State of mind: mental health services in New Zealand prisons
Policy Adviser, Department of Corrections
Policy Adviser, Department of Corrections
Kate and Josh are advisers in the Strategic Policy Team. Before joining Policy, they worked as probation officers in the fast-paced Lower Hutt Service Centre. Kate and Josh enjoy drawing on their life, academic and frontline experiences in the challenging and dynamic area of Corrections policy.
The scale of the challenge
The provision of mental health services is a challenging area of public policy as demand is increasing, issues are complex, and service provision is often costly. Over time, the shift away from institutional facilities to non-residential community based care has brought more people with mental health needs into contact with the justice system, with significant consequences for the Department of Corrections and other justice sector agencies.
Research conducted in New Zealand on behalf of Corrections by Indig, Gear, & Wilhelm (2016) has highlighted the extent and inter-connectedness of mental health issues in the prison population. Offenders have considerably more issues with both mental health and substance abuse disorders than the general population, with 91% of prisoners having been diagnosed with either a mental health or substance use disorder over their lifetime. Indig et al (2016) found that over the previous 12 month period:
- 62% of prisoners had been diagnosed with either a mental health or substance abuse disorder – a rate three times higher than the general population.
- 14% had thought about or attempted suicide – a rate four times higher than the general population.
- 20% had experienced two or more identified mental health or substance use disorders in the previous 12 months.
Comparing these findings from Indig et al (2016) against research commissioned by the Department in 1999 (Simpson, Brinded, Laidlaw, Fairley, & Malcolm) shows that rates of diagnosis are increasing across all mental health and substance disorder categories and levels of comorbid and complex disorders are high, requiring a multi-disciplinary response.
These trends are common to most OECD corrections systems and there is a growing recognition that new ethical and practical responses are needed. This article considers how New Zealand’s corrections system is responding to this challenge across the spectrum of mental health needs, from moderate through to acute.
How mental health services are provided in New Zealand
In New Zealand, primary health care in the community is provided by or through local District Health Boards. In prisons, Corrections provides all primary health services, including mental health services. As prisoners are in custody, the Department must respond to all health concerns, regardless of diagnosis or eligibility criteria. Increasingly, Corrections is managing long-serving prisoners, who present with increasingly complex physical and mental health needs.
The research from Indig et al (2016) has allowed Corrections to analyse the changing nature of mental health issues present amongst the prison population. As a result, the Department has decided to focus on providing increased services to these individuals.
A number of services are currently delivered to prisoners to support their mental health. These include screening for mental health needs on arrival, with additional assessments applied to those in distress or at risk of self harm. Corrections contracts clinicians at all prisons to work directly with prisoners who have moderate mental health needs. Clinicians focus on stabilising mental health issues within the prison environment. Prisoners also receive assistance with reintegration planning and the development of coping strategies once released to the community. Additionally, in some prisons clinicians also work with Corrections staff to recognise, manage and support prisoners experiencing mental health issues.
Addressing moderate mental health needs
In June 2016, the Department received $14 million from the Justice Sector Fund to pilot comprehensive and integrated mental health services to prisoners and community offenders. This will be invested in services for individuals with moderate mental health needs, with the aim of addressing mental health challenges before they escalate into more acute behaviours. New or supplemented services will be available across the prison estate and in four pilot Community Corrections districts over a two-year trial period. Corrections is negotiating these contracts with service providers. The intention is to increase opportunities for offenders to access consistent, high-quality mental health treatment and support.
The new services will operate under a continuity of care model, supporting prisoners throughout their time under Corrections’ management and during their reintegration into the community. Contracted providers will work directly with individuals to stabilise and address their mental health needs, ensuring they can manage within their current environment (in prison or in the community). Support will be provided through brief or crisis interventions and education around coping strategies – techniques which have been found to be highly beneficial engagement models (Taylor, 2009).
Alongside the significant rates of mental health issues among prisoners generally, Indig et al (2016) identified a key area of need for women: over half of women prisoners have a lifetime diagnosis of post traumatic stress disorder, which is four times the rate experienced by the general public.
