When Dr. Lenka Zedkova entered the Department of Psychiatry's Residency Program in 2005, she was still unsure about her long-term career plans.
After completing medical school at Charles University in Prague in the late 1990s and earning a PhD in the Department of Psychiatry Graduate Program in 2003, she knew only that she wanted to focus on clinical psychiatry with adult patients.
"I knew nothing about Forensic Psychiatry back then. I was part of a cohort that didn't even have to be exposed to the field of Forensic Psychiatry during Residency, so I really wasn't thinking about it," she recalls.
"Then in my fourth year of Residency I was assigned to do my rotation in rehabilitation psychiatry with forensic patients. I was a bit nervous because I really didn't know what I'd be dealing with, but it turned out to be a great experience. I loved learning about the legal system, the intellectual exercise associated with court-ordered assessments and so on."
That led Dr. Zedkova to pursue a Forensic Psychiatry Fellowship in 2010, a year after the Council of the Royal College of Physicians and Surgeons of Canada finally recognized Forensic Psychiatry as a Subspecialty of Psychiatry.
She became a Certified Forensic Psychiatrist in 2014 and since 2017 she has served as Program Director for the Department of Psychiatry's Forensic Psychiatry Subspecialty Residency Program, working mainly out of Alberta Hospital Edmonton (AHE).
"We're now one of seven accredited Forensic Psychiatry Subspecialty Residency Programs in Canada, and there are others applying as well. We were accredited in 2013 under the directorship of Dr Alberto Choy, who is now the Edmonton Zone Section Chief for Forensic Psychiatry."
The program offers Residents exposure to a broad range of training experiences in all areas of Forensic Psychiatry, including court-ordered assessments and report writing, continued treatment and rehabilitation of forensic patients during recovery and reintegration into the community, and civil assessments.
AHE, which has over 100 forensic psychiatry beds including maximum security designated forensic units at the Helen Hunley Pavillion, is the largest and most fully staffed forensic treatment facility in the province.
"There is a progression here, ranging from acute units to a medium security unit, where patients are typically more stable, have access to more programs and liberties, and if they're well, can walk on the grounds or in the city unsupervised. We also have two open rehabilitation units, which should theoretically be the last step before patients are released into the community."
Outpatient forensic services programs - which are provided at Alberta Health Services' Forensic Assessment and Community Services (FACS) office in downtown Edmonton - offer subspecialized assessment, ongoing treatment and outreach services.
The Forensic Psychiatry Subspecialty Program also offers Residents exposure to young patients through its Young Offender programs. These programs feature inpatient and outpatient programs that have been recognized for leadership in the rehabilitation of youthful offenders.
The Turning Point Program - designed around a 17-bed adolescent forensic unit at AHE - is a key element of this. It gives trainees exposure to young offenders who have been admitted for a variety of court-ordered assessments or treatment.
"We also offer outpatient young offender services through our Centre Point Program, which involves assessments and referrals for treatment from the courts, probation, parole officers and so on."
The Edmonton Remand Centre and various provincial and federal correctional facilities in the area also provide Residents with exposure to court-ordered assessments and opportunities to participate in correctional clinics.
"This is a small program, in terms of numbers. The PGME (Postgraduate Medical Education Office) has so far funded up to two spots but we typically have one Resident in the program," says Dr. Zedkova.
"But we offer quite a variety of training experiences here at AHE. Residents start their curriculum on the Acute Assessment Unit, and first learn what we call the bread and butter of forensic psychiatry," she explains.
That includes conducting pre-trial assessments of a patient's fitness to stand trial, their criminal responsibility under the law, and report writing, a key competency for forensic psychiatrists.
"From there Residents continue on to one of the Forensic Rehabilitation Units where it's a bit of a different setting. These units are for individuals who are already found unfit or NCRMD (Not Criminally Responsible due to a Mental Disorder) by the courts, and are now under the jurisdiction of the Alberta Review Board," she says.
"They provide treatment and rehabilitation for these patients based on the recovery model. They also provide ongoing risk assessment and risk management, and are involved in reintegrating these patients into society, which is ultimately our goal here."
In addition to the four core rotations outlined above - which are formally referred to as Acute Assessment and Treatment, Forensic Rehabilitation, Forensic Assessment and Community Services (FACS), and the Turning Point Program for young offenders - Residents can also pursue various electives within the curriculum.
