Public Safety Committee on Oct. 29th, 2009

[James Livingston, Researcher, Mental Health and Addiction Services, Forensic Psychiatric Services Commission of British Columbia]

Thank you very much.

Good morning, Mr. Chairman and members of the committee.

It's an honour to have this opportunity to speak to you today about mental health and addiction services in correctional settings. My name is James Livingston, and I'm a researcher with the Forensic Psychiatric Services Commission of B.C. Mental Health and Addiction Services. The Forensic Psychiatric Services Commission is a multi-site provincial health organization in British Columbia that provides specialized hospital and community-based assessment, treatment, and clinical case management services to adults with mental illness who are involved with the criminal justice system. I'm also a PhD candidate in the School of Criminology at Simon Fraser University.

When individuals with mental health and substance use problems are detained, imprisoned, or are supervised in the community, opportunities arise for detecting untreated illness, reducing suffering, and improving quality of life. Too often this opportunity is missed.

Earlier this year I was commissioned by the International Centre for Criminal Law Reform and Criminal Justice Policy to undertake a study of international standards and best practices in relation to the provision of mental health and substance use services in correctional settings, including jails, prisons, and community-based corrections. The centre is an independent international institute based in Vancouver, British Columbia, with a mandate to promote the rule of law, democracy, human rights, and good governance in criminal law and the administration of criminal justice domestically, regionally, and globally.

The research I undertook involved an extensive review of published and unpublished literature and a synthesis of the standards and guidelines contained in over 200 relevant documents. The preliminary findings of this review were refined through consultation with a small group of prominent experts in forensic mental health and addiction services.

I would like to spend my time providing you with an overview of our findings, which are detailed in a report entitled Mental Health and Substance Use Services in Correctional Settings: A Review of Minimum Standards and Best Practices. This report has been published and is available on the website of the International Centre for Criminal Law Reform and Criminal Justice Policy.

Our review revealed that published standards and best practices regarding correctional mental health and substance use services generally cluster around five service themes, including screening and assessment, treatment, suicide prevention and management, transitional services and supports, and community-based services and supports. For each of these themes, both best practices and minimum standards are identified and discussed in our report.

For the committee's purpose today, I will focus on the minimum standards that were identified in our research. Minimum standards are conceptualized as the policies, procedures, and practices that have been identified as essential for addressing mental health and substance use problems in correctional settings. Generally, these standards are formulated on the basis of legal and ethical considerations, particularly those that concern human rights.

The first service theme identified by our report relates to screening and assessment. Published guidelines and standards unanimously assert that providing systematic mental health and substance use screening and assessment in jails and prisons is a necessary, essential service. Our review identified five minimum standards in this area--for instance, training all staff members who work with inmates to recognize and respond to mental health and substance use problems, and screening all inmates upon arrival at correctional facilities to identify emergent and urgent mental health and substance use problems.

The second service theme is treatment, which involves providing services and supports to individuals with mental health and substance use problems in order to decrease disability, decrease human suffering, maximize the ability for individuals to participate in correctional programs, and create safe environments for those who live, work, and visit jails and prisons. With respect to treatment, our review suggests eight minimum standards, such as providing inmates who have mental health and substance use problems with access to the same level and standard of care available to individuals in the community, and ensuring that written, individualized treatment plans are created and regularly reviewed for inmates with mental health and substance use problems.

The third service theme is suicide prevention and management. On account of the high rates of suicide in jails and prisons, organizations have made considerable efforts developing comprehensive guidelines, standards, and programs to prevent and manage inmate suicide.

Regardless of the size or nature of the facility, all jails and prisons should establish adequate suicide prevention and management programs. Our analysis of the literature suggests six minimum standards in this area--for example, training all staff members who work with inmates to recognize verbal and behavioural cues that indicate potential suicide, and how to intervene, and housing potentially suicidal inmates in safe environments that maximize interactions with staff and others and minimize experiences of isolation.

The next service theme involves transitional services and supports. For inmates with mental health and substance use problems, the transition between custody and community can be acutely stressful, psychologically distressing, and disruptive to their recovery and treatment. Our review has identified three minimum standards in this area, such as providing inmates who have mental health and substance use problems with written transition plans that identify available and appropriate community resources prior to their transfer or release from prison or jail, and ensuring that inmates with mental health and substance use problems who require continued pharmacological treatment are provided with a sufficient supply of medication that can last at least until they are able to see a community health service provider.

