From Incarceration to Reintegration: Using the Human Services Model to Manage Canadian Prisoner Mental Health

Abstract

The effective delivery of mental health services in Canadian institutional settings has traditionally posed a challenge to the criminal justice system. Ineffective treatment options and methods of program delivery, inaccurate assessments and security classifications, the conditions in which prisoners live, restricted access to mental health professionals, high levels of individual strain, fragmented service administration, and a lack of continuity of care during the transition back to the community have all been found to have a significant negative impact on inmate mental health. The purpose of this paper is to review, and critique, the current literature on Canadian institutional mental health care and, based on this literature, make suggestions on how to improve the current system.

Institutional Management of Inmate Mental Health

Within Canadian institutions, mental health care starts with the screening and assessment procedures performed at intake. Accurate and in-depth assessments are crucial to identifying mental illnesses and inmate needs (Dupuis et al., 2013). Unfortunately, the current intake and assessment process is flawed (Dupuis et al., 2013) as the risk assessment tools being utilized only consider mental health concerns in the context of the inmate's risk level as opposed to a strictly clinical assessment, which could more appropriately detail the nuances of an individual's particular mental health struggles (Schizophrenia Society, 2012).

Compounding the difficulties presented by the inaccuracy of the screening process is the lack of properly trained staff to conduct the assessments. The Correctional Service of Canada (CSC) published a report stating that they have no record of who administers intake assessments, or what training and credentials they have (Evaluation Branch, 2009). The Schizophrenia Society of Ontario (2012) also found that stigma, and groundless beliefs surrounding mental illness and criminal behavior, leads to mentally ill inmates being classified as posing a higher risk. The consequences of inaccurately identifying an incarcerated person's risk profile are significant as an incarcerated person's correctional plan, rehabilitative progress, and reintegration potential could be based on incomplete, inaccurate, or nonrelevant information (Evaluation Branch, 2009).

Staff members cannot be optimally supportive of client progress if they are not up to date with current best practices and fully educated about treatment options. A study of New York institutional treatment staff found that staff who administered programming averaged a score of 70% on a test of their own program, and medically credentialed staff who provided services to participants averaged a score of 45% (Strauss et al., 2006). Formally educated staff who are trained in psychologically relevant and clinically informed treatment options can better minimize risk in incarcerated persons, as they have a deeper understanding of the goals and purposes of treatment and are more equipped to deliver programming effectively (Dowden & Andrews, 2004).

The Canadian federal government established the Institutional Mental Health Initiative in 2008, with the primary goal of overhauling the screening and assessment process by mandating that each incarcerated person be assessed four times within their first 14 days of incarceration. However, Dupuis et al. (2013) found that the majority of new admissions receive the first two assessments but less than half receive a third or fourth. The Schizophrenia Society of Ontario (2012) reviewed six other Canadian initiatives at both the provincial and federal levels between 2008 and 2012, including the CSC Mental Health Strategy, the Offender Program Tracking Module, and the Computerized Mental Health Intake Screening System. The initiatives included propositions of multistage assessments and more advanced assessment tools, multimodal forms of treatment, and the training of mental health care professionals to work within institutions. The review found that every single initial deadline for each of the initiatives had been missed and not a single member of staff had been trained specifically as a result of the initiatives (Schizophrenia Society, 2012).

The Institutional Environment as a Catalyst for Mental Health Issues

Correctional institutions have clear goals of control with social activity, to establish rhythms and develop habits, impose certain tasks and occupations, and to regulate this cycle in repetition, leaving incarcerated persons with little choice in their social world and causing issues among those who do not operate well in a pseudomilitary routine (Foucault, 1977). Emotionally, correctional institutions separate individuals from their friends and family, the effects of which often manifest in mood disorders, such as depression (Goomany & Dickinson, 2015). Organizationally, the institutional regime, culture, and structure cause a loss of autonomy and foster subcultures of drug use and violence, so much so that a study by Harty et al. (2012) found that nearly 85% of incarcerated persons misused substances. Overpopulation or poorly maintained environment of institutions can damage mental health (Appelbaum, 2011). The United States faces some overpopulation challenges in correctional institutions; while the country accounts for 5% of the world's population, it has 25% of the world's incarcerated population (Kantorowicz-Renichenko, 2018). These overpopulated institutions must deal with strained resources available to staff and restricted ability to provide mental health care (Goomany & Dickinson, 2015). Combined, these factors can exacerbate the symptoms of mentally ill incarcerated persons or contribute to the onset of wellness concerns for individuals who previously did not struggle with mental health concerns (Goomany & Dickinson, 2015).