These include the Sexual Offenders Assessment and Treatment Program and the Spousal Violence Program, both of which are conducted at the FACS location on 106 Street.
Other electives include Forensic Research, the Centre Point Program, and Civil Forensics, which involves cases from insurance companies, child welfare, professional bodies, law enforcement, institutions, and/or corporations.
Throughout the PGY-6 year, Residents are trained to provide expert testimonies for the Alberta Review Board or the courts, including the newly established Mental Health Court. This is one of the fundamental skills of a forensic psychiatrist.
"The strength of this program is that we can really offer a wide variety of learning experiences. We also have a great group of about 10 educators at AHE and at FACS who are involved in the program. There is a real sense of collegiality and dedication to this field, and I think that provides for a great learning environment," says Dr. Zedkova.
"As for the qualities we look for in assessing candidates for the program, we want to see genuine interest - as demonstrated in the Resident's letter of intent, their reference letters and in the interview. Forensic psychiatry is all about teamwork, so to be flexible and collaborative is also really important, as well as being flexible and open minded toward the forensic population, which can be quite complex."
The capacity for self-reflection, an awareness of one's own strengths and weaknesses, a sense of humility and the willingness to learn from others are also key traits, she says.
"One would hope that at this stage of their careers, Residents would no longer have any rigid, preconceived ideas about the forensic population. When you speak to a patient, no matter how serious their offences are, typically the countertransference is not as strong as during the initial research of the case," she says.
"It's important to understand the complexity of people, their mental illness, life circumstances, and genes that can drive them to commit serious offences. The direct encounters with patients are typically not as intimidating or off-putting as one might initially assume."
In addition to the challenges of working with forensic patients, Dr. Zedkova says the field also offers enormous rewards when very ill patients respond well to treatment and go on to live their lives in the community.
"Clozapine is an antipsychotic drug that's used for treatment-resistant schizophrenia. I've seen what I would call miracles with that particular medication when nothing else really helped. I've seen people improve quite significantly, getting to the rehabilitation unit, then out into the community, and not coming back. So when something like that happens, it's very, very rewarding."
After completing medical school at Charles University in Prague in the late 1990s and earning a PhD in the Department of Psychiatry Graduate Program in 2003, she knew only that she wanted to focus on clinical psychiatry with adult patients.
"I knew nothing about Forensic Psychiatry back then. I was part of a cohort that didn't even have to be exposed to the field of Forensic Psychiatry during Residency, so I really wasn't thinking about it," she recalls.
"Then in my fourth year of Residency I was assigned to do my rotation in rehabilitation psychiatry with forensic patients. I was a bit nervous because I really didn't know what I'd be dealing with, but it turned out to be a great experience. I loved learning about the legal system, the intellectual exercise associated with court-ordered assessments and so on."
That led Dr. Zedkova to pursue a Forensic Psychiatry Fellowship in 2010, a year after the Council of the Royal College of Physicians and Surgeons of Canada finally recognized Forensic Psychiatry as a Subspecialty of Psychiatry.
She became a Certified Forensic Psychiatrist in 2014 and since 2017 she has served as Program Director for the Department of Psychiatry's Forensic Psychiatry Subspecialty Residency Program, working mainly out of Alberta Hospital Edmonton (AHE).
"We're now one of seven accredited Forensic Psychiatry Subspecialty Residency Programs in Canada, and there are others applying as well. We were accredited in 2013 under the directorship of Dr Alberto Choy, who is now the Edmonton Zone Section Chief for Forensic Psychiatry."
The program offers Residents exposure to a broad range of training experiences in all areas of Forensic Psychiatry, including court-ordered assessments and report writing, continued treatment and rehabilitation of forensic patients during recovery and reintegration into the community, and civil assessments.
AHE, which has over 100 forensic psychiatry beds including maximum security designated forensic units at the Helen Hunley Pavillion, is the largest and most fully staffed forensic treatment facility in the province.
"There is a progression here, ranging from acute units to a medium security unit, where patients are typically more stable, have access to more programs and liberties, and if they're well, can walk on the grounds or in the city unsupervised. We also have two open rehabilitation units, which should theoretically be the last step before patients are released into the community."
