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Women Offender Programs and Issues

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Implementing Choices at Regional Facilities: Program Proposals for Women Offenders with Special Needs

IV. Psychosocial Rehabilitation (PSR) Program Model For Women with Basic Skill Needs and Cognitive Challenges

Conceptual Background of Psychosocial Rehabilitation
Women's Needs and the Applicability of Psychosocial Rehabilitation
Program Purpose and Objectives
Admission Criteria and Assessment Process
Psychosocial Rehabilitation (PSR) Planning
Characteristics of the Physical Living Environment
Daily Living Expectations and Skills-Teaching in the PSR Duplex
Work, Learning, and Leisure Programs and Skills
Behaviour Management in the Living Environment
Stigma Versus Peer Support and Teaching
Bridging for Community Integration
Staffing Complement, Qualifications, and Roles
Staffing Training, Support, and Communication
Program Evaluation
Implementation of a Pilot Program
Obstacles to Effective Implementation of the Program


Conceptual Background of Psychosocial Rehabilitation

Psychosocial rehabilitation has its conceptual roots in a response to the failure of the mental health system to assist disabled clients in coping with the psychosocial devastation brought on by severe mental or emotional illness, severe behavioural problems and its traditional treatment methods (i.e., institutionalization and medication; Nel, 1994). Medicine traditionally views recovery as the process that follows the curing of an illness (frequently defined in relation to the prescription of medication), yet given the life experiences of these clients, recovery does not occur spontaneously once they are "treated". Instead, their recovery and successful return to the community is halted by...

    ˇ their limited resources, skills, and supports,

    ˇ their isolation, sense of hopelessness and despair brought on by institutionalization,

    ˇ their deviant behaviour patterns learned through institutionalization,

    ˇ their loss of community learning opportunities and supports that accompanied institutionalization.

These characteristics result over time in individuals developing chronic impairments which are seen as pathological functioning of a physiological or psychological nature (Anthony, 1990; Nel, 1994). The resulting dysfunction in turn limits the person's ability to fulfill normal social roles and function independently in the community. Individuals redefine institutionalization as "normal" and exhibit a sense of hopelessness with respect to recovery. Women with basic skill needs and cognitive challenges in federal penitentiaries have similar characteristics, backgrounds, and histories of institutionalization.

The psychosocial rehabilitation approach to recovery is based on (1) the experiences and voices of consumers demanding participation and self-determination in treatment, (2) the recognition that core values such as hope, empowerment, and determination are essential to recovery, and (3) the importance of targeted skill development and specific environmental supports as means to overcome impairments and enable individuals to function effectively in normal social roles and community settings. Rehabilitation and recovery require all three of these characteristics. Moreover, "recovery is what people with disabilities do... rehabilitation (is) what helpers do to facilitate recovery" (Anthony, 1993).

Psychosocial rehabilitation brought together three applied programming models in the 1980s and has now evolved and expanded to become the most prominent conceptual approach in North America to working with persons with severe emotional disabilities and impairments. One major approach is "psychiatric rehabilitation," a model developed at Boston University by William Anthony, his colleagues, and consumers (Anthony, Cohen & Farkas, 1990). Clients work through a individualized rehabilitation process with key staff which is grounded in self-determination, core values, skills-teaching, and environmental support in order to overcome impairments. This specific process has been developed and elaborated for a Canadian context at the Brockville Psychiatric Hospital which now provides national training programs in the approach (Nel, 1994).

A second psychosocial rehabilitation approach, labeled the "clubhouse model," evolved from the development of Fountain House in New York City in the 1960s (Beard, Propst, & Malamud, 1982). It is a group-oriented model that emphasizes work as a means to provide respect and meaningful activity. Service to others and peer support are viewed as critical elements of the recovery process. Clients initially work with staff to provide practical services to their peers and eventually to the community on a paid basis. This model has been applied to work with persons with emotional disabilities who have suffered from institutionalization with significant success in a vast range of settings and communities across North America (Anthony and Blanch, 1987).

A third major psychosocial approach has been labeled "assertive community living" and involves the development of a psychosocial rehabilitation plan and provision of resources to support individuals to move from institutional to community living situations (Stein & Test, 1986). It departs from previous mental health models in that a community team of professionals accepts responsibility to work collaboratively with the client to provide whatever skills training and environmental support is necessary (e.g., up to twenty four hour home care) to maintain the person in the community.

Elements of these three approaches are combined in this program proposal. It is recommended that the psychiatric rehabilitation core values and technology be utilized to guide the individualized planning and treatment process, that the work and meaningful activity focus of the clubhouse model be utilized to give women the opportunity to develop positive self-esteem and productive social roles, and that concepts from the assertive community living model be utilized to guide the transfer and integration of the women back into the community at the end of their sentences.


Women's Needs and the Applicability of Psychosocial Rehabilitation

Women with basic skill needs and cognitive challenges as identified in part II have significant deficits in life skills plus deviant behaviours such that they have not been able to function in the community nor in the group living environment of the regional facilities. They have experienced lengthy periods of institutionalization in psychiatric hospitals or penitentiaries. When they are released to the community, their sense of despair, skill deficiencies, and lack of supports and resources are such that they re-offend and return to an institutional environment which is familiar and which will care for them. Their lack of basic skills and need for guidance is often viewed initially with sympathy from other women when they are in regular housing in the regional facilities, but this sympathy turns to irritation and anger when women offenders, already under high levels of personal stress, must cope with their skill deficits and behavioural difficulties on a twenty-four hour basis. These women become stigmatized, manipulated and ostracized by at least some of the offenders, patterns that they have typically already experienced in the community or previous institutions. They may respond by acting out their behavioural difficulties such that they can not be maintained in the regular houses and are transferred to maximum-security settings with increased structure and supervision, even though they do not require increased security and are not a high risk given appropriate structure and support. Given these histories and needs, these women will require support on a long-term basis upon release by professional care-givers if they are to successfully maintain themselves in the community, though hopefully it would be in decreasing amounts over time as their confidence and skills increase. The following strengths are frequently present for these women and must be acknowledged in the program model:

    ˇ Specific Likes & Dislikes for Practical Tasks. Individuals often have very particular tasks and skills that they like to perform along with those they dislike or fear. Thus one woman may enjoy cleaning while another is very content quilting, but the former may refuse to cook and the other clean. Programming must build on their strengths and teach skills on an individual basis.

    ˇ Moods and Mental State Reactivity to the Activity and the Environment. Individuals are very changeable and strongly influenced by their immediate environment. Support, consistency, and a sense of security facilitate positive behaviour while stress in the environment or difficulty with the activity result in acting out and inability to cope.

    ˇ Positive Attention and Trusting Relationships are Strong Motivators. These women are typically pro-social in that they want attention from those around them and will work to receive it. They have difficulty forming trusting relationships given past experiences, yet once they do, these relationships can become a key means to facilitate change and recovery.

    ˇ Confidence and Satisfaction Increase through Learning Practical Skills. Individuals learn and gain skills slowly through task-oriented instruction and repetitive practice. They value and benefit from one-to-one attention through an individualized teaching process that personalizes their successes.

    ˇ Criminogenic Attitudes are Less Dominant and Open to Modification. Individuals have ended up in the correctional system due to their inability to cope in the community, their skill deficits, lack of supports and resources, and emotional disabilities, relative to anti-social attitudes and lifestyles. Where they have developed these attitudes, their desire for positive attention can be used to move to a more pro-social perspective.

    ˇ Music, Art and Creative Expression are Valued Methods of Communication. Many of these individuals have a particular affinity and strength for communication through the creative arts.

The following limitations frequently apply to women with this constellation of needs and must be recognized within the program model:

    ˇ Sense of Hopelessness and Powerlessness. Their past failures and inability to function in community settings combine with their experience of dependence and lack of choice in institutional settings to result in individuals losing hope for a different future. Instead they find comfort in others caring for them. This hopelessness must be overcome if the person is to grow and learn. It requires skilled staff and a living environment with practical choices for offenders. Hopeful core values must be intrinsic to all activities and must be modeled and lived by staff. The person's past successes, however limited, must be explored to identify potential for success in specific community settings in the future.

    ˇ Past Failure and Low Self-Confidence Are Obstacles to Learning and Growth. New tasks and environments are associated with failure and thus learning programs and change must be based on slow, small incremental steps and personal successes.

    ˇ Reactivity to High Stress Environments. Individuals tend to react quickly and impulsively to stressful situations and settings with difficult behaviours. They require a program and physical structure that can limit stress and provide security in a crisis.

    ˇ Peer Relationships Produce Stress Given Poor Relationship Skills. Connection to others is very important yet their weak relationship and problem-solving skills result in interpersonal conflict and a stressful environment in which they are unable to cope. Even medium sized groups (6-8 persons) increase the interpersonal confusion and potential for conflict. Skills need to be taught on an individual basis.

