Public Safety Committee on Oct. 18th, 2011

[The Chair, Conservative, Kevin Sorenson]

Good morning, everyone. This is meeting number seven of the Standing Committee on Public Safety and National Security, on Tuesday, October 18, 2011.

I want to remind our committee that in the final 30 minutes of our meeting we will go in camera to consider committee business and details of our pending field trip to Kingston.

Today we will continue our study of drugs and alcohol in prisons. We're studying how drugs and alcohol enter the prisons and the impact they have on the rehabilitation of offenders, on the safety of correctional officers, and on crime within our institutions.

Today two of our witnesses will join us by teleconference from Toronto, Ontario. We will hear from the Centre for Addiction and Mental Health. Sandy Simpson is the clinical director of the law and mental health program, and Wayne Skinner is deputy clinical director of the addictions program.

On behalf on our committee, I want to thank you for joining us this morning via teleconference. We look forward to your conference. I'd just ask if we're coming in loud and clear.

[Dr. Sandy Simpson, Clinical Director, Law and Mental Health Program, Centre for Addiction and Mental Health]

Yes, you are.

[The Chair, Conservative, Kevin Sorenson]

All right, and likewise back.

I'm not certain if you've appeared before committee before, but we would welcome opening comments you may have on the subject and then we will go into a couple of rounds of questioning, if that suits. I'm not certain which of you would like to begin, or if you both of you have opening statements. I would assume that you do.

We look forward to your comments. Thank you for joining us today.

[Dr. Sandy Simpson]

Thank you very much, Mr. Sorenson and the committee, for hearing from us.

My name is Sandy Simpson. As you've said, I'm the clinical director of the law and mental health program at CAMH. I'm also head of the division of forensic psychiatry at the University of Toronto. Thank you for the opportunity to speak to you today.

CAMH is the largest mental health and addiction hospital in the country. We are involved with and interested in issues of substance misuse and criminal behaviour, among other things, and welcome very much the opportunity to speak with you today.

I'm a psychiatrist by trade. I'm relatively new to Canada. I came here 16 months ago. I'm from New Zealand, where I have 20 years experience in developing and running forensic mental health services there, and have done research in and service development in prisons in the area of mental health and addictions over the last decade or so.

To perhaps contextualize a little bit of the clinical work that law and mental health does, we have 165 beds at CAMH. We provide assessments, treatment, and rehabilitation services for review board patients under the Criminal Code, persons found NCR or persons unfit to stand trial. We have 300 patients in the community, about a third of Ontario's forensic mental health population.

We also provide court-related assessment services, a little bit of treatment services into the prison, and have a specialized sexual behaviours clinic, which has had contracts with Correctional Service Canada around the care of high-risk sexual offenders.

What is the nexus between substance misuse, abuse, and dependence, mental health problems, and the law? As the committee is well aware from the work that you've done previously, it is a highly prevalent problem, both among persons who are incarcerated.... Various epidemiological surveys show that, depending on where you put the severity cut, anywhere up to 90% of a standing prison population will have a lifetime problem of substance misuse or dependence. If one adds gambling to that, frequently comorbid with a number of those problems, substance misuse is a driver of crime. It is a driver of mental ill health and it is also a barrier to recovery, wellness, and reducing recidivism. Patently, it also represents major security and safety risks within the prison.

Our own experience is relatively limited to providing treatment services in prisons, and that is primarily focused around the persons who have a serious mental illness. For them, over 90% of them are comorbid for substance misuse as well. So the whole thing works together as one aspect of the problem. Frequently their offending is in part related to the need to obtain drugs through minor criminal offending, or a failing that occurs during periods of intoxication, though they may also have a mental health problem.

I guess we are more experts in treatment and rehabilitation than we are in running secure institutions, although the 165 beds I'm responsible for are secure beds. We have security and staff-related safety issues in relation to managing the problems of drugs getting onto our wards and the problems in behavioural dysfunction and staff safety that come from that. So we have a little bit of shared experience with corrections in that regard.

Thinking of it, though, more as a health opportunity, one would want to say that we see imprisonment as a health opportunity. It's not that prisons are of themselves a place for health treatment, but during the period of incarceration, if we're going to think in public health terms, trying to do something about the health needs of prison inmates is a good idea, because most of them will return to the community. If we can return them in better drug and alcohol health, mental health, and infectious disease health, then we're doing positive things for the community as a whole as well as for them. That hopefully will also impact risk of recidivism.

