Mental Health Symposium: Advancing Solutions to Offender Mental Health

Correctional Services Canada

Gatineau, Quebec
May 21-22, 2008

Presenters

  1. Julie Babineau
    Chief Executive, Justice Health
    New South Wales, Australia
  2. Professor Raymond Corrado
    Director, Centre of Social Responsibility
    School of Criminology, Simon Fraser University
  3. Keith Coulter
    Commissioner
    Correctional Services Canada
  4. Sean Duggan
    Director of Prisons and Criminal Justice Program
    Sainsbury Centre for Mental Health, United Kingdom
  5. Joel Dvoskin
    Assistant Clinical Professor
    College of Medicine, University of Arizona
  6. Joseph Lima
    Senior Parole Officer
    New York State Division of Parole
  7. Leslie MacLean
    Assistant Commissioner
    Correctional Services Canada
  8. Maureen C. Olley
    Director, Mental Health Services, Corrections Branch
    Ministry of Public Safety and Solicitor General
    British Columbia.
  9. Honourable Mr Justice Edward Ormston
    Justice, Ontario Supreme Court
    Chair, Mental Health and Law Advisory Committee
    Mental Health Commission of Canada
  10. Michele Steele
    Program Manager, Office of Health Services
    East Coast Forensic Hospital, Nova Scotia Health
  11. Elizabeth Tysoe
    Head of Health Inspection, HM Inspectorate of Prisons
    London, United Kingdom
  12. Phil Upshall
    National Executive Director, Mood Disorders Society of Canada
    Adjunct Lecturer, Department of Psychiatry, Dalhousie University

Day 1:

Welcome and Introduction

Keith Coulter
Commissioner
Correctional Services Canada

Leslie MacLean
Assistant Commissioner
Correctional Services Canada

Leslie MacLean welcomed participants to the Symposium and shared formal greetings from the Honourable Stockwell Day, Minister of Public Safety. In his greeting, Day thanked participants for their valuable contribution, saying, "Your advice, expertise, and support will help us in meeting the complex challenges associated with a changing offender profile."

MacLean said an interesting, enthusiastic, and knowledgeable group of speakers from Canada and abroad would provide background and context, as participants shared best practices and offered practical solutions to help Correctional Services Canada (CSC) improve mental health services provided to offenders. She also challenged participants to help identify the drivers and trends that would shape CSC’s work in mental health over the next five years. "We’re hoping you will find this an interesting learning opportunity," said MacLean.

MacLean introduced Commissioner Keith Coulter, who thanked the participants for their presence. Coulter stated that mental health is one of CSC’s top five priorities. He gave an overview of recent statistics on offender mental health issues.

Coulter said CSC is working hard to help the increasing number of men and women offenders suffering from mental health disorders. New realities and trends must be addressed, he said, such as the need to identify ways of introducing or expanding the delivery of mental health services for offenders upon their release into the community.

Coulter said the Symposium would help CSC ensure it is on track in terms of its new strategy to provide a sustainable, coherent national approach to mental health issues, by tapping into the experience, knowledge, values, and ideas of stakeholders. "One of the aspects of mental health we are trying to stress is the direct link between how well we respond to offender needs and public safety," he said.

"Each of you has been personally invited because of your expertise," said Coulter. "I know I speak for all CSC participants when I say we are grateful to those from other jurisdictions who are here today."

The Canadian Context

Overview:
Mandate and Work of the Mental Health Commission of Canada

Honourable Mr. Justice Edward Ormston
Justice, Ontario Supreme Court
Chair, Mental Health and Law Advisory Committee
Mental Health Commission of Canada

The Honourable Mr. Justice Edward Ormston, opened by saying that he was delighted to be speaking to people dedicated to improving mental health services. "We are finally out of the shadows with respect to mental illness," he said.

Ormston said mental illness could often be compounded by poverty and illiteracy. People in this situation, he said, "slip through the cracks and wind up in my court and in your jails."

As a long-time advocate on this issue, Ormston said he is aware of the importance of empathy and adequate training on mental health issues for personnel, such as social workers, law enforcement officials, and health care professionals. He said the Commission’s various committees have projects and proposals in place to "prove to the people who are suffering that we are doing something." The Commission’s overall goal is to create sound policy on mental illness, based on knowledge exchange and a strong national strategy.

Ormston gave participants an overview of the lessons learned through his experience with Toronto’s Mental Health Court. For many disadvantaged people, the main point of entry into the medical system regarding treatment for mental illness is "through the police." To ensure the best possible outcome, Ormston said, the client’s needs must be at the heart of the process at all times.

"Not everybody in your prisons is a bad guy. They didn’t all pick a life of crime," Ormston said. "If we identify mental illness quickly, we can deal with it and break the stigma."

Discussion

A participant asked Ormston to give his opinion on the possible creation of a Mental Health Court targeted at youth.

Ormston said such an initiative would be of great interest to the Mental Health Commission. He said children and youth suffering from mental illness and entering the criminal justice system often "come from the same place as adults" in terms of socio-economic indicators.

The problem is the lack of psychiatric beds for youth in Ontario hospitals, he said: "When I sit on the Mental Health Court and send a person to hospital for treatment, this person waits in jail for a bed. My concern is that a child will hang himself in jail, waiting for a hospital bed."

A participant asked if it would be better to resource mental health and forensic mental health beds in hospitals, rather than believing CSC is adequately equipped to deal with these offenders.