    ˇ Poor Responsiveness to Group Programs Unless Individual Assistance is Provided. Their unique needs and fears about learning new tasks require one-to-one attention. They have difficulty attending to and processing information in groups.

    ˇ Cognitive Challenges and Limited Attention Span. Programs must recognize these limitations by taking a holistic individualized approach and providing for informal interaction in a flexible manner.

    ˇ Difficulty in Transferring Skills to New Environments. A person may learn and demonstrate a skill in one environment but must re-learn it when moving to another environment. As the result, it is far preferable to teach skills in the environment in which they will be utilized. This is very problematic given that the priority is to prepare the women for community settings, yet the teaching may have to take place within a penitentiary.

    ˇ Difficulty in Developing Trusting Relationships. It takes time, and individuals may have great difficulty developing the trusting relationships that are essential to their independent functioning and success. They have difficulty making the transition to new environments because they lose their previous relationships and are confronted with their fears given past failures. It becomes imperative that trusting relationships support them through the transition to a new environment, be it the regional facility or a community setting, if they are to make a successful adjustment. Strong practitioner values and interpersonal skills are essential to developing trusting relationships.

    ˇ Long-Term Community Supports are Required for Successful Re-Integration. Community supports are required on a long term basis and yet the history of institutionalization and behaviour difficulties have resulted in individuals having few, if any, support persons. Human service systems typically do not provide for long-term supports and seek to withdraw services with time. These individuals act out in the community if supports are withdrawn.

A psychosocial rehabilitation model is the most appropriate approach to working with these women and has significant research to demonstrate its effectiveness (Anthony, 1990). However, this approach must be adapted in that these women can be distinguished from other persons with severe emotional disabilities given that their skill deficits and behavioural difficulties have resulted in their coming in conflict with the law while other persons with similar characteristics have not. Long term institutionalization within a prison has exposed them to and taught them a different set of behaviours than what they would learn in other facilities.

A common PSR conceptual model is also essential for the multi-disciplinary staff team and the administration in that it will provide a clear program structure and framework to fall back upon when they confront the complex interconnections in working with women with these needs and difficulties. These women offenders are very demanding and staff require on-going support from each other, a strong team, and administrative support to maintain the hopeful core values and the detailed skill development and planning that are required for success.


Program Purpose and Objectives

The purpose of the psychosocial rehabilitation (PSR) program is to support women offenders with basic skill needs, cognitive challenges, and behavioural difficulties to live successfully in regional penitentiary facilities while gaining skills which will enable them to experience greater satisfaction and success in a supported community setting upon release, reducing the likelihood of recidivism.

Objectives. By participating in the psychosocial rehabilitation (PSR) program, women offenders with basic skill needs and cognitive challenges will...

    ˇ increase their basic life skills in areas of need.

    ˇ function in a regional facility without persistent acting out difficulties.

    ˇ establish and follow through on a community correctional plan for release that will reduce the likelihood of recidivism.

    ˇ demonstrate increased self-esteem.

    ˇ express satisfaction with their living environment relative to their previous experiences.

Finding: The psychosocial rehabilitation approach is the most appropriate and potentially effective programming model for individuals with basic skill needs and cognitive challenges such that they can reside in the least restrictive environment in a regional facility. The approach must be adapted to the regional penitentiary setting by staff trained in the psychosocial rehabilitation approach. A disproportionate number of women in Canadian penitentiaries with basic skill needs and cognitive challenges come from Atlantic Canada.
Recommendation 1: Implement the psychosocial rehabilitation approach for women offenders with basic skill needs and cognitive challenges through a specific program model appropriate for the regional facilities, which incorporates relevant elements of psychiatric rehabilitation, the clubhouse model, and assertive community living. This model shall reflect the specific strengths and limitations of the women with this constellation of needs and be based on a specific purpose and set of objectives. The psychosocial rehabilitation program model should initially be implemented as a pilot project at Nova Institution in Truro, Nova Scotia.


Admission Criteria and Assessment Process

The following criteria are required for admission to this program:

1. Voluntary agreement by the individual woman to participate. It must be recognized that women with these needs are extremely changeable in their willingness to participate in any setting or set of activities and therefore their agreement should be developed over time through a trusting relationship in which they are encouraged to take time to understand their choices. They must also understand that there would not likely be other living accommodations available to them at a regional facility, as they could not cope without supervision in a regular house. The withdrawal of consent should also require time and working through a discussion process with a trusted person.

2. A medium- or minimum-security classification.

3. Recommendation for participation by the multi-disciplinary assessment team at the regional facility responsible for assessment for specialized mental health programs. This team will utilize existing mental health and risk assessments, and gather additional information or complete additional assessments as required to assure that the individual meets the following criteria:

    a. Significant deficits and needs in more than one of the following life skill areas:

    - self-care (e.g., personal hygiene and appearance, personal health care, sex education, organization of time, etc.)

    - household tasks (e.g., meal preparation, cleaning, laundry, budgeting, etc.)

    - basic communication skills (e.g., social manners, assertiveness, appropriate social interaction, problem-solving in relationships, etc.)

    - basic coping skills (e.g., stress management, anger management, basic problem solving, appropriate ways to seek help, etc.)

    - basic work skills (e.g., attention span and task completion, reliability, performance to standards, etc.)

    - leisure skills (e.g., ability to manage leisure time, practical skill development, etc.)

    b. Significant learning and cognitive challenges such that skill development requires an individualized or small group learning environment.

    c. Requirement for on-going support and supervision by staff in the living environment to solve problems, cope with peer relationships, and/or manage inappropriate behaviours.

The multi-disciplinary team responsible for assessment for specialized mental health programs will include the following positions and/or disciplines:

    ˇ psychologist

    ˇ coordinator of the psychosocial rehabilitation program

    ˇ registered nurse with psychiatric training and/or experience

    ˇ occupational therapist

    ˇ community integration worker

    ˇ warden and/or deputy warden

    ˇ intake case management officer

    ˇ team leader or director of programs

    ˇ coordinator of the dialectical behaviour therapy program (if existing at the facility)

The assessment process must include a formal cognitive assessment by the psychologist if it has not already been completed. It is expected that criteria 3b above will result in intellectual functioning in the low normal, borderline, or challenged ranges. The assessment process should also include a basic life-skills assessment by the occupational therapist if it has not already been completed so as to address skill needs outlined under criteria 3a above. The coordinator of the psychosocial program must meet with the woman to educate her about the program and consider behaviour issues and personal suitability for the specific group of women with whom she would be living. The psychologist should be the chairperson for the multi-disciplinary admission team and every effort should be made to make program recommendations based on a team consensus. This process should be facilitated within a two-week time frame if the individual has come directly from the court system.

Throughout the interview process for this research, staff identified the greatest threat to the implementation of an effective program as the possibility that the admission criteria would be circumvented due to national or regional operational pressures to move an inappropriate offender into the program, simply because the woman required a higher level of supervision in the regional facility. The mix of incompatible women with very diverse needs and skills was viewed as the most important reason for the failure of the previous structured living house at Nova Institution. The staff at Nova Institution expressed very strong feelings that this mistake not be repeated. It is imperative that the final approved program is defined in writing with formal, written admission criteria and a clearly defined decision-making process for admission.

Finding: Matching the needs of individuals with the program goals and structure is essential to success. Inappropriate mixes of women offenders will compromise the effectiveness of the program and represent a major threat to its effectiveness. This is a particular problem given the potential for operational pressure to place inappropriate women in the program simply as a result of their needing higher levels of supervision.
Recommendation 2: A formal written, multi-disciplinary assessment process with admission criteria based on the consent of the woman offender, a medium or minimum security classification, significant basic skill needs, significant cognitive challenges, and the need for staff supervision, is required for entry into the program. There must be an official, approved program description with clear admission criteria which requires staff at the regional facility to make the final decision on admission.


Psychosocial Rehabilitation (PSR) Planning

Psychosocial rehabilitation planning is based on a set of core values, basic principles, and a three phase planning process including eight major areas for work with clients (see Appendix B; Nel, 1994). The four core values are that the approach be: (1) client-driven, (2) non-judgmental, (3) hopeful, (4) and empowering. The ten principles that guide the approach are:

    1. Logical Technology. Work with the individual begins with the client's dissatisfaction with present circumstances, and the need for change motivates a series of logical planning steps.

    2. Concrete Concepts. Concepts are concrete, observable and measurable.

    3. Individualization. Rehabilitation work is tailored to each client.

    4. Goal-Driven Process. The client's goals drive the rehabilitation work.

    5. Satisfaction versus Success. Both the client's desires (which dictate satisfaction) and the environment's expectations (which dictate success) have to be considered.