Our evidence will be around issues of systems of care coming from that health focus, rather than quite so much from a security focus, although there may be comments that we can add that might be of assistance in that direction.

Perhaps I'll pause there and pass over to Wayne for the more specialist addictions perspective.

[Wayne Skinner, Deputy Clinical Director, Addictions Program, Centre for Addiction and Mental Health]

Good morning, and thank you, Sandy. It's a pleasure to be invited here today.

My name is Wayne Skinner, and I work in the addictions program at the Centre for Addiction and Mental Health. I'm deputy clinical director there.

My work over the last while actually has been in the area of concurrent disorders--co-occurring addiction and mental health problems. We've done some substantial work in that area. We've also done some work in terms of trying to work with our partners in the system to be more aware that to be working with either addiction or mental health clients is to very likely be working with people who have both sets of problems. Historically, neither of those systems has been well set up to deal with those services.

In the addictions program, we started with a few select concurrent disorder programs, and now we've actually moved to a broader approach whereby we're challenging ourselves to make all of our programs able to include and work with people because of their complexity. Historically, many people with complex problems were excluded from treatment because of the requirement that the other set of problems be either dormant or absent as a condition of entry.

The reality for many people with addiction and mental health issues is that they do have these complex issues. In fact, an axiom I have come to believe in, based on experience and the literature, is that when we're working with people with addiction and mental health problems, severity predicts complexity. Wherever we see people with severe problems, I think we should be challenging ourselves to be seeing what other issues are there. The logic, in my view, shouldn't be to be surprised; we should be challenging ourselves to prove that they're not there. The assumption should be that the complexity is there.

Certainly that means significant change in how we work in systems. When you think of the three axes of corrections, addictions, and mental health, there's a tidy assumption that people who go into those systems have a primary problem. That's how they get sorted in. And if the other issues are there, they're not significant. Actually, what we know from the real lives of people in these systems is that there is huge overlap. We work in addictions with people who have serious mental health issues, criminal justice involvement, and other social problems.

I'm very impressed with the report you issued in December 2010, in which you describe the problem in the correctional system very well. I think it creates a foundation for moving ahead to working on solutions. We don't need to bring the argument to this committee, I think, about the reality of these problems. It's a great opportunity, actually, to be able to sit with you and talk about where some of the solutions might be.

I have personally had the chance over my career to work with people at the Correctional Service of Canada. I've been involved in the National Summer Institution on Addictions that CCSA has co-sponsored in Prince Edward Island over the last decade on a bi-annual basis. One of the things I know is that some very good models of care and products, if you will, have been developed. Some of my colleagues at CAMH and in the addictions and mental health systems across the country have contributed to making really good treatment programs for women and men who are federal inmates. I think that represents an important resource in the criminal justice system for finding solutions for people.

I support the recommendation you make in your report that when we're looking at a policy and at systems approaches, we need to think of these things comprehensively. We need to think about the opportunity to do intervention with people who are in the criminal justice system. But there are also prevention opportunities with these individuals, because they're at risk of having other problems in their lives because of what they're dealing with already. We know about the higher suicide rate and the risks that go along with this population, for example. We know about the domestic violence and the like. To use Dr. Simpson's notion, there is an opportunity for intervention here that we are not making an optimal response to right now. Thinking about how to make better responses is really very important.

The other thing is that these approaches need to be oriented so there are phases to them. How do we identify the individual with these issues? What interventions do we have available to them? How do we support people as we ready them to return to communities, and when they are back into community life? We need to have that kind of phased approach to the work we do to be really successful doing it.

Those are the comments I want to make at this point. I'll stop here. I look forward to your questions.

[The Chair, Conservative, Kevin Sorenson]

Thank you, Mr. Simpson and Mr. Skinner.

We will proceed to the first round of questioning. We'll go to the parliamentary secretary to the minister, Ms. Hoeppner.

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

Thanks very much, Mr. Chair.

Thank you, Mr. Simpson and Mr. Skinner, for being here and for the expertise you're bringing.

We're studying quite specifically the whole issue of drugs in prison and the effect they have, not only on the inmates but on the staff, the officers--the whole picture of drugs in prison. One of the issues with any kind of addiction is enablers--those individuals who are around the addicted person and enable and almost help them. Sometimes they have the best of intentions, but they help the person in a system to continue their addiction.

We've all seen the show Intervention, where families have to come together to create a bottom line so that people who are addicted say “Okay, I'm going to get treatment because there's really no other option”. You transfer that whole idea into the prison system, where you already have people who have kind of reached the bottom already. Their addictions are probably in many cases what caused them to commit crimes or assist in crimes, so now they're in prison.

