Out of Sight, Back Into Mind: Federal Offenders with mental disorders preparing for release into the community

1.  Out of Sight, Back Into Mind: Federal Offenders with mental disorders preparing for release into the community Canadian Criminal Justice Association Pan-Canadian Congress Claude Tellier Veronica Felizardo October 2011

2. 2 Presentation Objectives Overview of Canada’s correctional systems Mental Health issues present in Correctional Service of Canada’s offender population Overview of the CSC Mental Health Strategy Key elements and results of the Community Mental Health Initiative Mental Health Strategy for Corrections in Canada

3. Overview of Canada’s Correctional Systems Responsibility for corrections is divided between the federal and provincial governments. Correctional Service of Canada is responsible for offenders serving sentences of two years or longer. Provinces and territories are responsible for offenders sentenced to terms of less than two years. As of 2008, the incarceration rate in Canada was 116 per 100,000 (CCRSO 2010). 3

4. Incarceration Rate 4 The numbers inserted in the map include provincial and territorial average counts of persons in adult correctional services, by program and by jurisdiction.The numbers inserted in the map include provincial and territorial average counts of persons in adult correctional services, by program and by jurisdiction.

5. Mental Health and Corrections People with serious mental illness (SMI) are often charged with more serious crimes than other people arrested for similar behaviours (Hockstedler, 1987; New York State Office of Mental Health Forensic Task Force, 1991) Persons with SMI are generally incarcerated for longer than those with no mental illness (Criminal Justice Mental Health Consensus Project, 2003; Ditton, 1999) In recent years, the population of mentally disordered people within the criminal justice system has been growing significantly (Schneider, 2000) 5

6. Mental Health and Corrections Estimates vary on the prevalence of mental health issues within prisons: Brink et al (2001) found that 31.7% of 267 new intakes in federal penitentiaries in British Columbia had a current diagnosis, with 12% meeting the criteria for a serious mood or psychotic disorder. Fazel & Dinesh (2002) found that “typically about one in seven prisoners in western countries have psychotic illnesses or major depression” (p.548). Data from Correctional Service of Canada indicates that 13% of male offenders and 29% of women offenders in federal custody self-identified at intake as presenting mental health problems, and these rates have approximately doubled since 1996/97. Approximately 90% of Canadian federal offenders diagnosed with a mental disorder have at least one other disorder. 6

7. 7 Canadian Context Out of the Shadows at Last: Transforming Mental Health and Mental Illness and Addiction Services in Canada (2006) Comprehensive examination of mental health needs and services in Canada Mental Health Commission of Canada (2007) National Mental Health Strategy Anti-Stigma Initiative Knowledge Exchange Centre Homelessness Research Demonstration Projects Partners for Mental Health

8. 8 Mental Health and Offenders:CSC’s Context Addressing offender mental health needs is a key priority of CSC Legislation requires CSC to provide essential health services, including mental health services, and reasonable access to non-essential mental health services that will contribute to the offenders successful reintegration into the community rehabilitation. CSC’s Mental Health Strategy approved in 2004; updated in 2010 CSC’s Independent Review Panel Report (2007) Includes several recommendations for a robust continuum of mental health services, from intake to release, with a strong focus on linking with community partners.

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10. 10 CSC’s Mental Health Strategy Approved in 2004; updated in 2010 Full-spectrum response to mental health needs in institutions and communities: Comprehensive mental health assessment at admission Enhanced primary mental health care in all institutions Enhanced resources at mental health treatment centres Development of intermediate care mental health units in regular institutions (currently unfunded) Increased mental health support in the community CSC is implementing a comprehensive strategy to improve service delivery which includes a full-spectrum response to mental health needs in institutions and communities CSC operates 58 institutions, 16 community correctional centres and 71 parole offices across Canada Approved by EXCOM in 2004. A way out of the dilemma came two years ago, spurred by testimony, including CSC submissions, at the Kirby Senate Committee on mental health. The committee’s report, which devoted a chapter to offenders with mental health problems, galvanized support for the wide-ranging 5 pronged mental health strategy and substantial funding. 2. Enhanced Primary (basic) Mental Health Care coordinated and comprehensive provision of mental health care to inmates, including treatment; psychological assessment and management; crisis intervention; and health promotion and maintenance in all regular institutions. delivered by a team consisting of psychologists, psychiatric nurses, social workers, and others. Intermediate Care Mental Health Units (ICMHU) Intermediate level intervention for men offenders with mental health disorders who require daily mental health care and support within specialized units in regular institutions. Need an accomodation unit where they can still work on their correctional plan, but have the treatment and support they need to manage their illness. At present, many OMDs are mixed with general population which exposes them to risks. Plan to create ICMHUs in each region, in about 25% of male institutions 4. Mental Health Treatment Centres upgrading facilities and staffing at CSC mental health treatment centres, to provide mental health care for inmates with acute mental health problems equivalent to that offered by community forensic psychiatric hospitals, while meeting correctional security requirements. CSC is implementing a comprehensive strategy to improve service delivery which includes a full-spectrum response to mental health needs in institutions and communities CSC operates 58 institutions, 16 community correctional centres and 71 parole offices across Canada Approved by EXCOM in 2004. A way out of the dilemma came two years ago, spurred by testimony, including CSC submissions, at the Kirby Senate Committee on mental health. The committee’s report, which devoted a chapter to offenders with mental health problems, galvanized support for the wide-ranging 5 pronged mental health strategy and substantial funding. 2. Enhanced Primary (basic) Mental Health Care coordinated and comprehensive provision of mental health care to inmates, including treatment; psychological assessment and management; crisis intervention; and health promotion and maintenance in all regular institutions. delivered by a team consisting of psychologists, psychiatric nurses, social workers, and others. Intermediate Care Mental Health Units (ICMHU) Intermediate level intervention for men offenders with mental health disorders who require daily mental health care and support within specialized units in regular institutions. Need an accomodation unit where they can still work on their correctional plan, but have the treatment and support they need to manage their illness. At present, many OMDs are mixed with general population which exposes them to risks. Plan to create ICMHUs in each region, in about 25% of male institutions 4. Mental Health Treatment Centres upgrading facilities and staffing at CSC mental health treatment centres, to provide mental health care for inmates with acute mental health problems equivalent to that offered by community forensic psychiatric hospitals, while meeting correctional security requirements.