    6. Support versus Skill Development. Dysfunction can be diminished by enhancing skills and/or increasing supports, and there is an interdependence between them.

    7. Skill and Support Development are Environment and Role Specific. Dysfunction is addressed at a very specific level and skills and supports are facilitated for the specific goal environment.

    8. Accountability. Rehabilitation plans are written, with time frames and specific people responsible for specific tasks. The client is the owner of the plan and the practitioner is accountable to the client.

    9. Client/Practitioner Relationship. Rehabilitation work is a partnership between client and practitioner. Personal closeness and trust is required to sustain the long and often arduous work.

    10. Sound Interpersonal Skills (of the practitioners). Rehabilitation technology is information-processing technology which can only be helpful if the practitioner has the interpersonal skills to establish and maintain a trusting relationship through which information can be shared. (Nel, 1994, pp. 11-12):

The core values and basic principles define a process that is in keeping with the strengths and limitations of women offenders with basic skill needs and cognitive challenges. The approach provides an individualized, value-based, skill-based process that is driven by the goals set by the woman offender. The actual rehabilitation work is divided into three phases in which the practitioner works through eight modules with the woman offender. These modules are sequenced as follows:

    PHASE ONE: Assessing the Rehabilitation Requirements

    1. Assessing and Overcoming Barriers to Commitment to Change. Frequently, individuals immediately present barriers to developing a commitment to change such as: lack of self-awareness, lack of environmental awareness, lack of feeling of self-efficacy, lack of perceived support from others, and/or lack of trust in the practitioner. Specific action plans may need to be defined and implemented to overcome these barriers and lack of awareness before the person can articulate any need for change or consider setting goals.

    2. Establishing the Demand for Rehabilitation. This step involves exploring the person's present dissatisfaction with living, learning, working, and socializing environments and the extent that the person hope's for, or visualizes change as an option for one or more of these environments.

    3. Establishing the Rehabilitation Goal and Choosing the Goal Environment. The person explores the nature of the changes that would lead to greater satisfaction and success, and identifies the specific environment that will best support this change. Ultimately a goal is set to fulfill a specific role in a specific setting.

    4. Skill-Use Assessment. This step explores and defines the specific skills the person will require to fulfill a work, living, socializing or learning role in a specific setting as defined by the goal.

    5. Resource Assessment. The task is to identify the types of resources and supports that the client requires to achieve satisfaction and success in the goal environment and to establish their availability.

    PHASE TWO: Planning the Rehabilitation Interventions

    6. Writing the Rehabilitation Plan. This represents the road map necessary to complete the rehabilitation interventions and achieve the goal in the specific environment.

    PHASE THREE: The Rehabilitation Interventions

    7. Skill Development. The process of skills-teaching is implemented in which skills are broken down into manageable steps and taught in a logical sequence, with lesson plans and extensive feedback.

    8. Resource Service Coordination. Strategies are implemented to overcome the resource deficits required to support the individual. This may require advocacy and negotiation to: make existing resources accessible to the individual, to coordinate existing resources in new ways, or to create new resources. (Nel, 1994, pp. 13-17)

This specific psychosocial rehabilitation technology differs from many traditional mental health program-planning approaches in several very important ways:

ˇ Skills are not assessed or taught until after the individual defines the change (goal) they are seeking. Therefore the goal motivates skills-teaching rather than a person participating in "programs" to teach them skills that others think they need. Skills-teaching and resource development are individualized. Work to increase awareness and overcome barriers to change will precede goal setting.

ˇ Goals are not set in a session or two but rather through an on-going individual relationship between the practitioner and the woman, which is structured through a lengthy assessment process. The difficulty in helping these women gain a sense of hope and overcome their barriers to change is acknowledged and built into the process. This requires a skilled practitioner.

ˇ Core values of hope and empowerment are deliberately built into all of the assessment processes that are utilized such that working through the specific tasks structures the process as client-driven.

ˇ Goals, skills, resources, and plans are structured around the specific role and environment that the individual chooses. The process is carried through separately for living, learning, working, and socializing environments and roles. The living role would typically be the first priority for these women.

The implementation of this approach in the proposed program requires:

1. A core group of staff committed to this process who each works with individual women on a consistent and regular basis. Relationship building and rehabilitation work is an on-going formal, as well as an informal process, which requires extensive interaction.

2. Staff explicitly trained in the approach who are competent to apply it with women offenders.

3. The psychosocial rehabilitation plan must be integrated into and become the correctional plan for release.

Finding: The psychosocial rehabilitation planning technology incorporates some traditional mental health planning approaches such as careful assessment and structured skills-teaching for women offenders with basic skill needs and cognitive challenges. It differs from traditional approaches in several important ways: goal setting precedes skills-teaching, emphasis on the need to overcome barriers in order to commit to change, explicit core values, and an explicit client-driven technology.
Recommendation 3: The individual programming with women with basic skill needs and cognitive challenges should be driven by the psychosocial rehabilitation technology process in which staff practitioners competent in the approach develop partnerships with the women offenders on an individual basis. Supportive relationships between the women offenders and a consistent and small number of staff is required to support this process.


Characteristics of the Physical Living Environment

Women offenders with these needs require a small group living environment with regular staff presence in order to minimize stress and allow for the time and space to implement the psychosocial rehabilitation process. It is proposed that it take the form of a one-story duplex, with each side serving up to four women. It should be built...

    ˇ to mirror the appearance of a house in a community context,

    ˇ to minimize dangerous objects in the environment in the event of acting-out behaviour,

    ˇ to provide security in the event of acting-out behaviour,

    ˇ to provide residents with a continuum of options and locales through which they can take greater or lessor responsibility, depending on the circumstances, for coping with stress and potentially explosive or self-destructive behaviour.

Careful planning involving architects, staff (including front-line staff and the PSR program coordinator), and women offenders, is required to simultaneously maintain a home-like appearance while minimizing dangerous objects and providing security for emergencies. Architects must take practical direction from experienced staff in defining the detailed elements of the duplex (e.g., types of lights, size of halls, ability to lock various areas, etc.) The program coordinator must be hired as soon as possible and should be responsible for gathering and facilitating staff and offender input into the design. With respect to the offenders, gathering input should include the coordinator visiting women in maximum-security facilities who are potential candidates for the duplex, explaining future placement possibilities, and seeking their input on the design.

Figure 2 presents a draft proposal for the duplex design which implements the following criteria:

ˇ A maximum of four clients per side in order to maintain a small group size while providing for adjacent dwellings so that staff can be shared. The two separate sides provide for flexibility in separating incompatible women. Although four persons per side is a small number, it must be recognized that increasing the size of the group results in an exponential increase in problems due to all of the new relationships which are introduced, rather than simply adding one additional person.

ˇ A home appearance which is attractive and bright and allows for women to decorate walls, have comfortable furnishings, and include plants. The interior design should facilitate women being able to make choices on the appearance of their home while decisions by one set of women can be altered by a later set (e.g., use of bulletin boards or picture frames in which images can be shifted). Music should be encouraged in the setting through the provision of a modest electric keyboard to accompany singing.

ˇ Multiple quiet and separate spaces for women should be available while maintaining reasonable ability for staff to monitor the setting.

ˇ Facilities for therapeutic quiet (see below) should be available and buffered by staff space. They may be used for a woman at the discretion of the woman offender or as required by staff policies and procedures. An immediate bathroom facility should be available in the therapeutic quiet area so that a woman does not have to return to the main living environment.

ˇ Two small bathrooms for residents should be provided in case there are hygiene difficulties or teaching needs such that one woman requires her own bathroom.

ˇ High quality sound insulation is required between the two sides of the duplex, between the bedrooms, and insulating the Den/Quiet Spot, so as to reduce the possibility of one person upsetting another. The quiet spot must be an attractive, peaceful, and relaxing room with good natural light.

ˇ Ability to lock down bedrooms in an instance where one woman is acting out and other women need to be separated from the situation.

ˇ A full kitchen should be available for preparing all meals and should open on to the rest of the house, yet be able to be locked when necessary (e.g., double doors might close it off).

ˇ A dining area with a table for meals should be adjacent to the kitchen.

Figure 2: Proposed Floor Plan for the PSR Duplex

ˇ Each side should have a backyard where women can establish their own sitting area and possibly a garden distinct from the broader compound. This area need not be fenced for isolation, but can be bordered for privacy.

ˇ Small offices should be provided for the coordinator and the community integration worker (CIW, see below) as well as a shared office to be used by PSR workers and clinical staff in the duplex so that staff roles are integral to the setting and maximize interaction with the women and staff. There should be an outside door into the staff lounge so that staff can come and go from the setting without having to move through the duplex.