I wonder if you can answer two questions.

First of all, what can we do as legislators to help families who are maybe smuggling in drugs for various reasons? Many times it's that same enabler mentality. They love their family member and are concerned about them. Maybe they're feeling pressure. There are so many issues surrounding why people who are not addicts would enable an addicted inmate who might be a family member or a friend. Are there things we as legislators can do to assist enablers and empower them to stop what they're doing? We need to make sure drugs aren't getting into the prisons.

Secondly, are we doing anything in these prisons? Are we enabling prisoners and sometimes giving them a soft landing when they need more of a harder floor or a harder bottom?

[The Chair, Conservative, Kevin Sorenson]

Thank you, Ms. Hoeppner.

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

Mr. Skinner might be able to answer that.

[Wayne Skinner]

Those were very stimulating comments. I think Intervention, the TV show, makes great television. It's not best practice, in terms of how to deal with families.

A fair bit of my work has been with families affected by concurrent disorders. We have to be careful here to not characterize family members as enablers in the way you described.

I don't know the percentage on this, but many families are concerned that ultimately they're going to be part of the solution people will need when they return to the community. Having social support and family engagement while people are incarcerated are positive things. The issue of detecting individuals who are collusive with an inmate who wants substances brought in or who think they're actually helping the inmate by doing that has a number of challenges against it, for sure.

Educating folks is an important thing in this regard, but I would frame it quite differently. We need to have more family engagement and support, including support for family members on a peer basis. You could create a culture where you would be promoting the message that the best solution for people with addiction issues in prison is to deal with the addiction, rather than feeding it while doing time.

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

Exactly. I appreciate that. All of us would certainly agree that positive and constructive family interaction is of benefit. But we hear about mothers bringing in drugs for their kids who are in prison. I'm thinking very specifically of people who are smuggling in drugs. There's the whole issue of gangs, drugs coming in because of gangs, and the monetary issue. But I guess I was hoping that with your expertise you might be able to deal directly with family members.

I agree we want to make sure that positive family interaction happens. But very specifically, for those who for various reasons feel guilt, pity, or a variety of emotions that cause them to bring in these drugs, is there something we as legislators can do? I guess you're saying that in your opinion it's more a matter of education, as opposed to any kind of a deterrent.

[Wayne Skinner]

I think education is one strategy. I'm not sure what the deterrent strategies would be except to have better detection as people come in. I do think it's worth noting that people who are in the criminal justice system with substance use problems are more likely than others to come from families that themselves have substance use issues. So being aware of family history and family context might be helpful in terms of the efforts to intervene preventively around this and in terms of surveillance. So that's another element I think is worth noting, that there are inmates whose families have substance use histories and they have perhaps learned these behaviours in the home. I'm not sure if those individuals are more likely to be smuggling substances in or not, but it's another factor I would suggest for consideration.

[Dr. Sandy Simpson]

I would respond on three levels. One is that you must have very tight security and detection at the gates. The best deterrent is your risk of getting caught, not the risk of the magnitude of the punishment. The higher the likelihood that you'll catch people at the gate, the more you will deter.

The second level of response has to be that your family member with the drug problem in prison will get care and support for that. You don't have to do that misplaced caring that you think you're doing by bringing drugs in. The more the prison and the health authorities within prison are saying to families that there is care and support for people who are dealing with these problems, the less families will need to keep fueling those problems.

The third response is dealing as much as you can with the family systems themselves that people will return to, even though in the federal system it will clearly be two years or more before they will get back, and there might be greater distance from the family. The more you can do that and reach out to the healthy members of the family rather than the co-dependent or co-addicted members of the family, the better long-term-recidivism impact you might have.

[The Chair, Conservative, Kevin Sorenson]

Thank you, Mr. Simpson.

We will now proceed to the opposition side.

Mr. Sandhu, go ahead, please, for seven minutes.

[Jasbir Sandhu, NDP, Surrey North, BC]

Thank you.

Thank you for being here today, Dr. Simpson and Mr. Skinner.

It's pretty clear. During this study so far, we've seen the government members attempt to look at the issue of drugs and alcohol in prisons in isolation, focusing narrowly on interdiction measures. Earlier this morning at the justice committee I clearly heard that families play a vital role in integrating the prisoner back into society. The interaction between family members and the prisoner is vital to making sure that the prisoner comes back into society as a good citizen.

