Development of Mental Health and Reintegration Services in the New Zealand Department of Corrections

Gilbert Azuela
Clinical Adviser, Mental Health and Reintegration Services, Department of Corrections

Author biography:
Gilbert Azuela is a Clinical Adviser at the New Zealand Department of Corrections, and part of the Mental Health and Reintegration Services (MHRS) team. He is responsible for the monitoring of key performance indicators and clinical quality standards of the MHRS programmes. Gilbert supports the successful implementation of these programmes across New Zealand’s prisons and community corrections sites.


Introduction

Mental health disorders occur globally and have a severe impact on people's well-being (Kessler, Aguilar-Gaxiola, Alonso, Chatterji, Lee, Ormel & Wang, 2009). In New Zealand, the prevalence of mental health disorders is comparable to the rest of the world, with approximately 20% of the population meeting the criteria of mild to severe mental health issues (Oakley Browne, Wells & Scott, 2006).

Psychiatric morbidity in New Zealand prisons is higher than in the general population. In particular, conditions such as psychosis, major depression, bipolar disorder, and substance misuse and dependence are more common amongst prisoners (Brinded, Simpson, Laidlaw, Fairley & Malcolm, 2001). The health needs of prisoners and offenders are multiple and overlapping, and there is often a correlation between mental health, substance misuse and abuse, and other co-morbid conditions (Williamson, 2007; Bowman, 2016).

In 2015, the Department of Corrections commissioned an investigative study into mental health disorders and co-morbid substance use disorders amongst prisoners. The study showed a higher prevalence of co-morbid disorders among prisoners compared to the general population (Indig, Gear & Wilhelm, 2016). These findings evidenced the high need for treatment options within prisons, and suggested that mental health services have a significant role to play in the care and support of prisoners. With the aim of developing mental health services, Corrections explored funding opportunities.

In mid-2016, Corrections secured funding of $14m to increase access to mental health and reintegration services for the prisoner and offender population. The proposal outlined four pilot initiatives that would be delivered over a two-year period:

  1. Improving Mental Health Service: mental health clinicians would be based in 16 prisons and four community corrections sites to increase mental health support to prisoners and offenders.
  2. Wrap around family/whānau support service for identified prisoners and offenders.
  3. Supported living service: transitional temporary community accommodation.
  4. Counsellors and social workers in women’s prisons.

Corrections sought interest from existing mental health service providers for added support in developing and delivering the services.

The four pilot services

1. Improving Mental Health Service

People presenting with mental health conditions are often seen in primary health care.  The provision of qualified mental health clinicians to deliver evidence-based interventions to people presenting with mild to moderate mental health needs was an identified need. Clinicians were expected to be registered nurses, psychologists, or occupational therapists with a specialist background in mental health screening, assessment and evidence-based interventions. These clinicians were to be placed in 15 prisons and four community corrections sites.  The number of prisons was expanded during implementation to include one additional prison that had been trialling a mental health service with an in-reach mental health clinician, making 16 prisons in total for this initiative[1].

The emphasis of the service is to support prisoners and offenders to stabilise their mental health so they can better manage their sentences, participate in and maximise the effectiveness of rehabilitation programmes, engage in employment opportunities and manage the transition between prison and the community.

This service has an additional training and education component aimed at increasing the mental health knowledge and awareness of Corrections staff.  This education component is an important facet of the service and includes supporting staff to understand the different presentations of people with mental health needs and useful techniques in managing people with mental health conditions. This education is delivered with the intention of increasing the capability and confidence of Corrections staff to work effectively with prisoners and offenders who present with mental health needs.

2. Wrap Around Family/Whānau Service

This service supports families/whānauof prisoners and offenders who currently engage with a mental health clinician through the Improving Mental Health Service. The Wrap Around Family/WhānauService (WAF) worker engages with that person’s family and links them with the necessary supports in the community. This service continues as the person transitions from prison to the community, and aims to improve the social, health and education outcomes of the whole whānau.

3. Supported Living Service

This service offers a 13 week transitional accommodation and support service for prisoners released to the Auckland and Hamilton area.  The released prisoner must meet criteria that include a mental health or cognitive impairment that impacts on their ability to function independently in the community, ongoing health and treatment needs, and high and complex reintegrative needs. This service is designed to assist people in the initial stage of leaving prison by linking them to existing community resources, helping them to socialise and actively engage with the community, and to secure permanent and stable accommodation, employment, health services and financial support.

4. Counsellors and Social Workers in Women’s Prisons

This service aims to improve female prisoners' wellbeing, reduce incidents of harm to self or others, and retain women’s positive relationships with families. This service provides access to professional counsellors and social workers to address female-specific needs around trauma, victimhood, and family. These professionals equip the women with a greater variety of skills to cope with their lives in prison and upon release.