ˇ The staff space should be divided by the main wall separating the sides of the duplex with a solid door in between the sections to maintain each setting as a separate living environment, while allowing staff to move quickly back and forth when needed. The staff space should integrate as openly as possible into the living environment on each side utilizing half walls. Items which must be maintained under lock and key could be kept in a locked closet or drawer in the staff area, or stored in one of the offices. This open plan for the staff space makes staff presence integral to the environment and encourages staff accessibility to and interaction with the women. In addition, staff are provided with their own bathroom and a small lounge so as to encourage breaks within the setting.

ˇ A multi-purpose meeting and program room. It can be used for individualized programming or as a meeting room for staff so that meetings can occur within the setting, allowing PSR workers to attend meetings while also providing staff supervision. It should have a movable room divider to separate the two halves.

ˇ The front and back doors should have an attached buzzer system which would warn staff of women leaving and entering the building if it is activated.

Finding: It is important to provide women with basic skill needs and cognitive challenges with a small group living environment which simultaneously provides a home-like appearance that mirrors community standards, while also insuring safety and security in instances of acting-out behaviour. Staff expertise and input from women offenders is required to balance these design criteria.
Recommendation 4: Plan and construct a duplex house with up to four women living on each side at the regional facility utilizing the proposed structure and criteria as a starting point for planning. The architects must utilize staff expertise, and input from relevant women offenders, to plan the house. The program coordinator must be hired as soon as possible such that the coordinator is able to facilitate staff and woman offender input into the design. A committee made up of the lead architect, the builder, the warden, and the PSR coordinator must have the final authority on all phases of the design and construction process.


Daily Living Expectations and Skills-Teaching in the PSR Duplex

Daily living tasks such as cooking, cleaning, laundry, and budgeting should be the responsibility of the women offenders but should be completed in partnership with staff members as is appropriate to the skill level and educational needs of the women. It is expected that since skill deficits are a criterion for admission to the program, that staff will play an important facilitation role with respect to the women working on these tasks. As individual women gain skills, staff roles may be reduced such that increased responsibility is transferred to the women. The women should be provided with as many options for input and choice as is possible in carrying out their daily tasks (e.g., menu choices, options with respect to cleaning tasks, etc.). Provision must be made for funds for food for staff members within the meal budget so that staff may eat with the women without reducing the women's resources. It is ineffective and distancing if staff are partners and facilitators of the meal preparation process and yet feel awkward eating the food due to imposing a drain on the budget.

The roles, responsibilities, and supports for individual women with respect to daily living skills must be connected to their psychosocial rehabilitation plans, either with respect to the second PSR module in which they are overcoming barriers to change and gaining awareness of living situation possibilities, or in the skills-teaching module once a goal has been set for their future living environment. The occupational therapist will assist staff in planning and carrying out work with women on daily life skills. The practical experiences of completing the daily tasks should be the primary mechanism for teaching skills and may be deliberately structured as a learning process for women with particular needs. Interpersonal relationships and social interactions in the house will also provide practical opportunities through which to teach positive communication, coping, and problem solving skills at a basic level. These experiences and the teaching process will be connected to the individuals' rehabilitation plans for the living and socializing environments. The psychologist and occupational therapist will assist staff with programming work with the women in these areas.

The amount of structure in daily schedules for individual women will vary with the abilities of the women based on their individual rehabilitation plans, but choice will be maximized within the boundaries of the individual being able to make safe choices for themselves and others. Again, given significant skill deficits, schedules may need to be structured at the outset.

Informal interaction and leisure opportunities between individual women, and between individuals and staff, are an important priority and means to develop the trusting relationships which are required for psychosocial rehabilitation work. Staff in the house will be expected to participate in and facilitate, to the extent necessary, positive leisure interactions.

Finding: The living environment is an important context in which these women can learn basic skills and take on practical responsibilities, but they will require assistance and support from staff to do so. Learning is most effective when it is a deliberate, structured part of carrying out daily living tasks with extensive feedback built into the process. Interpersonal communication difficulties will be an ongoing issue and a valuable forum through which to learn problem-solving skills.
Recommendation 5: Staff should plan skills training in order to take advantage of daily activities which are completed as a part of the regular lifestyle as teaching opportunities. Interpersonal communication and relationships should also be utilized as a context for teaching social skills. Skills-teaching action plans should be based on the psychosocial rehabilitation plan. Daily structured meetings should be held to facilitate management of daily tasks, interactions and responsibilities in the home.


Work, Learning, and Leisure Programs and Skills

The individual's psychosocial rehabilitation plans will determine participation in work, learning, and leisure programs and therefore it is impossible to determine exactly what learning experiences will be provided. However, a number of general guidelines can be suggested given the overall assessment of the needs of these women based on interviews with them and staff.

ˇ Integration into Regular Programming versus Specialized Programs. Participation in core correctional programs and educational programming with the general population is to be encouraged as long as it is beneficial to the individual woman and connected to the PSR plan. Typically, these women require a volunteer or peer support person to assist them in participation in regular programs. In at least some instances the PSR plan is likely to involve individualized programs or small group programming within the setting because the material is not offered in the regular program or the format is too complex for the particular women. This individualized or small group work will require careful planning and expertise from disciplines such as occupational therapy, psychology, and nursing. Staff in the programming section at the Prison for Women have put together a wide range of resource materials and simple programs for the women on their special needs unit which could be very valuable to planning and programming efforts in this program.

ˇ Emphasis on Creative Arts and Self-Awareness Activities. Self-awareness is important for these women and many have an affinity for music and art. These programs may best be offered in small groups or on an individualized basis and staffing must be included in the program staff complement. The women should also be encouraged to participate in the broader leisure programs offered at the institution as is appropriate.

ˇ Developing a Sense of Ownership in the Setting. Pride and a sense of belonging to the duplex are important for these women to gain confidence and a sense of self-efficacy. They have traditionally lived in settings where they have not had any control over their surroundings. Staff should facilitate projects in partnership with the women which assist them in developing a stake in the setting while engaging in meaningful activity (e.g. creating a garden, improving the internal appearance of the house, putting on small social events for other members of the community or for special events). Staff training in "clubhouse" approaches to working with disabled populations would be extremely helpful in providing a philosophical foundation for this work. There should be structured daily meetings of the small group of people living together in order to discuss and negotiate their practical daily concerns.

ˇ Promoting Self-Esteem and Personal Accomplishment through Work and Service Projects. Work projects will likely be an important element of PSR plans and should be defined as a result of them. Service may be in the form of projects which build a sense of pride in the living setting (developing a garden). In general, work and service should be emphasized in the context of the clubhouse philosophy in which work projects:

    ˇ are visible and valued by other persons in the duplex and/or the broader penitentiary community.

    ˇ are clear, structured, and manageable for the individual with evident accomplishments.

    ˇ provide frequent opportunities for immediate success and demonstrated progress.

    ˇ are valued in the broader community (e.g. selling items or services outside of the penitentiary).

    ˇ can be varied over time to allow for awareness of a diversity of tasks.

Traditionally cleaning has been a common work task in penitentiaries yet it may not necessarily meet these criteria, especially when it occurs in less visible areas. Individuals may not receive recognition for it and there is neither a highly visible result nor an opportunity for feedback. In contrast, more suitable tasks might involve the production of crafts which can be used, displayed and/or sold in the community (e.g., knitting clothes for a child of another inmate, cooking food for events, etc.). Special care should go into defining work placements based on the individual's PSR plan, their strengths and limitations, and the specific rewards inherent in the particular work role. The occupational therapist should assist in program development in this area and staff training in "clubhouse" approaches is required.

A limited amount of work area may be required in the general programming area of the institution where project work can be completed and stored. Nova has very limited space in its programming area and must examine how best to provide for this space.

Finding: These women are typically fearful of new learning situations given their past histories of failure in community settings. On the other hand they often value meaningful, structured and practical tasks where they receive positive feedback and recognition. They have a particular affinity for art and music.
Recommendation 6: Deliberate individual and small group activities defined through each person's psychosocial rehabilitation plan should provide opportunities for integration into regular programs, specific work and service projects, participation in creative arts activities for self-expression and awareness, and the development of a sense of ownership in the living setting. A clubhouse philosophy should guide this programming so as to promote recognition through work and service and teach skills through practical experiences.


Behaviour Management in the Living Environment

The effective implementation of the psychosocial rehabilitation values, the investment of the women in the process, and the structure and support of the staffing and program should reduce behavioral difficulties over time. However, these women have long-term behavioural difficulties that will inevitably manifest themselves and they must be addressed effectively in a team context. Behavioural acting out is for these women most frequently a response to specific stresses and circumstances in their setting or unexpected changes in their lives combined with inadequate coping and problem-solving skills. For women with cognitive challenges, consequences must be immediate, concrete, direct, consistent, and based on natural contingencies. Specific approaches must be applied consistently across the staff team so that an individual knows what is expected in concrete terms.