Ormston said judges often create a false expectation among offenders regarding the services to which they will have access in CSC facilities. "This creates resentment towards [the judge]," he said. "We haven’t been well educated. You don’t have the programs, but we think you do, and offenders think you do."

Another source of frustration, said Ormston, is the presence of concurrent disorders, such as in the case of a schizophrenic person who is also addicted to heroin. "The addiction community won’t take you in until you’re treated for your mental illness, and mental health resources won’t help you until you deal with your addiction."

A participant said while Mental Health Courts serve a purpose, they are unable to create options for many of their clients.

Ormston said he agreed: "Police do need better options than the hospital or jail," he said, but the Mental Health Court is not the only possible arena for this. People suffering with mental illness need positive feedback from an authority figure, and that could just as easily occur in a police station, for example. However, Ormston said, "Fear of litigation has created a chill in the use of discretion. As a result, we are plagued with trial delays in Ontario. We can’t process mental health problems--they take time. Empathy, understanding, and training are key."

Intergenerational Transmission of Risk Factors Related to the Impact of Residential Schools

Professor Raymond Corrado
Director, Centre of Social Responsibility
School of Criminology, Simon Fraser University

Dr. Corrado said he and teams of graduate students have been conducting research with young offenders for over a decade. In that time, they have interviewed over 1,000 youth who are violent and serious offenders. In Canada, he said, this group is referred to as the "four-percenters," the youth with mental illness who end up in correctional systems. To better understand this population, Corrado said his group’s questionnaire includes questions relating to demographics, psychopathic traits, and treatment needs, and the interviews take hours to complete. Corrado’s students conduct interviews with each individual at intake, during their stay, and at release.

Corrado spoke about the data compiled from studies of young offender risk-factor profiles between 2005 and 2008. He noted that adult violent behaviour is predictable with up to 85% accuracy when the individual is in kindergarten. Persistent school problems are particularly predictive; some of these children will change schools up to 50 times because of expulsion. Eventually placing them in alternative schools only brings them all together as one group, where they socialize and enter a sub-culture. Corrado said, "I see nothing wrong with alternative schools--I just want to see them placed elsewhere and called something else."

Persistent use of street drugs is another predictive factor. Publicizing the dangers of methamphetamine, also known as crystal meth, "has scared kids away from it, but these kids are already mentally ill and have serious cognitive disorders, so when you scare them, it doesn’t do any good." Corrado cited dysfunctional family profiles, especially if the child is exposed to violence, as another risk factor. He argued that a child raised by a single parent, typically the biological mother, has a higher incidence of behavioural issues than one raised to age 13 by both parents. He discussed the intergenerational transmission of criminality, mentioning one example in which a son was a major drug dealer and the father was prominent within organized crime. When treating a youth offender, Corrado said, it is important to treat the whole family.

He mentioned the ongoing discussion on dropping the age of criminality from 12 years to 10, or even eight years, as it is in some parts of the United States. The children in Corrado’s studies lack the capacity for any forethought, he said. "The major problem for my grad-student interviewers is getting these kids to focus." Neurobiologically, human beings are not mature until age 25, "so the same things that drive you at 15 are driving you at 24," he said; the belief that a person magically becomes an adult at age 18 is mistaken.

One major problem is diagnosis at the youth level, due to a simple lack of diagnostic instruments. Corrado said his team is working to develop these. They are trying to determine the reason for the large gap between what a youth feels and the actual diagnosis. Why do so many say they feel depressed, but only a small percentage are diagnosed with depression? In corrections, Corrado said, a single diagnosis does not give enough information. "We can’t just give up on these people who have pathological and psychopathic traits." Corrado recommended a more elaborate measure, using six domains to define a psychopathic personality disorder--including dominance, attachment, behaviour, and emotion--instead of two.

Corrado talked about the statistical significance of the number of Aboriginal and non-Aboriginal youth in prisons, of female young offenders in custody instead of treatment, and of the transfer of residential school-related post-traumatic stress syndrome from one generation to another.

Corrado spoke of the success of intervention programs in other countries, but said ad hoc contact does not work. The intervention with the family must take place daily, beginning with supporting a healthy pregnancy. Ages three through five are key for developing cognitive skills, and daily intervention can then help in addressing childhood risk factors, and greatly reducing adult risk factors before they occur.

Developing Strategic Partnerships and Facilitating Knowledge Exchange to Move CSC’s Mental Health Strategy Forward

Phil Upshall
National Executive Director, Mood Disorders Society of Canada

Advisor Stakeholder Relations for the Mental Health Commission of Canada
Adjunct Lecturer, Department of Psychiatry, Dalhousie University

Phil Upshall said the Mood Disorders Society of Canada (MDSC) is a volunteer health organization that collaborates with the public and private sectors to provide peer support, self-help groups, advocacy, and a stigma-free environment for people with mental illness. In addition to brochures and other printed materials, MDSC provides advice and information through Web-based applications.

One in five Canadians will personally experience a mental illness during their lifetime, Upshall said, and the estimated economic cost of mental illness in Canada is $51 billion. However, mental illness "is about people, not numbers." It carries broader societal implications that affect families and caregivers and relate to issues such as suicide, incarceration, homelessness,and discrimination.

