Towards a Continuum of Care

Official Title: Towards a Continuum of Care - Correctional Service Canada Mental Health Strategy

Introduction

Over the last several years, addressing the mental health needs of offenders has been identified as one of Correctional Service Canada's (CSC) top priorities. Significant progress against this priority has been made (see the timeline below in Table 1). The current document consolidates and updates components of CSC's Mental Health Strategy as reported in various previous documents, including annual Reports on Plans and Priorities (CSC, 2004, 2005, 2006, 2007, 2008a, 2009a) and internal documents produced by the Mental Health Branch (e.g. CSC, 2008b; CSC, 2009b). This document is intended as an overarching strategy, which is supplemented by mental health service delivery guidelines (e.g. CSC, 2008b; CSC, 2009b), and other strategy documents (e.g. CSC, 2009c, 2009f; CSC, 2002).

Strategy's Objective

Considerable attention has been given to the increasing prevalence of mental health needs of offenders, and the implications of this changing profile (e.g. CSC, 2009d; Office of the Correctional Investigator [OCI], 2009). Addressing the mental health needs of offenders promotes improved quality of life, reduces suffering, respects basic human rights, and meets legislative requirements under the CCRA to provide essential health care services and reasonable access to non-essential services (Livingstone, 2009). Furthermore, promotion of mental health stability may contribute to increased public safety either directly (i.e. by reducing mental health symptoms that are linked to an offender's offending cycle) or indirectly (i.e. by enabling participation in correctional programs to address those factors that support continued offending such as substance use, criminal attitudes, etc.).

Key Principles

The following principles are central to CSC's Mental Health Strategy:

• Offenders are the central partner in their interdisciplinary team and collaborate with staff to develop and monitor their individual treatment plans;
• Mental health services are delivered within a holistic framework, which merges all intervention models including medical, psychological, social, spiritual, correctional and recovery;
• Mental health services respond to the diverse backgrounds and needs of offenders, with particular emphasis on women and Aboriginal offenders^{Footnote 1} ;
• Information sharing respecting policy and legislative requirements is required to support an integrated continuum of mental health services;
• There is a shared responsibility among all invested partners (e.g. CSC, community agencies, etc.) to support an integrated continuum of care for OMDs through their sentence, and post Warrant Expiry.

Mental Health Needs in Corrections

Estimates vary on the prevalence of mental health issues within prison. For example, within the Canadian context, Brink et al (2001) found that 31.7% of 267 new intakes in federal penitentiaries in British Columbia had a current diagnosis, with 12% meeting the criteria for a serious mood or psychotic disorder. Fazel & Dinesh (2002) found that "typically about one in seven prisoners in western countries have psychotic illnesses or major depression" (p.548). Data from Correctional Service of Canada (2009d) indicate that 13% of male offenders and 29% of women offenders in federal custody self-identified at intake as presenting mental health problems, and these rates have approximately doubled since 1996/97. While these rates and definitions vary, it is clear that many offenders enter the system with existing mental health issues. With the continued implementation of the Mental Health Strategy, CSC will better understand the prevalence rate of mental health needs in corrections, which is widely believed to be underestimated based on existing data sources (Ogloff, 2002).

Preliminary data from a computerized mental health screen (Stewart et al., 2009) indicate that approximately 38% of incoming male offenders showed symptoms associated with possible mental health problems that require follow-up assessment by a mental health professional. Ongoing research projects will validate these results, and identify the percentage of offenders who were flagged by CoMHISS who required continued mental health involvement. Other research projects will examine the institutional adjustment of offenders with mental disorders (OMDs) as compared to non-disordered offenders to better understand how the needs of OMDs impact their performance throughout their incarceration and upon release.

OMDs typically present with more than one disorder (often presenting with co-occurring substance use disorders) and have a broad range of service needs (Lurigio, Rollins, & Fallon, 2004). For example Brink et al (2001) found that over 80% who presented with a major mental disorder also met the criteria for a substance use disorder. Many of these service needs are risk factors for continued criminality (e.g. substance use, antisocial personality, employment, housing, etc.; Hiday, 2006) that must be addressed in a holistic and integrated intervention plan.

Mental Health Strategy Components

CSC's Mental Health Strategy is founded upon five key components, falling along a continuum of care from intake through to warrant expiry. The components are (1) mental health screening at intake; (2) primary mental health care; (3) intermediate mental health care (currently unfunded); (4) intensive care at the regional treatment centres; and (5) transitional care for release to the community. These five components are supported by various management practices such as training and professional development, research and performance measurement, and tools to support front-line staff. Figure 1 illustrates the continuum of mental health services that underlie the strategy.

Screening and Assessment at Intake

Effective screening and assessment to ensure timely identification of offenders with mental disorders can significantly contribute to CSC's goal of ensuring safer institutions for staff and offenders. Appropriate referrals to address mental health concerns early in an offender's sentence will enable CSC to proactively respond to their mental health issues as opposed to responding to mental health crises.