There is a potential serious conflict between the emphasis on choice and empowerment which is fundamental to these women establishing hope, confidence, and a stake in their own lives, and behavioural programs and consequences that staff feel are required to manage difficult behaviours. Acting-out behaviours require consistency and actions that typically remove control from the individual women and reinforce dependency. If there is insufficient positive attention in the environment, negative consequences and the resulting attention can in fact reinforce behaviour for women who have received insufficient positive attention during long-term institutionalization. Moreover, if staff interactions with individual women are dominated by behavioral plans then it is difficult or impossible to develop genuine and trusting relationships with individual women. There is a very fine line between the need to take consistent action to manage behaviour and contravening key values of the psychosocial rehabilitation program. Several important elements are required to effectively walk this fine line:

House Expectations and Natural Consequences. Any group of people requires basic expectations in order to live together in a cooperative manner and these expectations need to be clearly defined by the women and staff in the setting at the outset. Failure to live up to these expectations should invoke natural consequences as opposed to "personal" consequences aimed at behavioral control of the individual. For example, others will not interact with a person who never bathes and therefore minimal hygiene would be an expectation of the house. A given woman may need skills-teaching, encouragement, and positive reinforcement for her hygiene efforts, but ultimately there may be a consequence for not meeting the hygiene expectation, e.g., the inability to eat with others. A "personal behaviour" consequence and a "natural" consequence may in some instances be very similar with respect to the actual result but the interpretation and process of developing them is different. In the first instance it is perceived as a staff response to control an individual's behaviour while in the latter instance it is an expectation set by all of the members of the setting (including staff) and implemented by staff as a part of their role in the setting.

Multi-Disciplinary Team Meetings and Communication. The development of balanced and consistent approaches to behavioural problems is a very difficult task requiring multiple perspectives and a high level of communication among staff. Formal multi-disciplinary team meetings should be held weekly to discuss the progress of the women in the program and to serve as a means to coordinate efforts and work on projects in smaller groupings. They should involve all of the key staff members in the program including the coordinator, psychologist, occupational therapist, nurse, community integration worker (see below), as many PSR workers as possible, and as many other staff as is possible who are relevant to the current work. Specific steps must be taken to structure the PSR worker's participation, and funds must be budgeted to allow for it. Scheduling options include:

    ˇ holding the meeting across the change of shift.

    ˇ providing compensatory time (to be used at a later point) for staff attending the meeting.

    ˇ meeting when the women are out of the house so that staff on shift can attend.

Careful Reflection on Staff Values, Interaction Styles, and PSR Values. It is imperative that staff reflect on their own values, psychosocial rehabilitation values, and their own behaviour and style of interaction as a means to considering specific responses to behavioural issues. Difficulties may be avoided in some instances if staff intervene in a preventative manner, while in other instances it may be important to ignore the situation, or to recognize that the behaviour may only be problematic for the staff rather than for the functioning of the individual or the safety of the setting. These decisions and strategies require team communication, a shared vision of the program, and a foundation in psychosocial rehabilitation and behaviour management. Staff training and team building are important elements in achieving success.

Continuum of Quiet Options. Another key element of behaviour management is working with individual women in order to improve their coping and problem-solving skills with respect to specific stresses. They require a continuum of options through which they can take steps to control their behaviour and/or ask for help from staff. There must be space to "get away" within the setting when they are under stress. The options should include:

    ˇ enabling their bedroom to be a relaxing spot through their ability to decorate and control its appearance, and by insulating it from sound from the rest of the setting.

    ˇ establishment of an outdoor quiet spot behind each side of the duplex where a woman can relax.

    ˇ provision of a den/quiet spot in the setting as an alternative refuge which is attractively furnished, well lighted, and insulated for sound.

    ˇ provision of therapeutic quiet, a safe room which can be locked and viewed by camera. A woman should be able to ask to enter therapeutic quiet for her own safety, or she may be placed there for her own safety by staff according to specific policies and procedures.

Recommendation 7: Staff must balance the need for hope and empowerment inherent in psychosocial rehabilitation with the need to cope with offenders' behavioural difficulties. Setting the appropriate balance should involve the use of group defined house expectations, natural contingencies, multi-disciplinary team meetings, staff reflection on values and interaction style, and a continuum of quiet options.

Therapeutic Quiet. Therapeutic quiet is an essential element of the duplex design and must be regulated by specific procedures developed for the setting. Women with cognitive challenges may lose control of their behaviour and/or act out such that they require short-term, externally locked control and clear consequences, be it for a few minutes or a few hours. However, lengthy isolation is counter-productive as the offender loses focus on why she is isolated and she may become more desperate, hopeless and dependent. Invoking segregation is often inappropriate for the circumstances and yet a brief therapeutic quiet option is required if it is to be avoided. Segregation always does exist as a last resort but one would not expect to use it, and if it was used with some frequency for an individual, staff would have to question the effectiveness of the program for this woman. The psychologist should work with the staff team in consultation with the institutional administration to define specific written procedures for the use of therapeutic quiet. The psychologist should consult with the programming team at the Prison for Women to draw on their expertise and experience with the use of therapeutic quiet with special needs women. For experienced correctional staff unfamiliar with the use of therapeutic quiet, there may be a perceived risk in using it in instances where the staff member might have formerly relied on segregation. It will be important to train and support staff to use therapeutic quiet.

Medical/Psychiatric Involvement and the Use of Medications. PRNs and specific medication regimes can be used to assist women in crisis and teach coping skills. In this instance, medication can represent a form of chemical restraint much as therapeutic quiet can represent a form of physical restraint. Both approaches have benefits, serious side effects, and the potential to limit a person's rights. Penitentiaries historically have normalized the benefits of physical restraint while downplaying the side effects and rights abuses, yet have frowned upon chemical restraint, in this instance pointing to the dangerous side effects and potential rights abuses. Significant medical/psychiatric and nursing involvement in the staff team is essential so as to weigh the potential benefits and dangers of medication usage and determine appropriate written procedures for its use. The nurse should be responsible for developing these written procedures in consultation with doctors, the staff team, and the administration. Provision should be made for the consulting doctor to participate in at least part of the weekly multi-disciplinary team meeting.

Recommendation 8: Therapeutic quiet must be an essential element of the duplex design through which women can learn to better manage stressful situations, and through which they can be secured when a danger to themselves. Specific written procedures must be developed to monitor its use. Staff must be trained in its use. Medication may also be a useful tool to assist women in stressful situations but its use requires stringent monitoring and written procedures.


Stigma Versus Peer Support and Teaching

Women with basic skill needs and cognitive challenges may be viewed by other offenders, and other members of the community, in a range of ways varying from disdain and rejection to solidarity. Frequently their experience has been one of isolation, rejection, and stigma. The previous structured living house at Nova suffered from the label of the "crazy house". In contrast, individual offenders often express a willingness to help these women if they do not have to co-exist with them twenty-four hours a day. If the women in the PSR program become severely stigmatized by others, they will reject the program for themselves and act out to disrupt it. Women with basic skill needs and cognitive challenges will inevitably be viewed as "different" as a function of their behaviour and their involvement in the program. However, stigma associated with these differences must be minimized or avoided. Several elements are essential to address the issue of stigma:

ˇ Peer Support and Teaching. The most essential element is to provide opportunities for other offenders to work with women in the PSR program through voluntary, structured, one-to-one interaction and peer support, as a part of their regular activities. This process can break down the isolation of the women and allow other offenders to interact with them in a caring and productive manner which gives both individuals a sense of accomplishment. The women with basic skill needs become unique individuals who benefit from support and in turn can respond with caring. The peer-support offenders can become advocates with other offenders for the women in the PSR program who may have communication problems with them. The peer-support offenders benefit from the satisfaction of helping others and the individual women benefit from the one-to-one attention they require to participate in programs or learn skills.

ˇ Peer Education. Other woman offenders should be educated about the nature of the PSR program and the needs of the women involved in it from the vary outset of their time at the institution. The need to mobilize peer-support workers can become a basis through which to initiate the education process and it should be carried out on an on-going basis through the regular offender orientation program. The peer-support workers should play a key role in educating new offenders through the orientation sessions.

ˇ Peer-Support Training. Program staff must work with the inmate committee to design and deliver a training package for offenders who volunteer to work with the women with basic skill needs and cognitive challenges. It is important that they have an understanding of the difficulties these women face, their skill needs, the psychosocial rehabilitation approach, and effective ways to work with them.

