VOL. 32, NO. 1

A Continuum of Care

CSC Launches a Comprehensive Mental Health Strategy

What happens when the criminal justice system becomes, by default, the health care system? For many offenders with mental health disorders, this is what has been happening in Canada over the past 10 years, due in large part to gaps in community-based mental health services.

In 1997, seven percent of male offenders coming into the federal correctional system were diagnosed as having a mental health problem. By 2007, the proportion had jumped to one in eight—a 71 percent increase. A similar rate of increase has been seen for women offenders, at least 25 percent of whom are now diagnosed as having mental health problems at the time they're admitted to federal institutions.

"In our communities, we have significant mental health needs that are not being met," says Dr. Françoise Bouchard, CSC's Director General of Health Services. "The result is a population that cannot adjust to society. Often, they end up breaking the law and being sent to prison."

	Dr. Françoise Bouchard, Director General of Health Services, CSC

The Challenge

But Dr. Bouchard notes that, once incarcerated, many offenders with mental health problems fail to receive the treatment they need because the system is not equipped to cope with the sheer numbers.

"Nevertheless, we have a legal obligation to provide essential health services to a professional standard for all offenders under our jurisdiction," she emphasizes.

"The other important element is that most of these offenders are released back into the community once they serve their sentence. If their mental health problems have not been addressed, either in the institution or in the community, they are more likely to breach their release conditions and end up back in prison."

Support for Change

A way out of this 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 a wide-ranging, five-pronged mental health strategy and substantial funding.

The strategy, developed by Health Services in consultation with the regions, proposes a continuum of mental health services, from the time offenders arrive at an institution, to their release into the community.

Intake Screening and Assessment

The first element of the mental health strategy will involve voluntary screening of all offenders when they arrive at a regional reception centre. At present, the centres don't have the means to administer a battery of psychological tests to all new inmates. But this will soon change with the introduction of a standardized approach to screening at intake. (See article on p. 6.)

"Often, some people, if not being identified at intake, end up later being placed in segregation or in the special handling unit because of their underlying mental health condition," explains Dr. Bouchard. "Now, with the computerized mental health screening tool, we will have a way of assessing everyone who comes in, and be able to intervene earlier, so that offenders do not suffer needlessly from their illness and are better able to pursue their correctional plan."

Increased safety for prison staff, volunteers and other inmates is another expected benefit, she adds.

Systematic computerized screening is also expected to yield more accurate data on overall mental health needs, helping CSC make system-wide programming decisions.

Primary Care

The second element of the strategy is primary, or basic, mental health care in each institution. In principle, all CSC institutions are supposed to have mental health teams comprised of psychologists, psychiatric nurses, social workers and other professionals, such as psychiatrists or occupational therapists.

"The reality," says Dr. Bouchard, "is that we don't have these teams functioning on a regular basis in all our institutions because the staff is overwhelmed with crisis management. And often, our psychologists are busy with risk assessments — managing the risk that offenders present as opposed to their mental health condition."

This, too, will change with the creation of full-fledged mental health teams in a number of maximum and medium-security institutions.

"We don't want a situation where the only way one can access mental health services is by being referred to a treatment centre," says Dr. Bouchard. "We want to have the services right in the institution, as close as possible to the offender."

Making this happen will require training for the newly constituted teams, to orient them to best practices in correctional mental health. Correctional officers will also be trained to better understand signs and symptoms of mental illness so they can better interact with the inmates and know the signs whereby the best response would be a referral to the mental health team.

Intermediate Care

The third component of the strategy recognizes the fact that some mentally disordered offenders, while not requiring hospitalization in a treatment centre, need more structure than that offered by a regular institution. They need an accommodation 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 offenders with mental health disorders are mixed in with the general prison population, which exposes them to certain risks and does not allow the provision of more structured interventions," says Dr. Bouchard. "So, in each region, we're planning to establish intermediate health care units in some of our institutions."

Intensive Care — Regional Treatment Centres

The Regional Treatment Centres, designed to provide intensive care for offenders with acute mental disorders, such as schizophrenia, will also receive new resources under the mental health strategy, to help all five facilities either earn or maintain their accreditation as psychiatric hospitals, with standards comparable to those found in the community.

"In many cases, the staff-to-patient ratio is not up to par," says Dr. Bouchard. "So we need to standardize that, along with ensuring proper training of staff, consistent standards of care, and use of force that is adapted to mentally ill offenders."

With comprehensive screening of all offenders coming into the correctional system, CSC will also be better able to develop uniform criteria for admission to the treatment centres.

"We have never established standardized admission criteria," says Jane Laishes, Senior Manager, Mental Health Services, CSC national headquarters. "We need something that's consistent right across the country, so that an inmate can't say, 'Well, I was able to get that treatment out West and now I'm in Ontario and it's not available.'"

Transitional Care — Back into the Community

The fifth element of the strategy, CSC's Community Mental Health Initiative, is well under way, having been launched in 2005, with nearly $30 million in funding for a five-year period. (See Let's Talk, Vol. 30, No. 4 and this issue, p. 19.)

"What we had observed," says Ms. Laishes, "is that offenders who had mental health problems were the least likely to be released on parole. Often, we were unable to ensure continuity of care once they left the institution, which meant that these offenders would be on their own, with no community support."

"Better discharge planning, starting nine months before the offender's release date, along with specialized mental health staff in selected district parole offices, should make for a smoother and safer transition back into the community," says Ms. Laishes. The other key element will be CSC partnering with community service providers, to ensure mentally ill offenders continue to get the help they need when they are no longer on parole.

"Hopefully, we will end up with offenders who follow their treatment plan and there will be fewer problems in terms of breach of parole or behavioural dysfunction and safety issues within the community," says Ms. Laishes.

Setting Priorities: A Two-year Pilot

In 2006, Dr. Bouchard and her team consulted with the regions on the first four components of the strategy, to see if it reflected their needs. There was wide endorsement, and general agreement that the initial focus should be on intake assessment and primary mental health care.

CSC now has $21 million in funding for the next two years. The money will be directed towards the computerized screening project, recruitment, training, provision of services by primary care mental health teams, training correctional officers and improving in-patient care at the treatment centres.

	Jane Laishes, Senior Manager, Mental Health Services, CSC National Headquarters

With universal screening, it's estimated that up to 25 percent of new inmates will be flagged for further assessment and follow-up. Dr. Bouchard is confident that the organization will be able to address the predicted increase in demand for services.

"We have the resources. What we need to change now is our recognition of the problem and the way we treat mentally ill offenders," she says. "The mental health strategy has given us a direction for quite a few years. It shows we can do something right and do it well. Ultimately, everybody benefits if we can reduce the human suffering caused by mental illness — our staff and volunteers, offenders and their families, and the community at large." ♦