that in senior leaders. The UK and much of the world separate them out and it’s either one or the other. CAMH came knocking as they were looking for a new clinical director of forensic psychiatry. It offered those challenges and my son was off to university in the UK. It was a time feasible to move and this job and the opportunities it represented looked really exciting.
In New Zealand, you were heavily involved in developing culture-specific inpatient treatment services for Maori – can you speak to the issue and importance of cultural safety and how you see cultural safety developing in Canadian healthcare?
Cultural safety was a concept heavily developed in New Zealand. The concept was, early-on, named by a friend of mine, Irihapeti Ramsden, an academic nurse and leading thinker. Cultural safety refers to interpersonal safety: that one’s cultural identity and the things that one holds dear will be respected and held safe through the process of healthcare. It’s morphed a little bit in its definition in the world literature but those elements remain strong.
Because of the demography and the constitutional issues, it was vital that we got that right in New Zealand, otherwise, we would be another oppressive state agency. That’s not what forensic services wanted to be. So, building cultural responsiveness into all levels of service design was a crucial component of what we did. That involved having Maori elders at governance levels, having cultural advisors working at all stages across the service, identification of and promotion through training of Maori staff to be able to occupy clinical roles and to develop by Maori and for Maori pathways.
You never achieve cultural safety; you always strive for it. There is always tension and there are compromises along the way. But if you do that with respect and dignity, you can go a long way.
Here, the challenges are different. Certainly, in downtown Toronto, with the multiplicity of cultures, that same sort of governance for half the people you need to serve is not there. Rather, we are dealing with people who are immigrants. The Indigenous group within the population we serve is relatively small; it’s a tenth of the proportion here than it was in New Zealand.
Outside downtown Toronto, those dynamics shift very significantly. If you look at correctional services or forensic services in other parts of the province or Canada, the proportion of Indigenous peoples rises very rapidly. That same kind of partnership and the same conceptual practice demands of cultural safety need to be addressed.
Here, the culture of medicine and healthcare is different. So, the reverence of Western psychiatry and science knowing best is much higher here. You need to tread a little more carefully when you’re working sensitively cross-culturally, and be more open to other meaning systems and the ability to integrate that into how we do things. We’re not as skilled as that here, generally, as health services – although there are now tools that we could use that could help us with that. I’m thinking of the cultural formulation interview of the DSM-5. If we integrated that into all of what we did, we would start to open up the way in which we think about our patients more broadly than we do at the moment. I think that could enhance cultural engagement and safety for people here.
More recently, a few months ago, you wrote a reflection on the passing of a woman, for whom you were the forensic psychiatrist for seven and a half years, and emphasized our common humanity – what are some ways that you remain centred on humanity and connectedness as a forensic psychiatrist given often difficult psychiatric and forensic issues at the fore?
I think it is an attitude and approach to people: a belief that we’re not separate classes of people, but that we’re fellow travellers ultimately. I was recently challenged because of a paper I had written on medical aid in dying on whether I was biased or whether I had a religious conviction. I don’t have a religious conviction. I work all the time with and have people in my life with strong religious faith. I don’t – I cannot somehow cope with supernatural ideas. But I do hold the sacredness of common humanity and the dignity of all people and that matters to me profoundly. Music, literature, and art, and day-to-day relationships with prison inmates and all the people I work with keep me centred on humanity and connectedness. It’s a personal philosophy and it’s as close as I come to faith. It’s not a supernatural faith and not a belief in a divine being, although I know how vital that is for other people.
I think it’s from a personal ethic and belief that drives me in terms of how much I love clinical work and contact with patients, and how much I love creating systems of care that will deliver to their needs. All of those levels matter to me.