ˇ Sense of Ownership and Attractiveness of the Living Setting. The women who are potential candidates must be involved in the design of their setting from the very outset and staff should facilitate their efforts to decorate and improve the setting from the moment they arrive. The duplex design is such that it will have attractive features relative to the other houses (e.g., smaller group living, a den/quiet room, a private outdoor space, etc.) such that the individuals will see practical benefits in their living accommodations. These elements must be emphasized and staff must work to encourage a sense of ownership in the setting among women along with providing education to promote self-awareness of why this setting is suited to their needs.

ˇ Integration into Regular Programs. The women in the PSR program should have opportunities to participate in regular programs and leisure programs as long as it is beneficial to their interests. Staff must be particularly cognizant to avoid standard security procedures for women in the program such as requiring escorts which would drastically limit their ability to integrate into regular programs due to a lack of staff resources. Creative alternatives developed through the multi-disciplinary team should be utilized when some monitoring is essential, e.g., use of peer support, volunteers, communication with staff in the programming area, etc.

ˇ Adherence to the Admission Criteria. Departure from the admission criteria and inclusion of women who are functioning at a higher cognitive level or do not have evident basic skill needs will blur the perception of the house as a positive education program and emphasize it as a setting for those who act out.

Recommendation 9: Stigmatization and labeling of these women offenders poses a serious threat to the success of the program and should be minimized or avoided through: a peer support program, peer education, facilitation of a sense of ownership in their home, adherence to the admission criteria, and their integration into regular programs.


Bridging for Community Integration

Women with basic skill needs and cognitive challenges will require on-going support in the community in one form or another for the rest of their lives. It is imperative to recognize that if the correctional system does not either provide this support or ensure that others do, it will inevitably fall back on the correctional system to maintain these women in a penitentiary, which is expensive and detrimental to the women, and to the society as the result of the additional offenses they would commit. Moreover, based on staff and inmate interviews, and the research of others (Kendall, 1995), the existing correctional plan and release process has serious problems for women in the general population, particularly with respect to the lack of bridging, communication, and involvement between the penitentiary and community resources, be they within or outside the correctional system. This process is even more problematic for women with basic skill needs and cognitive challenges because they have much greater difficulty adjusting to new settings and relationships and transferring their skills and relationships across settings. Transitions must be slow and supported by stable relationships to be successful. The present relatively impersonal community release process of handing a person to new correctional staff and support persons across jurisdictions is a recipe for recidivism for these women. An alternative model is required based on the "assertive community living approach" conceptualized and implemented by Stein & Test (1985).

The key community integration worker must be based in the institutional program such that the foremost priority is to build a strong relationship with each individual woman to assist her in moving to the community. It is not possible to develop this type of relationship with these women if the worker is based in the community and can only come to the institution periodically. However, it is possible for an institution based worker, who has a strong relationship with the individual offender, to go to her home community and develop effective relationships with community support organizations and workers so as to facilitate the transition.

Community Integration Worker. A specific staff role and process is proposed for the PSR program which has the primary purpose of providing the bridge between the work in the penitentiary with the woman and the support system to be provided for the woman upon release in the community. The key elements of the "community integration worker" role are:

    ˇ to develop a trusting relationship on an individual basis with the offenders through informal and formal interaction.

    ˇ to participate in the psychosocial rehabilitation planning process for the woman developed through the woman's partnership with her PSR worker. The goal environment for the individual's living situation must be based on the individual's personal criteria. Extensive effort must be placed on discovering what worked and did not work in the past along with the assessment results of what the person can and can not do at present.

    ˇ to contribute to the action plans, skills-teaching, and individualized programming with each woman as is appropriate.

    ˇ to establish contacts and visit the release community to advocate for, negotiate, coordinate, and create support systems for release, in partnership with the woman based on her PSR plan.

    ˇ to provide training and education to persons and organizations who will provide community supports upon release with respect to the needs, goals, and experiences of the individual woman.

    ˇ to assume primary responsibility for case management functions once the individual enters the PSR program.

    ˇ to accompany the individual upon release and to support her in the community living situation for a transition period as is appropriate. This might involve remaining in the release community for a number of days.

    ˇ to visit the woman in the release community with some regularity while monitoring and continuing to educate key staff in the community support system.

    ˇ to identify, educate, and support key community workers in centers where the women typically move upon release. Since many of the women who are potential candidates for this program come from Newfoundland, support work in St. John's will be particularly important.

The community integration worker is essential to maximizing the likelihood of success in the woman adjusting to the support system upon release so as to reduce the potential for recidivism. This individual requires strong interpersonal skills to develop trusting relationships with the women, a hopeful, persistent and direct approach in order to advocate for resources, and sophistication in coordinating and educating community support workers.

Financial Resources for Community Integration. Each community release process and PSR plan will be unique to the needs of the individual and local resources, individual personalities and organizations, and particular arrangements. Standard community correctional centres with a majority of male residents and a large group-living situation are most frequently inappropriate for the release of these women. To facilitate community integration and effective individual release plans, funds must be budgeted within the PSR program to allow for:

    ˇ frequent travel to communities across the region, particularly Newfoundland.

    ˇ travel on an occasional basis by key community support workers in order to facilitate an understanding of the woman's experience within the penitentiary setting.

    ˇ training for key community workers in the PSR approach.

    ˇ additional contract support workers to support the women through a longer transition process in the community if necessary.

Cooperative Efforts for Partnership with Provincial Mental Health and Community Services. In both Nova Scotia and Ontario, provincial health and community service departments are recognizing the importance of psychosocial rehabilitation work at a conceptual and philosophical level, and some programs are in place, yet financial restraint has severely limited their willingness to serve women offenders since existing services are overburdened with their own clients. One potential strategy would be to work in partnership with key provincial decision-makers so as to contribute toward new joint programs that might serve clients from both jurisdictions from the outset.

Finding: The present correctional release process is ineffective for women with basic skill needs and cognitive challenges due to its failure to provide a bridge of consistent relationships for the women to the community setting. There must be a process through which to advocate for and develop individualized plans, including education of community support systems.
Recommendation 10: There must be an alternative release model in which a community integration worker builds a strong relationship with the individual woman in the penitentiary and then uses this relationship as a bridge to establishing her in a supported community setting. Sufficient funds must be provided to support this community integration process. The community integration worker must be based in the institution in order to develop the strong relationship with the individual offender that is required for success.


Staffing Complement, Qualifications, and Roles

Staff Complement. The following staff complement is proposed for the PSR program for a maximum of 8 women offenders. This complement is above any existing staff already present in the penitentiary. The complement should be:

    ˇ 1 full-time program coordinator

    ˇ 2 PSR workers on the day and evening shifts, seven days per week (one PSR worker must be a R.N. with psychiatric experience)

    ˇ 1 night security staff on the night shift seven days a week (ability to call in a second staff if needed)

    ˇ 3 days per week of an occupational therapist

    ˇ 2 days per week of a psychologist

    ˇ 1 full-time community integration worker

    ˇ 2-3 hours per week of a medical physician

    ˇ consulting psychiatry, chaplaincy, First Nations Elders, and community resource persons

    ˇ 1 day per week of contracted staff for specialty programs (e.g., art, music, skills-training)

    ˇ 1 day per week for an evaluation consultant (preferably this would be an additional day per week for the psychologist or occupational therapist, if either one has the required skills)

This complement is high relative to the existing complement of the regional facilities. However, it must be recognized that the purpose of this program is to transfer and maintain high-needs offenders presently in maximum-security facilities to the regional facilities. This staffing complement is low relative to the resources presently provided within maximum-security facilities. A significant part of the reason that these women have not been in, or have had serious difficulties in regional facilities, is because there have been inadequate staff resources to support them.

Program Coordinator Role and Qualifications. The coordinator should have the minimum qualifications of...

    ˇ a university degree in a social sciences, human services, or health field,

    ˇ experience in the correctional system,

    ˇ demonstrated skills and interest in working with women with serious difficulties/disabilities,

    ˇ core values which include hope, empathy, respect, connection and empowerment that have been demonstrated through the person's work,

    ˇ an interest in and willingness to commit to a psychosocial rehabilitation approach,

    ˇ strong organizational and interpersonal skills to manage and facilitate the multi-disciplinary team.

The coordinator might be a person already working at a primary worker or higher level within the penitentiary who has demonstrated these qualifications through previous work. Although it would be preferred that the individual have mental health expertise and/or experience, the priority must be on hiring a person with strong interpersonal skills, interest in this group and approach, relevant core values, and organizational skills. The psychosocial rehabilitation skills can be learned through the staff training process defined below.

The coordinator should devote approximately half their time to leadership, coordination and administration and half their time to direct work and programming with the women offenders. The coordinator should be involved at a practical level in the program on a regular basis. The coordinator should be responsible for the overall direction of the program and should work cooperatively with staff members and the woman offenders to define the program.