The final service theme identified by our review relates to community-based services and supports. The community corrections system has a significant role to play in ensuring that probationers and parolees have access to appropriate mental health and substance use services. Our review suggests five minimum standards in this area, including screening all probationers and parolees to identify emergent and urgent mental health and substance use problems, including potential suicidality, and ensuring that probationers and parolees with mental health and substance use problems have access to the same level and standard of care available to individuals in the community who are not involved with the criminal justice system.

In closing, we recognize there is no single blueprint for creating a correctional mental health and substance use service system. Implementation of minimum standards and best practices should be flexible, varying according the types of settings and population, as well as other contextual factors, such as geography and resources. However, the conceptual framework and the minimum standards and best practices outlined in our report provide a useful guide to inform decision-making concerning mental health and substance use services in correctional settings. Currently, the minimum standards described within our report are being considered for adoption by correctional authorities throughout Canada in order to assess the strengths and gaps of their systems in providing mental health and substance use services.

Thank you for this opportunity to share our work. Should the members of the committee be interested in learning more about the best practices and minimum standards described within our report, I can provide additional examples and elaborate on the process we undertook in our research.

I look forward to your questions and wish you all the best with this important study.

Thank you.

[The Chair, Conservative, Garry Breitkreuz]

Thank you very much. I appreciate that outline of your research on the correctional mental health and substance use services.

Our next witness is Mr. Frank Sirotich, from the Canadian Mental Health Association. Go ahead, sir.

[Dr. Frank Sirotich, Program Director, Community Support Services, Canadian Mental Health Association]

Good morning. Thank you.

I am very pleased to be here today, and I'd like to thank you all for the opportunity to speak with you on the very important issue of addressing mental illness and addictions within the federal correctional system.

I will begin by briefly providing sorne background about the Canadian Mental Health Association, followed by an overview of community-based mental health services that have been funded within Ontario to address mental health needs of individuals within the provincial criminal justice and correctional systems. These initiatives may have some applicability within the federal correctional context. I will conclude by identifying broad recommendations pertaining to reintegration strategies for mentally ill offenders through the provision of specific services and cross-sector planning and coordination.

The Canadian Mental Health Association is a nationwide charitable organization that promotes the mental health of all persons and supports the resilience and recovery of people experiencing mental illness. It strives to achieve this objective through research, through the provision of public policy advice to government, through public education and mental health promotion campaigns for the community, and through community support services to men and women with serious mental illness. Each year it provides direct services to more than 100,000 individuals through the combined efforts of more than 10,000 staff and volunteers across Canada in 135 communities.

At CMHA's Toronto branch, as well as at a large number of branches across the country, we have a variety of services that operate at the interface of the mental health and criminal justice systems. I should add that many other community mental health agencies also provide services specifically targeting persons with mental illness and criminal justice involvement.

Within Ontario these mental health and justice services are organized across juncture points within the criminal justice, correctional, and forensic mental health systems. These services are aimed at reducing the involvement of persons with serious mental illness in the criminal justice system.

First among these services are prevention or pre-charge diversion programs, to which police can refer an individual for linkage to mental health services when the police believe the individual has a mental illness and that the person is at risk of coming into conflict with the criminal justice system or may have committed a minor public nuisance offence. The individual may be referred to treatment services in lieu of criminal arrest.

Second, there are court diversion initiatives, including mental health courts, which link mentally ill accused to treatment services. Criminal prosecution is stayed when the individual is successfully linked to mental health and addiction services. These court-based programs also assist in developing bail release plans and service care plans, which may be incorporated into probation orders for the remand population.

Third, we provide release-from-custody programs through which mental health workers within detention centres develop discharge plans for individuals pending their release to promote their successful reintegration into the community.

Fourth, we also provide intensive case management services dedicated to persons with justice involvement. These case management services include specialized programs targeted at persons with concurrent disorders--that is, a mental illness and an addiction--and/or a dual diagnosis, which is a mental illness and a developmental disability.