Implementation of the initiatives across prison and community corrections sites

Corrections decided to directly recruit and employ the counsellors and social workers for the women’s prisons. This service commenced in November 2016 with one counsellor and one social worker per site, following an induction period that included Frontline Start[2] and a specific two-day “welcome to the new service”.  Guidelines to support practice were developed for the counsellors and social workers and their managers.  Referral pathways and treatment modalities were not specified to allow a service to develop that could respond to the varied and complex needs of the women.

In contrast, a decision was made to contract out the other three initiatives. In August 2016, the Request for Proposal (RFP) for IMH and WAF went out to market, while the supported living service was a tender by invitation as Corrections had experience in working with providers on similar supported accommodation services.

Corrections awarded contracts to five providers with extensive experience and expertise in delivering services to people with mental health needs. The table below represents the MHRS services delivered by region and provider.

Table 1. Contracted Providers of the New Zealand Department of Corrections MHRS

Providers
New Zealand Regions
MHRS
Improving Mental Health
Wrap around family/whānau
Supported Living
Emerge Aotearoa and Pillars
Northern
Central
PACT
Lower North
 
Rural Canterbury Primary Health Organisation (RCPHO) and WellSouth Primary Health Organisation (WSPHO)
Southern
 

The providers commenced their recruitment process following successful contract negotiations for 38 mental health clinicians and four WAF workers. However, there were challenges with recruitment over the four regions, in particular in the Northern and Central regions, and this resulted in an unanticipated delay to the start of some of the services.

The hiring of mental health clinicians was targeted to registered nurses, psychologists, social workers and occupational therapists. The focus was on employing clinicians with the ability to:

  • conduct comprehensive mental health assessments
  • formulate collaborative care plans
  • provide evidence-based interventions.

Mental health clinicians must:

  • have extensive mental health experience
  • belong to a registered body
  • have the ability to work collaboratively in a challenging environment.

All candidates had to be approved by Corrections to ensure their experience and skills matched contractual expectations. Corrections supported recruitment processes where possible.

In addition, the contracted provider began the search for appropriate housing to deliver the Supported Living service in Auckland and Hamilton. Securing appropriate housing introduced new challenges to the intent of the programme and ultimately Corrections was required to exclude some offenders (such as child sex offenders) in order to confirm housing in both regions. The Supported Living service began delivery in June 2017 in Auckland and in November 2017 in Hamilton. The service supports offenders to prepare for their exit from Corrections oversight, and transition into the wider community. It facilitates ongoing access to various services, including health, treatment, employment, education, housing, welfare and family/whānau reconnections.

In April 2017, the first of four planned induction workshops was held at national office in Wellington for the newly recruited clinicians, WAF workers, and support workers. The first part of the induction workshop was five days in duration, and had an emphasis on introducing provider staff to Corrections’ operations and to the MHRS operational processes and design.  Providers’ managers joined their staff for these workshops, where they were able to gain an understanding of how Corrections works, in order to support their staff as the services commenced.

This induction was followed by site orientation as part of a comprehensive introduction to the Corrections' environment.  Provider staff then returned to Wellington for the second part of the induction workshop. This workshop focused on reflections from their experience on site and aimed to forge valuable collegial relationships. When the induction was completed, the staff moved to their respective sites and began to deliver mental health services, WAF services and supported living services.

Multi-level collaboration between Corrections and providers

Building relationships and collaborative partnerships are important in developing and implementing mental health services (Magnabosco, 2006). The following were established to embed effective relationships between Corrections staff, their stakeholders, and the providers.

1. Mental Health and Reintegration governance board

The MHRS has an executive governance board responsible for monitoring performance and leading the direction of the services. This governance board consists of the chief executives and/or senior managers from the contracted providers and key people from Corrections. The governance board reviews key challenges and successes and ensures that the programmes’ intent and purpose remain in focus. The governance board reviews recommendations on current best practice and considers trends both nationally and internationally that may have an impact, positive or negative, on the delivery and outcomes of the services.

2. Regional clinical governance

Clinical governance supports the clinical quality in delivering mental health services. Corrections has MHRS clinical governance groups across the four regions: Northern, Central, Lower North, and Southern. The groups are led by the regional clinical director and include the MHRS clinical advisers, clinicians, WAF worker, provider managers, and, in some cases, other stakeholders e.g. forensic services who provide care across each region.  The regional groups meet separately each quarter and review clinical and service quality against the Improving Mental Health Quality Framework. Additionally, this meeting is the forum where serious and sentinels events are discussed and reviewed. The clinical governance groups discuss and find solutions for issues such as waitlists, care plans, appropriate treatments and interventions, collaboration between primary and secondary services, and the impact of the operational aspects of service delivery. Any high risk or difficult issues are escalated to the MHRS Steering Group.

