Reprinted from "Criminal Justice" issue of Visions Journal, 2005, 2 (8), p. 27-29
While crime and prisons are never far from the minds of the media, many dimensions of prison life are little known and often distorted in the eye of the public. Perhaps no other segment of the prison population is as poorly understood as those who suffer from mental illnesses. Typically, they are men and women with major psychiatric disorders—schizophrenia, bipolar disorder, and major depression, for example. An array of developmental disabilities frequently compounds their illnesses and, all too often, they bear the physical and psychic wounds of family violence. Add to these disadvantages substance abuse and you have a formula for individuals who occupy the lowest rungs and maintain the feeblest grasp on our social ladder.
Some offenders with mental disorders are incarcerated in the federal correctional system rather than in provincial mental health facilities because they have been judged responsible for their crimes despite their illnesses. Their histories of abuse often fill the records of social agencies, police, courts and prisons. They can be dangerous, mostly when not treated; they are often unpredictable and, for the majority, reintegration potential is low. These are the inmates that CSC employees—psychiatrists, psychologists, nurses, and security staff—deal with every day at regional treatment centres across the country.
An Increasing Population
Their numbers are growing. Statistics show that over the past seven years there has been an 80% increase in the number of inmates who on admission to CSC facilities are taking prescribed medication for a mental health problem. There has been an increase of 61% over the same time period in the number of inmates who, on admission, report having a psychiatric diagnosis.
Each region has a treatment centre to deal with the most seriously mentally disordered offenders. At the Ontario Regional Treatment Centre (RTC) inside the walls of Kingston Penitentiary, at the time of writing, 114 inmates were being treated. They have been admitted on a priority basis while others, back at their parent institutions, await their turns. Fiftyfive are lifers and 99, in total, have little chance of ever being freed on statutory release. They come from institutions across the region where they could not fit or function in the mainstream population. Often preyed upon by more able prisoners, these mentally disabled prisoners get moved into segregation for their own protection, they have withdrawn into themselves or, conversely, acted out in an aggressive manner. By the time they reach the RTC, they are in serious need of further treatment.
The Acute Care Unit
On 1B, the RTC Acute Care Unit, stabilization is the first goal. “Men arrive here in crisis,” says Correctional Supervisor Les Jung. “If we can stabilize them so that they can function within the normal correctional environment and participate in their correctional plan at their parent institution—that is one of our measures of success.”
From a therapeutic angle, the measures are different explains Occupational Therapist Crystal Grass. “Success here is measured not only from a correctional standpoint but by mental health measures from the time they arrive at the acute care ward to the time they are living in a more communal setting, getting up and showering in the morning, holding a job in the institution or going to school. These are the real measures of success from our point of view.”
The Cornerstone of Treatment
Psychiatrist Dr. James Hillen is one of the first of the interdisciplinary team to assess an inmate who presents with symptoms of mental illness. “When they come to me, it’s because they want help. I listen to what they say and, more importantly, how they express it. I’m judging their ability to process thoughts, first by asking them very openended questions that require thought organization. In someone with a mental illness, that thoughtprocessing ability has broken down.”
Dr. Hillen says that medication is the “cornerstone” of treatment. The right combination of drugs helps to stabilize inmates so they can once again comprehend their surroundings. “We have no cures for mental illness but we can treat the symptoms very effectively. Medication affects neurochemistry and reestablishes equilibrium within the brain,” Hillen explains.
Not all the inmates are willing partners in their own treatment. Some are so disturbed when they first enter an RTC that a psychiatrist must certify them as a danger to themselves or others in order for them to be treated without their consent. It takes anywhere from 8 to 12 weeks for patients to stabilize.
Margo Butler - Correctional Programs Officer, Regional Treatment Centre
“We focus on the positive and try to build [inmates] confidence. Many of them have had little positive reinforcement in their lives. Although the measures of success are different than those for the general population, the rewards from helping to alleviate the torment of their mental illness are great.”
Spotting Trouble Early
“Ideally, we try to spot early signs of illness in these men before there is a need to send them to the RTC,” says Dr. Hillen. “If the illness is identified in its first stages and treated, the prognosis is better. The cost of medication is small compared to that of treatment and care later on in the disease process.”
Once stabilized, a patient is moved from the acute care unit to another unit where he can interact with inmates and staff and deal with issues that are part of his correctional plan. He benefits from the expertise of psychologists, social workers, occupational therapists, and others who have special experience dealing with inmates with mental disorders.
In the same vein, medical staff at the RTC, Pacific Institution launched a pilot project for identifying mental illness in its early stages. Psychiatric nurses carried out a comprehensive screening process of all new inmates. RTC interdisciplinary teams (and case management for follow-up) targeted those at greatest risk, and treating their mental health needs became the first priority in their correctional plans. Those requiring immediate psychiatric care were quickly moved from the general population to the RTC before they had a chance to deteriorate.
A secondary benefit of the project: psychiatric nurses were able to deal with their patient’s fears and anxieties, which many new inmates experience when first incarcerated. As a result, correctional officers reported the number of disturbances had dropped inside the reception centre.
