Canadian Developments in Alternative Sentencing: Mental Health Courts (Part 2)

Contributed by Souhila Baba

Part two of this two-parts series on the theme of psychology showcases alternative sentencing measures regarding mental health courts in Canada (read part 1 on young adult courts here).

In June 2009, Donald Kushniruk was arrested after taking out a knife in a public park in Alberta. He chose to self-represent at trial, and although a lawyer was appointed to consult with him, neither him nor the lawyer ever applied for bail. He had been diagnosed with bipolar disorder, and possibly suffered from schizophrenia. Due to recurrent delays, Kushniruk spent over two and a half years in jail awaiting trial for an offence for which he would ultimately be sentenced to seven days. A few months after his release, Kushniruk was arrested again after an argument with his parole officer. Two weeks into his incarceration, he committed suicide. Although the problem of over-incarceration of individuals with mental illnesses has led to the implementation of mental health courts across Canada, our conceptions of individual capacity and autonomy suggest that there may be some theoretical and practical barriers to their success . In exploring this sentencing alternative, we will first look at the functioning of these courts across Canada and then zoom-in on Québec as a case study.

The Mental Health Court

Across Canada, mental health courts share similar overarching goals: increasing the well-being of those involved, decreasing recidivism, improving access to services, and enhancing community safety. However, there are variants of the mental health court across provinces: Old City Hall Court in Toronto is a fully independent court, working full-time in parallel to other courts. While in Montreal, the court is integrated into the criminal division of the Municipal court, a program termed PAJ-SM (Programme d’Accompagnement Justice-Santé Mentale).

ForkRoad Mental Health Courts provide an alternative path to traditional criminal trial or guilty plea. || (Source: Flickr // Miwok )

Actors Involved in Mental Health Courts

In general, the mental health court team consists of crown attorneys, judges, defence lawyers, health care providers (i.e., general practitioners and psychiatrists), and justice system actors (i.e., police officers, parole officers, and criminologists). Assistant crown attorneys are most likely to be involved in the creation process of the courts (in Ontario, in 68% of cases), while judges and mental health workers often aide in the process (in Ontario, in 37% of cases).

Diversion Programs

A diversion program is an alternative to traditional criminal trial or guilty plea. A diversion plan, devised by health workers, may implement a variety of conditions based on available resources, including consulting a medical practitioner, complying with medication requirements, refraining from alcohol or any illicit drugs, and attending information or training sessions. Most of the time, these are soft conditions, meaning that contravening them does not necessarily lead to reprimand (although there is the possibility of being removed from the court program).

In Quebec, there are two types of diversion programs offered by PAJ-SM: “Suivi”, which is similar to the Ontario program, or “Liaison” which constitutes a softer approach, where the interventions from the court and health workers are minimal. In both programs, non-compliance with one of the conditions leads to the individual being tried more strictly by law, although the judge may consider mental illness in her decision. Most Quebec mental health courts, in addition, offer support services as part of the diversion program such as crisis and emergency response, safe beds, support for housing, and so forth – again, based on available resources.

Eligibility Criteria

Another difference in the functioning of the mental health courts across Canada is the different eligibility criteria for participating in the program. While almost all courts require the individual to agree to participate in the process (i.e., in Montreal and in most of Ontario), Old City Hall Court in Toronto does not require such willingness. Moreover, in Windsor, the court does not have any eligibility or entry requirements, but rather it relies on the judge to decide on eligibility, based on the general evidence obtained.

Despite growing interest in these alternatives, there are only a few mental health courts in Canada, especially compared to the hundreds in the US. Across the board, major concerns for these courts is the lack of dedicated funding and availability of psychiatrists.

Case Study: Québec

Central to mental health courts is the complicated relationship between supporting individuals with mental health issues and respecting autonomy of the individual. In Québec, this is represented in an ongoing debate between various stakeholders: victims rights groups, families of individuals with mental health concerns, hospitals and health practitioners, human rights advocates, prison officials, the police force, other criminal justice actors, governmental institutions, and society at large. From this debate, three interconnected points are most relevant: first, the stigma of differentiating individuals with mental health problems within the court system, second, inconsistent application of laws related to individuals with mental health issues, and third, links between mental health concerns, homelessness, drug addiction, and the criminal justice system.

