Thank you, Mr. Chairman and members of the committee, for inviting me to be a witness.
I come wearing three hats. I juggle a few hats, but these are the ones I'm wearing today.
As a prison family physician, I've worked in corrections systems for 16 years, mostly with women and mostly in the provincial system, but I do have some experience with men's facilities and federal systems.
The second hat I wear is as a clinical professor in the UBC department of family practice. Amber has talked about some of the research in which I'm involved.
My third hat, more recently acquired, is as director of the Collaborating Centre for Prison Health and Education. It is a group of academics and community organizations--actually anybody who wants to join--that is looking at ways to facilitate collaborative opportunities for health education research service and advocacy for people in custody, their families, and communities.
I'd like to share with you five personal reflections that I formulated about mental health, primarily in female corrections. These personal reflections are consistent with prison health publications, which I've footnoted in my written submission to you. I'd be happy to supply any of the documents to you if you'd like to read them further at a later stage. Don't hesitate to ask me.
It's well established that prison populations throughout the world suffer more ill health than the general population, and that female prison populations suffer more ill health than male prison populations. As a prison physician I've witnessed this over the years. As I've witnessed women cycle in and out of the system over the years, I've come to learn that most women are incarcerated because of crimes due to their disordered health and social lives. Therefore I've come to realize and reflect that the key to women's successful reintegration into society lies with figuring out how to empower incarcerated women to improve their health.
The second reflection pertains to the aboriginal people, who are tragically overrepresented in our systems. Over the years I've listened to aboriginal patients and aboriginal colleagues explain to me about their understanding of health. They've taught me that mental health is not a stand-alone thing. It is closely interwoven with a person's physical, emotional, and spiritual health. I realize that I started off in my career with a very Eurocentric or western-centric view of health, and I've come to appreciate that in order to engage incarcerated people to improve their health, we all need to improve our cultural knowledge and sensitivity.
My third reflection that I wish to share with you is that women with incarceration experience are experts about their own health. This was reinforced for me during this participatory health research project that we started in prison. I thought we would focus our research on HIV, hepatitis C, and addictions, but in fact when we asked women in prison what they would like to research in order to improve their health they told us they wanted to become better mothers. They wanted to become involved in meaningful work. They wanted to improve their community support and have safe housing.
The goals that women in prison identified that were important to improving their health were very similar to my own goals and probably to your goals. They are consistent with the public literature that pertains to mental health, social inclusion, and health promotion. All of these published studies agree that in order to improve the mental health of a population we have to affirm people's self-confidence, engage people in decision-making processes, and focus on people's strengths rather than their deficits. Doing so will enhance their sense of hope and their belief that they can succeed and change.
A fourth reflection that I've learned through my work with the collaborating centre is that numerous multi-sector organizations are keen and eager to collaborate with prisons to foster health. In fact, they recognize that they should be playing a role, particularly in two components of service.
First, individuals in prison should be offered the best multidisciplinary, patient-centred prison services that we can, including health. The second component is that during their transition to the outside community, individuals should be offered well-coordinated continuity of care. I can share three examples of that: inter-ministerial collaborations in other countries on health, academic collaborations on health, and collaborations at the local prison community level, if you wish.
The final reflection I wish to address is that most of the incarcerated people I've met are not mentally healthy. The prevalence rates, as you know, vary, depending on how you diagnose mental illness or how you measure it. In the literature it varies from 12% up to between 76% and 80%, and you've heard those figures in the statements of your previous witnesses.
Most of the women I see in prison clinics do not fall into a mentally ill psychiatric diagnosis, nor do they warrant transfer to a psychiatric hospital or treatment centre. However, the majority of people I have met in prison suffer from mental health difficulties such as anxiety, insomnia, flashbacks to previous trauma, depressive episodes, interpersonal conflicts, and poor impulse control. Many also have substance dependence, which is associated with their mental health difficulties. Some may be related to an under-diagnosed or under-screened condition such as a learning difficulty or fetal alcohol syndrome.
Regardless, women in prison across the board tell me that if they could figure out how to improve their mental health while they're inside prison, they will have a better chance of succeeding when they leave prison. I have reflected on about six suggestions--probably more--over my experience of working with people in prison, and also reading the prison literature.
The first one would be that incarceration in this country should be viewed as an opportunity for individuals to improve their mental health and to turn their lives around. Therefore, we should be doing everything we can to nurture processes inside prison that demonstrate success in improving health.
The second one is that we should be incorporating into every correctional system participatory processes that listen to and act upon the voice of individuals with incarceration experience about ways to improve mental health.
The third one is that prisons are really stressful places to work. There's a real tension that staff experience between nurture versus security and it's very wearing on prison staff. The mental health of inmates is really influenced and impacted by the morale of prison staff. Therefore, prisons should adopt what the literature calls a “whole prison settings approach” for health promotion that engages staff and inmates, because then prisons will become more effective in helping the mental health of inmates.
The fourth suggestion is that healthy prison environments should be fostered, because healthy environments will reinforce the educational benefits of inmates who participate in prison educational programs. By contrast, unhealthy prison environments will negate and undermine the benefits of these programs.
The fifth one is that prisons that use creative alternatives to solitary confinement foster healthier mental health both for the staff and for the incarcerated individuals. The use of solitary confinement does not enhance an individual's mental health. It worsens it, especially among those with pre-existing mental health difficulties. In Canada, therefore, we should support and commend prison management teams that do not use solitary confinement. In fact, we should discourage the use of solitary confinement in Canada.
The sixth suggestion is that because the overall prison ethos influences the mental health of inmates and staff, we should do everything we can, from top ministerial levels all the way down the chain, to support prison management teams that create and sustain a healthy prison ethos.
Thank you very much for listening to my reflections, and I welcome your questions.