Dr. Art Gordon, Executive Director, Pacific RTC comments, “We were able to reach out to more inmates who otherwise might not get the chance to see a mental health professional. It was an excellent project and we are hoping to get it funded and back in operation.”
A second project in Pacific Region involves two ambulatory psychiatric nurses, Dave Kereliuk and Trevor Nicholl, who last year made more than 1,400 contacts at institutions across the Pacific, following up with inmates who had been treated previously at the RTC. The goal of the project is to assist staff at regional institutions to support and maintain gains that have been made at of the treatment centre. The nurses will also accept referrals from any institution and pass them along to RTC psychiatrists concerning potential new cases.
“Their input is of great value to the case management team,” says Dr. Gordon. “They make a huge number of contacts; it’s an extremely valuable service that we hope can expand into the community so we can ensure continuity of care. Again, we hope to get funding for this extremely effective and relatively low cost service to continue.”
The Intensive Healing Program
Moving eastward across the country from Pacific Region to Saskatoon, it is worth noting the work done in the Intensive Healing Program at the Churchill Women’s Unit of the CSC Regional Psychiatric Centre. Its goal is to improve the mental health of women offenders, often through the use of short-term behavioural agreements and monitored behavioural checklists. When treatment goals have been reached, patients are discharged to their home institutions, much as they would be discharged to their homes if they were hospitalized in the outside community. The Churchill Unit is the only CSC based option for the intensive care of women offenders experiencing episodes of acute mental illness. The Unit has admitted women from each of the five CSC regions, as well as Saskatchewan women on remand, and on provincial sentences.
Audrey Hobman, a program officer in the Intensive Healing Program comments, “Components of the program have a special Aboriginal perspective due to the large numbers of Aboriginal women participating. We add Native teachings, a touch of humour, and we depend on the counsel of Elders who are an integral part of the program.” Audrey, a Nakotan woman from the Carry the Kettle, First Nation, has shared some of the hardships that many of her patients have been through. She, too, was a part of what Native people call the “1960s scoop” during which Aboriginal children were taken from their families and placed in non-Aboriginal foster or adoptive homes.
“Not only did they lose their families but their language, their culture and their community connections as well. This loss of identity,” says Audrey, “has contributed to their illnesses and to getting into trouble with the law. We help them understand what their family roles can be outside of the institutions and help them prepare to be those things—mothers, daughters, aunties—once they are released. We try to make them see that they are something besides ‘offenders’ and that they can fit in somewhere else.”
Into the Community
treatment centres across the country have expanded their roles, arranging interdisciplinary community supports for those about to be released. This is not an easy task; both provincial and municipal resources have shrunk in recent years and psychiatric beds are in high demand. “And there is still the stigma connected with mental illness,” says Ontario RTC Psychologist Dr. Dorothy Cotton. “Ordinary people react with fear to the mentally ill. They often equate their odd appearance or behaviour with danger. And not all halfway houses are equipped to handle these people, nor are they obligated to accept them.”
CX II larry sharpe and inmate in 1 - Rtc acute care unit
Despite the daily difficulties in handling inmates with mental disorders on the acute care unit, Correctional Officer II Larry Sharpe balances security enforcement with compassion. He goes out of his way to bring the inmates small comforts and encouraging words. Once stabilized, inmates move out of high-security acute care to a more open environment. Other correctional officers at the RTC, such as Kevin Sweeney, are qualified psychiatric nurses as well as possessing security training. “At the RTC, we have the opportunity to interact with inmates on a more personal level,” he says, “and work closely with medical staff, teachers and parole officers.”
New Demands on the System
In a presentation to the Kirby Senate Committee on mental health in February 2005, spokespersons for CSC pointed to four areas where new funding is needed: thorough mental health assessments for all offenders at reception; maintaining consistent standards in all five RTCs across the country; establishing intermediate care units in some regular institutions; and creating a community mental health strategy that will ensure continuity of care for inmates once they are released.
Recently, Minister Anne McLellan announced that almost $30 million in new funds will be available over the next five years for the community mental health strategy.
The psychiatric problems of federal offenders are numerous, complex and longstanding and the quality of treatment provided by CSC has a direct effect on the success of releases into the community and, ultimately, on the safety of the Canadian public. Despite the many obstacles they must overcome, including increasingly tight budgets, staff at RTCs across the country are working hard to ensure that offenders with mental disorders receive the best care possible.
Greg Kane - Registered Nurse, Regional Treatment Centre
Greg Kane, a 31-year veteran of the Service, is a nurse on 1B—the acute care psychiatric unit—where inmates are first admitted to the RTC, many of them in psychotic states due to full-blown mental illnesses such as schizophrenia. They may be homicidal, suicidal or attempting to injure themselves and require round-the-clock monitoring for their own safety, the safety of staff and for treatment.
“We have some of the most dangerous offenders in the entire country here,” Kane comments. “Staff must use extreme caution in their day-today interactions with them. People work in this stressful environment because that’s where they choose to be. They want to be here. And there are benefits: everyone on the team is part of the decision-making process; we take pride in doing our jobs well, knowing that we are effective. We can see the positive results in the inmates. ”
About the Author
Communications Officer, Communications and Citizen Engagement, Correctional Service of Canada (CSC)