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 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

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

Incarceration Rate Rate per 100,000 adult population, 2010 *Numbers include federal, provincial and territorial incarceration rate (Source: Statistic Canada)

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

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 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 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.

Warrant Expiry Date Intake Throughout incarceration 6-9 months prior to anticipated release Release to the community Mental Health Initiatives, Public Health and Regional Treatment Centres IMHC *CoMHISS CoMHISS: Computerized Mental Health Intake Screening System IMHC: Institutional Mental Health Care CMHC: Community Mental Health Care Intermediate Mental Health Care (currently unfunded) IMHC Primary Care Training Regional Treatment Centres Public Health Discharge planning (physical health) CMHC Discharge planning (mental health) Training CMHC Mental Health Specialists Contracts (psychiatrists and community agencies) Training Community Psychology Community Partnerships 9

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’s Mental Health Strategy: Institutional Mental Health Care (IMHC) 11  Computerized Mental Health Intake Screening System (CoMHISS)  Mental health screening to identify offenders with mental health needs at intake in order to assist in identifying offenders  Given to all offenders at intake in order to assist in identifying offenders who show symptoms associated with possible mental health problems who show symptoms associated with possible mental health problems that require follow-up assessment by a mental health professional that require follow-up assessment by a mental health professional  Primary Mental Health Care Team is available in all mainstream institutions. institutions.  teams employ a multi-disciplinary approach focusing on mental health promotion, prevention, early intervention, treatment, support, and continuing care

CSC’s Mental Health Strategy: IMHC Results CoMHISS As of March 2011:  Approximately 8600 men offenders and 500 women offenders have completed CoMHISS  Automatic referrals are made to Psychology for offenders that exceed cut-offs  System “automatically” produces statistical reports at institutional, regional and national levels  Mental health data available for research and reporting 12

CSC’s Mental Health Strategy: Throughout Incarceration IMHC  Primary Care  Training  Mental Health services for those identified with mental health needs or in crisis periods  Offenders will be identified at screening or can be referred anytime by institutional staff Regional Treatment Centres  Specialized mental health treatment to offenders with mental health needs who are in an acute state or needing long term care Intermediate Mental Health Care  Included in strategy  Intended for offenders whose mental health needs are not so severe as to require care in a psychiatric facility  Implemented as a pilot at Kingston Penitentiary (Ontario) 13

CSC’s Mental Health Strategy: Throughout Incarceration Primary Mental Health Care As of March 2010:  64 front-line positions staffed to establish primary mental health teams  17 contracts in place (psychiatry and other mental health services) From April 2010 to March 2011:  9200 offenders received mental health services  93.2% male  6.8% female  17.5% Aboriginal Training As of March 2011, CSC has provided 4300 institutional staff mental health training:  3300 correctional officers  400 nurses  300 parole officers/program officers Results (IMHC) 14

6-9 months prior to anticipated release Public Health  Discharge planning (physical health)  Discharge planning by institutional nurse regarding health services follow-up in the community and discharge medication  Given to all offenders  Offenders are seen 6-9 months and 3 weeks prior to release. CMHC  Discharge planning (mental health)  Training*  Comprehensive discharge planning to prepare offenders with mental health needs for their return to the community  Referred by Institutional Parole Officers 9 months prior to release  Elaboration on next slide 15

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

CSC’s Mental Health Strategy: CMHC CMHC Mental Health Specialists Contracts (psychiatrists and community agencies) Training Community Psychologists Results As of March 2011 CSC has trained:  Approximately 1265 community case management staff (e.g. parole, community correctional centre and halfway house staff)  Approximately 350 staff working in the community have received a one day follow-up training on FASD and/or Effective Intervention Strategies  Risk of suspension and revocation in the group who received Community Mental Health Specialist Services was 34% and 59% lower, respectively than the comparison group (CMHC Evaluation)  As of March 2011, approximately 2600 unique offenders have received Community Mental Health Specialist Services and approximately 750 unique offenders have received a Clinical Discharge Planning service. 17

Warrant Expiry Date Community Partnerships  Transfer of care to provincial health services  Referred by Community Mental Health Specialists prior to Warrant Expiry Date Results Community Capacity Building  Since April 2007 to March 2011, CMHC staff have made approximately contacts with individuals and agencies  CMHC staff have communicated with approximately 5400 different individuals and agencies. National Corrections Mental Health Strategy Heads of Corrections established an FPT working group on mental health whose mandate is to develop a Strategy in consultation and collaboration with the Mental Health Commission of Canada 18

19 OFFENDER Institutional Parole Officer Institutional Mental Health Team Clinical Discharge Planning Services Community Resources Meaningful Occupation Family/Support Network Leisure/Social Activities Community Mental Health Services Community Parole Officer

Mental Health Strategy for Corrections in Canada Background 20 Federal/Provincial/Territorial Working Group established in November 2008 Mandated to develop a Mental Health Strategy for Corrections in Canada Strategy and Action Plan approved in June 2011

Mental Health Strategy for Corrections in Canada VISION 21 Building Wellness along the Continuum of Care: Connecting Services Individuals in the corrections system experiencing mental health problems and/or mental illnesses will have timely access to essential services and supports to achieve their best possible mental health and well-being. A focus on continuity of care will enhance the effectiveness of services accessed prior to, during and after being in the care and custody of a corrections system. This will improve individual health outcomes and ultimately contribute to safe communities.

22 Mental Health Strategy for Corrections in Canada Key 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.

Mental Health Strategy for Corrections in Canada Key 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

Mental Health Strategy for Corrections in Canada Key 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

Mental Health Strategy for Corrections in Canada Key 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

Mental Health Strategy for Corrections in Canada Key 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

Mental Health Strategy for Corrections in Canada Strategic 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

Mental Health Strategy for Corrections in Canada Strategic 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 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

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.

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

32 For more information Internet: Claude Tellier, Director, Community Mental Health and Partnerships Veronica Felizardo Senior Project Manager, Federal/Provincial/Territorial and Mental Health Partnerships