Stigma, in particular, is "the elephant in the room." Upshall said, "People are very uncomfortable when talking about mental illness." Canada has conducted several national consultations on stigma and discrimination, from various perspectives,including Citizens for Mental Health, the Canadian Collaborative Mental Health Initiative, the Stigma Research Workshop, and the Mental Health Literacy Consultations. The most current initiative, implemented by the Mental Health Commission of Canada, is a 10-year national anti-stigma campaign.

In an emergency situation, those with mental illness are often handled by the police and met with Tasers and handcuffs. In contrast, Upshall said those with physical illness or injuries are treated by paramedics and assisted with support equipment, such as wheelchairs and crutches.

Upshall outlined the six-tier system for mental health care in Canada, which includes the provincial/territorial health authority; Employee Assistance Programs; NGOs that provide peer support and self-help, such as the MDSC; street nurses; correctional facilities; and charities, such as soup kitchens.

Discussing the options and opportunities currently available, Upshall said federal and provincial mental health initiatives and leadership are steps in the right direction.

Upshall said he recommends that CSC engage with the MHCC’s anti-stigma campaign, its Web-based Knowledge Exchange Centre, and its work to develop a national strategy to address mental illness. He also suggested establishing relationships with various advisory boards, anti-violence campaigns, homelessness initiatives, and other anti-stigma campaigns.

CSC should also build partnerships with other government agencies and departments with national responsibilities. Upshall listed the RCMP, Canadian Forces, Health Canada’s First Nations and Inuit Health Branch and its National Wellness Strategy, and national bodies with responsibility for Canada’s workforce.

Other potential partners include:

  • The Canadian Collaborative Mental Health Initiative
  • Human Resources and Social Development Canada (HRSDC)
  • Mental Illness Awareness Week
  • The Canadian Alliance on Mental Illness and Mental Health
  • The Canadian Population Health Initiative of the Canadian Institute for Health Information (CIHI)
  • The Canadian Association for Suicide Prevention
  • Canadian Institutes of Health Research (CIHR)
  • The Canadian Centre on Substance Abuse 

In addition, CSC should engage other groups not normally considered "stakeholders," and conduct an internal evaluation of program results with the aim of improving conditions in facilities to enhance offender mental health and self-esteem.

To seize these opportunities, CSC will need to dedicate staff and resources, prioritize opportunities, keep communication flowing, and support the initiatives of others that may, in turn, support CSC’s goals. CSC will also need to sponsor multi-party workshops and help with funding outcomes. Most important, it must reach out to engage others, and stay engaged.

In conclusion, Upshall posed several questions for participants to consider:

  • What is meant by the continuum of care?  Is CSC a continuum of care within itself, or is it part of the larger health continuum of care?
  • Why has CSC not engaged offenders, particularly those who have served their sentences, for both focus group and peer support purposes?
  • Can CSC change its culture and practices to look outward to networking, researching, and otherwise partnering with non-traditional partners? 
Group Discussion:
Key Factors, Drivers, and Trends

Leslie MacLean
Assistant Commissioner
Correctional Services Canada

Ms. MacLean invited participants to break into groups to address the following question: What are the key factors, drivers, and trends that will affect CSC’s work in the area of mental health over the next five years?

Following the discussions, representatives from each group reported back in plenary.  The factors, drivers, and trends identified were as follows:

An increasing number of young offenders with serious mental illnesses are heading to CSC.

CSC must strengthen recruitment and build capacity to meet the growing need among this population; staff must be highly qualified to deal with the complexity of mental illness.

Interdisciplinary teams need support, and CSC must break down silos and engage all employees who work with offenders.

Approach information sharing from a positive angle that focuses on what offenders need to be successful.

Re-humanize management of offenders

CSC must also enhance resource sharing with community mental health partners.

CSC must seek out and engage non-traditional partners if it wants to take effective advantage of levers for change.

CSC must link with other organizations and provincial administrations, and involvement of all staff is key.

As diagnosis becomes more robust, the public will have higher expectations for CSC to demonstrate results and show both legal and financial accountability, CSC may need to redefine some traditional roles and mechanisms for service delivery.

Provide more training to CSC staff regarding the basics of mental health. Those with cognitive impairments have different needs which may require differentiated staff training.

Launch an anti-stigma campaign, both internally and externally.

Partnering with other organizations is important, to provide case management over a lifetime.

Need to advocate for increased resources in prevention and early identification.

CSC is generally perceived as isolationist and must improve its image to become an employer of choice.

There is a large increase in young offenders, especially girls, who have been violent or have a background of gang affiliations. CSC must become better at dealing with this population

Keep pace with the increasing trend of mental health recovery as an approach to treating offenders with mental illness.

Build structured communities where these offenders can go upon release.

The Mental Health Service Delivery Continuum

Overview: A Review of the Mental Health Continuum in the United Kingdom

Elizabeth Tysoe
Head of Health Inspection, HM Inspectorate of Prisons
London, United Kingdom

Elizabeth Tysoe gave an overview of mental health services in institutions in England and Wales. She also summarized her organization’s review of the conditions and treatment of inmates suffering from mental illness in British prisons.

Two findings stand out from this review, said Tysoe. First, too many gaps in service provision still exist. Moreover, there remains too much unmet and unrecognized need, both for prisoners and for others who, as a consequence of lack of support and provision of services, are likely to end up in the criminal justice system. The second finding, said Tysoe, "is that need will always remain greater than capacity, unless community mental health and services are improved and people are appropriately directed to them before, instead of, and after custody."