The Stigma

Issues of labelling, diagnosis, and stigma are prevalent in any mental health question. For mental health courts, these stem from differentiating a “normal” court from a “specialized” court. Certain stakeholders argue that judicializing mental illness in this way further stigmatizes individuals living with mental illness as they are isolated and segregated from the rest of the process. Furthermore, although the program is voluntary, some argue that there is no true choice between the possibility of going to jail and having a matter be processed through this alternative court. Consequently, individuals who do not think they suffer from any mental illness, or do not wish to be diagnosed, may nevertheless choose to take part in the diversion program. This begs the question: are we looking out for what we believe to be in the individual’s best interest, or their freedom and autonomy to make decisions for themselves?

The Law

In Québec, there is a variety of legislation that includes provisions dealing with mental health issues: the Québec and Canadian charters of human rights and freedoms, the Civil Code of Québec (a.27-31), the Quebec Code of Civil Procedure (a.123; a.391-397), the Act Respecting Health Services and Social Services and, the most controversial: the Act Respecting the Protection of Persons whose Mental State Presents a Danger to Themselves or to Others (la loi P-38). Briefly, P-38 aims to provide a structure for various stakeholders in the confinement of individuals whose mental health issues may be dangerous to themselves or others.

HospitalWard La loi P-38 allows for involuntary confinement of individuals with mental health issues || (Source: Flickr // Vancouver Coastal Health )

The controversy over this law is clear: while the Charters protect the right to freedom, P-38 allows for involuntary confinement, irrespective of criminal behaviour. The legal framework in Québec can lead to some inconsistent results when dealing with individuals with mental health issues. Under P-38, without committing any crime, a person could be confined within a hospital or health care institution. Conversely, within the framework of the mental health court, after committing a crime, a person could be set-free.

The Social Context

The vast majority of individuals living with mental illness do not encounter the criminal justice system in their lifetime.  However, the over-incarceration of individuals with mental illnesses reminds us that some still do. For many stakeholders, this is not due to a question of criminality, but rather to lack of access to the services needed, be it treatment, social support, financial resources, housing, and/or others. Moreover, most mental illnesses can occur comorbidly with other mental health issues (e.g., drug or substance abuse, depression, eating disorders, etc.), which may strain individuals further, and lead to criminality. Indeed, a study by Jaimes and collogues supports that most crimes committed by individuals with a mental illness are minor crimes, usually related to homelessness, low-income status, and other social circumstances.

Under P-38, without committing any crime, a person could be confined within a hospital or health care institution. Conversely, within the framework of the mental health court, after committing a crime, a person could be set free.

We arrive then at a circular issue: lack of resources compounded with mental health issues may lead to criminality, which is dealt with through mental health courts, which in turn lack sufficient resources to support individuals. Mental health courts come as a second thought, a reactive measure, while there should be preventive measures in place.

This two-part series on alternative sentencing is aimed at understanding the various intricacies of criminal justice and health law, and the need for creativity and innovation with regard to issues disproportionally affecting certain groups in society. This is in the hope that our deeper understanding of human development, behaviour, and mental health will help to shape our legal frameworks.

Souhila Baba is a Senior Online Editor with the McGill Journal of Law and Health with a keen interest in mental health, access to health services, and access to justice. She holds a BSc in Psychology from Concordia University. Since she joined the Faculty of Law at McGill University in 2016, she has been able to expand her interests in policy, technology, science, and the law, and the important contributions that women make to these fields and their intersections. Souhila is currently interning with the McGill Research Group on Health and Law at the CIUSSS du Centre-Ouest-de-l’Île-de-Montréal under the supervision of Me. Nathalie Lecoq.