PSR Worker Role and Qualifications. The PSR workers should have minimum qualifications of...

    ˇ a university degree in a social sciences, human services, or health field, and/or equivalent,

    ˇ demonstrated skills and interest in working with women with serious difficulties/disabilities,

    ˇ core values which include hope, empathy, respect, connection and empowerment that have been demonstrated through the person's work,

    ˇ strong interpersonal skills,

    ˇ an interest in and willingness to commit to a psychosocial rehabilitation approach.

Preference should be given to workers presently at the facility if other qualifications were equal as a number of primary workers have expressed an interest in taking on job responsibilities which are more program oriented. Individuals would be required to voluntarily apply for these positions and they would be interviewed and selected through a formal hiring process. Additional casual PSR workers will need to be hired to fill in occasional spots in the rotation and to be available to move into the program quickly if full-time PSR workers leave with little notice or take leaves of absence. These casual PSR workers should receive the full PSR training but may be assigned other duties in the facility if possible when they are not required in the program. Overall, the staffing should be allocated so as to minimize regular part-time workers as they increase the size of the staff team and make team consistency and communication more difficult.

The PSR workers should work exclusively in the program on a three-year term basis on day and evening shifts. At the end of that term it would be the decision of the coordinator in consultation with the PSR worker as to whether the person would continue for another term or shift to another role in the facility. This would provide the opportunity for rotation and relief for individuals as work with these woman offenders can be extremely draining over time. It also would give the opportunity to provide cross-pollination of ideas and concepts between the PSR program and staff working with the general population.

The PSR worker role should involve direct, informal support work with the women in the setting, primary responsibility for psychosocial rehabilitation work with one or two individual women, monitoring of the setting, and assistance in specialized programming in the setting with other staff. The PSR workers should report to the program coordinator and must participate in the full psychosocial rehabilitation training program.

Night Security Staff. The women in the PSR duplex require supervision at night for security, support and supervision purposes. The night shift should be staffed separately such that there is no rotation between night, and day or evening shifts. The essential elements of the PSR worker roles on the day and evening shifts are to build strong relationships with the women and help with programs. he night shift does not provide an opportunity to carry out these roles and has a security and supervision function. If day and evening workers are placed on the night shift, it will require more program PSR workers to staff the duplex which in turn results in more staff with whom the women in the house must develop intensive relationships, and these staff would be present during the waking hours less frequently. This does not meet the needs of the women offenders who have difficulty developing relationships with larger numbers of staff and who require a consistent approach from a small staff team. Staff communication and informal consultation become more difficult, particularly with respect to facilitating a weekly meeting with most of the staff present on the day shift. Instead, the duplex should be staffed at night by a different set of workers whose function is to provide supervision if a woman is upset or wakes up. These staff must be regular Correctional Service of Canada employees who are able to intervene with the women when required.

The duplex would require at least one night security staff. A second person would be required if the women were particularly upset, or if the staffing of the institution on the night shift was such that one could not be count on a second person arriving in the duplex quickly in the case of an emergency.

Psychologist Role and Qualifications. The psychologist should possess the following qualifications:

    ˇ registration or candidate registration as a psychologist,

    ˇ demonstrated skills and interest in working with women with basic-skill needs and cognitive challenges,

    ˇ core values which include hope, empathy, respect, connection and empowerment that have been demonstrated through the person's work,

    ˇ an interest in and willingness to commit to a psychosocial rehabilitation approach,

    ˇ demonstrated, effective interpersonal skills.

The psychologist should contribute formal assessment expertise to the team and should facilitate the multi-disciplinary admissions committee. The psychologist would also be a key consultant to staff and the multi-disciplinary team with respect to the design of individualized treatment and behaviour management programs. The psychologist would be expected to develop strong relationships with the individual woman and play a role in practical programs.

Nurse & Physician Roles. It is essential to have a registered nurse with additional psychiatric training and/or experience as a member of the staff team and this could be assured by requiring this qualification of one PSR worker, who would likely work a greater percentage of weekday shifts. The nurse must take responsibility for coordinating health care and work with the physicians for the women in the program. Physical complaints and drug-seeking behaviour are very common among women with these needs. It is complex and important to separate out legitimate uses of medication from drug seeking and it is difficult for doctors during brief consultations to gain the full picture without the presence of a well-informed nurse. The nurse should be present with the individual woman whenever possible during consultations with the doctor so as to understand what the woman is telling the doctor and to understand what the doctor has told the woman. The nurse is responsible for ensuring there is a consistent team approach to medical treatment. The nurse will also play an important role in the program with respect to health and medication education, providing individualized and small group programming with the women, and serving as a consultant to staff in working with these issues.

The physician must be an integral member of the multi-disciplinary team and time should be allotted for the person to attend at least a part of the multi-disciplinary team meetings so as to be aware of key health issues on a weekly basis. The physician should have a primary role, in consultation with the nurse, in determining medical policies and procedures. Referrals to specialists should be processed through the physician in order that there be a holistic approach to treatment.

Occupational Therapist Role. The occupational therapist should possess the following qualifications:

    ˇ registration as an occupational therapist,

    ˇ demonstrated skills and interest in working with women with basic-skill needs and cognitive challenges,

    ˇ core values which include hope, empathy, respect, connection and empowerment that have been demonstrated through the person's work,

    ˇ an interest in and willingness to commit to a psychosocial rehabilitation approach,

    ˇ demonstrated, effective interpersonal skills.

The occupational therapist will play an essential role in individualized and small group skills-teaching in relation to the PSR plans. The occupational therapist will provide consultation and support to PSR workers and other team members in skills-teaching work with individual women as well as playing an important assessment role in evaluating the suitability of women for the program.

Excellent interpersonal skills, values, and experience are particularly important given the occupational therapist's leadership role in the skills-teaching areas. Occupational therapist training programs typically provide graduates with many of the key skills that are essential to quality skills-teaching in a psychosocial rehabilitation program. However, the sequencing and philosophy through which these skills are used in psychosocial rehabilitation departs significantly from many standard occupational therapy approaches. It is therefore particularly important that the occupational therapist be open to the PSR approach and participate fully in the training process.

Community Integration Worker. The community integration worker should possess the following qualifications:

    ˇ a university degree in a social sciences, human services, or health field,

    ˇ demonstrated skills and interest in working with women with serious difficulties/disabilities,

    ˇ core values which include hope, empathy, respect, connection and empowerment that have been demonstrated through the person's work,

    ˇ strong interpersonal and advocacy skills,

    ˇ creative initiative in problem-solving,

    ˇ training and/or experience in developing and coordinating community resources,

    ˇ an interest in and willingness to commit to a psychosocial rehabilitation approach.

The community integration worker role has been described previously.

Spirituality. Psychosocial rehabilitation views recovery as a holistic process with a foundation of positive values. Many of the women who are potential candidates already have a commitment to spirituality in their life and this is an important pillar of support which should be strengthened in relation to their interests. The chaplain should play a valuable role through developing individual relationships with the women and supporting their spirituality.

Support for Cultural Diversity. Given the small group context, an individual woman from a First Nations, African-Canadian, or other distinct minority culture is likely to be isolated from her own cultural context in her living situation. It is essential to involve resource persons who can share and support her culture as an integral part of the PSR planning process. Provision must be made for key support persons to participate in elements of the psychosocial rehabilitation training in order that they appreciate the approach, and recognize its strengths and limitations in relation to the woman's cultural background.

Volunteer Support. Awareness of community opportunities is an essential element of the PSR approach in helping women to define goals and plan for the future. This process is difficult in a penitentiary context given security policies and procedures which restrict a woman's access to the community. Volunteers from the community can play an important role in working with women in one-to one programming. Simultaneously they can help to expand the woman's horizons by sharing who they are and their community perspectives.

Finding: High quality and committed staff are essential to an effective program. They must be committed to both direct work with difficult women and to the PSR program model. Although staffing is expensive for a program for these women with special mental health needs, insufficient or poorly trained staff will result in failure. The recommended staffing level is lower than the level of a maximum-security facility where these women would otherwise be maintained.
Recommendation 11: It is essential to select staff with strong interpersonal skills and values for work with these women while allowing for a mix of expertise to provide for diverse perspectives. Programming will be most effective if there is a small, multi-disciplinary staff who can support each other and provide a consistent approach to work with the women. Core staffing should include a program coordinator and a community integration worker, two PSR workers on day and evening shifts, a night security staff, and a part-time psychologist, occupational therapist, and program evaluation consultant. Part-time PSR worker positions should be avoided wherever possible, as intermittent staff presence makes communication and coordination more difficult. Night staff should only work on night shifts with a security and supervision function.