Tysoe said the lack of training and support for medical personnel and support staff is a major hurdle in the delivery of mental health services. Prisoners with mental health problems indicate the need for a caring, supportive, and stimulating environment. However, prisoners with such difficulties can often find themselves segregated because of the challenges their behaviour poses.

Tysoe said a holistic approach to mental and emotional health is important, especially with regard to women inmates. This echoes the four determinants of a "healthy prison," according to Tysoe’s organization: safety, respect, purposeful activity, and resettlement. Health care is included in the "respect" determinant, Tysoe said.

As a result of the thematic review, the Inspectorate of Prisons made several recommendations to address the gaps in provision of services at all levels and across a variety of agencies, from national to local, commissioners, and providers.

Recommendations include the need for a blueprint for the delivery of mental health services in prison, with appropriate external support and governance and internal integration with other prison staff and services. They also take into consideration the need for a wider range of mental health interventions available in women’s prisons.

Tysoe said, "The failure to identify need, and provide support, at an earlier stage is the reason why some people offend in the first place."

"Prisons can provide better and more focused care for those who need to be there," she said, "but they will only do so effectively if there is sufficient alternative provision for those who should not be there, and effective community support for those who leave prison. Unless those gaps are filled, mentally ill people will continue to fall through them, and into our overcrowded, increasingly pressurized prisons."

Primary Health Care Delivery in Prisons

Sean Duggan
Director of Prisons and Criminal Justice Program
Sainsbury Centre for Mental Health, United Kingdom

Diversion can result in re-offending rates that are "lower; really remarkably lower," said Sean Duggan. He said an international review of diversion models and their effectiveness would take place in autumn 2008. Participants from Australia, North America, and the United Kingdom attended an international video conference to discuss obtaining support for diversion, the costs and benefits, local initiatives, and what the offenders can be diverted to. One outcome from the discussion, he said, is that while a national approach to diversion is important, strongly supported local initiatives are also necessary. Numerous organizations are involved in diversion, including health, criminal justice, community services, and others. Duggan said, "Before you start, it helps to spell out what your capacity is; otherwise, it will all fail."

Applying the diversion model to children, Duggan said early intervention and pre-arrest are key, as is training police officers in intervention and places for diversion, including the agencies that need to be involved and their roles. "Early interventions are working quite well."

Duggan discussed the option of using  community sentence orders--which include a mental health requirement--instead of imposing custodial sentences. However, far fewer mental health treatment requirements are used than could be, he said, given the proportion of mental health issues of those who appear before the courts for sentencing. This is partly because these community and treatment sentences are fairly new, and judges may need more clarification about how they work. "This is a good idea and I think we should pursue it, but it’s not working at the moment."

Imprisonment for public protection (IPP) sentences are bad for mental health, Duggan said, but the rates are rising. A study of women prisoners with high levels of mental health problems found short sentences to be very damaging and community sentences more beneficial. The prisoners’ multiple complex needs cannot be properly met during imprisonment. In addition, he said the screening of remand prisoners for mental health problems is very poor.

Duggan described the facets of Pathways through the criminal justice system. Phase 1 consists of modeling criminal justice care pathways. Phase 2 will incorporate pilot projects, and the Sainsbury Centre for Mental Health (SCMH) and its partner organizations have a team of people dedicated to helping prisons make changes and apply policies on the ground. In addition, Duggan said, a two-year research project will identify effective employment pathways for people within and leaving the prison service, and for people with mental health problems.

No national information is available on the amount spent on primary or mental health care in prisons, Duggan said. Interviews with prisoners, staff, and service providers at five prisons in England showed higher significant rates of trauma--domestic violence, gangland behaviour, and torture, and overseas prisoners who were tortured--among the prisoners there. He said SCMH has introduced a range of psychological therapies based on this information, but a lot of it "won’t find its way into the prison service, and that will have to change."

National Health Service and primary care trusts have the power to commission health services and housing for people. Post-prison transition is a significant issue, Duggan said, but "we have the opportunity to get it right"; he said he would work to raise the profile of this issue. Primary care trusts have the money, but do not spend it on health and mental health primary care.

Duggan said he applauded the initiative of this conference in taking an international perspective to learn from one another. He said upon his return to England, SCMH would publish its first mental health economics paper, indicating that investment is at about 30% of what is needed. Prisons are receiving major investments for primary care and drug abuse, he said. "We’re saying some of that money should go toward mental health."

Screening Tools in the Mental Health Assessment Process

Maureen C. Olley
Director, Mental Health Services, Corrections Branch
Ministry of Public Safety and Solicitor General, B.C.

Maureen Olley gave an overview of the Jail Screening Assessment Tool (JSAT) used in British Columbia.

Intake is key, as it is a time of turmoil for inmates. The faster a high-need individual can be identified, the earlier effective management, treatment, and prevention of more severe mental illness can take place.

Current literature estimates that as many as 25% of inmates will require a referral for mental health services and/or specialized placement, Olley said. Moreover, among jail detainees with severe mental disorders on admission, about 72% have co-occurring substance use disorders.

Studies have demonstrated the potentially negative impact of incarceration on mentally ill offenders, and B.C. Corrections mandates mental health screening across the province. In B.C., the JSAT has been developed as the guideline for mental health screening in jails.