On this side of the table, the New Democrat members believe that in order to conduct an effective study, we need a balanced approach that is focused on understanding the problem that exists and on finding real solutions based on evidence and measurable outcomes.

In our prison system, mental health and drug use are interrelated. Overpopulation of prisons and drug use are interrelated. Gangs and organized crime in prisons and the spread of HIV/AIDS and drugs are interrelated. I think we have to look at the whole issue not in isolation but as co-dependent upon a number of different issues.

Having said that, my first question would be to Dr. Simpson. Given the interrelated nature of these issues and the knowledge that prison populations show a greater prevalence of mental health issues than does the general population, Dr. Simpson, could you explain to us how the greater prevalence of mental health problems affects the use and demand of contraband substances in prison? Also, do these drugs play a role in individuals' day-to-day lives in coping strategies?

[Dr. Sandy Simpson]

In answer to the first question as to how the intercorrelation between drug addiction and mental health problems gives rise to more people being in prisons, or with those problems, there are multiple pathways to that in people's lives. We see some people who develop a primary mental illness and who self-medicate to some degree with drugs or alcohol, particularly cannabis, which drives both criminal behaviour and mental ill health.

So you wind up with people in prison with both problems. They have whatever the symptoms of mental illness and distress they may be suffering, but they also have problems of addiction and poor patterns of using drugs to cope with symptoms of illness, which actually, perversely, exacerbate the very problems, coupled, then, with the withdrawal from those effects. You get a complex mix of addiction, withdrawal, and the loss of the health-damaging mechanisms that the person has developed, as well as the mental health problem. Those things wind up getting bound together.

It's not a matter of treating only one. You must be able to address both, as well as the criminogenic drivers from whatever the attitude sets are, and the criminal thinking that the people have as well. People will continue to seek drugs within prison, and that may lead to problems of security, of mental instability, of violence, and of standover tactics and vulnerability and so on that can emerge in that regard, which places security risks between inmate and staff, and there's an inmate-to-inmate violence risk as well. So clearly, being able to address across those multiple levels is very important to both screen for and address health and addiction problems in different ways at different phases of the process while they're in custody.

You made reference to families and community reintroduction at the end. Clearly, whatever those processes are that have gone on within prison, they need to relate to the reintegration approaches that are taken at the end, so that whatever gains may have been achieved during imprisonment are able to be transferred to the community. We're not terribly good at that at the moment, and that's not a Canada-specific statement; that's an international statement.

[Jasbir Sandhu, NDP, Surrey North, BC]

Thank you.

Mr. Skinner, I have a question for you. Given your knowledge of concurrent disorders, can you explain what sorts of outcomes we might expect from a patient who does not receive a holistic approach to their treatment, such as, for instance, if a person were to stop drugs cold turkey but not receive adequate rehabilitation or counselling?

[Wayne Skinner]

First of all, it's worth noting that about three-quarters of people who seek addiction treatment have a prior mental health history. There is an important relationship to note between these. Again, it's just a common thing, so one of the realities we can speak about is that people with co-occurring disorders and who are in the general health care system are more likely to seek help, but we do a worse job of retaining them in treatment and they have poorer outcomes.

So again, one of the problems we have is systems of care that really don't do a good job of addressing complexity in terms of being able to engage people and retain them. Where we're coming from generally is a bit of a disadvantage. We know that when we can offer integrated programs of care with people--and there has been some important research done, particularly with people with severe mental illness and addiction--we do have better treatment engagement and better long-term outcomes.

The interesting thing about some of this research is that the programs that have worked with individuals with severe mental illness and addiction have needed periods of time of up to five years to be able to demonstrate the efficacy of the treatment. If these are long-term interventions with people with chronic problems, you usually don't show an immediate effect. You need time. Then you can demonstrate an effect.

In Ontario, for example, in the 1990s when, for a variety of reasons, there were some reductions in health spending, the government of the day actually--it was a Conservative government--invested actively in ACT teams, assertive community treatment teams, which offered integrated treatment for people with serious addiction and mental health problems. The important thing about it was that the economics were suggesting that by making that investment they were saving money in other ways.

So generally, the advice for people with co-occurring addiction and mental health problems is to have strategies that offer integrated care. There is a high level of confidence that when you do that, even though it requires a particular kind of investment, you produce savings in a whole bunch of different sectors, not just in the health care sector, but in terms of criminal justice and a variety of areas across a person's functioning.

[The Chair, Conservative, Kevin Sorenson]

Thank you, Mr. Skinner.

