Public Safety Committee on Oct. 18th, 2011

[Sylvain Chicoine, NDP, Châteauguay—Saint-Constant, QC]

Thank you Mr. Chair.

Good day Mr. Skinner. Dr. Simpson, thank you for sharing your viewpoint on these matters with us.

Mr. Skinner, you spoke earlier about an integrated care model which has allowed Ontario prisons to achieve some economies in other situations, or on another scale. I would like you to tell us about the savings that were achieved by adopting this integrated care strategy.

[Wayne Skinner]

Indeed. I wasn't speaking about this as a program in prisons. I should clarify that. I'm talking about a substantial body of research that has been done with people with severe, persistent mental illness who also have substance use problems.

The problem with those populations is that one of the great factors that predict relapse is their return to substance use. Yet traditionally programs were mainly oriented to doing mental health treatment and not very interested in dealing with substance use issues.

What happened when they created integrated treatment teams, which included addiction treatment expertise and worked with individuals, was that they found that the longer they were actually able to retain people in treatment the better the health outcomes. The clients' draw on other parts of the health care system—emergency resources and the like, the need for hospitalization—and their involvement with the criminal justice system were reduced. On the positive side, their ability to be doing pro-social things, like part-time work or the like, and maintain housing in a stable way and to have better community and family connections were enhanced.

So the model of care was integrated. It does require a directed kind of investment. The result is that you make a savings over time.

The research that led Ontario to do it is worldwide right now, but a lot of the work was actually done in the United States, where there's a lot of really helpful knowledge. Canada is now building some of this knowledge base about integrated treatment as well. Again, it's for people with severe mental illness and addictions, and it's about using integrated strategies that do a better job of keeping them out of hospital and functioning better and actively as members of communities.

[Sylvain Chicoine, NDP, Châteauguay—Saint-Constant, QC]

Thank you.

In Canada, was this type of approach promoted afterwards or was it set aside?

[Wayne Skinner]

No. In Ontario the government has made a substantial investment, and now I think there are over 60 ACT teams--assertive community treatment--in Ontario alone, and it's seen as a best practice in working with severe, persistent mental illness and addictions. So it's definitely where the health care field is going, and I think you'll see evidence of this in every province across the country, actually, and broadly around the world. It is working with that 3% of people or less who have severe, persistent mental illness, and in that population, maybe the 60% who have high rates of co-occurring substance use. The model has been tried with other kinds of problems as well, actually, with as much promise.

[Dr. Sandy Simpson]

The evidence is pretty clear that ACT delivers best mental health outcomes and substance misuse problems when, as we were talking earlier, the two are combined. Unfortunately, ACT teams have been disappointing, in terms of reducing re-arrest or re-incarceration of people with serious mental illness and drug abuse problems. The only models showing improvement on ACT ones also have aspects of a community treatment order or some coercive element, in addition to the ACT team, with both mental health and addictions treatment going on for people.

So for that even smaller group—the ones who are the frequent flyers between courts, prisons, mental health facilities and police arrest—none of our services are managing terribly well. We need quite complex responses that have the ACT mental health element, the ACT substance-misuse elements, and some degree of integration with criminal justice to make sure that care is effective and stops those cycles.

[The Chair, Conservative, Kevin Sorenson]

Thank you very much, Mr. Chicoine.

We'll now go to Mr. Leef, please. Mr. Leef, you have five minutes.

[Ryan Leef, Conservative, Yukon, YT]

All right.

Thank you, Dr. Simpson and Mr. Skinner.

I want to go back quickly to a comment that came out of a question a little earlier, and just a point of clarification.

In your opinion, would it be a fair characterization to say that the federal system doesn't necessarily deal with the harder-core withdrawal issues that the provincial remand centres or police cellblock issues deal with? From that perspective, that’s not really in the federal system where our attention or support or resources need to go, in terms of that support of the hard-core stuff—the DT’s and things that typically happen within the real, immediate sense for an inmate population.

[Dr. Sandy Simpson]

Generally, those acute medical problems will be more common within the provincial remand centres. There may be a little of that, of people at first point of sentence who've been on bail in the community entering federal corrections directly, but that will be a relatively small number and it's for a relatively short period of time. That sort of acute medical withdrawal is an hours-to-days’ problem in a year’s sentence. It's a relatively short area and not specifically one in need of major focus, though clearly acute alcohol or drug withdrawal can be a significant medical emergency. So there have to be good medical care facilities available to detect that straight away.