Effective Management of Mentally Ill Inmates

The current structure of Canadian institutional mental health care is fragmented and poorly implemented, resulting in incarcerated persons never receiving treatment, or receiving inadequate care (Reingle-Gonzalez & Connell, 2014). In 2014, Reingle-Gonzalez and Connell performed a systematic review of the rate at which various federal mental health services were accessed and found that 36% of mentally ill incarcerated persons used institutional counseling services and 21% used self-help groups, while only 18% of those who could benefit from medication were currently taking medication and 61% of those who were medicated did not access any other treatment. Of particular concern is the fact that up to 50% of incarcerated persons who reported being on psychiatric medication at intake did not receive medication in the correctional institution (Reingle-Gonzalez & Connell, 2014).

Incarcerated persons who were not diagnosed with a mental illness prior to conviction but were diagnosed as mentally ill during the institutional intake were even less likely to receive appropriate treatment. They were found to be at a high risk of treatment failure, as the process is very seldom individualized and not delivered on a case-by-case basis; rather, it is delivered to groups of people who meet a particular set of criteria (Reingle-Gonzalez & Connell, 2014). This speaks to the need for a multifaceted approach, one that combines clinical assessments with direct referrals to any relevant and applicable services, to be administered and supervised by trained mental health care professionals (Reingle-Gonzalez & Connell, 2014).

Appropriate mental health care, or lack thereof, has been shown by Konrad and Opitz-Welke (2014) to significantly impact recidivism rates. Instead of receiving treatment, mentally ill incarcerated persons are often subject to punishment due to misbehaviors, which occur partially as a result of their symptoms (Konrad & Opitz-Welke, 2014). Due to the negative effects of punishment on mental health, in combination with the institutional setting, disciplinary measures such as solitary confinement should be eliminated as a management strategy for mentally ill incarcerated persons and replaced with clinically informed methods of treatment delivered by trained professionals (Konrad & Opitz-Welke, 2014).

The lack of mental health care treatment delivered in Canadian correctional institutions is a leading cause of recidivism (Goomany & Dickinson, 2015). Gagliardi et al. (2004) report that mentally ill incarcerated persons recidivate at a rate of nearly 75% compared to less than 50% among those who are not mentally ill. This difference is concerning, considering that findings by Anestis and Carbonell (2014), Rotter and Carr (2011), and Visher and Travis (2011) show that effective treatment can reduce recidivism in mentally ill incarcerated persons by nearly 10%.

Human Services Overhaul

Despite all of the flaws and challenges facing the Canadian mental health care system within institutions, there is evidence to support the implementation of human services-oriented treatment programs. The programs that adhere to this philosophy and are currently being delivered within Canadian institutions largely focus on relationships, thought processes, communication, and emotional management, helping incarcerated persons to more intimately understand their risk factors that lead them to criminal behavior (Evaluation Branch, 2009). The central principles of the programs are in line with a human services philosophy, but their delivery is not. Substance abuse, anger management, anti-criminal thinking, domestic violence, and sexual offending programs are considered “non-core” rehabilitative programs and are only offered at specific sites in Canada. Furthermore, incarcerated persons cannot access these programs in the community if they have not completed them within the institution (Evaluation Branch, 2009; Schizophrenia Society, 2012). This means if an incarcerated person is inaccurately assessed and sent to an institution that does not offer the programs they need, they may never receive the treatment that could benefit them.