11. CSC’s Mental Health Strategy: Institutional Mental Health Care (IMHC) 11

12. CSC’s Mental Health Strategy: IMHC 12

13. CSC’s Mental Health Strategy: Throughout Incarceration 13

14. CSC’s Mental Health Strategy: Throughout Incarceration 14

15. 6-9 months prior to anticipated release 15

16. 16 Fundamentals of Mental Health Training: Objectives Increase understanding of what it’s like to have a mental disorder stigma, discrimination Increase knowledge of offenders with mental disorders Symptoms and interventions/treatments Relationship between mental disorder and risk legislation, CSC initiatives Enhance skills and strategies for effectively interacting with and supporting offenders with mental disorders recognizing and describing symptoms communication and interpersonal skills tailoring skills and strategies for women offenders, Aboriginal offenders referring, consulting and collaborating with mental health professionals, community resources, family members One goal is to try to understand what it’s like to have a md (reduce stigma, discrimination) Training exercise designed to simulate the challenges faced by inds as they attempt to access services Learn about challenges surrounding mental health and mental disorders. These factors need to be kept in mind when working in the field because they may cause people to treat mh less seriously and increase the stigma and discrimination that those with md may face. Skills: Symptoms- Some behaviour (e.g. yelling, throwing items from cell) may be a symptom of a person’s mental disorder or failure to receive treatment rather than an intentional wrongdoing Communication and interpersonal skills - interviewing techniques, calming approach methods, de-escalation techniques To improve the overall management of correctional institutions Reduce the frequency of disruptive behaviour among inmates, and improve our response to incidents which do occur The aim will be to promote an interdisciplinary approach to working with offenders with mental disorders - When to refer to a mental health professional One goal is to try to understand what it’s like to have a md (reduce stigma, discrimination) Training exercise designed to simulate the challenges faced by inds as they attempt to access services Learn about challenges surrounding mental health and mental disorders. These factors need to be kept in mind when working in the field because they may cause people to treat mh less seriously and increase the stigma and discrimination that those with md may face. Skills: Symptoms- Some behaviour (e.g. yelling, throwing items from cell) may be a symptom of a person’s mental disorder or failure to receive treatment rather than an intentional wrongdoing Communication and interpersonal skills - interviewing techniques, calming approach methods, de-escalation techniques To improve the overall management of correctional institutions Reduce the frequency of disruptive behaviour among inmates, and improve our response to incidents which do occur The aim will be to promote an interdisciplinary approach to working with offenders with mental disorders - When to refer to a mental health professional

17. CSC’s Mental Health Strategy: CMHC 17 Note: 3700 includes CMHS and CMHI contract servicesNote: 3700 includes CMHS and CMHI contract services

18. Warrant Expiry Date 18

19. 19 These are some areas that form the bio-psycho-social-spiritual assessment and planning - When the offender is released into the community, the CPO is the primary case manager for the offender with the CMHSs working in close consultation them in the provision of clinical servicesThese are some areas that form the bio-psycho-social-spiritual assessment and planning - When the offender is released into the community, the CPO is the primary case manager for the offender with the CMHSs working in close consultation them in the provision of clinical services

20. Mental Health Strategy for Corrections in CanadaBackground 20

21. Mental Health Strategy for Corrections in CanadaVISION 21

22. 22 Mental Health Strategy for Corrections in CanadaKey Elements Mental Health Promotion The effective delivery of mental health services along the continuum of care is realized in an environment that promotes wellness, prevents illness and makes active efforts to reduce stigma. Screening and Assessment Early identification and ongoing assessment of mental health needs of individuals is essential for providing appropriate support and treatment of those who are at risk for harming themselves or others, for commencing timely treatment, and for information placement and correctional planning.