Included along this continuum of specialized community support programs are forensic assertive community treatment teams, which are mobile multidisciplinary teams that include psychiatrists, nurses, social workers, vocational specialists, addiction workers, and case managers. These forensic ACT teams work to reintegrate mentally ill offenders who are under the purview of Ontario Review Board pursuant to a finding of not criminally responsible due to mental disorder.

In addition to these community support programs and court-based and custody-based services, a continuum of residential services were also developed. These include short-term residential beds, often referred to as safe beds. These residential programs provide 24-hour on-site support for up to 30 days and provide interim housing pending linkage to longer-term housing. In addition, there is dedicated long-term supportive housing, with different levels of support that range from independent to 24-hour on-site support. There are also transitional rehabilitative programs that provide high-support housing and case management to individuals transitioning from the Ontario Review Board system to community mental health services.

In order to coordinate these services, both across program areas and across sectors, local and regional committees and a provincial human service and justice coordinating committee were established. These coordinating committees were established in response to a recognized need to coordinate resources and services and to plan more effectively for people with serious mental illness, developmental disability, acquired brain injury, and/or drug and alcohol problems who are in conflict with the law or at significant risk of coming into contact with the criminal justice system.

These committees are a joint collaboration between the ministries of the Attorney General, Community and Social Services, Child and Youth Services, Health and Long-term Care, and Community Safety and Correctional Services and various community mental health and addictions organizations.

Some elements in the continuum of services, such as forensic ACT teams, transitional and long-term housing programs, and specialized case management services, may have direct relevance to the federal correctional system. Moreover, these coordinating bodies may provide a vehicle for intergovernmental planning and coordination of services for individuals who are transitioning from the federal correctional system to community-based services. Conceivably, they could be replicated in other jurisdictions. Increased collaboration between the federal correctional and provincial health and justice systems is necessary to ensure continuity of care.

However, though these services may be transferable to the federal corrections population, it is important to recognize that these services alone may not he adequate. We currently do not have an adequate program infrastructure to address the complex range of needs of this population. Moreover, there is limited capacity among existing services to meet the needs of the federal correctional population. New investments are needed to build community capacity to provide adequate services for federal offenders who have serious mental illness. Moreover, such services would need to be evidence-based and targeted at criminogenic needs that predispose a person to recidivism, such as substance abuse, antisocial attitudes, and anger management problems. They also need to target the social determinants of health, such as having adequate housing and opportunities for employment.

Moreover, it is recommended that funding for the evaluation of new programming be included in any investment in the development of services. Building an ongoing infrastructure for research and development is necessary to ascertain more effective solutions and to ensure accountability for fiscal investments.

In sum, enhancing community capacity through the development of an infrastructure of specialized, evidence-based programming that addresses the complex needs of offenders who have mental illnesses and/or addictions, and coordinating with provincial and local human service and justice providers to enhance service continuity, will serve to lower the risk of recidivism, increase public safety, and improve the quality of life of persons with mental illness who are re-integrating into society from the federal correctional system.

Thank you for this opportunity to speak on some of efforts of community mental health organizations to address the needs of persons in the criminal justice and correctional systems who have mental illness and to outline potential strategies this committee may consider in its deliberations.

[The Chair, Conservative, Garry Breitkreuz]

Thank you very much, sir, for that presentation. I appreciate it.

We'll now go to Ms. Gail Czukar, from the Centre for Addiction and Mental Health. Welcome to our committee. You may give your presentation.

[Gail Czukar, Executive Vice-President, Policy, Education and Health Promotion, Centre for Addiction and Mental Health]

Thank you. I too would like to thank you very much for the opportunity to appear before this committee.

CAMH, the Centre for Addiction and Mental Health, is the largest mental health and addictions facility in Canada. We're a teaching hospital fully affiliated with the University of Toronto, with central clinical and research facilities. We also have 26 locations around the province. We serve 20,000 unique individuals annually and we have a staff of about 2,700 people including 200 full-time psychiatrists.

CAMH operates in-patient facilities in downtown Toronto. About 30% of our beds—170 in total—are forensic mental health beds. We house clients within our forensic mental health program who have been referred to CAMH for psychiatric assessment, and some are on pre-trial treatment orders. The majority of the forensic mental health clients are people who the courts have concluded cannot be held criminally responsible on account of their mental disorder or are unfit to stand trial under part XX.1 of the Criminal Code.

