Public Safety Committee on Oct. 18th, 2011

[Francis Scarpaleggia, Liberal, Lac-Saint-Louis, QC]

Thank you, Chair.

Good morning, Mr. Skinner.

You were mentioning that 80% of inmates are grappling with a drug addiction problem. Is that correct? Do I understand correctly, or is it just simply 80% who are inmates have used drugs? When we're talking about that 80% of inmates who have some involvement with drugs, are we talking about serious addiction?

[Dr. Sandy Simpson]

Serious addiction. We're talking about more than simple use. The 80% involves...some people have abuse problems, rather than true addiction.

The core addicts might be much more like what, 30% or so, Wayne?

[Wayne Skinner]

Right, but your own report I think gives this figure, and it describes people as having serious addiction. That is more than moderate, shall we say. It's a very significant problem.

[Francis Scarpaleggia, Liberal, Lac-Saint-Louis, QC]

Of this 80% of the prison population who have a serious problem with drugs—excuse me if this question is simplistic—what's the cause-and-effect relationship? Are mental health problems driving these problems with drugs among that 80%, or are some of the problems with drugs of another nature? How would you break that down? I know it's very hard to do that, but if you had to make a point about that, how would you do it?

[Dr. Sandy Simpson]

Yes to all of the things that you listed, I think.

For some people, if you have a risk of developing a mental illness and you also use drugs and alcohol, your risk of manifesting that mental illness goes up. Once you then have the mental illness, the risk of it being worse in terms of its course and outcome is raised by ongoing drug and alcohol use. For some people, drug and alcohol abuse and dependence arises as they self-medicate for low-mood, post-traumatic abuse problems. Aspects of psychosis that some people can self-medicate from results in worsening of the course and outcome. They're not only having the core problem they had to begin with, but now an addiction problem on top. There are other people for whom the problem is a primary addiction one that results in secondary mental health problems as the rest of life tends to decay. So I think all of the above are pathways, and in each individual case you need to—

[Francis Scarpaleggia, Liberal, Lac-Saint-Louis, QC]

But of the 80%, we're dealing essentially with addiction and mental health problems; whether as cause or effect, there's a strong mental health component.

[Dr. Sandy Simpson]

The prevalence of serious mental illness in prison is much lower than that. Psychotic illness runs in a varying rate between about 5% and 8% of the standing prison population; bipolar disorder, around 2% to 3% of the prison population; and current major depression, maybe 15% to 20%, depending upon which study you look at. So the total is about 25% or so.

Between 15% and 25% have one of those diagnoses. Of the people who have one of those diagnoses and are in prison, more than 90% will also have a drug addiction or alcohol addiction problem. Once you have a mental illness, your co-morbidity is very high against the rest of the prison population.

[Francis Scarpaleggia, Liberal, Lac-Saint-Louis, QC]

When someone enters a penitentiary, would you say a large proportion of these new inmates suffer from serious drug or alcohol withdrawal in the clinical sense—not as in wishing they had some substance to satisfy themselves but they don't and are frustrated, but a serious withdrawal problem? Are they coming in with serious withdrawal problems, and are these being treated by proper professionals upon entry into prison?

[Wayne Skinner]

I think acute withdrawal depends on the circumstances of people's entry. Certainly upon arrest some individuals might well be drug-dependent and would show a variety of withdrawal symptoms from whatever substance they were on. That's one level of dependence, if you will. But if people have been using substances as a way of coping with stress and now find themselves in a hyper-stressful environment, their urge to use is going to be very high. That's part of the pathology of addiction, actually: that you really have one way of coping, which is to use substances.

But on your particular question about the moment of entry and whether people are in withdrawal, usually if people are in acute withdrawal they show demonstrable signs that can be assessed and treated.

I'm not sure what the answer is in terms of the numbers.

[Francis Scarpaleggia, Liberal, Lac-Saint-Louis, QC]

And concerning the help they need upon entry, are they getting access to the psychologists? I was told that there are many unfilled vacancies for psychologist positions in our institutions. That would imply that you have a prison population that is dealing with some very serious addiction or other mental health problems that require the intervention of a psychologist and other professionals; yet from the get-go they may not be getting the treatment they need.