To address this issue, Corrections is employing social workers and counsellors in women’s prisons, supporting women to manage their trauma related needs and providing practical assistance relating to family and parenting issues. It is intended that engaging with social workers and counsellors will provide opportunities for women in prison to develop resilience, establish practical tools and strategies for managing their complex situations, and improve their own responses to external barriers.
Corrections’ investment in enhanced mental health services and support for women prisoners aims to reduce barriers to engaging in rehabilitative programmes and reintegrative opportunities, contributing to better outcomes in the longer term.
The purpose of the community pilot is providing support to released prisoners and community offenders to access and engage with their local community mental health services. Mental health and addiction issues cannot be addressed in isolation; they are broader components of overall health and their effective treatment requires an integrated response from Corrections and community health agencies.
Compton et al (2003) found that mental health issues are one of the biggest predictors of poor outcomes in alcohol and drug treatment outcomes. Unsupported mental health issues are also linked to poor engagement with education and employment (Mental Health Commission 1999). Corrections intends that the new mental health services will support better overall health and wellbeing, leading to increased engagement in employment, education, and rehabilitation.
Addressing acute mental health needs
Addressing the mental health needs of offenders in prison and in the community at an early stage may help prevent escalation of their needs. This is vital to support offenders to remain in the community. Many offenders have acute, complex, or high-risk mental health issues, and therefore require a comprehensive response from prison mental health services.
This is a challenge for many jurisdictions. The intersection of mental health and correctional responses is complex. International models provide examples of different service delivery options for complex mental health issues, however, demand and resources continue to be a barrier.
New Zealand model
In New Zealand, Corrections is responsible for providing mental health services as part of primary health care to prisoners. Secondary and acute services are provided by regional forensic mental health services (that are part of District Health Boards), and prisoners are eligible for the same services as the general population.
Prisoners are particularly complex mental health service users. As discussed, they have higher rates and complexity of mental health needs than the general population. However, their access to services can be limited. This is the case for two key reasons:
- Regional forensic mental health inpatient beds are in high demand, and members of the general population may receive higher priority. This is partly because prisoners may be perceived to be in a physically safe and secure environment, while members of the public may have more complex and urgent circumstances, such as homelessness, in addition to their mental health needs.
- Many prisoners have personality disorders, the treatment of which is complex and problematic in many jurisdictions (UK Ministry of Justice, 2011).
‘At-risk’ units are used to manage prisoners who are at risk of or are actively self-harming. However, these units are not equipped to treat or respond to the underlying causes of self-harming or suicidal behaviour (Harris, 2015). Instead, they are about managing and preventing self harm and suicide by close monitoring of prisoners. People displaying the same acute mental health needs while in hospital care would generally be managed differently (Human Rights Commission, 2011).
Addressing the scale and complexity of at-risk unit admissions has become a priority for Corrections. Since 2013, additional support has been provided to prisoners experiencing mental distress at three pilot prisons. This has resulted in a reduction in the number of admissions and length of time spent at the at-risk units. Corrections is investing in expanding this support to all sites to ensure the mental health needs of prisoners are appropriately met.
In Canada, the federal Correctional Service Canada (CSC) is responsible for the delivery of essential health care to prisoners (CSC, 2014). Demand for psychiatric care and treatment is steadily increasing, which is putting pressure on the allocation of specialist beds. The CSC is proposing to address the pressure on specialist beds by increasing the availability of intermediate care facilities seemingly with the intention of managing need at an earlier level and to prevent escalation. Intermediate care facilities provide for prisoners who either do not require, or do not consent to hospital admission and whose needs exceed the services available in mainstream prisons. In its 2014 – 15 Annual Report, the Office of the Correctional Investigator noted its concern that the CSC was potentially underestimating the demand for both acute psychiatric care and intermediate care beds by 50% (Sapers, 2015). This highlights the challenges of appropriate resource allocation for groups who have high needs.
In Victoria, Australia, Forensicare (a statutory body set up to provide, promote and assist in the provision of forensic mental health) delivers specialist mental health services at prisons under a contract arrangement with the Department of Justice. These services include assessments upon reception, acute units within prisons, and outpatient treatment (Forensicare, n.d.). Forensicare provides clinical services that span the mental health and justice sectors, and claims this as a unique strength, in having scope and expertise in delivering forensic mental health services. The contracting arrangement with the Department of Justice seems to ensure that issues over eligibility and availability do not arise, as treatment by Forensicare in prisons is not linked to the demand for services from the general population but is reserved solely for prisoners.
