Time may have healed Smith: doctor

Forensic psychiatrist tells inquest maturity often eases disorder

It appears Ashley Smith never saw a glimmer of hope, but if only she had stayed alive long enough, the serious mental disorder which crippled her life and led to her death probably would have abated.

And so, says a seasoned forensic psychiatrist who has treated dozens of women like Ashley, she likely could have become a law-abiding productive citizen “and also (have been) happier.”

Dr. Renee Fugere of the Philippe-Pinel Institute, a forensic psychiatric hospital in Montreal where Ashley stayed for about a month, was completing her expert evidence Thursday at the coroner’s inquest examining the 19-year-old’s death.

Using a ligature she had made herself, Ashley asphyxiated in her segregation cell at the Grand Valley Institution for Women, a federal prison in Kitchener, Ont., on Oct. 19, 2007.

Correctional officers who had always rushed to her aid before, often several times a day, remained outside the cell, paralyzed by their new orders not to intervene too often or too soon.

Yet, though that delay played a role in Ashley’s death, it appears almost inevitable that, as Fugere put it, “something fairly dramatic” was going to happen to her.

Ashley was diagnosed with anti-social personality disorder with severe borderline features, Fugere told the jurors.

Personality disorders are considered Axis II disorders, as compared to Axis I illnesses, which encompass schizophrenia, bipolar disorder, psychosis and most of the better-understood mental illnesses.

Basically, a personality disorder is marked by a long-standing and pervasive pattern of maladaptive behaviour — in Ashley’s case, by a flagrant disregard for and violation of the rights of others.

The “borderline features” meant she also craved constant attention, was terrified of abandonment and created chaos in her wake.

Everywhere she went in the federal correctional system, she sucked up institutional resources so that other inmates resented her, exhausted and tormented staff, and achieved a number of “firsts” or “mosts” — first patient to be assigned to a special restraint chair; first to be restrained in a special bed for so long; most uses of the emergency response team, etc., etc.

For Fugere, for instance, Ashley was the first patient for whom she ordered a body cavity search in more than 30 years of forensic practice.

Though none of the correctional officers or psychiatrists who knew her believed she wanted to die, Ashley was nonetheless a compulsive “self-harmer,” though the delicate language hardly describes what the teenager did to herself.

She “tied up,” as she called it, multiple times a day, wrapping her homemade nooses tightly around her neck. She suffered physical damage (swelling of her eyes, a near-permanent line on her neck, and swelling of her face).

And she could make ligatures out of anything.

She made nooses from material she had torn with her teeth from mattresses, from the purportedly indestructible security gown that was her only garment, from sweatpants and T-shirts and towels, even from dental floss.

And she secreted spares in her vagina, the one sure place where, in the ordinary course, a system bent on preserving the dignity of female inmates only infrequently would dare to have searched.

In a pinch, if Ashley was out of nooses, she would also bang her head against wall or floor, and she also occasionally cut herself, though superficially.

“You had to wait for her to decide to change her behaviour before you can change her behaviour.”

DR. RENEE FUGERE

Personality disorders are difficult to treat, Fugere said, and require “a lot of investment and time and courage” from the patients themselves. A significant barrier for Ashley was her age: She was simply too immature to have the insight to understand her illness and accept it.

As Fugere said, and this was the catch-22 of this strange young woman, “You had to wait for her to decide to change her behaviour before you can change her behaviour.”

While people don’t choose to have a personality disorder, Fugere said in reply to a juror’s question, there is nonetheless an element of choice to the disease.

“What … your responsibility is, when you suffer from such a condition, is how are you going to cope? How are you going to contain the disorder?”

Ashley hadn’t even reached the “pre-contemplative” stage that comes before a patient is ready to even consider that “Maybe I have a problem,” Fugere said.

On a scale of one to 10, Fugere told her lawyer, Mark Freiman, Ashley “would fall at 11” in terms of the difficulty in managing her.

But she said she had probably treated another 40 women as challenging as Ashley, all elevens. Personality disorders tend to become less florid with age, and by the time a woman is 40, she may be relatively mellow.

“We know by experience, it’s not a permanent condition; it could be improved,” she said.

How cruel: Ashley Smith ran out of time before time could help her.