[Dr. Sandy Simpson]

If you're talking about acute biological withdrawal, often that will manifest in the police lock-up over the first couple of days after arrest and in the provincial receiving remand prisons, rather than at the federal level. From what I've seen through the contact I've had with those cases locally in Toronto, the health care staff in the prisons are on to that as a risk, and the primary mental health and drug and alcohol screening and general practitioner services there are certainly looking for those things.

In terms of addiction counsellors being available to follow up from there, I think they are thin on the ground, from what I've seen.

Of course, remand prisoners particularly are in very unstable situations. Soon after you've been arrested, you don't know how long you'll be in for. It's an entirely new world—or it may be a familiar one for you, if you're a frequent flyer. For some of those people, engagement at that point is really very important, particularly—and this is a provincial rather than a federal issue, I guess—for the rapidly turning-over remand people, who often have less serious offending but may have major drug and alcohol problems. Getting those people to turn to drug and alcohol treatment at that point is something for which you would get a good bang for your buck.

[The Chair, Conservative, Kevin Sorenson]

Thank you very much.

We'll now move back to Mr. Garrison.

[Randall Garrison, NDP, Esquimalt—Juan de Fuca, BC]

Thank you, Mr. Chair, and thank you to Dr. Simpson and Mr. Skinner for sharing both your time and expertise with us this morning.

I think we have a common concern around the committee table with public safety, and my own view really focuses, since such a high number of offenders have both substance abuse and mental health disorders, on the treatment.

There are two things I'd like to ask about. The first concerns your emphasis on the concurrent substance abuse and mental health disorders. Would you say that corrections treatment programming now reflects that concern well? How well does corrections deal with the concurrent disorders?

[The Chair, Conservative, Kevin Sorenson]

Mr. Simpson.

[Wayne Skinner]

I'm not in a position, actually...because I am not familiar on the ground with their programs and how they are delivered. I am familiar with attempts to develop models; for example, in the treatment of women with substance use and mental health issues some good models have been developed. But I am not sure how well disseminated or available those programs are to people in the correctional system.

I think the understanding of the need to offer concurrent treatment is well established with the staff who do this work in correctional services, but I am not sure about the prevalence of the programs or how they are actually delivered.

[Dr. Sandy Simpson]

I would say similarly, from the work I have done since I have been here in contact with federal and provincial corrections and from the things I have read—both your report from late last year, as well as Howard Sapers' report after the Ashley Smith death—and the contact I've had in terms of the work federal corrections is doing around trying to develop systems of care within corrections, that I have no doubt that federal corrections understands how vital this area of work is.

The people I have spoken with have a strong sense that they have a long way to go in developing the services. They have a vision and drive that they want to implement, but they are the first to admit that services are not where they want them to be now. So the high-level commitment is clearly there, as well as the recognition that although there may be areas where good programming is going on, we don't know much about what percentage of all the people who have need are actually getting it met in the current system. That is clearly one of the answers one would wish the system to be able to give.

[Randall Garrison, NDP, Esquimalt—Juan de Fuca, BC]

To follow up on that, are there models of concurrent programming or treatment that would show differences with respect to gender and cultural background in the concurrent treatment, or are you talking about a more focused approach?

[Dr. Sandy Simpson]

Most of the correctional literature concerns males, obviously, as 90% of inmates are male. The concurrent work, as Wayne was saying earlier, shows that getting your mental health and addictions treatment from the same team works better than farming it out among different providers. Particularly for the people with serious mental illness, the more we can integrate the care with one treatment intervention group, the better. That seems to work for men and for women.

In terms of different models of care, my own experience is that culture-specific programming improves efficacy. Often, people of minority ethnicity or first nations people feel marginalized. Creating therapeutic venues in which their culture is celebrated and given primacy helps them rebuild a sense of self, which puts them in a position in which they are better able to pick up the same therapeutic challenges that everybody else has.

Altering the cultural context within which the same evidence-based practices are delivered improves efficacy. So looking at where you have common cultural groups of sufficient size to permit having some of your programming culturally based would improve the likelihood of its success.

[Randall Garrison, NDP, Esquimalt—Juan de Fuca, BC]

Thank you.