Changing the Face of Health Care through Artificial Intelligence: Emerging Ethical and Legal Debates

The McGill Journal of Law and Health is pleased to invite you to attend its 10th annual Colloquium: Changing the Face of Health Care through Artificial Intelligence: Emerging Ethical and Legal Debates. The aim of this bilingual and student-based initiative is to foster interdisciplinary dialogue on issues that lie at the intersection of health and law. It is our hope that such dialogue will have a positive influence on health and social policy-making in Canada.

La discussion sera divisée en deux tables rondes. La première table ronde donnera un aperçu du développement des technologies d’intelligence artificielle et discutera des défis éthiques que posent les nouvelles possibilités de soins de santé. La seconde portera plus particulièrement sur le chemin vers un cadre réglementaire de l’intelligence artificielle dans le domaine du droit de la santé au Canada.

*Un dîner et des collations seront servis*

This year’s event will feature some big names in the artificial intelligence field including: Christelle Papineau, Daniel Weinstock, Frank Rudzicz, Nicole Mardis, Antoine Guilmain, and Jonathan Kanevsky.

The event is wheelchair/stroller-accessible and the MJLH is happy to welcome all those with children! If you have any dietary restrictions, or any particular arrangements need to be made, please feel free to contact

Please RSVP to the event HERE.


Stewart v Elk Valley Coal Corp., 2017 SCC 30

Contributed by Jenny Wang

Earlier this year, the Supreme Court of Canada confirmed and clarified the legal regime governing discrimination in the workforce based on disability pursuant to s.7 of the Alberta Human Rights Act (Act). In Stewart v. Elk Valley Coal Corporation, the majority of the court upheld the Alberta Human Rights Tribunal’s decision that the termination of a cocaine addicted employee did not constitute discrimination in the workplace. There has been a lot of discussion regarding the implications of the majority’s decision. Some believe that its practical effect would be to deprive drug-dependent employees of human rights protection in the workplace, while others argue that the highly dangerous nature of the work environment necessitated such a decision.

Mr. Stewart worked in a mine operated by Elk Valley Coal Corporation (the employer). As the mines were extremely dangerous, workplace safety was a primary concern for Elk Valley Coal Corporation. The employer established a policy requiring employees to disclose whether they had any drug dependencies or addiction issues. Upon disclosure, these employees would be offered treatment from the employer. In addition, the policy specified a “no free accident” rule such that if one were to be involved in a workplace accident and was subsequently tested positive for drug use, the employee would be terminated immediately if he or she had failed to disclose the addiction.

After being involved in a workplace accident, Mr. Stewart was tested positive for drugs and admitted that he was addicted to cocaine. Nine days later, Elk Valley Coal Corporation terminated Mr. Stewart. As addiction is a recognized disability under the Act, Mr. Stewart argued that the termination constituted discrimination based on disability pursuant to s.7 of the Act.

To claim discrimination under the Act, the plaintiff must first show a prima facie case of discrimination. To do so, the employee must prove: “(1) a disability which is protected under the Act; (2) adverse treatment with regard to his employment or a term of that employment; and (3) that the disability was a factor in the adverse treatment.” Once a prima facie case is established, the onus shifts to the defendant to show that the employer accommodated the employee to the point of undue hardship for the employer.

Alberta Human Rights Tribunal Decision

The tribunal held that Mr. Stewart failed to establish prima facie discrimination. The tribunal relied on expert evidence to conclude that Mr. Stewart was in fact addicted to cocaine at the time of the incident. Moreover, it also considered Mr. Stewart’s termination to be adverse treatment. However, the tribunal was of the opinion that the disability was not a factor in the termination and therefore Mr. Stewart failed to meet the three-step test to establish prima facie discrimination. It argued that the employer would have terminated Mr. Stewart regardless of whether he was an addict or a casual user of cocaine under the established policy. Mr. Stewart argued that his denial of his addiction prevented him from disclosing his condition prior to the incident. However, the tribunal dismissed this argument, holding that Mr. Stewart’s denial was irrelevant because he had the capacity to comply with the policy’s terms and decide not to take drugs prior to work.

