Transforming intervention and support for at-risk prisoners

Deborah Alleyne
Regional Director Practice Delivery (Southern Region), Department of Corrections

Author biography:

Deborah has worked for Corrections for the past 11 years, initially in health leadership roles. Her professional background is in mental health nursing, and she has a Masters of Health Sciences (Nursing). Before coming to Corrections, she was Nurse Practice Consultant for Forensic Psychiatric Services with the Canterbury District Health Board.


Prisoners have significant mental health needs that place them at risk of self-harm and suicide, and act as a barrier to engagement in rehabilitation that reduces their risk of re-offending. The Department of Corrections has committed to transforming the way we manage prisoners who are at risk of self-harm and suicide. We will establish multi-disciplinary teams that will include psychologists, occupational therapists, mental health clinicians, social workers and cultural workers. These teams will provide earlier assessments, develop individualised plans and provide therapeutic interventions and support. Our new approach will be flexible to prisoners’ changing needs. We will do everything we can to improve people’s overall wellbeing so they can engage in activities aimed at helping them stop offending.

Executive summary

The Department of Corrections (Corrections) is responsible for managing a prisoner population that presents an increased risk of suicide and self-harm. High rates of mental illness, dysfunctional personal backgrounds, and the experience of prison itself, can all increase risk.

A preliminary review shows that no single model of care has significantly reduced these risks. However, a number of elements can individually support improved outcomes. These elements could make a more substantial impact if they were implemented collectively. The elements are reflected in the following six best practice themes:

  • Workforce development
  • Screening
  • Multi-disciplinary teams
  • Social connections
  • Improved physical environments
  • Prison culture.

Corrections will develop a new model of care which incorporates these six themes. The approach consists of three focus areas: improved identification and assessment of prisoners at risk of self-harm, integrated intervention and support in the wider prison environment, and the establishment of new Intervention and Support Units.


Mental illness in New Zealand prisons

International and New Zealand literature highlights that prisoners have a higher prevalence of mental illness than the general population:

  • A 1999 co-morbidity study found that up to 70% of New Zealand’s prisoners had drug and/or alcohol problems. A significant proportion also had various mental health issues, particularly major depression, post-traumatic stress disorder, schizophrenia, and personality disorder (Simpson et al, 1999).
  • A 2015 study of prisoner substance use and mental health disorders, found 91% of those assessed had been diagnosed with a substance use or mental health disorder over their lifetime. This was three times higher than the general population (Indig et al, 2016).
  • From 1 July 2010 to 30 June 2016, 39 prisoners took their own lives in New Zealand prisons. In 2015/16, 11 prisoners committed suicide, a rate  of 118 per 100,000, which is approximately ten times the suicide rate for the community1.

Due to these high rates of mental health issues among prisoners, Corrections is managing more people with mental illness than any other institution in New Zealand.

At-Risk Units

At-Risk Units (ARU) were established in New Zealand prisons to provide a safe environment to accommodate prisoners who are at risk of self-harm. In 2015/16, 3,088 prisoners were placed in ARUs on 4,281 occasions. The average length of stay was seven days. Prisoners are placed in ARUs for various reasons, including:

  • significant mental health or behavioural disturbance
  • active self-harm
  • alcohol or drug detoxification
  • anxiety related to first time in prison
  • medical observation
  • hunger strike
  • inability to complete reception assessment due to language barriers or disability.

Corrections works with external agencies to manage at-risk prisoners, in particular the District Health Board Regional Forensic Mental Health Services (RFMHS). RFMHS have responsibility for treating prisoners with severe mental health needs who meet their criteria, which includes providing inpatient beds in facilities such as the Mason Clinic.

Preliminary review

New Zealand is not alone in having high rates of prisoner self-harm. A direct comparison of suicide rates with overseas correctional jurisdictions is difficult however, prisoners generally have a significantly higher rate of self-harm than the general population (Willis et al, 2016; Howard League 2016; WHO, 2007).