My last question concerns discussion of how long it takes to treat addictions and of there being some implication that people should spend longer times in institutions. Would you say, given the length of time it takes for treatment, that it could be started in an institution and then, with proper follow-ups, be more successfully completed in the community?

[Wayne Skinner]

Yes, I would. In fact, I would say that this is an ideal way of thinking about it.

When we work with people with even serious addictions, the length of time they need to be in a residential program or whatever would be measured at most in months. The important work, actually, is the work of continuing care and change maintenance when they return to the community. That is really the testing point. That is where you need services and supports. I think the same model would apply in criminal justice.

[The Chair, Conservative, Kevin Sorenson]

Thank you very much.

We will now move back to Ms. Young.

[Wai Young, Conservative, Vancouver South, BC]

I'd like to echo my colleagues. Thanks for your very insightful and interesting testimony this morning.

I now would like to take us back from looking at individual mental health issues, as we've been discussing in these last series of questions, to looking at systems. Obviously in the correctional system we have certain programs in place. Let's bring that back a bit, in particular noting Mr. Sandhu's comment earlier and to remind the NDP members of this committee that they did vote against the $122 million that this Conservative government put toward primarily preventive programs. We heard from the corrections office head that this has resulted in a decline of drug use in prison from 12% to 7.5%, which is substantive, I understand, and an envy internationally. We now have countries across the world coming to see what Canada's doing that has resulted in this great outcome.

I think this government has been outcome-focused, and it has put a substantive amount of funding into preventive programs. We're seeing the fruit of that investment in this. Having said that, though, I want to acknowledge that while people are still in jail and there's still the prevalence of drugs, that's why we're conducting the study and that it is important. We acknowledge that we perhaps need to take a multidisciplinary approach to this, and that's why you from the mental health centre are here today. We hope to also hear from people from the justice system as well.

Drug addiction in jail is obviously not an isolated issue. It's like peeling back the tree bark, in that we now seem to be seeing roots all over the place. Issues spring up in the community. It's obviously a key focus in terms of marketing and the whole system that's in place around drugs in jail. We know the money is coming in and out, so it appears to be a far bigger issue than inmates being addicted in jail.

What other measures can we leverage or develop to further support the goal of establishing a drug-free prison? I want you to think specifically about systems and operations as opposed to individuals at this point. Do you have recommendations for us?

[The Chair, Conservative, Kevin Sorenson]

Thank you, Ms. Young.

Mr. Skinner or Dr. Simpson.

[Wayne Skinner]

It's obviously a very important question: drug-free prisons from a systems point of view. When I think of what goes on there, I think right now of prison cultures that are very oriented to obtaining and using drugs. So are there things you could do to shift that culture or to create cultural alternatives for people in prison? That would be one thing I would think of doing.

Obviously, availability is a huge factor, so the ability to intercept or to reduce efforts people make to get drugs into prisons is a key element here.

I think the other thing would be actually trying to create a more health-oriented culture in prisons, where people are actually starting to go back to what Dr. Simpson mentioned at the beginning. Nobody wants to be in jail. However, is jail an opportunity to actually do a turnaround in your life, and are the resources there to support that?

When we talk with people who are trying to deal with addictions, they often are reluctant to change, and maybe, even worse, they don't believe they are personally capable of change. They'd love it perhaps, but they consider themselves losers. By creating a recovery culture in treatment that actually starts to get people to imagine that things could be different for them, you see change happen. That is a process. It takes time.

So changing the prison environment from one that is itself perhaps criminogenic to one that is more therapeutic I think would be an important thing for these individuals.

Those are some of the areas I would look to.

I found this very interesting. I was invited to speak to correctional staff because some of the work I do is in motivational interviewing. The staff were incredibly interested in using a whole different frame of working with people that is actually more strengths-oriented and more empowerment-oriented.

So there are these approaches we could pursue in trying to change. I see it as a bit of a culture shift that you'd be initiating in the prison environment. You actually indeed could make it more of an opportunity. I firmly believe this. I think there is evidence to guide that, actually. So it's not just my enthusiasm, which I hope I'm conveying, but also I think that if you looked at the evidence, it would lead you to want to do that and would tell you how to do it.

[The Chair, Conservative, Kevin Sorenson]

Thank you, Mr. Skinner.

Mr. Chicoine, you have five minutes.