Staffing Training, Support, and Communication

Staff Training. Psychosocial rehabilitation is a precise, logical approach that requires practitioners who have a fundamental grounding in the values, a full understanding of each element of the approach, and the skills to apply it. Staff must bring a strong values foundation and set of interpersonal skills to the work and then must receive detailed training to be able to apply the approach with women who have great difficulties and can be extremely demanding of staff.

An eight-week training and team-building process should be provided over a six-month period beginning with a two-week team-building and psychosocial rehabilitation training component. This training must include the coordinator, PSR workers, occupational therapist, psychologist, and community integration worker. The eight-week program should include:

    ˇ six weeks of training in psychosocial rehabilitation technology

    ˇ one week of training in clubhouse and assertive community living approaches

    ˇ one week devoted to team-building, program planning and evaluation, and selected mental health topics

The psychosocial rehabilitation training course is provided in Canada through the Brockville Psychiatric Hospital and is based on the work of Anthony (1990). There are trainers in Nova Scotia and Ontario. It provides a detailed structured curriculum in which there are a series of training sessions which include presentation, modeling, and practice, followed by "homework" in which participants work through each module and set of skills with an individual woman. Sessions with the individual women are videotaped for feedback and supervision purposes. Time is required between modules in order that participants can work through the planning process with an individual woman.

A clubhouse training program is provided in Nova Scotia through the Connections Clubhouse in Halifax which has utilized this approach for more than a decade and has been cited as a model mental health program in Canada. The Connections coordinator is facilitating a workshop presented by Dr. L.I. Stein, one of the founders of the "assertive community living" approach in Halifax in June of 1998. Other key elements of the training with respect to team building, mental health topics, and program planning should be facilitated by the program coordinator in consultation with those with expertise within the correctional system and the relevant professional communities.

The eight week training process should be conducted in two groups on successive weeks so that there will continue to be some regular program staff working with the women during the training weeks. A brief two-day training program should be provided for the night security staff, physician, contract programmers, and relevant Elders and community resource persons. This program should be organized and facilitated by the program coordinator.

Staff hired from outside of the correctional system would be expected to participate in the standard training programs for work with women in corrections which are required of all staff.

Support and Communication. The program coordinator, staff team, and the institutional administration must recognize the importance of on-going team support and communication to make this program effective, as these women are extremely demanding on staff. Staff can quickly lose perspective and patience if they do not have communication and support within the team and from the broader facility. This commitment to team and communication must come from the individual staff but it requires an administrative context in which the legitimate use of staff time for team meetings, informal consultation, and support is recognized and supported. In particular, there must be opportunities on a regular basis for all of the key staff to meet together at one time. This requires funds to bring in or replace PSR workers.

Finding: Effective staff-training and support is essential to the success of the program and the ability to attract and retain quality staff.
Recommendation 12: All core staff must participate in an eight week training program including six weeks of training in psychosocial rehabilitation, one week of training in clubhouse and assertive community living approaches, and one week devoted to team building, program planning and evaluation, and selected mental health topics. A brief training program should be provided for auxiliary staff. There must be on-going commitment and resources for staff communication and support.


Program Evaluation

Given that this program represents a major new initiative involving high-needs women, program evaluation must be built into the process from the outset and should include a blending of qualitative and quantitative approaches with process and outcome measures. There are two options for obtaining program evaluation expertise. Preferably, the psychologist or the occupational therapist would have significant program evaluation expertise (possibly with some continuing education) and could design and carry out the evaluation in consultation with the team and the women. In the developmental phases of a program there are particular benefits to internal evaluation processes in that they encourage the staff team to build a continuous quality improvement ethic into all of their work on a daily basis. However, if there is no one with this particular expertise on the team, then an external contract should be tendered for a professional to design and complete the evaluation work in consultation with the staff team and the women offenders. It is expected that the evaluation would require one day per week for the first two-year period. If the psychologist or occupational therapist took on the evaluation role, they would require an additional day per week to fulfill the task.

Finding: Program evaluation is essential to program improvement and accountability.
Recommendation 13: Either a team member with evaluation expertise or an external consultant should design and conduct the program evaluation in consultation with the staff team and the woman offenders.


Implementation of a Pilot Program

Based on the analysis of the women presently in maximum-security facilities who would be potential candidates for this program (see Section II), it is recommended that this program model be applied and evaluated initially through developing one duplex with eight spaces at Nova Institution in Truro, Nova Scotia. There are presently four women at Springhill who are candidates for this program and there are two additional candidates from Atlantic Canada in the Special Needs unit of the Prison for Women. This disproportionate number from Atlantic Canada makes Nova the reasonable location. In addition the program should be open to women from other regions with basic skill needs and cognitive challenges. It might be appropriate to begin with six women, three per side, in order to allow the staff team and facility to gain experience with smaller numbers. Once the program is operating, it may be possible to involve appropriate individual women who are functioning effectively in regular houses in a psychosocial rehabilitation planning process and relevant programming yet they would remain in a regular house.

The proposal to begin with one program at Nova Institution which may accommodate some women from other regions does conflict with the concept of trying to serve women as close to their home communities as is possible. However, this program requires a high level of resources, and given the very small number of women with basic skill needs and cognitive challenges, it makes sense to start small and recognize that it may not be possible to provide every special and intensive mental health program in every region. The program is voluntary but it does put the woman in the situation of moving from her region if she wants to participate in a program that may be most suited to her needs. However, for many of these women, they do not have significant supports in their home communities given their long term difficulties and time spent in institutions. In addition, the regional facilities serve extremely large regions at present, such that women are often at a great distance from their home communities. The increased distance if she is in another region may not be psychologically significant. If the program model proves effective and there are the sufficient numbers, a second program can be implemented in another region so as to maintain more women in their own region. It also might be possible to provide a modified program model in a maximum-security facility if there were enough women with these types of needs who could not obtain a medium-security classification due to persistent and severe behavioural difficulties.


Obstacles to Effective Implementation of the Program

The following issues could become major obstacles to the implementation of an effective program and therefore must be recognized and strategically addressed from the outset:

1. Failure to hire and/or maintain quality staff. Strategies to avoid this problem include:

    ˇ the provision of adequate time and attention to hiring.

    ˇ ensuring there are individuals on the hiring committee who have direct experience working with these women and this type of program.

    ˇ drawing on existing staff who have demonstrated exemplary performance for the PSR worker positions.

    ˇ an upbeat recruiting effort which emphasizes the innovative nature of the program to attract specialty disciplines to a small-town Nova Scotia community.

    ˇ an administrative and resource priority on providing time for staff training, support and communication.

2. Conflicts with broader penitentiary policies and requirements. Potential strategies to avoid these problems are:

    ˇ a clear vision and written program description recognized throughout the institution which allows for a relatively high level of program autonomy.

    ˇ a formal, documented multi-disciplinary admission process with clear criteria that is honoured at the institutional, regional, and national levels, even if there are operational pressures to take contrary actions.

    ˇ initial start-up planning time involving the administration and staff team in order to identify and problem-solve with respect to potential policy conflicts.

    ˇ a flexible administrative approach to the program and a willingness to grant reasonable autonomy and support staff judgment.

    ˇ a staff team with correctional experience that recognizes policy concerns in a penitentiary.

    ˇ on-going efforts by the staff team to educate other staff and women offenders about the purpose, practices, and challenges of the program. Recognition by the staff team of the potential for resentment from other staff with respect to new resources for a new program when existing resources are limited.

    ˇ program participation in regular communication forums at all levels in the institution.

3. Inability of the staff team and the local administration to control planning decisions. Potential strategies to avoid this problem are:

    ˇ ensuring that staff are hired and in place in advance of program-start-up. This includes hiring key staff as soon as possible, even if they perform some other functions initially while the planning and implementation process gathers momentum. Pressure must be resisted to proceed too quickly given the priority on transferring individual women out of maximum-security environments.

    ˇ ensuring that there are effective mechanisms for staff control and input into the building design at a detailed level so that the structure reflects programming and security needs. Problems in the physical structure can be a permanent drain on the program and staff.

    ˇ ensuring that the program has flexibility with respect to policies and procedures wherever appropriate.

4. A rapid and ineffective transition process for individual women transferring from maximum-security facilities. Potential strategies to avoid this problem are:

    ˇ education of the staff at the existing maximum facilities with respect to the program so that they can realistically present it to potential candidates, set appropriate expectations, and facilitate the transition process.

    ˇ education work with the individual women by the program coordinator before they come to Nova.

    ˇ accompaniment of the women on the transfer by those they trust from the maximum-security facilities.

    ˇ careful planning for and a staggered transfer of women so that they do not all arrive simultaneously.

    Recommendation 14: Specific strategies must be adopted from the outset to overcome these obstacles to the effective implementation of the PSR program with women offenders..