Prisoner risk factors

The World Health Organisation describes prisons as “repositories for vulnerable groups that are traditionally among the highest risk for suicide”. Risk factors for suicide or self-harm are over-represented in the prisoner population. These factors include:

  • being young and male
  • under the influence of, or withdrawing from, substances
  • history of mental illness
  • previous self-harming
  • unstable personal background
  • having exposure to recent adverse life events (WHO, 2007).

Risk factors related to being in prison are also identified, including:

  • remand status
  • early days in custody
  • being segregated
  • violent offending, particularly domestic violence (Willis et al, 2016; Prisons and Probation Ombudsman (PPO) for England and Wales 2015; Weinrath et al, 2012; Power & Riley, 2010; WHO, 2007).

The prison environment may also contribute to heightened risk, including factors such as:

  • isolation from support networks
  • the quality of prisoner/staff and prisoner/prisoner relationships
  • the degree of order or disorder in the prison
  • prisoner numbers
  • the impact of transfers
  • access to meaningful activity (PPO for England and Wales, 2015; Camilleri et al, 1999).

Prisoners who incur debts to other prisoners, or are subject to threats or violence, may be at increased risk. These prisoners may deliberately self-harm or attempt suicide with the intention of being moved to another location. Staff often view this behaviour as manipulative, however it may be symptomatic of a level of distress or ineffective coping skills that may lead to successful suicide or serious injury (PPO for England and Wales, 2015; Office of the Correctional Investigator, 2014; WHO 2007; Camilleri 1999).

While this broad range of factors has been identified, there is limited understanding of why some prisoners choose to self-harm and others do not. This final part of the puzzle may lie in the level of resilience of individuals. A sense of hopelessness is a feature amongst prisoners who do self-harm and, in combination with other stressors, may be the trigger to act (Power & Riley, 2010; Camilleri et al, 1999).

Research in other fields is also relevant to correctional settings. The New Zealand Police reported 10 suicides in custody during the period 2000 to 2010. They found similar risk characteristics as in correctional settings, and also acknowledged the challenge of determining who was at greatest risk when so many presented with multiple risk factors (Independent Police Complaints Authority, 2012). They also noted that an initiative in Police stations to provide immediate access to mental health professionals had significant positive impacts.

Mental health sector

Inpatient mental health units also contain people who are at high risk of self-harm and suicide, and there are parallels in the way risk has been managed. Historically, mental health units have used restraint and seclusion (segregation) as treatment options; however, research has demonstrated that these interventions actually increase risk for people who are already experiencing mental health issues because they traumatise or re-traumatise those who have been victims of past violence (Royal Australian & New Zealand College of Psychiatrists (RANZCP) 2016).

In response to this research, the New Zealand mental health sector is implementing a trauma-informed practice based model, the Six Core Strategies checklist for reducing seclusion and restraint in mental health facilities (Te Pou o Te Whakaaro Nui (Te Pou) 2015).

The checklist is based on an American Six Core Strategies model which has been shown to promote a reduction in the use of both seclusion and restraint. The core strategies are:

  • Leadership towards organisational change
  • Using data to inform practice
  • Workforce development
  • Use of seclusion and restraint reduction tools
  • Service user/consumer roles in inpatient units
  • Debriefing techniques.

The approach views restraint and seclusion as last-resort safety responses, which are only to be used to manage an emergency situation that cannot otherwise be resolved (Te Pou, 2015).

Best practice

The best practice responses to a prisoner’s risk of
self-harm, as identified in a preliminary New Zealand, United Kingdom, Canadian and Australian literature review, are summarised below.