JSAT is a computerized tool that allows health care staff to document the results from interviewing and observing inmates at intake. The tool emphasizes early identification, prevention, and management. It also recommends erring on the side of caution and ensuring the mental health screener is part of a team that includes such professionals as nurses, correctional officers, psychologists, and psychiatrists.

Olley said the JSAT consists of a series of questions that gather information, including social demographic characteristics, the inmate’s legal situation, history of violence and suicide/self-harm, level of substance use, and history of mental health issues and treatment. The JSAT uses the Brief Psychiatric Rating Scale, which focuses on symptoms rather than diagnosis, to assess an individual’s current mental health status.

The tool takes a maximum of 30 minutes to complete. During the interview, the screener also records mental health observations based on the inmate’s appearance, behaviour, mood, cognitive functioning, speech, and insight. The screener makes referral, placement, and management recommendations so inmates who require mental health services can receive further assessment and/or treatment. The screener also identifies the inmate’s level of risk in terms of suicide/self-harm, violence, and victimization.

Olley presented the results of two studies that have demonstrated the validity of JSAT for identifying individuals who need mental health services. Specifically, the studies examined whether the tool had problems with under- and over-identification. The research concluded that JSAT is useful in both male and female jails and pre-trial centres. It also found mental health screening to be a cost-effective way of evaluating a large number of individuals with diverse mental health issues.

Lessons learned in the implementation process include the importance of communication, collaboration, information sharing and use, training, ongoing supervision of screeners, provision of clinical feedback, evidence-based practice, continuing monitoring through research, and a user-friendly computer interface.

Screeners must have training in psychopathology and assessment, including interviewing skills, and they need skills to enable them to recognize subtle cues and clinical symptoms. Olley also said it is important to err on the side of caution.

In the prison context, the reasons for referral are likely similar, Olley said, while factors such as release planning and level of motivation can supplement screening to contribute meaningfully to treatment plans.

Discussion

A participant asked about the process for reassessing inmates who are being readmitted. Olley said the screener still conducts the entire interview, as situations can change quickly. Moreover, the electronic files available today allow for clinical continuity and integration with past information.

Olley noted that the JSAT is designed to identify acute illness requiring immediate intervention rather than more chronic conditions. 

Another participant asked about the issue of consent and the timeframe between referral and treatment. The system is based on verbal consent at present, said Olley. Some inmates do refuse, and the screener then refers them to the mental health program or to another screener. She said the timeframe between referral and treatment varies depending on the situation. A psychologist sees those at risk of suicide the next day, while other cases may take longer.

A participant asked if attempts are made to verify responses and obtain collateral information. Olley said proper collateral checks take time, but screeners may seek out community resources and occasionally can refer to old files.

Continuum of Care for Offenders with Mental Health Illnesses

Joel Dvoskin
Assistant Clinical Professor
College of Medicine, University of Arizona

Dr. Dvoskin said "continuity of care" starts with the prevention of child abuse. He said CSC’s priorities coincide with what the system needs: safer prisons, increased inmate accountability, employment and employability, and enhanced community infrastructure, capacity, and partnerships.

"You can’t have treatment without security, and you can’t have safety without treatment for mental illness," Dvoskin said. "Mental health, custody, programs, and medical treatment must work together."

The criminal justice system has a high prevalence of mental illness and substance abuse, with the frequency of anxiety, depression, trauma, and custodial parenting issues twice as high for female as for male offenders. This situation has resulted from the failure of many service delivery systems, including those related to mental health, housing, and other social services, intellectual disability, substance abuse, and child protection.

However, Dvoskin discussed some positive developments that include Mental Health Courts, intensive parole, generalist case managers, and "assertive community treatment," which focus on community-based preventive services.

Dvoskin said mental illness should be viewed from the perspectives of skill deficits, social disconnectedness, and spiritual crisis. Integrated treatment is consistently associated with better outcomes, including keeping people housed and employed.

He recommended the work of several experts:

  • Robert Drake on co-occurring disorders
  • Bruce Perry on the effects of trauma on the developing human brain
  • William Miller on motivational interviewing
  • Marsha Linehan on Dialectical Behavioural Therapy
  • Sam Tsemberis on housing

Some effective treatment strategies include job coaching and supported employment, pathways to housing, and motivational interviewing that respects the stages of change and sees relapse as a part of recovery. In particular, inmates need to learn skills--educational, vocational, psychosocial, and behavioural--to help them manage emotions, avoid risk-laden situations, and prevent relapse.

Meanwhile, "Catch them doing something right," said Dvoskin, because ultimately praise is a powerful reinforcer and a key to behaviour change.

He also encouraged participants to "consider the possibility that they are doing the best they can" and engage inmates as partners who have the power to determine success.

In addition, adaptive behaviours in jails or prisons are often maladaptive behaviours in the free world. Dvoskin suggested that parole officers consider the four S’s: support, scrutiny, service, and structure.

Dvoskin said faith, hope, and charity are key. "Of all the gifts you bring to inmates, if you can express the vision of them living a better life when they can’t, then that’s the best gift," he said. "Nobody ever recovered without hope."

Group Discussion:
Ideas to Explore for Implementation

Leslie MacLean
Assistant Commissioner
Correctional Services Canada

Leslie MacLean asked the group to discuss the themes of the day’s sessions. "Of all the ideas we have heard this afternoon, which ones do you think CSC should actively explore for implementation?" she asked.