These clients fall under the jurisdiction of the Ontario Review Board. Most of CAMH's review board clients live in the community, but we're responsible for monitoring and treating them according to the terms of the review board orders.

Stigma is a huge barrier to treatment and support. The vast majority of incarcerated individuals with mental illness or addiction are in federal or provincial correctional facilities, not in the forensic mental health system. Your committee has already heard testimony about the prevalence of mental illness and addiction within federal correctional facilities, as well as estimates of those who are able to access treatment and those who aren't.

I won't repeat those numbers, but it's important for the committee to know that all across Canada, across settings as diverse as prisons, schools, workplaces, and city streets, a large percentage of people who need treatment and support for their mental health or substance use problems don't get the help they need.

As is the case in federal correctional facilities, there's no single explanation for this gap in service. We know people often don't seek help or choose not to accept help that's offered, but we also know there's an overall lack of system capacity. Both of my co-presenters today have spoken to that.

While mental health and addictions account for roughly 13% of death, disability, and illness, it receives only 5% of Canadian public health care expenditure. All of these problems have their roots in stigma. We continue to see mental health and addiction problems as frightening, threatening, and shameful.

CAMH has addressed stigma in various ways, but the Mental Health Commission of Canada is very committed to addressing stigma. The commission has done extensive research on how best to confront stigma, and this research has led them to launch some highly targeted initiatives customized to particular audiences and settings.

There are anti-stigma initiatives that have been evaluated and proven to have an impact. One of those is offered by my own organization. I encourage your committee to connect with the work of the Mental Health Commission and explore the most effective ways to address stigma in the correctional culture among both staff and prisoners.

Mental health and substance use problems are complex. The roots of these problems defy simple explanation and the paths to recovery are diverse. These problems are, above all, health problems. And our focus must be on finding the most effective treatment and support to help individuals to heal, to take greater control over their lives, and ultimately, to be successfully integrated or reintegrated into the community.

The groundbreaking 2006 report of the Senate, Out of the Shadows at Last, recommended that the standard of care for mental health within correctional institutions should be raised to the equivalent of non-offenders in the community. This is a worthy objective and one that your committee may want to endorse.

The best treatment within correctional facilities must be rooted in the lives and experiences of the individual. For CAMH and many other addiction providers, this means that we offer health services and supports to people with substance use problems who are still using drugs, including illegal drugs.

Health interventions that do not require cessation of use as a precondition are sometimes referred to as harm reduction, and those interventions often generate considerable controversy. But I would say that the single most important test that harm reduction measures must meet is whether they make people healthier.

Initiatives such as needle exchange programs have been evaluated and proven to reduce the transmission of infectious disease. I believe that the decision about needle exchange programs should be based on the best available evidence about its impact on the health of the prison population.

Connecting to community resources post-incarceration is also important. Regardless of the type of treatment, connecting to community resources upon release from prison can be challenging. Federal inmates who are released on parole continue to receive services funded by Correctional Service Canada, often through community agencies providing contractual services. CAMH has a small program of this type, funded by CSC.

There is no question that continuity of care—particularly once the warrant has expired—is a challenge. Like everyone else, people released from custody must navigate a system of care that can be confusing and is often poorly coordinated, but they carry the additional disadvantage of an extra label. Ontario, and likely other provincial-territorial jurisdictions, struggle to develop the most effective way of connecting people to services. We know that effective, responsive case management can help solve this problem. But case management requires system capacity. Simply put, you have to have services that the case manager can connect to.

In its draft national strategy document, the Mental Health Commission reports that only one-third of people living with a mental health problem or illness get access to services and supports, and that the situation is worse for populations in rural and remote communities. One of the commission's recommendations is that there be “robust and well-coordinated monitoring of mental health status and measuring of performance”. Federal and provincial governments should be working together to monitor the ability of those leaving correctional facilities to gain access to appropriate treatments and supports.