Although the tribunal recognized that the distinction between termination due to disability and termination due to failure to comply with policy may appear to be superficial, it nevertheless found that Mr. Stewart’s termination was based on noncompliance with the policy and not because of his disability.

The Alberta Court of Queen’s Bench and the Alberta Court of Appeal both upheld the Tribunal’s decision.

Majority Opinion

McLachlin C.J., writing for 6 judges of the Supreme Court, dismissed the appeal. In the analysis, the majority showed deference to the tribunal’s decision, stating that the court’s role is to determine whether the tribunal’s judgement was within a range of possible and acceptable outcomes. The court deemed that the decision was in fact reasonable in the circumstances as there was evidence supporting the tribunal’s conclusions.

The majority recognized that in some cases, drug and alcohol addiction may affect one’s ability to comply with rules, while under other circumstances addiction does not. In the former scenario, the breach of workplace rules will be inextricably connected with the addiction whereas in the latter, the noncompliance would not be associated with the addiction. In this case, the majority concluded that the facts do not support the conclusion that Mr. Stewart failed to comply with the policy due to his addiction.

Furthermore, the majority refused to assess whether the employer’s termination decision was stereotypical or arbitrary. McLachlin C.J. believed that to add a fourth step would result in shifting the focus to determining whether there was discriminatory intent rather than discriminatory impact.

Concurring Opinion

Unlike the majority, Moldaver J. and Wagner J. believed that there was prima facie discrimination. However, this discrimination was justified because Elk Valley Coal Corporation could not further accommodate Mr. Stewart without incurring undue hardship.

According to these two judges, the residual control that Mr. Stewart had on his decision to use cocaine reduced the extent to which his addiction contributed to the termination but did not eliminate it as a factor. Therefore, Mr. Stewart’s addiction was still a factor in the adverse treatment. However, the concurring judges were of the opinion that the employer reasonably accommodated Mr. Stewart. As the mines are extremely dangerous, the policy sought to deter employees from using drugs such that it would affect their work and result in dangerous working environments. Had Elk Valley Coal Corporation not terminated Mr. Stewart and provided him with a less serious consequence instead, the deterrence effect of the policy would be greatly diminished. Therefore, Moldaver J. and Wagner J. found Mr. Stewart’s immediate termination to be reasonable in the circumstances.

Dissenting Opinion

Unlike the majority and concurring judges, Gascon J. found Mr. Stewart’s termination to be discriminatory. Gascon J. focused on the stigma that exists surrounding those who are addicted to drugs: “Still, stigmas surrounding drug dependence – like the belief that individuals suffering from it are the authors of their own misfortune or that their concerns are less credible than those of people suffering from other forms of disability – sometimes impair the ability of courts and society to objectively assess the merits of their discrimination claims. These stigmas contribute to the ‘uneasy fit of drug addiction and drug testing policies in the human rights arena’ noted by the Alberta Human Rights Commission.”

For Gascon J., a policy resulting in immediate termination prima facie discriminates against those who are dependent on drugs. Moreover, the two types of accommodations that Elk Valley Coal Corporation provided Mr. Stewart – namely, treatment had he disclosed his addiction prior to an accident and the possibility for him to reapply to the corporation after participating in a rehabilitation program – did not justify the discrimination.

The first accommodation was not accessible to Mr. Stewart because at that time, he was unaware of his dependency, a symptom of his addiction. Furthermore, the second option does not constitute accommodation for the purposes of this case. Reasonable accommodation requires the employer to provide options for the employee while he or she is still an employee, rather than giving him or her the option to reapply after the fact. These two options failed to consider Mr. Stewart’s circumstances, and therefore, the second prong of the test was not met.


In this case, the court reiterated the two-pronged test used to establish a case of discrimination based on disability under the Act. Although the majority did not the change the legal regime, their application of the law have left some with a heavy heart. In effect, the mere existence of addiction does not establish prima facie discrimination if the court concludes that one was terminated due to noncompliance of workplace policies. Although the highly dangerous nature of the work was an important consideration, some argue that the court adopted a narrow interpretation of addiction.