Key Points



  • Training for all prisoner facing staff, particular focus on custodial staff
  • Training includes: impact of prison on risk of suicide, staff attitudes, potential pre-disposing factors, risk factors, warning signs and symptoms, history taking, response to suicide attempt/self-harm, effective communication
  • Resilience training for staff
  • Access to supervision

(SASH Project, 2016)

(PPO for England and Wales, 2015)

(Te Pou, 2015)

(Short et al, 2009)

(WHO, 2007)

(Camilleri et al, 1999)


  • On reception and as required
  • Comprehensive
  • Conducted by appropriately qualified professionals
  • Include checklist options for non-qualified staff
  • Information to be shared
  • Risk should be viewed as a continuum and regularly reassessed

(PPO for England and Wales, 2016)

(SASH Project, 2016)

(PPO for England and Wales, 2015)

(Te Pou, 2015)

(Office of the (Canadian) Correctional Investigator, 2014)

(Schilders and Ogloff, 2014)

(Volm & Dolan, 2009)

(WHO, 2007)

Multidisciplinary Team (MDT)

  • Timely access to appropriately qualified professionals
  • Care continuity and responsiveness
  • Accurate, accessible, comprehensive documentation
  • Effective and timely communication
  • Integrated approach
  • Interagency support

(PPO for England and Wales, 2015)

(Te Pou, 2015)

(Office of the (Canadian) Correctional Investigator, 2014)

(Ministry of Justice, 2013)

(WHO, 2007)

Social Connections

  • Segregation increases risk
  • Connection with support networks important
  • Quality of prisoner relationships, with staff or other prisoners, is important
  • Peer support schemes add value

(Willis et al, 2016)

(PPO for England and Wales, 2015)

(PPO for England and Wales, 2015)

(Te Pou, 2015)

(Office of the (Canadian) Correctional Investigator, 2014)

(South et al, 2014)

(Ministry of Justice, 2013)

(WHO, 2007)

(Camilleri, 1999)

Physical Environment

  • Option of shared cell accommodation
  • Safe cells do not have to be bare
  • Minimisation of ligature points

(Willis et al, 2016)

(PPO for England and Wales, 2015)

(Office of the (Canadian) Correctional Investigator, 2014)

(Ministry of Justice, 2013)

(Power & Riley, 2010)

Prison Culture

  • Need for whole of prison approach
  • Importance of relationships between staff, particularly across disciplines
  • Impact of bullying within the prison
  • Effective policies and procedures
  • Effective staff response to suicide attempt/ self-harm
  • Effective assurance processes

(PPO for England and Wales, 2015)

(Te Pou, 2015)

(Office of the (Canadian) Correctional Investigator, 2014)

(Ministry of Justice, 2013)

(WHO, 2007)

(Camilleri, 1999)

Current Corrections practice

From the mid-1990s, New Zealand prisons introduced At-Risk Units (ARU) for the safe management of prisoners with mental health needs and increased self-harm risk. Practice in the management of at-risk prisoners has focused on the use of tools to identify risk, maintain a prisoner’s physical safety through close observation, and referral to RFMHS to provide specialist treatment.

In the last five years, Corrections has strengthened the management of at-risk prisoners in a number of ways, including:

  • Training staff in suicide awareness, effective communication and, in the case of nurses, primary mental health
  • Introducing new screening processes that have improved our identification of risk, for example revised Reception and Review Risk Assessments conducted by custodial staff, the Mental Health Screening Tool administered by nurses and the Columbia Suicide Severity Rating Scale, currently being trialled
  • Implementing Packages of Care where prisoners can access a suite of therapeutic interventions from counsellors. This initiative is being extended in response to high demand for the service
  • Piloting mental health in-reach clinicians (based in prisons) with a primary mental health focus, to undertake assessments and provide short-term interventions to referred prisoners presenting with mental health issues, as well as supporting prison staff to deliver appropriate interventions
  • Investigating options to embed trauma informed practice within prisons.

Additionally, some individual sites have undertaken their own improvement programmes.

Current risk management in prison

The current risk assessment processes include:

  • A Risk Assessment at reception
  • A Health Triage at reception
  • A Mental Health Screen at reception.