In conclusion, I would say that the Mental Health Commission is developing a national strategy on mental health. A broad-based group that was convened by the Canadian Centre on Substance Abuse--of which I was part as a member of the Canadian Executive Council on Addictions, and which CAMH participated in--has developed recommendations for a national addictions strategy. One of the messages of both plans is the need for services to be seamlessly integrated across institutions, sectors, and settings to meet the needs of individuals.

This is a challenge for all of us who work in mental health and addictions care. It is of course particularly challenging for people emerging from correctional facilities who are likely to have both serious problems and inadequate connection to communities and the services they offer.

We have much work to do to develop services in correctional facilities that meet the needs of prisoners and that offer the continuum of care that we know can work. Canadians across all sectors must find ways to meet the growing demands of people with mental health and addiction problems. The growing demand for mental health and addiction services can be celebrated as testimony to lower levels of stigma and a far greater awareness of the impact of these problems. Meeting this demand will require both greater investment and greater integration of mental health and addictions supports and services with all health services.

Thank you for your attention. I’d be happy to answer questions.

[The Chair, Conservative, Garry Breitkreuz]

Thank you very much. I appreciate your presentations.

We'll move immediately to the Liberal Party. Mr. Holland.

[Mark Holland, Liberal, Ajax—Pickering, ON]

Thank you, Mr. Chair.

Thank you to the witnesses.

Maybe I could begin by talking about where our correctional system is today and the trajectory of where it's going.

I had the opportunity of being at the Grand Valley facility and to be in the cell in solitary confinement where Ashley Smith had passed away after more than eleven months in solitary confinement. She was an individual who was never diagnosed as having a mental health issue, but clearly did.

The report of the correctional investigator on that I think was disturbing, not because Ashley was so badly failed, although that was a great tragedy, but because the correctional investigator said this was symptomatic of what's happening generally. Ashley's story is unfolding every day in many prisons right across the country, and we are fundamentally failing in our approach to how we deal with mental health issues in our prison facilities.

Two days ago we had Dr. Jones before this committee, who's the executive director of the John Howard Society of Canada. His statement on the approach that's being taken right now, taken by the government, said it contradicts evidence, logic, effectiveness, history, justice, and humanity.

I'm wondering about your reflections on where we are right now. Do you agree that the current approach being taken in corrections is ineffective and, frankly, inhumane?

[Gail Czukar]

I don't work in prisons, and I can't really comment on that. I think what we know is that people who are in prisons and have mental illnesses identified, have addiction problems identified, not all of them are getting the help they need. From my reading of some of the testimony before this committee and some of the reports, it sounds like maybe half of the people who are identified with mental health problems—and these tend to be fairly serious mental health problems—get the help they need. So there's clearly a need for a lot more services.

I understand there's also a problem with the level of remuneration for staff, so it's hard to hold good staff. We're all facing that problem in the health field. If you're paying 40% less than the competition, you're going to have a very hard time having good staff in those facilities. We do know that there's a shortage of good services, and that on the addictions side in particular, most of the investments recently have been in interdiction and trying to prevent drugs from getting into prisons rather than trying to address the demand side of the question in terms of treating people's addictions. That's not uncommon in drug policy around the world today, but it's not, in the long run, an effective strategy. Sooner or later you have to address the demand question and help people with their addictions.

[Mark Holland, Liberal, Ajax—Pickering, ON]

One of the concerns that has been raised is that most of the way that more serious mental health prisoners are dealt with is through solitary confinement because they don't have the resources to be able to deal with them in a facility. First, would you agree that the approach of putting somebody who has mental health issues in solitary confinement would exacerbate their problem? It's probably one of the worst ways to deal with that issue. Second, given the fact that in a lot of situations these individuals are being released directly out of solitary confinement back into the general population, not only is it bad for them, but it's bad for society, because obviously, if they're coming directly out of solitary confinement into communities, these are not individuals who are likely to have been rehabilitated.

[James Livingston]

I'm fairly novice as to the current state of operations of our correctional system and what's happening on the ground, so my comments are really limited to my understanding of the research and literature.

Back to your question about ineffective and inhumane, it's obvious from the literature that not providing people with mental health and substance use services who need them is inconsistent with minimum standards that are endorsed by the World Health Organization, the United Nations, and many international and national correctional organizations. So I would refer you to those documents, but I can't say how they map against our current system.