[Ryan Leef, Conservative, Yukon, YT]

Fair enough. Thanks. I just wanted to clarify that a bit.

Now, this might be a little bit of a hypothetical scenario, but we've talked a bit about the federal corrections policy to have zero drugs within the correctional system in Canada. I’m just wondering, from your perspective, how difficult is treatment when we have that constant temptation, opportunity, threats, coercion, the sorts of things that come along with day-to-day availability and access to drugs in a correctional centre? In other words, how successful or positive do you think programming and addictions counselling would be if we were to have zero access to drugs, if there were no way they could get them?

And I understand this is hypothetical and an absolute perfect-case scenario, but in comparison to what we have now, where drugs are available all the time and they're accessible—and there's that temptation and threat and coercion that people fall into—if you were to compare zero access for somebody, how much more successful do you think the programs would be? Could you put some kind of variable to that?

[Dr. Sandy Simpson]

It is a hypothetical that one couldn't give a hard number to. I would say the 7.5% figure given earlier is impressive. If we think of 80% of people having the problem, and fewer than 10% of them actually manifesting it within prison, well, that's progress.

To get to zero, you would probably need to choke off a vast amount of access to community. So probably the cost of getting to zero would include other aspects of things you would want to do, like maintaining relationships with key people in the community, having exposure through rehabilitative opportunities, and preparing people for reintegration in the community. That means at some point in the process you'd have to ease off on the restrictions and allow people to make choices for themselves, which they would do well in some cases and badly in others. If you don't let people have a chance to make a mistake, they will never have the chance to test out their ability to resist making mistakes. Any system of treatment and rehabilitation has to have a graded re-exposure so people have to manage the learning they've achieved. That can mean some access to the community. That means some re-exposure to risk. Achieving zero percent drug and alcohol use within prison is theoretically possible if it is hermetically sealed, but in terms of dealing with the problems of reintegration of people back into the community, you'll be losing at that end if you try to aim that high.

Would it be fantastic to take all the things you've talked about--the standover tactics, the manipulation, the violence that comes from people fighting over access to drugs, and the things that people will do to get drugs--out of the equation within prisons so that people would have the opportunity to direct and find better ways of dealing with large problems? You bet. I don't think that's measurable, however. But there is that balance between needing eventual community reintegration to be a reality and trying to get the amount of drugs in prison down to as low as possible.

[The Chair, Conservative, Kevin Sorenson]

Thank you very much.

Madame Morin.

[Marie-Claude Morin, NDP, Saint-Hyacinthe—Bagot, QC]

Good day. First, I would like to thank Mr. Simpson and Mr. Skinner for being here today, even though they are not here physically.

My first question is for Mr. Simpson.

Earlier, you talked about your experience in New Zealand. I found this very interesting and I would like you to tell us a bit more. You explained that the inmate population in New Zealand is about twice the inmate population in Canada. We know that the Canadian inmate population is going to increase and I would like to know whether you feel this is going to make curtailing drug addiction and drugs more difficult in prisons.

[Dr. Sandy Simpson]

Not of itself more difficult.... It will be larger because there will be more people.

We don't have any good evidence in New Zealand or internationally as to whether in those countries with rising rates of incarceration the people coming into prison have more mental health or addiction problems than the prison populations had before that rise occurred. We don't have good epidemiology internationally to tell us whether that is so. But if the prison population thrives we will have more people with drug and alcohol problems in prisons, so we will need better health responses for them.

National and international controversy is being debated most clearly at the moment south of the border, because of the fiscal level that they've reached, as to what the right model for the war on drugs is: when is it right to use a more therapeutic response--the drug courts and those kinds of models; when is it necessary to use incarceration as the appropriate response; and who are the people we should be incarcerating for public protection, to hold people to account for the severity of their actions and the ongoing risk they may present to the public? Each society sets those thresholds a bit differently.

New Zealand has a higher crime rate than Canada, so that explains some of the increase. But some of the moves to mandatory sentencing of certain sorts--and we've even now got a three-strikes piece of legislation, which I'm not terribly enthusiastic about--do create other problems.