In 2010 and 2011, CSC piloted two programs to train staff and offer more individualized programs; however, neither program was ever implemented due to budget restraints (Schizophrenia Society, 2012). The result of these failed pilot programs is that correctional institutions continue to be marred with untrained staff, which results in mental health professionals being largely limited to determining and distributing medication, and they are even restricted in this regard (Schizophrenia Society, 2012). They face obstacles including an inconsistency in dispensing procedures among institutions, an inability to acquire medications in a timely manner, problems obtaining accurate medical histories for incarcerated persons, and a lack of options and avenues for educating incarcerated persons on their treatment needs and the effects of their medication (Schizophrenia Society, 2012). Canadian correctional institutions must be staffed with more mental health professionals and provide more training if the structure of mental health care is to be made functional.

The Practical and Proven Use of the Human Services Model

In order to most effectively treat mental illness in incarcerated persons, institutional programs must adopt a human services-oriented model of treatment. Human services-oriented programs are effective because they focus on change at the individual level and impacting the incarcerated person's thought processes and behaviors permanently (Visher & Travis, 2011). These programs follow the five principles of effective treatment and use them as guidelines to shape the content of the interventions. These principles include strong program integrity, the identification and attempted modification of criminogenic factors, employing a multimodal treatment approach to address multiple facets of treatment, using actuarial risk assessments and classifications in order to accurately treat patients of various risk levels, and ensuring responsivity between the person's learning style and the mode of program delivery (Lattimore & Visher, 2013).

One study by Lattimore and Visher (2013) analyzed nearly 1,700 recently released adult males, half of whom were attending one of 12 human services-oriented reentry programs, and found these programs to be crucial to reentry success. Overall, participants involved in these programs were more likely to have full needs assessments prior to their release and to have a release plan developed compared to those who were not involved (Lattimore & Visher, 2013). They also reported lower rates of drug use, a 2% reduction on average; participants were 12% more likely to find stable employment upon release, and most importantly, were 35% more likely to secure housing than those who did not (Lattimore & Visher, 2013). This last point regarding housing is the most encouraging, as the link between mental illness, homelessness, and incarceration has been shown time and time again (Lamb & Weinberger, 1998).

Human-services principals have been adopted and are being implemented by many community-based treatment alternatives in Canada, such as intensive case management, diversionary programs, and mandated assisted outpatient programs (Markowitz, 2011). As mentioned previously, effective transitional monitoring to ensure that incarcerated persons have a human services-oriented program or service waiting for them upon release is key to reentry success. A study of nearly 2,000 released mentally ill incarcerated persons showed that those who were immediately connected to programming upon release and had a case manager working to ensure their attendance were 52% less likely to recidivate in the first 12 months of release than those who were not connected to programming (Case et al., 2009).

Continuity of mental health care during the transition to the community is essential to avoid recidivism (Harty et al., 2012). Community engagement for incarcerated persons on release, such as group therapy and counseling, can increase their ability to integrate into social groups and has a positive effect on their mental health (Caie, 2012). Aside from the direct and intended effects of the treatment they receive in these settings, simply participating will positively and indirectly support their mental health as it provides structure and stimulation to their daily lives. The majority of people released from institutions will initially live with a family member, which makes that family member a potential link for continuity of care; therefore, providing these family members with mental health and drug abuse support is crucial (Caie, 2012; Visher & Travis, 2003). Improving engagement with community supports will allow formerly incarcerated persons to receive appropriate mental health care during and after the transitional period of release, and potentially reduce recidivism rates.

Recommendations

There is Canadian legislation in place that aims to aid in the provision of services including social assistance, health care, education, skills development, and housing by partnering the justice system with public health and community outreach organizations (Pogorzelski et al., 2005). However, the appropriate efforts are not being made under this legislation, as nearly every initiative that has been undertaken to address the administration of institutional mental health care in Canada has failed to be implemented properly (Schizophrenia Society, 2012). Despite the intentions of progressive legislation and policies, the incompetent implementation of these resources is undermining the reintegration potential of incarcerated persons.

