Remarks for Howard Sapers
Correctional Investigator of Canada

Mental Health and Corrections

Presentation to the
Pacific Region National Joint Committee of Senior Criminal Justice Officials
2014 NJC Police/ Parole/ Crown Workshop

February 25, 2014 @ 9:30-11:00
Justice Institute of British Columbia
New Westminster, BC

It is a pleasure to be here. Thank you to the workshop organizers for the invitation to address you this morning.

Today I would like to provide some remarks on how the federal correctional system meets the needs, challenges and costs associated with a population that has complex mental health needs.  

In managing mentally ill people in our society, we should not expect the police, courts, prosecution, parole or correctional authorities to do the impossible. When it comes to corrections, we must remember that prisons are not hospitals. However, that said, some offenders are in fact patients.  I don’t have to tell anyone here just how challenging that contradiction can be.

Let me take a few moments to remind you of my Office’s mandate. The Office of the Correctional Investigator functions as an ombudsman for federally sentenced offenders, those serving sentences of two years or more.

As Correctional Investigator of Canada, I am authorized under Part III of the Corrections and Conditional Release Act to conduct investigations into problems of offenders related to decisions, recommendations, acts and omissions of the Correctional Service of Canada (CSC).

Decisions to commence, or terminate, as well as the methods used to conduct an investigation, are at my discretion. These are broad authorities that aid in the pursuit of fair, accountable, safe and effective corrections.

My Office is a component of Canada’s federal public safety system. In my role, I am fully independent of the Minister of Public Safety and the Correctional Service of Canada. I report to Parliament on the individual and systemic concerns that offenders bring to my Office, and the ability of the CSC to implement solutions.

The Office is an oversight, not an advocacy body; my staff does not take sides when investigating offender complaints. We have access to all documents, facilities and employees under the control of the Commissioner of Corrections. Investigators regularly visit federal penitentiaries to meet with and interview inmates and staff. In our investigations, we look for compliance, fairness and legality.

On an annual basis my Office receives and addresses thousands of offender complaints, contacts and inquires. The Office has 35 permanent staff, most of whom are directly involved in the day-to-day resolution of offender complaints. In 2012-13, investigators spent 337 days in federal penitentiaries, responded to approximately 5,450 offender complaints and interviewed more than 1,500 offenders.  The Office also conducted more than 1,400 use of force reviews and 165 reviews of deaths in custody and serious bodily injury cases.

The top areas of concern most frequently identified by federal offenders in 2012-13 were:

  1. Health care
  2. Conditions of confinement
  3. Administrative Segregation
  4. Cell effects
  5. Transfers

An increasing number of federal offenders present with mental health concerns at admission to a penitentiary:

  • Nearly 40% of male offenders require further assessment to determine if they have mental health needs.
  • 30.1% of women offenders compared to 14.5% of male offenders had previously been hospitalized for psychiatric reasons.
  • In FY 2011-12, CSC delivered at least one institutional mental health service to 48.3% of the total inmate population, with 47% of Aboriginal offenders and 75% of women offenders receiving services.
  • A recent snapshot of CSC data indicates that 63% of federally sentenced women were prescribed psychotropic medication.  In the Atlantic region in particularly, almost 3 in 4 women were prescribed psychotropic medication.

Findings from recent CSC research shows that federally sentenced offenders with mental health disorders are:

  • more likely to be considered higher risk and higher need
  • more likely to be penitentiary placed in maximum security
  • less likely to be granted parole and more likely to be released by statute (two-thirds of the sentence)
  • more likely to serve a greater proportion of their sentence behind bars
  • more likely to be revoked for technical violations of parole conditions
  • more likely to incur more minor and major institutional charges leading to higher rates of voluntary and involuntary segregation.

Source: CSC Research Report: Federally Sentenced Offenders with Mental Disorders: Correctional Outcomes and Correctional Response, May 2012.

This profile of high needs, elevated risk and poor outcomes is increasingly problematic when you overlay the influence of substance abuse and addiction issues on top of mental health conditions. On comparison, offenders with concurrent substance abuse and mental disorders:

  • Had the highest risk and need ratings (employment, attitudes, associates and community functioning)
  • More extensive criminal histories
  • Higher rates of admission to segregation
  • More likely to reoffend

We also know that people struggling with concurrent disorders are at increased risk of coming into contact with the criminal justice system:

  • Upon admission, 80% of federally sentenced offenders have a serious substance abuse problem.
  • Over half reported that alcohol or drug use was a factor in the commission of their offence.
  • Over 90% of offenders diagnosed with one form of mental disorder suffer from at least one other disorder, usually though not always, substance dependence.

Providing prison-based health care is increasingly complex and expensive.  Health care is consuming a greater share of the corrections budget envelope.  The total annual health services expenditure for federal corrections now exceeds $210M.  The cost to provide physical health care to inmates accounts for the majority of the health care budget – almost 70% or $150M annually.  In contrast, mental health care services account for about one-third or $66.4 M. 