Some participants suggested reducing caseloads to allow more meaningful interaction with offenders, adequate training for staff, and the creation of checks and balances to ensure that services offered are relevant. Others suggested bringing back community programs to institutions or cancelling some programs whose screening criteria exclude those most in need, for reasons such as addiction.

Several participants also mentioned the importance of housing support and vocational training as effective measures to help inmates successfully return to the community. Participants said resources available within institutions to train offenders for employment upon release are not being maximized. "Let’s use common sense and accentuate the positives in inmate behaviour," one participant said.

Some participants suggested bringing back token economies within facilities, noting that CSC should "use carrots rather than sticks." Several participants also said they liked the idea of independent, unannounced site inspections, site and health services accreditation, and the use of community partners as in-reach teams within facilities.

Participants said the common themes they had heard throughout the day were reassuring. Breaking down silos to create a collaborative, integrated and multidisciplinary approach is key to ensuring offenders suffering from mental illness will receive the help they need. "Action is what’s needed," said one participant.

MacLean thanked the participants for their comments. She said the day’s speakers had given Symposium attendees valuable content, which would provide them with a great deal to consider as they continue to strive for excellence in their work.

Day 2:

Introduction

Leslie MacLean
Assistant Commissioner
Correctional Services Canada

Leslie MacLean said that while the first day of the Symposium had focused on the International and Canadian context in advancing solutions to offender mental health, the second day would focus on partnerships and collaboration. The presentations and discussions would address the questions of how to sustain partnerships and with whom to build partnerships, both inside and outside "the wall."

Partnerships and Collaboration

Parole-Intensive Case Management in the Community

Joseph Lima
Senior Parole Officer
New York State Division of Parole

Joseph Lima discussed partnership approaches to coordinating the discharge of offenders with serious mental illnesses. He also spoke about parole-intensive case management programs for these parolees, and gave suggestions on how parole officers with mental health caseloads can overcome various challenges.

Lima supervises 10 parole offices who work with parolees with serious mental illness. While they aim for a supervision ratio of about 25 to one, the ratio is actually about 32 to one.

The Parole Board is reluctant to release offenders with serious mental illness to parole supervision, Lima said. "We all have stigma and attitude toward those with mental illness. Regardless of what we may say, the fact is there is clearly a stigma in general society and the criminal justice system."

Three New York State government agencies have responsibility for offenders with serious mental illness: the Division of Parole, Department of Correctional Services, and Division of Probation and Correctional Alternatives. All three recognize the special needs of this group, but NYS has faced lawsuits regarding lack of supervision for this population. Most parole officers have some concern about working with mentally ill people; they consider them more dangerous, unpredictable, and difficult to deal with, and resist working with them.

Lima discussed the need to have parole officers on specialized caseloads. Regular parole officers supervise 60 to 75 parolees, and he said even one or two parolees with serious mental illness can "rattle you completely." Most regular drug programs do not even accept people with mental health problems, and most mentally ill parolees who go to regular parole officers violate parole very quickly.

Parole officers with specialized caseloads, on the other hand, have reduced workloads and can take time to establish relationships and work with various agencies and their parolees. Lima said he encourages his officers to find safety nets for their parolees, identify the agencies responsible for providing services, and hold these agencies accountable. "The need to develop partnerships with various agencies is a key point to the success of dealing with this population," he said.

For parolees with mental illness, "too often we think they have no idea of what’s going on," said Lima. However, evidence-based practices confirm that engaging this population in treatment and linking them to services immediately will result in greater success.

Lima discussed the importance of working closely with the intensive case managers at the NYS Office of Mental Health to connect these parolees to psychiatric and other services. In particular, close collaboration helps guard against parolees setting one parole officer against another. While intensive case managers are typically social workers, parole officers wear side arms, carry handcuffs, and put on bullet-resistant vests, he said.

The NYS Division of Parole has developed close partnerships with the Department of Labor and the New York City Department of Homeless Services. It also works with some special community-oriented core programs to help parolees with mental illness overcome challenges related to accessing services and benefits, engaging in treatment, surviving in a shelter, finding standardized or permanent housing, complying with medication, and in general being successful in parole.

The biggest problems parolees face are homelessness and drug abuse, said Lima, and "every agency has resisted taking parolees." Sometimes when officers become frustrated, they think sending a client back to jail is a good shortcut for dealing with problems, so developing and implementing good plans is very important for facilitating the success of parolees. Support from high-level administration is key, Lima said.

Discussion

When asked about caseload ratio, Lima said "the lower the better" and the more a parole officer can be involved in providing services to the clients.

A participant asked what supervision changes have resulted from the lawsuits Lima mentioned. Lima said these have often been class-action suits related to individuals who did not receive legitimate opportunities to succeed on parole. The most recent lawsuit dealt with parole violators not receiving enough opportunities for alternatives to incarceration. As a result, within the next year, NYS will provide for mental health caseloads state wide.

Another participant asked about the level of mental health-related knowledge and professional development expected of mental health parole officers. Lima said he would like all parole officers to have a significant amount of training in mental health and the supervision of mental health cases. Currently, most have relatively little formal training, compared to on-the-job training that comes from supervision and decision-making about particular cases.