Custodial staff can also complete a review of the Risk Assessment any time they consider it necessary, including in response to specific situations such as a return from court, change in legal status, change in sentence status, use of force, or a change in family circumstances.

Prisoners identified as at-risk are accommodated in the ARUs. On arrival at the unit they are searched, including after having been in another location such as during visits.

Departmental policy requires that prisoners in ARUs be provided with “suitable resources for their management” including clothing and bedding. An At Risk file is started which contains an At Risk Management Plan. The plan is developed in consultation with appropriate personnel, including health staff, cultural advisers and whänau. The plan includes frequency of observations, access to support, programmes, response to any special needs, and a review timeframe. There is also a plan for removal from at-risk status and necessary ongoing treatment or monitoring. At-risk prisoners are expected to have the same opportunities for involvement in prison activities as other prisoners, consistent with maintaining their safety.

The diversity and complexity of prisoners’ mental health issues creates a very challenging environment in the ARU. Opportunities for meaningful activity or interaction with others may be limited by requirements for high staff-to-prisoner ratios, the competing needs of prisoners, and variable access to appropriately qualified clinicians or therapists. In addition, ARUs were originally designed for the sole purpose of preserving life, and in this they have been largely successful. However, over time the Department has moved toward a more therapeutic focus and some facilities are not well designed for this new approach.

ARUs hold regular meetings between custodial and health staff to discuss individual prisoners, which sometimes involve staff from RFMHS. The removal of a prisoner’s at-risk status is generally agreed in discussion between custody and health staff, with RFMHS input if the prisoner is on their case load. Ultimately, the decision rests with custodial staff, although considerable weight is given to the views of health staff.

Despite the challenges, many teams make considerable effort to interact in a meaningful way with prisoners and access relevant supports. They also implement effective transition plans for prisoners who have had extended stays in ARUs, and engage with staff in the receiving unit. However, there is limited opportunity to provide additional observation and support in the wider prison environment.

Future state

Corrections has committed to transforming the way we manage prisoners who are at risk of self-harm and suicide. We recognise risk of self-harm as a continuum along which people may move up or down, depending on their circumstances. We will develop a new model of care where support is matched to an offender’s particular needs. A range of options, such as intensive care within a specialist Intervention and Support Unit (ISU) or an Integrated Intervention and Support Plan (IISP) for prisoners maintained in the wider prison environment, will be considered as part of the model. Overseas correctional jurisdictions have already developed graduated responses to managing at-risk prisoners (such as in Australia, and Canada). These are a mix of prescribed actions and frameworks to support staff to use their professional judgement to keep prisoners safe.

Strengthened interagency collaboration, particularly in the care of prisoners with complex needs, will also be a feature of the new model. A joined-up approach within the structured prison environment may provide the best opportunity to address issues, promote engagement with agencies who can support them on release, and reduce the burden on individual agencies.

Combining elements of these approaches will provide a model where risk is identified at the earliest opportunity, safety of both prisoners and staff is prioritised, appropriate strategies that recognise individual prisoner’s strengths and needs are in place, and responses are sufficiently flexible to address both the dynamic nature of risk and the challenges posed by the prison environment. The new model will disrupt a pathway of escalating mental health issues, which can have significant flow-on effects for government and wider society.

Budget 2017 initiative

In Budget 2017, Corrections received $11.6 million over the next four years to develop the new “whole of prison” model of care. We will design and implement the model at three sites:

  • Auckland Prison
  • Auckland Region Women’s Corrections Facility
  • Christchurch Men’s Prison.

The model will primarily be delivered by new multi-disciplinary teams (MDTs) which may include psychologists, occupational therapists, mental health clinicians, social workers and cultural workers who will work with, and provide support to, custodial staff. It will involve:

  • improved screening and assessment tools
  • transforming existing At-Risk Units into specialised ISUs, including enhancements to the physical environment to soften the look and feel of the units
  • therapeutic intervention and support plans for prisoners in ISUs, including increased support to transition back into the wider prison environment
  • intervention and support plans for at-risk prisoners who can be safely accommodated in mainstream units.