Jenny Wang is a third-year student in the B.C.L./LL.B. program at McGill University, Faculty of Law and is a Senior Online Editor with the McGill Journal of Law and Health. Prior to starting at McGill, Jenny completed the Arts and Sciences program at Marianopolis College.

Saadati v Moorhead, 2017 SCC 28

Contributed by Pouya Dabiran-Zohoory


Canadian Tort law has developed to require four broad criteria to satisfy a claim in negligence: 1) A duty of care which is owed to the plaintiff, 2) a breach of that duty which, 3) leads to damages, and 4) a legal and factual causal relationship. Historically, the common law has been hesitant to recognize non-physical injury as compensable, with additional requirements for proving psychiatric injury. Canadian common law has been shifting away from this requirement, with both the Mustapha v Culligan (Mustapha) decision in 2008 and the recent decision of Saadati v Moorhead (Saadati) in 2017, discussed here. Saadati has made it less onerous for plaintiffs to prove “psychiatric” injury.

The main issue in Saadati was defining “mental injury” in a claim of negligence, and deciding how that can be determined to exist in court. More specifically, the issue was whether a claim of mental injury must conform with what an expert witness from the medical community has defined as a psychiatric injury, or whether the determination necessarily belongs to the trier-of-fact.

Facts and Judicial History

The plaintiff, appellant to the Supreme Court of Canada (SCC), was involved in a car accident when his tractor-truck was struck by a vehicle driven by the defendant, the respondent. Although the appellant’s truck was damaged, he seemed uninjured. This accident was the second in a series of five accidents that the appellant suffered between the years of 2003 and 2009. The appellant sued the respondents, the three parties involved in the first three accidents, for non-pecuniary damages and past income loss, before suffering the two later accidents.

At the Supreme Court of British Columbia, the respondents collectively admitted liability for the accidents but took the position that the appellant did not suffer any damage. The trial judge concluded the appellant had not suffered any physical damages, but had suffered “psychological injuries, including personality change and cognitive difficulties” based on testimonies of friends and family of the appellant. The British Columbia Court of Appeal decided that the appellant had failed to prove he had suffered a medically recognized psychiatric or psychological illness or condition, and therefore no injury, holding that such illness or condition must be demonstrated by “expert medical opinion evidence”.


The court began the analysis with a look into how the common law has historically viewed negligently caused mental injury. The judgement outlined the early common law’s “suspicion and sometimes outright hostility” toward such claims. The court showed how this skepticism continued into the past century by highlighting that mental injury was not compensable unless accompanied by physical injury. This, along with further barriers to recovery outlined in common law cases surrounding classes of victims and different types of proximity, were used to show the how difficult recovery has been in common law jurisdictions globally.

The court differentiated Canadian common law developments by citing Mustapha as the leading authority for the requirements to recovery for mental injury which held them to be no different than the “criteria applicable to any successful action in negligence”. The court held that the additional barriers to recovery for mental injury weren’t “based on legal principle, but on policy […] founded upon dubious perceptions of, and postures towards, psychiatry and mental illness in general: that mental illness is subjective or otherwise easily feigned or exaggerated; and that the law should not provide compensation for trivial matters”.

The court took issue with the premise that to compensate for mental injury, a plaintiff would need to obtain relevant expert testimony from the medical field as proof that they have suffered a “clinically diagnosed, recognizable psychiatric illness”. The court emphasized that to confine compensable mental injury to conditions identifiable with these diagnostic tools is suspect as a matter of legal methodology, and that the law is not concerned with accurate diagnoses, but rather with “symptoms and their effects”.

Responding to potential criticisms of the judgement leading to indeterminate liability, the court emphasized that the framework for negligence – particularly the proximity analysis in the duty of care component – will satisfactorily contain potential liabilities. In a transsystemic fashion, the court drew a comparison to Québec Civil law which allows compensation for “moral” injury under article 1457, to show that liability can still be contained.