Integration of Correctional and Mental Health Service Delivery

Michele Steele
Program Manager, Office of Health Services
East Coast Forensic Hospital, Nova Scotia Health

Michele Steele described the elements of an integrated mental health system, based on the inter-relationships among the Central Nova Scotia Correctional Facility (CNSCF), the East Coast Forensic Hospital (ECFH), and the Capital District Health Authority (CDHA).

Nova Scotia’s population is about one million. The province’s Correctional Service, under the Department of Justice, has five adult correctional centres. The largest is the CNSCF in Dartmouth, which has a full capacity of 336 inmates. A unique feature is its link to a forensic psychiatric facility, the ECFH, which operates under the CDHA.

The project is a public/private partnership. The decision to co-locate was based on the ability to share services such as the chapel, laundry, and gym, as well as dietary, maintenance, and other services. The project also boosted the capacity to provide rehabilitation services.

In 2001, the Deputy Ministers of Health and Justice determined that the Department of Health would be responsible for the budget and all health services, while the Department of Justice would provide security to the ECFH.

Steele deals with the health of offenders at the ECFH. She noted that the hospital section provides a serene environment, in contrast to the loud and active setting at the correctional centre. The ECFH’s services are based on the Boston Recovery Model for providing community psychiatric care. The hospital has 12 beds for mental health cases from across the province.

Steele said the ECFH partners with the Nova Scotia Sea School, whose philosophy is based on the foundation that "all you really need to know in life is how to build a boat that will sail." Part of the ECFH’s recovery program is to have clients build a boat under the guidance of Sea School staff. They then experience a two-week sea expedition in their boat. The second phase of the partnership is for clients to work in the Sea School area downtown.

Stigma causes difficulties in finding housing for mental health clients, however, Steele said. The ECFH partners with a community service that has built an attachment to one of its homes to house ECFH clients.

The Vice President of Clinical Care at CDHA oversees its Mental Health Program. Offender Health Services and Community Mental Health are two of the areas in the program’s eight areas of responsibility, and some case management features are getting under way.

In terms of access to health records and appointment scheduling, the same admission and transfer system applies to the entire health authority. The CDHA is considering creating a job-swap program for nurses willing to work in different areas.

A 2004 survey studied the profile of health problems experienced by offenders, focusing on substance abuse and psychiatric illness. Of the offenders surveyed, 61% reported using drugs, 48.7% expressed mental or emotional problems, and 93.9% expressed feelings of hopelessness.

Nova Scotia’s largest corrections mental health clinic has two registered nurses who provide bio-psychosocial assessment and provisional diagnosis, 40% of a psychiatrist’s time, and a methadone clinic. The clinic had 1,500 visits last year and the psychiatrist handled 350 new admissions. Rural sites have Telehealth services and make referrals to the large clinic if necessary. In two locations, a physician makes short visits once every two weeks.

Mental health screening is an ongoing process, said Steele. The sites refer non-emergency cases to general practitioners and carry out regular follow-up. Staff at the sites may put emergency cases on special watch or suicide watch. In consultation with the general practitioner and psychiatrist, they will choose a treatment option. Usually they transfer emergency cases to one of the 12 beds at the ECFH.

In terms of follow-up, ECFH sends referral and discharge summaries back to community teams. Its Mental Health Program is initiating the use of the Camberwell Assessment of Need, a questionnaire to assess clients’ needs for community mental health services. The program also has a mobile crisis team and is studying how to apply the new federal mental health strategy. The challenge is getting clients back into the community, and community services and support are key in this regard, said Steele.

Discussion

A participant asked about lines of reporting for the correctional officers who work at the hospital. Steele said although the agreement was that the hospital would be in charge, negotiation and dual reporting have been best for the partnership.

Another participant asked about the mobile crisis team. This service has been very successful, said Steele. It provides limited service due to its resource base, but it has received expanded funding. The team provides an 18-hour service and offers education to the police and to families in crisis.

Overview: Delivery of Mental Health Service in New South Wales, Australia

Julie Babineau
Chief Executive, Justice Health
New South Wales, Australia

Julie Babineau’s presentation focused on the delivery of mental health services in her jurisdiction. She described the process of commissioning and opening a new 135-bed forensic hospital and a 65-bed prison hospital at Sydney’s Long Bay Complex.

Babineau compared inmate populations in Canada and Australia, saying she had noted many similarities between the two countries, such as the percentage of Aboriginal people in custody. She also gave an overview of health expenditures in New South Wales, and mentioned an increase in this jurisdiction’s mental health funding since 1994-95. She said they expect further budget increases, particularly in the Justice Health division.

Babineau said the rate of people in New South Wales experiencing a mental illness had remained relatively stable, at one million for the past five years, with 2% to 3% of this group suffering from a severe mental illness. Commenting on a graph showing the sharp decrease in mental health beds available in her jurisdiction since the 1940s, Babineau said people suffering from mental illness who once had access to clinical care, food, and shelter in institutions are now left with three choices after deinstitutionalization: homelessness, social housing, or prison.

Babineau said New South Wales funds and provides health care services within the criminal justice system through a specific health entity called Justice Health. Babineau is head of this organization, which is governed by a Board, and her power is enshrined in legislation. She also has unrestricted access to all facilities within her jurisdiction. "We’re not just there because we have bleeding hearts," she said. "We have to be there."