For me, the best model comes from an international group of criminologists and criminal psychologists. The “good lives” model was developed by Tony Ward and the Victoria University of Wellington, New Zealand, with a number of international colleagues, including Canadian, North American, Australian, and British colleagues. That model sees offenders not as a different class of being, but as fellow travellers, people who have problems in life that overlap but are not entirely separate from ourselves, and for whom we engender crucially important aspects of common humanity, hope, and accountability. So if we imprison people for the things they have done wrong, and rightly so, then that space we bring them into needs to be as healthy as we can make it as we hold them to account, and it gives them the opportunity to learn better ways, rather than have their maladaptive old ways simply reinforced.

We're probably good at reinforcing maladaptive old ways, and at times with the young offenders teaching them bad ways, rather than creating incarceration as a different sort of opportunity, and that's holding people to account. One's duty as a citizen means respecting the rights of other citizens. Imprisonment is a vital means of passing that message to people: that if you have violated the rights of others you need to be held to account for that and pay a debt; and while you are doing that, we will also give you the opportunity--it's not necessarily the right, but the opportunity--to rebuild your life in a better way.

Getting that mix of messages right, as well as having long-term incarceration for that small number of people who do present a very long and serious risk to the population as a whole, is that kind of balance we need to get. I'm not sure New Zealand has got any of that right, but I think we need all of those pieces on the agenda as we discuss these issues.

[The Chair, Conservative, Kevin Sorenson]

Thank you very much, Dr. Simpson.

Now we'll move to Ms. Hoeppner, please.

[Candice Bergen, Conservative, Portage—Lisgar, MB]

Thank you, Mr. Chair.

Mr. Simpson, I just want to thank you for your comments. I think you articulated very well what all of us around this table are looking at, which is the right balance between true accountability and protecting victims and innocent people, but also helping those individuals who are incarcerated. I think all of us would agree with your statement, and I want to thank you for making it. It's something I think all of us can look back on in this study.

I want to shift gears for a moment. With your expertise, when you look at individuals who are working in correctional facilities--staff and guards--can you talk a little bit about some of the increased pressures and stress and very immense challenges they face every day when they go to work? They're not only in a setting where they're dealing with people who have broken the law, but they're also dealing with a large percentage of individuals who are addicted to drugs, and it's not only the addictions, but also the gangs and the very dangerous activities that surround those addictions. Can you talk a little bit about the cost to society and about rehabilitation in prison? Because we have guards and staff who are under tremendous pressure and probably dealing with a lot of their own issues. Can you just tell us what they might be dealing with, from your experience?

[Dr. Sandy Simpson]

Thank you for that.

I think the things that we ask prison officers to do are complex and difficult. We often underestimate the magnitude of their task, especially when we're trying to tell them to be rehabilitative as well when they're in situations where there are people who have got their way through life using manipulation, menace, and standover tactics as the ways of getting the things they want in life, as offenders are wont to do. That is a difficult world in which to live and to face when you come to work every day.

I think the other group that prison officers talk about having real trouble coping with are people who do things like chronic self-harm and behave in irrational ways that they can't understand. Coping with people with severe personality disorders and maladept at coping styles are also very difficult for prison officers. That can result in very significant emotional burnout and hardening of attitudes, and the interpersonal distance that comes from that in any institution. That's true of a secure hospital just as it is of a prison. The more staff under pressure, under threat and menace, then the more risk of negative staff practices emerging, as well as staff burnout and inappropriate use of authority or bullying.

How to create interpersonal environments where people can grow is what we're expecting of the inmates, and a healthy work environment for staff to come into who don't get burned out is very important. Good staff training, good levels of staffing, and good staff supervision are all crucially important to that, and having specialized units able to cope with people with particular levels of difficult need is also very important.

Some officers will be better at dealing with people at different phases of recovery. Some that I've worked with over the years are extremely good at working with mentally ill people in custody. Other officers will say they don't want to have anything to do with that inmate group, but they'll be very good in the minimum secure places and the work gangs and other areas like that. So I guess it's having emotionally and HR-sophisticated personal leadership that can provide staff with the training and support, staffing levels and awareness of the workplace hazards, the risks of burnout, the risks of malign behaviour, the risks of gangs to prison staff members, of intimidation, of threats to staff.