The court also took issue with treating mental injury and physical injury as distinct under the law. The concern was that requiring a claim of mental injury in negligence to be classified as such in the medical community, but not requiring the same condition for physical injury claims, would lead to “less protection [for] victims of mental injury” and “for no principled reason”.

Having said this, the court was cognizant of the difference in nature between mental and physical injuries – that the latter is more readily apparent than the former. In discussing this, the court made clear that even without requiring expert testimony to prove mental injury, the courts will still only compensate for mental injury which “rises above the ordinary annoyances, anxieties, and fears that come with living in civil society”.

Lastly, the court was very clear in maintaining that expert testimony can still be helpful in determining whether or not mental injury has occurred, by determining, for example, how seriously the plaintiff’s cognitive functions were impaired. The court even went so far as to say that not adducing relevant expert evidence to assist the triers-of-fact can run the risk of damaging plaintiffs’ cases. Nevertheless, the court reiterated that, while expert testimony may help a claimant prove the existence of mental injury, it is not required as a matter of law.

The court found the trial judge to have been correct in their application of the law, and found that mental injury had occurred even without the existence of expert testimony.


The court’s primary concern in Saadati seemed to be the abdication of judicial responsibility in cases of negligence causing mental injury. Specifically, the court repeatedly mentioned how classification becoming a necessary component of the law of negligence would be problematic.

It is unclear in the judgement, however, why it is not possible to take into account expert testimony regardless of whether the expert believes that the plaintiff’s injury falls within a specific classification under diagnostic lists such as the Diagnostic and Statistical Manual of Mental Disorders (“DSM”) and the International Statistical Classification of Diseases and Related Health Problems (“ICD”) which were mentioned in the case. The court’s concern with these diagnostic lists not always being at the edge of scientific development in the field are reasonable. However, if this is the primary concern, it is unclear why an expert cannot still be required to inform the deliberation over whether psychiatric injury has occurred, based on that expert’s understanding of the current state of knowledge. Justice is important, and therefore it is equally important that there not be a miscarriage of justice based on faulty assumptions, which the court itself emphasized earlier in the case.

It is possible that the court wished to expand the scope of compensation for recovery of mental injury to include not only psychiatric harm, but also pure emotional harm, which the courts have historically not allowed compensation for, unless accompanied by physical injury. This isn’t objectionable from the perspective of redefining what constitutes justice in a case of negligence.

However, even if the courts intend to treat psychiatric and pure emotional injuries as the same under the umbrella of “mental injury”, how will the courts differentiate between mental injuries which rise “above the ordinary annoyances, anxieties, and fears that come with living in civil society”, and others which do not? As Dr. Stephen Smith notes, it could be problematic to conflate emotional harm with psychiatric harm, since the Anns-Cooper test for duty of care developed in Cooper v Hobart is not designed to limit liability based on the nature of the injury.

Perhaps using the term “mental harm” instead of “mental injury” would be helpful in alleviating some confusion. The court specified that they are concerned with “symptoms and effects”. An injury leads to symptoms and effects which cause harm to an individual, and so the true justiciable question may be whether the plaintiff suffered mental harm rather than a mental injury, which is a question a trier-of-fact may be better able to address without assistance from a medical expert. This is because the question would focus on how the plaintiff has been negatively affected, rather than diagnosing the injury leading to those effects.

Nonetheless, the precedent set by this case may help alleviate access to justice concerns for plaintiffs who cannot afford experts but have suffered very real mental harm, for which they should be compensated.

Pouya Dabiran-Zohoory is a Senior Online Editor with the McGill Journal of Law and Health, with a keen interest in sustainable development, specifically with a focus on climate change and its effects on human and animal health. He holds a Bcomm in law and business from Ryerson University. Since he joined the Faculty of Law at McGill University in 2016, he has taken an interest in how the common law, civil law, and regulations address health issues.