Although Budget 2017 funding only enables us to deliver the model of care at three sites, we intend to design and test a national service that can be delivered to additional sites as more funding becomes available.

Alignment with existing mental health services within prisons

The RFMHS caseloads are comprised of prisoners with moderate to severe mental disorders who meet their treatment criteria. Those individuals will continue under RFMHS care, but will receive additional support within the ISU or wider prison environment. In addition, all prisoners entering the ISU will be referred to RFMHS, ensuring that prisoners with significant mental health needs who have not come to their attention previously will now do so.

In 2016, Corrections received $13.8 million over two years through the Justice Sector Fund to pilot increased support for offenders with mild to moderate mental health issues. The pilot contains four components:

  • More clinicians working with offenders and staff: Teams of contracted mental health clinicians are working with prisoners and community-based offenders across 16 prisons and four community corrections sites. These clinicians work directly
    with individuals to stabilise and address their mental health needs and support Corrections staff in their work with these same individuals. The clinicians provide links with existing community services for community-based offenders and prisoners on reintegration.
  • Support for women in prison: Counsellors and social workers are working with female prisoners at the three women’s prisons to address specific needs around trauma, victimhood, and family, which many women entering prison struggle to deal with.
  • Supported Living: This contracted service enables a small number of offenders with high and complex mental health needs or cognitive impairment to live temporarily in supported accommodation upon release from prison. This is available for women and men in Auckland and Hamilton. A Supported Living service provider helps these individuals to link into a range of community agencies to support their exit from Corrections’ oversight and transition into long term accommodation in the wider community.
  • Wrap-around family/whānau support: The service supports the families/whānau of offenders who are engaged in mental health services during their imprisonment or while serving a sentence or order in the community. The initiative connects children and families of prisoners with community services to improve their social, health and education outcomes. Families are supported to reunite or stay united with offenders, and support the progress made by the offender.

The Budget 2017 initiative will align with RFMHS and the new Justice Sector Fund services to form a suite of options available to prisoners who are at risk of self-harm. There is likely to be an increase in referrals to these services due to more effective assessment processes. It is likely that prisoners who are in crisis will be recognised earlier by custodial staff or other prisoners. The additional training provided to staff as “first responders” and the potential for peer supporters will increase the likelihood of proactive intervention before matters escalate.

Expected outcomes

Transforming the way in which we manage at-risk prisoners will lead to a reduced rate of self-harm in prisons. The new model is expected to benefit individual prisoners, and ripple out to impact on staff, the wider prison environment and the community:

  • For individuals, the benefits relate to reducing self-harm, addressing mental health issues, improving quality of life, improving the ability to participate in rehabilitative activities therefore increasing the likelihood of successful reintegration and a crime free life.
  • For staff, it reduces the traumatic experience of responding to suicide or self-harm incidents. There may also be a reduction in violence within prisons as prisoners are supported to develop more effective approaches to dealing with stress and distress.
  • For the wider community, the potential benefits result from prisoners being released with better mental health include fewer victims, improved family functioning, and less burden on health and social agencies.


Corrections is committed to improving public safety and reducing re-offending. Part of improving public safety is ensuring that prisoners are managed in a safe, humane and legitimate way. We aim to transform the management of our most vulnerable prisoners by addressing mental health issues that lead to suicide or self-harm. These changes will take time, and will require collaboration with other agencies and stakeholders. We will work closely with the Ministry of Health and District Health Boards, particularly forensic units such as the Mason Clinic, the Ombudsman, service providers and our justice sector colleagues. By investing in better mental health for offenders, we will improve their chances of changing their lives and shaping a new future for themselves, their families, and our communities.

1 Subject to coronial review for confirmation of cause of death


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