It's a tough place to work. It's very important work. The sophistication with which we can bring support structures around prison officers so they can understand that, so they can do things like develop people more, use things and pick up on issues like motivational interviewing that they're often hungry for, is really important.

[Candice Bergen, Conservative, Portage—Lisgar, MB]

Thank you very much for that. I also want to talk a bit about drug treatment. We had a previous witness talk about the fact that we need to find ways to actually measure whether the treatment programs work.

When you're treating someone, is the measurement very simply that they are no longer addicted to whatever substance they were addicted to? In the prison system, how would we measure whether the program actually worked, or whether someone simply went through a program for a variety of reasons, maybe so they could tick off a box and get their parole? Maybe it was for the right reasons, but we're not sure if we've had success. How do you measure success when you're implementing a drug treatment program?

[Dr. Sandy Simpson]

Whether you attend, whether you contribute, whether you learn and pick up stuff in the program itself are the sorts of things the people running the programs will be measuring. Much of that is the kind of acquisition of knowledge and information, becoming more educated and having an understanding and taking pride in graduating from the program.

Within prison, as you've implied, there are a number of drivers that may be good or may be about gaming the system. It may be about if I do the right courses and show I've done these things it will improve my chance of release. The proof of that pudding is what happens in the community when re-exposure emerges again and how the work that has started within the prison, because it doesn't finish there.... You do the program, but then it is how you implement that, how that gets translated into real world experience that is crucially important. We know that from residential and community drug and alcohol work. We know that in terms of mental health in-patient treatments, community-based treatment. It's all very well to get the learning and understanding within one venue. It is your capacity to translate that learning into the new one that is where the rubber hits the road, and that's where you need high-quality community reintegration, supervision, and follow-up to ensure success. That's really the only place in which you can tell that it's worked or not, and that means measuring abstinence.

[Candice Bergen, Conservative, Portage—Lisgar, MB]

Sorry for interrupting. I have a very short moment and I want to ask if you can very quickly comment.

You touched briefly on the importance of culturally appropriate treatment in reference to aboriginal people. Aboriginal culture and spirituality are very closely related. Would you agree, moving that further to other faiths, that faith-based treatment also can be effective, whether it's for Christians, Muslims, Jews, or aboriginal people? What's your opinion on that? Do we again get into the problem of mixing religion with government programs?

[Dr. Sandy Simpson]

No, I don't think it brings religion or spirituality into government programs. I think it's being culturally specific in one's delivery of care. I've seen faith-based units in New Zealand--Christian faith-based ones--that have received encouraging data. There's not a lot of outcome data on that. There's better outcome data on culturally based things.

It's about connecting with healthy social, cultural, and spiritual practices. It's about developing healthy aspects of people at the same time as you address the unhealthy aspects. I think that's important in terms of working with the whole of a person.

Most of the long-standing prisoner rehab organizations have been charities that are based on Christian values. The John Howard Society, the Salvation Army, and so many others over the years have had a Christian base to what they've done. They have often been the only social groups willing to step up to help offenders. I think we need to tap into those healthy cultures and spiritual practices.

[Wayne Skinner]

I was going to add to your comment that all prisons have abstinence cultures that are oriented around the twelve-step movement. They're already there. Again, what is important is thinking of where the alternatives are we can build on and tap into.

Just to support your question, I think they deserve a lot of respect. We need to think of ways of seeing it as a base that can draw people together, and certainly respect spirituality as a very important aspect of recovery.

[The Chair, Conservative, Kevin Sorenson]

Thank you.

Mr. Aspin, you have a comment. We have about 30 seconds left.

[Jay Aspin, Conservative, Nipissing—Timiskaming, ON]

Gentlemen, as you're aware, our government has expanded the use of correctional plans to help offenders get off drugs. Could you offer a quick comment on that--positive, negative, any quick comment?

[Wayne Skinner]

I'm not sure what you mean by correctional plans, but this work actually does require, as much as possible, identifying problems early to intervene actively when people are in jail and then plan and offer continuing care. I'm assuming, when you speak of correctional planning, that those are the things being developed.

Yes, I think it is very important, on a person-by-person basis, to have a very intentional strategy, based on an understanding of a person's strengths and needs, to help people move forward with their lives.

[The Chair, Conservative, Kevin Sorenson]

Thank you very much.

We'll move to Mr. Sandhu. This may be the last question. Maybe we'll take one more quick one.