We'll now move back to the government side with Mr. Aspin.

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

Thank you, Mr. Chair.

Good morning, gentlemen.

I'm particularly interested in your stance on mandatory drug testing. I'd like to obtain the views of each of you on mandatory drug testing within our federal institutions. Do you feel that those who are caught using drugs and alcohol should be remanded further, not just by taking away their perks, but by treating them as they might be treated outside the prison walls with respect to further charges and possible extensions of their prison sentences?

[Dr. Sandy Simpson]

There are two questions in that. One is whether or not we should have mandatory testing; the other is what the response should be to somebody's testing positive.

As many people are in prison for drug-related offences, does testing positive for drugs mean that one is then further punished for the thing one has already been caught for? Is that a thing that warrants treatment? We get to one of the nubs of the problems here: addiction is a problem with health and criminal justice consequences.

How we view a model of response to it, as a health issue or a correctional issue, becomes important for one to be clear about. We can wind up with both systems either tripping over one another or working synergistically. If drug misuse is a major contributor to why somebody is offending, should there be ongoing assessment of whether or not they're still abusing drugs? I think that's perfectly legitimate to do.

From a correctional perspective, what should be the response to somebody's testing positive? Should that be a right that ups your priority for getting treatment for that problem, or does that result in an extension of your incarceration or a loss of privileges? That's the point at which you get mixed messages about whether this is a health or correctional system response.

Why is that important? If you're wanting people from a health perspective to take responsibility for what they're doing, you want them to own up. If owning up is going to result in a worse outcome for them, rather than access to the treatment that they need, then you might drive further underground the problem that you're trying to address. Getting clarity in what we're doing is important.

Does this have to be mandatory for people with drug and alcohol problems in prisons? Yes, I think it probably does, but where it leads is also an important issue to get clear. It should be a process that encourages people to own up to what they're doing and then to access appropriate care. I know of some systems of in-prison drug and alcohol treatment under which a positive test for drug use makes you less likely to get treatment, because you're not yet abstinent, which seems perverse. You'd think it would be an increased demonstration of your need to get into treatment.

We have to be careful about not creating perverse drivers. We want a policy that encourages people to own up and then get access to treatment. This results in greater safety within prison as well as reduced public risk. Mandatory testing for ongoing drug use may well be a reasonable thing to do.

[Wayne Skinner]

From a treatment point of view, we have experience with drug screening. We have clients who want us to do this. We have other people who are reluctant to do it. But we need to determine what model we're operating from. Is this primarily a health problem, or are we trying to impose consequences on people for rule violations? These are two different ways of going about the same thing.

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

Mr. Simpson, you said that you spent 20 years in New Zealand doing your work there. I wonder if you can share with us any experience from that work that would shed some light on our current situation with the drug and alcohol problems we have in prisons in Canada.

[Dr. Sandy Simpson]

There is much that is similar. There are significant things that are different, but much that is similar in terms of the nature of the problems, and I think those are problems with offenders, drugs in prisons internationally. We have similar prevalence rates for drug misuse in New Zealand prisons, not quite the same drugs as here. Alcohol and cannabis are big ones. There's much less crack in New Zealand, much more methamphetamine as a major driver of crime and a major problem in terms of gangs bringing drugs into prisons. We were not too bad at screening for problems, and with quite good focus areas for drug and alcohol treatment within prisons that were quite effective.

The other model that is strong in New Zealand, and is relatively less so here, is culture-based, Maori-based programming using indigenous models of well-being creating.... Maori are the indigenous people, the first people of New Zealand. For them, running treatment services, or more properly for them setting the cultural context in which treatment services occur, both for sexual offender treatment and drug and alcohol and non-violence treatment within the prisons was a very effective thing in rebuilding healthy cultural structures around people. It relates to some of the things we were talking about earlier about families as well, and some of those things, particularly where there are large numbers of first nations people, I think have a number of successful models that could be valuable for Canada to learn from.

The other experience is that we in New Zealand imprison about twice the number of people per capita that Canada does. We're at about 200 per 100,000; Canada is just over 100 per 100,000 now. So the New Zealand fondness, and increasing fondness, for incarceration was leading us to quite difficult positions as well, and major problems with keeping up with the health needs of our rapidly rising prison population. It's a problem that's clearly been anticipated here, and much has been written about it at the moment.

[The Chair, Conservative, Kevin Sorenson]

Thank you very much, Mr. Simpson.

We'll now move to Mr. Scarpaleggia.