23. Mental Health Strategy for Corrections in CanadaKey Elements Treatment, Services and Supports A range of appropriate and effective mental health treatment and adjunct services is essential to alleviate symptoms including risk of self-injury and suicide, enhance recovery and well-being, enable individuals to actively participate in correctional programs, and for safer integration of individuals with mental health problems or mental illnesses into institutional and community environments. 23

24. Mental Health Strategy for Corrections in CanadaKey Elements Suicide and Self-Injury Prevention and Management A comprehensive approach to the prevention and management of suicide and self-injury is essential for managing the increased risk of suicide and self-injurious behaviour among individuals in the corrections system. Early identification of risk for suicide or self-injury is important in establishing mental health treatment, monitoring and support plans, as well as for placement considerations. Staff are trained to identify symptoms and factors that may indicate an elevated risk for suicide or self-injury, and to intervene appropriately. 24

25. Mental Health Strategy for Corrections in CanadaKey Elements Transitional Services and Supports Dedicated transitional services are required to support a seamless continuity of care from the community to the corrections system and upon return to the community. These services will be provided during the pre-sentence period, at the time of intake, within and between institutions, and upon release to the community, with an emphasis on connecting with community resources. 25

26. Mental Health Strategy for Corrections in CanadaKey Elements Staff Education, Training and Support Staff require ongoing support and comprehensive education and training in mental health to enhance their well-being, knowledge, and skills to interact effectively and provide appropriate support for individuals with mental health problems and/or mental illnesses. Community Supports and Partnerships Outreach initiatives to build relationships with partners are essential to optimize individual mental health and well-being, enhance continuum of care, and contribute to the shared responsibility of public safety. 26

27. Mental Health Strategy for Corrections in CanadaStrategic Priorities and Key Plans Knowledge Generation and Sharing Prevalence Data Enhanced Service Delivery Evidenced-based screening tools Evidenced-based assessment tools Discharge planning practices Suicide and Self-Injury Prevention 27

28. Mental Health Strategy for Corrections in CanadaStrategic Priorities and Key Plans Improved Human Resource Management Mental health training Staff support for cumulative and critical incident stress management Building Community Supports and Partnerships Information-sharing and collaboration between correctional jurisdictions and key stakeholders/partners. 28

29. 29  Challenges / Barriers to Community Reintegration  Institutionalization Reluctance to work with offenders with mental disorders Post-release aftercare Mental Health = Risk for Violence? Disconnect between federal and provincial services RELUCTANCE TO WORK WITH OFFENDERS WITH MENTAL DISORDERS: Sense of general reluctance and try to find a reason not to work with them, versus trying to find a reason to work with them agencies may perceive that if all the needs are not met for OMDs then there is a high risk for the individual to reoffend; when most research suggests that OMDs are at no greater risk to reoffend than those without a SMI In addition to the community stigma that exists, even where there are individuals willing to support OMDs, the NIMY syndrome rears it’s ugly head; we begin to consider our families and loved ones and suddenly we perpetuate the stigma- we support the individual and their success but not in my community! POST-RELEASE AFTER-CARE: -there simply does not exist enough community resources to assist the ever-growing numbers of OMDs leaving our institutions (e.g.. lengthy wait lists, complex referral processes) / access to community services due to availability or stigma -Agencies tend to address pieces of an individual instead of the individual as a whole (i.e. treat the schizophrenia, but not the brain injury; find housing but no health care) -CMHI is a modest yet valuable attempt to address this concern; I’ll be speaking a little more about this in a few minutes -Expectations: This goes both ways…if you lower your expectations people will respond accordingly, if your expectations are reasonable, people will have an opportunity to maximize their potential. If your expectations are too high, you are already setting the person up for failure. There is a real tendency for professionals to lower their expectations for persons with a mental health disorder, which can be disabling to them. MENTAL HEALTH- RISK FOR VIOLENCE????? Risk of violence associated with : substance abuse, community disorganization, command hallucinations to be violent…. Factors that determine risk for violence is the same in offenders with or without a mental disorder DISCONNECT BETWEEN FEDERAL AND PROVINCIAL SERVICES: ID: health card can only be replaced after return to the community affecting referrals to nursing home care; timely access to disability assistance; RELUCTANCE TO WORK WITH OFFENDERS WITH MENTAL DISORDERS: Sense of general reluctance and try to find a reason not to work with them, versus trying to find a reason to work with them agencies may perceive that if all the needs are not met for OMDs then there is a high risk for the individual to reoffend; when most research suggests that OMDs are at no greater risk to reoffend than those without a SMI In addition to the community stigma that exists, even where there are individuals willing to support OMDs, the NIMY syndrome rears it’s ugly head; we begin to consider our families and loved ones and suddenly we perpetuate the stigma- we support the individual and their success but not in my community! POST-RELEASE AFTER-CARE: -there simply does not exist enough community resources to assist the ever-growing numbers of OMDs leaving our institutions (e.g.. lengthy wait lists, complex referral processes) / access to community services due to availability or stigma -Agencies tend to address pieces of an individual instead of the individual as a whole (i.e. treat the schizophrenia, but not the brain injury; find housing but no health care) -CMHI is a modest yet valuable attempt to address this concern; I’ll be speaking a little more about this in a few minutes -Expectations: This goes both ways…if you lower your expectations people will respond accordingly, if your expectations are reasonable, people will have an opportunity to maximize their potential. If your expectations are too high, you are already setting the person up for failure. There is a real tendency for professionals to lower their expectations for persons with a mental health disorder, which can be disabling to them. MENTAL HEALTH- RISK FOR VIOLENCE????? Risk of violence associated with : substance abuse, community disorganization, command hallucinations to be violent…. Factors that determine risk for violence is the same in offenders with or without a mental disorder DISCONNECT BETWEEN FEDERAL AND PROVINCIAL SERVICES: ID: health card can only be replaced after return to the community affecting referrals to nursing home care; timely access to disability assistance;