3. MHRS Steering Group

The MHRS Steering Group was created to replace the Programme Governance Board, whose responsibility it was to oversee the service design and implementation. The Steering Group represents a variety of interests within Corrections, including quality and assurance, psychology, health and probation. The primary role of this group is to ensure that services meet objectives and deliver the projected benefits during the pilot phase. The Steering Group meets once a month to discuss reports from the clinical advisors on clinical performance and quality, with an emphasis on strategic clinical service development and safety. They also discuss operational and contractual matters with the senior adviser (contracts).

How are we going?

The social workers and counsellors commenced services in women’s prisons in November 2016. The other three pilot initiatives were introduced in April 2017. To date, these services have seen a high uptake through referrals, face-to-face sessions and education delivery (see Tables 2 and 3).

Table 2. Referrals, face-to-face hours and education hours of Improving Mental Health Service

 

Improving Mental Health

Referrals

Hours of Face-to-Face Time Delivered

Hours of Education Delivered

April 2017 - Jan 2018
Prisons
2,136
6,276
1,525
Community
588
1,715
720
Total
2,724
7,991
2,245

Table 3. Referrals, declines, and active clients of WAF, Supported Living, counsellors, and social workers

 
Counsellors
Nov 2016 – Jan 2018
Social Workers
Nov 2016 – Jan 2018
WAF
April 2017- Jan 2018
Supported Living
April 2017- Jan 2018
Referrals
715
570
61
61
Declines
0
0
0
30
Active
163
163
39
4

This quantitative data indicates that prisoners and offenders are able to access mental health services within prison and community corrections. The number of referrals reflects a steadily increasing trend. The number of education hours delivered to Corrections staff contributes to staff level of awareness and engagement to MHRS. It also suggests a complementary practice through relationship building between MHRS clinicians, custody staff, Corrections’ health teams, and forensic teams.

Positive outcomes for improving mental health

Personal stories that reflect the value of the services are collected regularly from all services since the programme commenced. Each month the mental health clinicians, social workers and counsellors provide a story of success to illustrate the impact and positive outcomes that clients are experiencing.

Twenty-seven year old male. Came to the service with depression and anxiety, and 14 years of P use. First time in prison, and was scared. He discussed his upbringing - having to watch his dad rape and beat his mum. Started taking P at 13, as it was “the only thing that made me feel warm”. Stated that being off the drugs and actually having someone to talk to and work with has helped him feel the best that he has in his life so far. He states that he has the motivation to keep himself on track when he is released.

(Mental Health Clinician - 01)

Man with social anxiety who always thought he was “dumb” and “a slow thinker”. Turns out he is a kinaesthetic learner and lost focus with traditional teaching methods. Today tells me that he doesn’t think he needs meds, and the work we’re doing together is really helpful. His self esteem is improving and he has gone from planning to live with mum on release and going back to his old life, to moving out and going to MIT and purposely not returning to his old life.

(Mental Health Clinician - 02)

I first met with Ms A, a 36 year old mother of four, at the end of January 2017. She had served 3.5 years of a 17 year, non parole sentence. She often experienced physical symptoms and complaints that most often had no explanation or real manifestation. Ms A’s hope for counselling on the first day we met was “not to feel so broken” and “to move forward”. Her grief at her separation from her four children and her long term sentence was overwhelming and close to consuming her completely. The bulk of the work we did together was around her profound grief and trauma at the multiple losses she had experienced throughout her life.  After many months of treatment she had the following statement to make: “I am no longer overwhelmed when things go wrong. I just know I can get through crap times because I have survived so much in the past. I have a new hope for the future and a restored belief in myself…I just don’t let crap weigh me down anymore. I have my mana back!”

(Counsellor - 01)

Increased motivation, improved self-esteem, self-discovery of their learning style, and regaining self trust are just few of the many positive impacts that prisoners and offenders who are receiving MHRS have identified.

Looking ahead

Corrections is committed to ensuring the successful implementation and development of MHRS and we are actively identifying challenges and barriers and addressing them as the pilot progresses. We are monitoring opportunities to develop the services through the following structured processes and also through informal meetings with lead managers in prisons and community corrections sites to identify programme-wide development needs and site-specific barriers and opportunities. This strategy will ensure that services can be delivered as core business solutions once the pilot has been completed.