The Service has five regional treatment centres which operate under applicable provincial mental health legislation and offer acute and chronic mental health care to inmates suffering from the most serious conditions requiring in-patient treatment. The total capacity of the treatment centres is approximately 680 acute care beds.  The total operating costs of the regional centres is approximately $110M annually.

The CSC is the largest single employer of nurses and psychologists in the federal public service. Today, the Correctional Service employs a total of approximately 1,200 health care professionals, of which the vast majority are nurses followed by psychologists, pharmacists, medical doctors and social workers. 

But even with these employee numbers, the Service still faces serious staffing, recruitment and retention challenges for mental health professionals.  These issues relate to scope of practice, inter-provincial licensing, pay, professional development, and terms and conditions of employment.

For FY 2011-12, the national vacancy rate for all health care positions in CSC was just over 8.5%. The psychologist vacancy rate in 2011-12 was 16% or 51 positions. In reality, the vacancy rate is much higher considering that 50 of 329 psychologist positions (or 15%) were filled by incumbents who are non-licensed staff (or “under-fills”) and cannot deliver the same level or range of services as licensed psychologists. In other words, nearly one-third of CSC’s total psychologist staff complement was either vacant or “under-filled”.

In my 2011-12 Annual Report, I reported that the incidence of prison self-injury in federal penitentiaries is increasing – more than tripling in the last five years.  An investigation released September 30th by my Office assesses the response of Correctional Service to incidents of chronic self-injury among eight federally sentenced women. I would like to share some of the findings and recommendations of this investigative report, which is entitled Risky Business, to provide some further context to my concerns about the capacity to safely manage mental illness in a correctional setting.  I have left some copies of this report and some other publications from my Office in the lobby.  Please help yourself.  You can also check our website if you want additional information.

Over the 30-month period under review, a total of 802 institutional security incidents were recorded for these eight women; just over half of these incidents were reported as self-injury or suicidal events. Nearly one-third of the documented self-injury incidents involved a use of force intervention (e.g. physical handling, pepper spray, use of restraints).

The Office found considerable tension between mental health care and security-focused interventions. Indeed, perceived security concerns, regardless of individual risk, tended to trump clinical or mental health care needs.

Seven of the women served considerable periods of time under some form of seclusion. Five women were routinely placed in administrative segregation following acts of self-injury. Resistive or assaultive behaviour most often occurred after staff intervened in an act of self-injury and was most frequently observed in context of mandatory strip searching required for an administrative segregation or clinical seclusion placement.

In general, security and control responses were found to be disproportionate to the risk presented, inappropriate from a mental health needs perspective and counterproductive to therapeutic treatment aims.

For example, for some women, prolonged periods of seclusion and isolation exacerbated the frequency and severity of their self-injury and/or escalated their resort to other resistive behaviours. Some women associated segregation as a form of discipline or punishment for their acts of self-injury.

Similarly, the frequent use of physical restraint equipment to gain control of, manage or prevent self-injury was often found to be problematic. Although CSC policy directs that physical restraints are neither a medical or clinical measure, some of the treatment plans provided for the “consensual” use of restraints to manage or prevent self-injury.

In some extreme cases, reliance on the near perpetual use of physical restraints was deemed to be a “life-preserving” measure. 

The report contains sixteen recommendations, among them:

  • enhanced training for staff working with chronic self-injurious offenders;
  • strengthened monitoring and reporting on the use of physical restraints in the management of prison self-injury;
  • prohibition on placing self-injurious offenders in conditions of prolonged seclusion or segregation;  
  • appointment of an independent patient advocate or quality care coordinator at each of the five regional treatment centres
  • transfer the most chronic and complex cases of self-injury to external community psychiatric facilities.  

There has been some notable progress.  Since Ashley Smith’s death in October 2007, there has been a significant infusion of new money to resource the main pillars of the Service’s mental health strategy. There is now a well-defined institutional mental health strategy, as well as a community health component.

Offenders are now being screened for mental health problems at intake. Training in mental health awareness has been rolled out across the country and more multi-disciplinary interventions teams are in place to manage complex cases. CSC has also achieved accreditation of their physical health services and realigned the health care functions and reporting relationships at the five treatment centres.  

I am also encouraged by the June 2012 public release of the Mental Health Strategy for Corrections in Canada, a framework document developed by the Heads of Corrections Federal-Provincial-Territorial Working Group in Mental Health, in consultation with the Mental Health Commission of Canada. It is the first national strategy of its kind, responding to a significant need to better coordinate and strengthen services and supports across jurisdictional boundaries.