[Mark Holland, Liberal, Ajax—Pickering, ON]

I think it's now becoming more widely accepted that mental health concerns and addiction concerns are intertwined; they're more often than not inseparable, they're very much linked, and they can't be treated in isolation. I'm wondering if you would agree with that and what your thoughts on that are.

[Gail Czukar]

I would just address that, and since we are the Centre for Addiction and Mental Health, say that they are intertwined. We serve many people with concurrent disorders. They're not always seen together. The key is to have the most appropriate services for people, so you have to have accurate assessments of whether the person has only a mental illness, only an addiction problem, or both together. Where both together are assessed, they do need to be treated together. We don't have a good record of that in our system generally, so I wouldn't expect that it would be significantly different in correctional facilities.

We do find in our forensic programs that we have a higher representation of people with concurrent disorders than in the normal population of people who use mental health services. Substance use problems, I understand from your previous testimony, are about 80% in correctional facilities, so it's very likely you're going to find a pretty high percentage of concurrent disorders.

[Mark Holland, Liberal, Ajax—Pickering, ON]

There is testimony before this committee that around 12% of the prison population is facing a serious mental health issue, but we heard from Dr. Jones two days ago, whose comments were that this is probably understated and that the concerns you've just talked about, about the concurrence, mean that percentage might actually be much higher. Would you agree with that?

[Gail Czukar]

My understanding is the 12% to 20% estimate is for people who've been diagnosed with a serious mental illness at intake, and it doesn't take into account people who might have a more moderate problem and it doesn't take into account people who become ill while they're in prison. It seems like, given the conditions that someone's in—separated from family and support and in a very different kind of environment with high discipline and so on—they would be vulnerable and probably come in vulnerable, to some extent, to developing mental health problems. So it's probably an underestimate, yes.

[The Chair, Conservative, Garry Breitkreuz]

I'll have to cut it off there and move over to the Bloc Québécois now.

Monsieur Ménard, please.

[Serge Ménard, Bloc, Marc-Aurèle-Fortin, QC]

Thank you.

Has anyone among you ever visited a prison or been in a prison to offer professional services?

[Dr. Frank Sirotich]

I can respond. I have not done that at a penitentiary, but at a local remand centre, yes, sir.

[James Livingston]

No. As I stated earlier, I'm a researcher, so I don't provide clinical service.

[Serge Ménard, Bloc, Marc-Aurèle-Fortin, QC]

Do you believe that a prison environment is conducive to the treatment of mental illness?

[Dr. Frank Sirotich]

It would depend on what the illness is. Certainly in terms of treatment, there are facilities that have special needs units, though they seem to be woefully resourced, at least at the provincial level. Again, I couldn't speak about at the federal level.

I think what would be key is that you have the treatment resources, further to what Mr. Livingston was indicating, that are comparable, that would be available in a community context so that you have adequate addiction services, adequate psychiatric resources for psycho-pharmacological intervention, but one of the difficulties in local remand centres is often those services aren't available.

In terms of the term “dead time”, it's often applied to that context because such services aren't available.

[Serge Ménard, Bloc, Marc-Aurèle-Fortin, QC]

Do I err in thinking that the kinds of resources you are talking about are almost non-existent in Canadian correctional institutions?

For instance, what do you think of the fact that the Commissioner of Corrections was asked about the annual cost for keeping an inmate in a Canadian prison? The cost is $101,000 of which only 2% is devoted to programs while the balance is for accommodation and security.

Do you believe that the Canadian correctional system has, at this time, the necessary resources to treat mental illnesses?

[Dr. Frank Sirotich]

I couldn't speak to the actual figures. Again, the context from which I'm coming at it is really local remand centres or detention centres, which certainly, from my experience, from what I've seen, are woefully under-resourced.

[Serge Ménard, Bloc, Marc-Aurèle-Fortin, QC]

If this was compared to institutions or centres which are treating addictions outside of prisons, even if it might be a residential centre…

Have you heard of Portage in Quebec? It is a government organization inspired by the New York model.

[Dr. Frank Sirotich]

I'm sorry, sir, I'm not familiar with that model.

[Serge Ménard, Bloc, Marc-Aurèle-Fortin, QC]

Maybe others--