Babineau told the participants that Justice Health’s mission is to provide "international best practice health care for those in contact with the criminal justice system." She gave an overview of Justice Health sites throughout her jurisdiction, as well as personnel and patient statistics. She said Justice Health’s role is to provide health services to adults and juveniles who come into contact with the criminal justice system. The organization assesses and monitors risk of self-harm and harm to others, takes preventive measures to minimize the spread of infectious diseases, and monitors the provision of health services. "A jail is a community. Inside the jail is a community health centre, and we manage it," said Babineau. "If we can’t do it, we refer them to outside services."

Babineau outlined the health and socio-economic statistics of its clientele, saying Justice Health’s role is to give every individual entering a facility a primary health assessment. "We have a good population health approach," she said.

Babineau said her jurisdiction’s Integrated State-wide Mental Health Service ensured mental health care services and corrections personnel were working together. Two components of this model, ambulatory care and in-patient care, have recently expanded. New mental health screening units have been created, and new hospitals are planned to cater to an increased demand for in-patient care and to introduce new services targeted to such populations as women, young people, and older inmates.

A new facility located at Sydney’s Long Bay complex will allow Justice Health to deliver mental health services that meet national and international best practices in a facility more like a hospital than a prison, said Babineau.

Babineau briefly touched on other aspects of the Integrated State-wide Mental Health Service, such as its court diversion service, community forensic mental health service, teaching and research activities, and psychiatric reports. She said particular emphasis falls on staff recruitment, training, and retention, with incentives such as scholarships and training allowances.

 "Our model works because it’s integrated, and focuses on early intervention," Babineau said. "This means catching mental illness as soon as people come in, especially with young people." She said her organization’s success is due in large part to its ability to monitor its activities and deliver results. "We deliver, we measure, and we go see the treasury with our data for more money," she said.

Babineau congratulated Symposium participants and CSC for their hard work in this field. "What you are doing here is great," she said. "It’s a good way forward."

Discussion

Asked for insight on recruitment and retention of psychiatrists, Babineau said, "If you build it, they will come." She said her organization is quite aggressive in recruiting personnel, including psychiatrists.

"We have a 95% retention rate, because of our model and what we do." Babineau said a generous pay scale and opportunities for training are also helpful in ensuring that individuals can continue to learn and grow while remaining part of her organization.

A participant asked Babineau for advice on ensuring a smooth transfer of the delivery of health care services to regional authorities. Babineau said she likes that model of service delivery, and such a model makes it easier to link with local resources. However, she said it requires a shift in mentality to ensure clients are not seen simply as "prisoners." "None of the models are easy because of the population we have," said Babineau, "but they’re not all mass murderers." She said demystifying the issue and providing tangible data helps in this regard.

Focus Group Discussions:

Leslie MacLean
Assistant Commissioner
Correctional Services Canada

MacLean asked each group of participants to consider the following question: What partnerships do you think Correctional Services Canada should be focusing on, both in-house and for service delivery?"

Participants said it is important to foster partnerships at the local, regional, and departmental levels. These partnerships would include sharing best practices, exchanging services, integrating mental health services, providing partnership initiatives with human and financial resources, and inviting community mental health resources to share their needs. They also said CSC must be open to case management and to working with interdisciplinary teams.

Other  participants said CSC must "develop a way of being open, honest, and transparent." CSC personnel, and everyone working in offender mental health, must be proud of their work. They also suggested discussing best practices in such forums, and also "what we do badly, so we can improve."

Participants identified the need for a "real national strategy" by collaborating with the provinces and territories.

Some participants suggested hiring and training senior staff to lead partnership efforts. They said this could help to bring the community on side, give them a voice in the dialogue, and demystify mental health. They also said, "CSC needs to develop true partnerships, since we have a reputation for entering into partnerships and trying to control our partners." Participants also mentioned the idea of partnering with universities for scholarships and recruitment in certain professions, as well as training and retention incentives for personnel.

They said a client-focused partnership with employers would also be useful. "It can’t be just the community and people from the outside," said a participant. "Let’s remember we have partners on the inside, and engage the offender."

Other participants asked where the "connectivity project" fits into the bigger picture. "We need to link health and corrections, both federally and provincially," they said. They suggested developing clear partnership goals, communicating them to everyone within CSC, and identifying "champions in all partnerships at all levels." They also said enhanced training opportunities, such as internships, would be beneficial. This group asked how CSC could tap into resources and programs announced in the Speech from the Throne.

The participants also said creating a "consumer and community group" would be an effective way to receive input on policy from stakeholders. They suggested juvenile early intervention services should partner with CSC. While a national communications trategy is important, communicating with employees within CSC is also crucial.

Finally, participants said, "Mental illness does not spring anew when entering prison." Offenders suffering from mental illness or cognitive deficiencies have often previously accessed resources in the community. "We should be keeping those people informed and in the loop, letting them know we are only a temporary keeper," they said. "We need to demystify and de-terrify the process."

Conclusion

MacLean thanked the participants for their comments and for the excellent ideas put forth during the discussions. She said the idea of CSC being open to partnerships is "important and challenging," as it involves risk and must be sustained.  Changes in the correctional context can be slow because of the risk involved.  It is important to get it right.

MacLean said while it was "good to hear no one has the magic answer," she was impressed with the candour of both the speakers and the participants when discussing best practices and lessons learned. She said this symposium would provide material for the creation of an action plan, "with two or three concrete things we can move on."

MacLean thanked the Symposium organizers and staff for their hard work, with special thanks to Heather Lockwood for her outstanding contribution in organizing the logistics for the Symposium.