As significant as these achievements are, the physical conditions of confinement in today’s federal penitentiaries are still far from optimal or healthy.  To quote a recent legal study of prison health:   “(Prisoners may be) …incarcerated in overcrowded, unsanitary, stressful and violent conditions, alongside others who share the same increased health vulnerabilities.  As a result, the prison environment is one marked by disease transmission, environmentally exacerbated health decline and death, and heightened risks of mental illness.”

The design and purpose of the modern penitentiary does not easily lend itself to care and compassion.  Let me illustrate my concerns. I recently visited the new RTC Ontario at Millhaven and was very concerned about some of the conditions under which mentally disordered inmates are confined.  The Regional Treatment Centre (RTC) for Ontario was formerly located within the Kingston Penitentiary complex.  After KP closed on September 30, 2013, inmates that were in the RTC were transferred to two separate institutions.  Those with acute needs were moved to Millhaven, while the remainder was moved, temporarily, to Collins Bay with a final destination of Bath Institution once construction there is completed.  

Some of the most acutely ill male offenders in the system are now held in the old segregation wing of Millhaven Institution. These cells are located on the first floor, underneath the current segregation unit and opposite the special needs unit.  From a community standards and therapeutic perspective, this infrastructure is inadequate:

  • The facility is basically a narrow corridor, not a standalone area within the institution or built to hospital standards.
  • There is very little natural light and poor ventilation.
  • There is no common area for inmates to congregate or eat their meals – offenders prepare their food and return to their cell to eat.
  • The exercise yard is exceedingly small and sterile.
  • Dedicated program rooms have not been completed so programs are currently taking place in a temporary space.
  • There are patient confidentiality issues.

Staff reported to my office that they were concerned with the lack of routine in the unit, noting that this is not conducive for treatment and highly problematic for a population that requires routine as part of their mental health care.  Overall, staff are frustrated that the RTC was moved so early given the disruptions in routine, programming and treatment for these patients.

While I understand that the situation is one where the CSC is ‘doing the best that it can with the resources and facilities available,’ it is simply inadequate.  As a psychiatric facility, it does not reflect community standards of care.

My Office asked CSC to develop an immediate action plan to address the deficiencies.  I know staff and management are working hard to resolve these issues and my Office will continue to monitor their progress.      

On December 19, 2013, the Coroner’s inquest into the death of Ashley Smith reported its verdict and recommendations. The jury’s 104 recommendations touched on a number of the same measures and concerns identified by my Office.  For example:

  • Create intermediate mental health care units in federal penitentiaries.
  • Recruit and retain more mental health professionals.
  • Treat self-injurious behaviour as a mental health, not security, issue.
  • Prohibit the use of long-term segregation of offenders at risk of with acute mental health issues.
  • Expand the range of alternative mental health service delivery partnerships with the provinces and territories.
  • Provide for 24/7 health care coverage at all maximum, medium and multi-level institutions.

I am more convinced than ever that these measures would have a beneficial impact on the Service’s ability to more safely manage mental health disorders.

I want to leave you with a few more thoughts about what I believe to be among the most serious and urgent requirements for prison-based mental health care.  This list is not an exhaustive or comprehensive, but it is an important starting point for initiating dialogue, setting priorities and implementing reforms.

  • First, as I have stated before, there are a handful of mentally disordered offenders whose symptoms, behaviours or severity of illness is beyond the capacity of CSC to safely manage.  These offenders should be transferred to community psychiatric or forensic hospitals as a matter of priority.
  • Second, the use of prolonged isolation or segregation to manage offenders at risk of suicide or self-injury as well as offenders with acute mental health issues should be prohibited – a point reiterated in the Ontario coroner’s inquest. 
  • The conditions that prevail in segregation units (isolation, deprivation) can exacerbate symptoms of mental illness.  Indeed, a distressing number of prison self-injury and suicides occurs in segregation cells under close observation.
  • Third, more staff with training and experience in mental health and psychiatry need to be hired.  Sensitivity and awareness training regarding issues affecting the complex needs of the changing offender population should be added to the training courses of both new recruits and experienced staff.
  • Fourth, the system could benefit from the appointment of independent patient advocates or quality care coordinators, particularly with respect to forensic or psychiatric treatment settings. While I appreciate that health care professionals routinely act as advocates for their patients, additional oversight will help the Service meet the most rigorous standards of professional and community practice. 

While I see these reforms as urgently required and important, I understand that they cannot be accomplished by CSC alone.

All jurisdictions and components of the criminal justice system have important parts to play in ensuring a coherent, integrated and seamless delivery system – a system that begins at first contact and follows offenders as they eventually reintegrate back into the community.

Finally, let me make the pitch that there is much more room to divert the mentally ill into treatment rather than the criminal justice system.  This will take increased Federal/Provincial/Territorial cooperation and a willingness to share risk in order to improve outcomes.

Thank you again for inviting me to speak today at this workshop.  I wish you all the best of success in your work.