The Computerized Mental Health Intake Screening System (CoMHISS) provides standardized processes to identify offenders that require a more in-depth mental health assessment and/or intervention. Early identification of mental health concerns facilitates timely access to mental health services and assists in the development of an intervention strategy for offenders throughout their sentence. Mental health screening normally occurs within 3-14 days of the offender's admission to the institution and follow-up assessments occur within 3 months depending on their mental health needs and priority.

Primary Mental Health Care

Primary mental health services are integrated within the wider correctional planning and institutional supervision frameworks, mindful of the multiple needs with which offenders with mental disorders present (e.g. health, employment, substance abuse, education, programming, etc.). Given the shared responsibility across sectors and stakeholders to address these needs, interdisciplinary mental health care teams collaborate with other institutional resources to provide a holistic and coordinated response for offenders with mental disorders. A spectrum of mental health services is offered, including group and individual interventions in the areas of mental health promotion, prevention and early intervention, assessment and individualized treatment planning, and evidence-based treatment and support services in a manner respectful of diversity (i.e. Aboriginal and women offenders). Interdisciplinary mental health teams also consult with and advise other institutional sectors regarding effective practices and strategies in the management of mental health needs of offenders. Finally, the teams facilitate continuity of care through linkages with treatment centres, community mental health staff and community contractors and agencies.

Intermediate Mental Health Care

Intermediate mental health care units (IMHCUs) and Complex Needs Units (CNUs)^{Footnote 2}  are required to bridge the gap between primary mental health care and treatment centres. The goal of IMHCUs is to address the needs of offenders who are unable to cope in regular institutional settings, but whose mental health problems are not so severe as to require care in a psychiatric facility (i.e. Regional Treatment Centre). IMHCUs will provide safe, structured, supportive care beyond what can be offered through primary mental health care services to meet the needs of this group.

Intensive Care at Regional Treatment Centres

Each region has a Treatment Centre to provide treatment for acute and sub-acute mental health needs. An audit of treatment centres is currently underway, which will identify opportunities for improvement. Intensive mental health services coupled with effective communication and collaboration between treatment centre and institutional staff are key to addressing the acute and sub-acute mental health needs of offenders. When clinically appropriate, plans are put in place to transition the offender back to his or her parent institution, while maintaining the continuum of care to meet the offender's level of need.

Transitional Care for Release to the Community

Transitional care leading up to and following release to the community enhances the existing case management and clinical supervision model. Mental health staff in institutions support OMDs by preparing clinical discharge plans to promote continuity of services and better prepare OMDs for release to the community. Upon release, community mental health specialists at selected community sites provide specialized support to address the particular needs of OMDs, including direct service provision (e.g. crisis intervention and counselling), linkage with community agencies, coordination and support (e.g. accompaniment support, assistance completing forms and applications). Prior to the offender reaching warrant expiry, CSC staff work to establish linkages with provincial or territorial health services and community agencies to avoid breaks in mental health services for OMDs. Effective information sharing, collaboration to ensure a seamless transition from correctional to community health care services is critical to support the reintegration of OMDs.

Management Practices

The five aforementioned components of the Mental Health Strategy are supported by management practices including: (1) professional development for correctional and mental health staff; (2) the development of tools to support staff in their daily interactions with OMDs; (3) and research and performance measurement activities to identify best practices and areas for improvement; (4) partnerships.

Professional Development. CSC developed a two day mental health awareness training package tailored to the specific needs of various front line groups including case management staff, institutional health care nurses, and correctional officers. The training aims to enhance knowledge of mental health issues among staff and to provide effective strategies when interacting with OMDs. Feedback from training attendees and identification of training needs across the service will continue to inform future modifications to the package and the prioritization of target groups to receive the training.

In addition to training for front-line staff, CSC supports mental health professionals to attend professional development activities such as workshops and conferences. Attendance at these events ensures that mental health professionals have access to the most current information on best practices in working with individuals with mental disorders, and facilitates partnerships and networking with colleagues external to CSC.

Tools to support staff. Various tools support front-line staff understanding of complex behaviours (e.g. self-harm), legislation (e.g. information sharing) and other challenges that they may encounter. These tools may include guidelines, case scenarios and templates among others to facilitate consistent, efficient and effective mental health services. The development of similar tools to address future needs that may arise will support implementation and ongoing development of the strategy.

Research and Performance Measurement. Evidence-based practice is central to effective mental health service delivery (Livingstone, 2009; Prins & Draper, 2009). To this end, research projects examining the mental health needs and outcomes of OMDs will inform future developments and updates to the Mental Health Strategy. Performance measurement and related activities will monitor progress in implementing the strategy and support Evaluation and research. Through these activities CSC will be better positioned to accurately measure the prevalence of mental health needs and properly allocate resources to provide timely evidence-based services.

Partnerships. The challenges faced by CSC in responding to the needs of OMDs are not unique to CSC. Provincial, territorial, and international correctional and forensic mental health services often face similar challenges, and many offenders transfer between systems. Sharing of best practices, joint initiatives and cost-sharing offer efficient solutions for agencies to enhance the quality of mental health services for OMDs. Partnerships with universities and colleges offer knowledge transfer and research opportunities to keep CSC up to date on current best practices.