30. 30 Successes Improvement in the discharge planning process and transition of offenders with mental disorders to the community. The provision of more effective and timely mental health intervention and services to offenders in the community. Improved correctional results for offenders with mental disorders with the impact of increased public safety. Improved quality of life for offenders with mental disorders. Vision - As one of the many organizations involved in the management of offenders with mental disorders in Canada, CSC’s contribution is to provide an integrated continuum of mental health care to offenders from sentencing to warrant expiry and beyond by utilizing trained mental health professionals to complete assessments and deliver interventions that respond to offender mental health needs in the most cost-effective and least restrictive manner. Vision - As one of the many organizations involved in the management of offenders with mental disorders in Canada, CSC’s contribution is to provide an integrated continuum of mental health care to offenders from sentencing to warrant expiry and beyond by utilizing trained mental health professionals to complete assessments and deliver interventions that respond to offender mental health needs in the most cost-effective and least restrictive manner.

31. 31 Challenges Recruitment of mental health professionals Integrating new mental health positions within CSC infrastructure Establishing linkages between the offender and limited community resources – finding synergies Need is bigger than just persistently mentally ill Staffing delays – Apr 05, but didn’t receive $ until Dec 2005, Created positions – 9 months – pregnancy – national generic work description, classification rationales, assessment preocess. first clinical staff – beginning of year 3 Working collaboratively with the offender, case management team (CMT) and mental health teams to assess the psychosocial needs and public safety risk of the OMD to effect their safe and seamless transition to the community; Needed to educate parole about the positions, referall process, address concerns; assist POs Identifying required community resources and establishing linkages between the offender and these resources;Building bridges; education aboutoffenders and CSC. Long waiting lists. Reticent or exclusion criteria to take federal offenders While some funds have been secured, CSC will continue to seek permanent funding to implement the full Mental Health Strategy. CSC hosted an international mental health symposium on May 21 and 22, 2008, to discuss practical approaches to addressing mental health issues within the correctional system and advance our work in response to the recommendations of the Independent Panel. Staffing delays – Apr 05, but didn’t receive $ until Dec 2005, Created positions – 9 months – pregnancy – national generic work description, classification rationales, assessment preocess. first clinical staff – beginning of year 3 Working collaboratively with the offender, case management team (CMT) and mental health teams to assess the psychosocial needs and public safety risk of the OMD to effect their safe and seamless transition to the community; Needed to educate parole about the positions, referall process, address concerns; assist POs Identifying required community resources and establishing linkages between the offender and these resources;Building bridges; education aboutoffenders and CSC. Long waiting lists. Reticent or exclusion criteria to take federal offenders While some funds have been secured, CSC will continue to seek permanent funding to implement the full Mental Health Strategy. CSC hosted an international mental health symposium on May 21 and 22, 2008, to discuss practical approaches to addressing mental health issues within the correctional system and advance our work in response to the recommendations of the Independent Panel.

32. 32 For more informationInternet: www.csc-scc.gc.ca Claude Tellier, Director, Community Mental Health and Partnerships Claude.Tellier@csc-scc,gc,ca Veronica Felizardo Senior Project Manager, Federal/Provincial/Territorial and Mental Health Partnerships Veronica.Felizardo@csc-scc.gc.ca