Outpatient forensic services programs - which are provided at Alberta Health Services' Forensic Assessment and Community Services (FACS) office in downtown Edmonton - offer subspecialized assessment, ongoing treatment and outreach services.
The Forensic Psychiatry Subspecialty Program also offers Residents exposure to young patients through its Young Offender programs. These programs feature inpatient and outpatient programs that have been recognized for leadership in the rehabilitation of youthful offenders.
The Turning Point Program - designed around a 17-bed adolescent forensic unit at AHE - is a key element of this. It gives trainees exposure to young offenders who have been admitted for a variety of court-ordered assessments or treatment.
"We also offer outpatient young offender services through our Centre Point Program, which involves assessments and referrals for treatment from the courts, probation, parole officers and so on."
The Edmonton Remand Centre and various provincial and federal correctional facilities in the area also provide Residents with exposure to court-ordered assessments and opportunities to participate in correctional clinics.
"This is a small program, in terms of numbers. The PGME (Postgraduate Medical Education Office) has so far funded up to two spots but we typically have one Resident in the program," says Dr. Zedkova.
"But we offer quite a variety of training experiences here at AHE. Residents start their curriculum on the Acute Assessment Unit, and first learn what we call the bread and butter of forensic psychiatry," she explains.
That includes conducting pre-trial assessments of a patient's fitness to stand trial, their criminal responsibility under the law, and report writing, a key competency for forensic psychiatrists.
"From there Residents continue on to one of the Forensic Rehabilitation Units where it's a bit of a different setting. These units are for individuals who are already found unfit or NCRMD (Not Criminally Responsible due to a Mental Disorder) by the courts, and are now under the jurisdiction of the Alberta Review Board," she says.
"They provide treatment and rehabilitation for these patients based on the recovery model. They also provide ongoing risk assessment and risk management, and are involved in reintegrating these patients into society, which is ultimately our goal here."
In addition to the four core rotations outlined above - which are formally referred to as Acute Assessment and Treatment, Forensic Rehabilitation, Forensic Assessment and Community Services (FACS), and the Turning Point Program for young offenders - Residents can also pursue various electives within the curriculum.
These include the Sexual Offenders Assessment and Treatment Program and the Spousal Violence Program, both of which are conducted at the FACS location on 106 Street.
Other electives include Forensic Research, the Centre Point Program, and Civil Forensics, which involves cases from insurance companies, child welfare, professional bodies, law enforcement, institutions, and/or corporations.
Throughout the PGY-6 year, Residents are trained to provide expert testimonies for the Alberta Review Board or the courts, including the newly established Mental Health Court. This is one of the fundamental skills of a forensic psychiatrist.
"The strength of this program is that we can really offer a wide variety of learning experiences. We also have a great group of about 10 educators at AHE and at FACS who are involved in the program. There is a real sense of collegiality and dedication to this field, and I think that provides for a great learning environment," says Dr. Zedkova.
"As for the qualities we look for in assessing candidates for the program, we want to see genuine interest - as demonstrated in the Resident's letter of intent, their reference letters and in the interview. Forensic psychiatry is all about teamwork, so to be flexible and collaborative is also really important, as well as being flexible and open minded toward the forensic population, which can be quite complex."
The capacity for self-reflection, an awareness of one's own strengths and weaknesses, a sense of humility and the willingness to learn from others are also key traits, she says.
"One would hope that at this stage of their careers, Residents would no longer have any rigid, preconceived ideas about the forensic population. When you speak to a patient, no matter how serious their offences are, typically the countertransference is not as strong as during the initial research of the case," she says.
"It's important to understand the complexity of people, their mental illness, life circumstances, and genes that can drive them to commit serious offences. The direct encounters with patients are typically not as intimidating or off-putting as one might initially assume."
In addition to the challenges of working with forensic patients, Dr. Zedkova says the field also offers enormous rewards when very ill patients respond well to treatment and go on to live their lives in the community.
"Clozapine is an antipsychotic drug that's used for treatment-resistant schizophrenia. I've seen what I would call miracles with that particular medication when nothing else really helped. I've seen people improve quite significantly, getting to the rehabilitation unit, then out into the community, and not coming back. So when something like that happens, it's very, very rewarding."