Priorities

Specific deliverables for each of the key elements and management practices outlined above are elaborated in the accompanying Key Projects, which will be monitored regularly and updated on an annual basis. In addition, three key areas are highlighted as ongoing priorities in support of the mental health strategy: 1) funding, 2) recruitment and retention and 3) development of a Pan-Canadian Mental Health Strategy

Funding. Gaps in services may stall or reverse progress in addressing mental health needs of offenders. As such sustained funding for all components of the strategy must be secured to ensure a continuum of services as outlined above.

Recruitment and Retention. Recruitment and retention issues also pose challenges towards the full implementation of this strategy. Particularly in remote areas, hiring qualified mental health professionals has proven challenging. Furthermore, ensuring that staff are effectively supported in their work given the demands and unique challenges of providing mental health services in a correctional environment is a key priority for CSC.

Pan-Canadian Mental Health Strategy. In addition to integration of services within CSC, collaboration with provincial and territorial partners is a key component to the mental health strategy. A federal correctional mental health strategy will provide opportunities for CSC and its partners to better integrate mental health services for all offenders to promote better health and correctional outcomes.

References

Brink, J.H., Doherty, D., & Boer, A. (2001). Mental disorder in federal offenders: A Canadian prevalence study. International Journal of Law and Psychiatry 2, 330-356.

Correctional Service Canada (2002). The 2002 Mental Health Strategy for Women Offenders. Ottawa: Correctional Service of Canada. http://www.csc-scc.gc.ca/text/prgrm/fsw/mhealth/toc-eng.shtml. Prepared by Laishes, J.

Correctional Service Canada (2004). Report on Plans and Priorities - 2004-2005. Ottawa: Author.

Correctional Service Canada (2005). Report on Plans and Priorities - 2005-2006. Ottawa: Author.

Correctional Service Canada (2006). Report on Plans and Priorities - 2006-2007. Ottawa: Author.

Correctional Service Canada (2007). Report on Plans and Priorities - 2007-2008. Ottawa: Author.

Correctional Service Canada (2008a). Report on Plans and Priorities - 2008-2009. Ottawa: Author.

Correctional Service Canada (2008b). Community Mental Health Initiative: Clinical Discharge Planning and Community Integration Service Guidelines. Ottawa: Correctional Service Canada. Prepared by Champagne, D., & Turgeon, C.

Correctional Service Canada (2009a). Report on Plans and Priorities - 2009-2010. Ottawa: Author.

Correctional Service Canada (2009b). Institutional Mental Health Service (Primary Care) Guidelines. Ottawa: Author.

Correctional Service Canada (2009c). National Strategy to Address the Needs of Offenders Who Engage in Self-injury. Ottawa: Author.

Correctional Service Canada (2009d). The Changing Federal Offender Population: Highlights 2009. Ottawa: Author. http://www.csc-scc.gc.ca/text/rsrch/special_reports/sr2009/sr-2009-eng.shtml

Correctional Service Canada (2009e). Computerized Mental Health Intake Screening System (CoMHISS): National Guidelines. Ottawa: Author.

Correctional Service Canada (2009f). A Wellness Path to Health and Safe Reintegration: Aboriginal Health Strategy 2009-2012. Ottawa: Author.

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Fazel, S., & Danesh, J. (2002). Serious mental disorder in 23 000 prisoners: A systematic review of 62 surveys. The Lancet, 359, 545-550.

Hiday, V.A. (2006). Putting community risk in perspective: A look at correlations, causes and controls. International Journal of Law and Psychiatry, 29, 316-331.

Livingston, J.D. (2009). Mental Health and Substance Use Services in Correctional Settings: A Review of Minimum Standards and Best Practices. Vancouver: International Centre for Criminal Law Reform and Criminal Justice Policy.

Lurigio, A.J., Rollins, A., & Fallon, J. (2004). The Effects of Serious Mental Illness on Offender Reentry. Federal Probation, 68(2), 45-52.

Mills, J.F. & Kroner, D.G. (2003). Depression, Hopelessness and Suicide Screening Form - 03: User's Guide. Kingston: Authors.

Office of the Correctional Investigator (2009). Annual Report 2008-09. Ottawa: Author.

Ogloff, J.R.P. (2002). Identifying and Accommodating the Needs of Mentally Ill People in Gaols and Prisons. Psychiatry, Psychology and Law, 9(1), 1-33.

Prins, S.J., Draper, L. (2009). Improving Outcomes for People with Mental Illnesses under Community Corrections Supervision: A Guide to Research-Informed Policy and Practice. New York: Council of State Governments Justice Center. http://consensusproject.org/downloads/community.corrections.research.guide.pdf

Stewart, L.A., Harris, A., Archambault, K., Wilton, G., Cousineau, C., Varrette, S., & Power, J. (2009). An Initial Report on the Results of the Pilot of the Computerized Mental Health Intake Screened System (CoMHISS). Ottawa: Correctional Service of Canada.