Staff can be deeply affected by working with people in crisis, more so when crises extend for significant periods of time. The prison environment is complex, and staff resilience can be tested when working with prisoners displaying a range of behaviours from anxious, withdrawn, or depressed through to aggressive, self-harming, manic, or suicidal. Dealing with this range of behaviour is challenging and can have long-lasting consequences on the ways in which staff are able to interact with prisoners, in turn affecting both staff and prisoner welfare.
The Department has a programme of work to strengthen custodial knowledge and practice around mental health. The provision of training and supervision for staff working with prisoners with mental health and substance abuse needs will lead to more holistic offender management practices and increased capacity and capability within our workforce.
The Canadian federal system, and the Victorian system, both offer an alternative model for supporting prisoners with complex mental health needs. Under any system, support must still be available for all levels of need.
Providing support for complex and acute cases presents challenges in a prison environment, but is necessary to improve wellbeing, safety, and rehabilitation outcomes. Our investment in mental health care and support is intended to reduce the escalation of mental health needs, and ideally – over time – reduce the number of prisoners who require intensive mental health support.
Prisoners in New Zealand are eligible for the same health services and care they would receive in the community. Providing equivalent services requires prison and health agencies to share resources, staff, expertise, and facilities. We must aim to ensure that wherever a person experiencing crisis happens to be located – prison, community, or mental health facility – they receive the appropriate level of care, while avoiding duplication. This is both a practical and an ethical consideration.
Agencies are committed to making changes in mental health services to ensure the best outcome for service users. An example of this commitment is the new Police-led working group undertaking a whole of sector “gap analysis” which will investigate access to mental health care and support for people in contact with justice agencies, and identify where and when appropriate interventions should take place. Implementing any significant changes to treatment for mental health will require buy in from all parties, and there is a need to avoid duplication.
New Zealand needs to be open to the possibility of doing things differently, focusing on designing services that are evidence-based and will provide effective and appropriate treatment. In the context of a growing prison population and estate, we must think about the future of the prison environment, and the most effective way to ensure access to care and support for those under Corrections’ management.
Compton III, W. M., Cottler, L. B., Jacobs, J. L., Ben-Abdallah, A., & Spitznagel, E. L. (2003) The role of psychiatric disorders in predicting drug dependence treatment outcomes. American Journal of Psychiatry, 160(5), 890-895.
Correctional Service Canada. (2014). Health Services. Retrieved 1 September, 2016, from http://www.csc-scc.gc.ca/health/index-eng.shtml
Forensicare. (n.d.). Prison Services. Retrieved September 01, 2016, from http://www.forensicare.vic.gov.au/pagetransfer.aspx
Harris, A. (2015). Care-Oriented Practice in At-Risk Units: Risks, Realities, and the Role of Multi-Disciplinary Teams. Retrieved September 1, 2016, from http://researcharchive.vuw.ac.nz/xmlui/bitstream/handle/10063/4997/thesis.pdf?sequence=7
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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
Mental Health Commission (1999) Employment and Mental Health – issues and opportunities. A discussion paper. Mental Health Commission.
Sapers, H. (2015, June). Annual Report of the Office of the Correctional Investigator. Retrieved September 1, 2016, from http://www.oci-bec.gc.ca/cnt/rpt/pdf/annrpt/annrpt20142015-eng.pdf
Simpson, A., Brinded, P., Laidlaw, T., Fairley, N., & Malcolm, F. (1999) The National Study of Psychiatric Morbidity in New Zealand Prisons. Department of Corrections
Taylor, S. (2009). Mental Health Brief Intervention: Does It Work? An Evaluation of Practice. Retrieved September 2016 from: http://www.tepou.co.nz/assets/pdf/Mental%20Health%20Brief%20Intervention%20(Taylor,%202009).pdf
United Kingdom Ministry of Justice National Offender Management Service (2011, January). Working with personality disordered offenders: a practitioners guide. Retrieved September 2016 from: https://www.justice.gov.uk/downloads/offenders/mentally-disordered-offenders/working-with-personality-disordered-offenders.pdf