1. Programme evaluation

The MHRS evaluation has two phases. The first phase evaluated the programme’s operational processes, including fidelity to service design, uptake of referrals, and successes and challenges of the programme’s delivery. Results of the first evaluation are reported in Sonia Barnes’ article in this journal.

The second part of the evaluation will have a strong focus on outcomes to determine if the objectives of the MHRS programmes are being achieved.  Outcomes expected include improving continuity of mental health care for prisoners transitioning from prison to community, improving timely access to mental health treatment, and improving individuals’ mental health stability in prison and community corrections. The outcome evaluation will also assess reintegration success, reduction of incidents of dangerous and harmful behaviours, level of participation and completion of rehabilitative programmes, engagement with family and community supports, employment outcomes, and reduction of time on benefits. In addition, the capability of Corrections’ staff to manage offenders with mental health needs will be evaluated.

2. MHRS Service Development Working Group

The MHRS Service Development Working Group was formed after the MHRS combined workshop in October 2017. At this workshop the operational managers from the contracted service providers offered their time and expertise to help ensure the quality of the services and work alongside Corrections in a collaborative and proactive manner. The MHRS Service Development Working Group meets monthly to identify and agree service development needs, e.g. a review of the assessment tool agreed at the beginning of the pilot.

3. Quality frameworks

Measuring the quality of the services is critical to achieving desired outcomes and supporting continuous improvement.  Quality frameworks for each element of the programme have been developed with the Improving Mental Health Service framework.  The quality framework for the mental health clinicians has a three stage approach, with self assessment, manager review and review by the MHRS clinical advisors all in place.

4. Practice model of care

The primary care model is the foundation of prison health services (Møller, Stӧver, Jürgens , Gatherer, & Nikogosian, 2007). However, when there is an unmet health need, a review of the primary care model is required (Warr & Hoyle, 2007; Williamson, 2007). The need for a practice model of care specific to mental health is paramount to support the mental health clinicians and for Corrections to deliver efficient and effective mental health services.  The model of care will undergo further development as the Intervention and Support Project (see article by Love & Rogers ) model of care takes shape to ensure referral pathways are clear, and services are integrated.

Conclusion

The establishment of mental health services in prisons and community corrections is fundamental in providing a quality healthcare service to prisoners and offenders. The four MHRS pilot initiatives: improving mental health, wrap around family/whānau, supported living and social workers and counsellors are being embedded by the New Zealand Department of Corrections as part of healthcare delivery. These services have multiple successes and positive impacts for prisoners, offenders and Corrections staff. The MHRS plays a significant role in supporting individuals’ wellbeing so they can make better life choices and engage more meaningfully in rehabilitation.

References

Bowman, J. (2016). Comorbid substance use disorders and mental health disorders among New Zealand prisoners. Practice, The New Zealand Corrections Journal, Vol. 4, Issue 1, 15-20. Department of Corrections.

Brinded P., Simpson A., Laidlaw T., Fairley N., & Malcolm F. (2001). Prevalence of psychiatric disorders in New Zealand prisons: a national study. Australian & New Zealand Journal of Psychiatry, Vol 35, Issue 2, pp. 166 – 173,

Indig D, Gear C, & Wilhelm K. (2016). Comorbid substance use disorders and mental health disorders among New Zealand prisoners. New Zealand Department of Corrections, Wellington. Accessed 18 September 2017

Kessler, R. C., Aguilar-Gaxiola, S., Alonso, J., Chatterji, S., Lee, S., Ormel, J., & Wang, P. S. (2009). The global burden of mental disorders: an update from the WHO World Mental Health (WMH) surveys. Epidemiology and Psychiatric Sciences, 18(1), 23-33. doi: https://doi.org/10.1017/S1121189X00001421

Magnabosco, J. L. (2006). Innovations in mental health services implementation: A report on state-level data from the U.S. Evidence-Based Practices Project. Implementation Science, 1, 13–22.

Oakley Browne M.A., Wells J.E., & Scott K.M. (Eds). 2006. Te Rau Hinengaro: The New Zealand Mental Health Survey. Wellington: Ministry of Health. Accessed 18 September 2017

Møller, L., Stover, H., Jürgens , R., Gatherer, A., & Nikogosian, H. (Eds.). (2007). Health in prisons - Europe. A WHO guide to the essentials in prison health. Copenhagen, Denmark: World Health Organization Regional Office for Europe. Accessed 18 September 2017

Warr, J., & Hoyle, C. (2007). Women’s mental health in prison: Developing an integrated care pathway. Mental Health Practice, 11, 24–27.

Williamson, M. (2007). Primary care for offenders: What are the issues and what is to be done? Quality in Primary Care, 15, 301–305.