A comprehensive, cross-disciplinary, and multimodal approach to institutional mental health care is needed to replace current practices. The ideal system is one that combines clinical assessments with personalized treatment and guaranteed continuity of care, to be delivered by trained and certified mental health professionals (Blaauw et al., 2000). Treatment programs must begin in the institution and persist through the transitional period, until the individual is stabilized in the community (Lattimore & Visher, 2013; Visher & Travis, 2003). Programs have to drive individual-level change by altering antisocial thought processes and beliefs and directly addressing criminogenic risk factors (Dupuis et al., 2013; Lattimore & Visher, 2013; Visher & Travis, 2003, 2011). Policies and procedures should be developed that mandate staff training, implement multilevel mental health assessments and more personalized assessment tools, establish quality transitional period management, and invest in coordinated relationships with community organizations that support released incarcerated persons (Lamb & Weinberger, 1998; Pogorzelski et al., 2005).

Limitations

The findings and recommendations of this review must be interpreted in the context of its limitations. As the findings reported throughout this review come from varying contexts, the generalizability of these results is limited (Broome et al., 2007; Hartzler et al., 2014; Margetić et al., 2012; Reingle-Gonzalez & Connell, 2014; Strauss et al., 2006). The majority of the reviewed research studies involving correctional populations were conducted in Canadian institutions, restricting the generalizability of these findings. The European correctional system has traditionally favored programs and modalities that promote rehabilitation and reintegration, whereas the American correctional system has favored restitution and punishment (Costelloe & Langelid, 2011; Subramanian & Shames, 2013). Both the American and European systems differ from the Canadian in assessment and intake processes, legislation, and treatment delivery model. The differences in these approaches result in varied issues and achievements within the systems, and the successes of other systems should be looked at for best practice recommendations.

Further Research

The most significant limitation of this investigation is the generalizability of the information presented, which warrants further research in several key areas. In comparison, European correctional institutions are significantly more effective in treating mentally ill incarcerated persons (Konrad & Opitz-Welke, 2014). Further research should probe the successes of the European systems, the principles of treatment, and how treatment is delivered to gain perspective on best practices for managing mentally ill incarcerated persons.

Further research is required in comparing the effectiveness of the mental health system's ability to reduce recidivism rates by addressing mental health concerns to the traditional correctional system, as well. The current literature supports the methods and intentions of treatment in the mental health system; however, the majority of the research does not account for the different objectives of the two systems, rehabilitation versus restitution (Anestis & Carbonell, 2014). Additionally, the current research on this subject is limited and there is very little evidence to establish the reliability and validity of the findings. Further research should prioritize replicating previous findings of the mental health system's effectiveness, which would establish consistency, and should consider the potential for misinformation and bias in self-reporting studies before these findings can be generalized.

Conclusion

It is essential that the structure of institutional mental health care be revised to maximize treatment and rehabilitative efficiency. Ineffective treatment options and methods of program delivery, inaccurate assessments and security classifications, the conditions in which inmates are forced to live, restricted access to mental health professionals, high levels of individual strain, fragmented service administration, and a lack of continuity of care during the transition back to the community all contribute to the need for a systematic overhaul (Blaauw et al., 2000; Dupuis et al., 2013; Goomany & Dickinson, 2015). Legislation and policies exist to aid justice services and health care collaborations, and research on forensic hospital effectiveness highlight that the collaborations are working, supporting a comprehensive overhaul to institutional mental health care (Bastert et al., 2012; Pogorzelski et al., 2005). Collectively, utilization of the human service model provides a framework to maximize treatment potential for incarcerated persons and minimize future recidivism. Clinical assessments should be administered alongside personalized treatment and be provided by educated mental health professionals (Byron, 2014; Canada, 2013; Canada & Watson, 2013; Dupuis et al., 2013; Lattimore & Visher, 2013; Visher & Travis, 2003).

Author Disclosure Statement

The authors disclosed no conflicts of interest with respect to the research, authorship, or publication of this article.

Funding Information

The authors received no financial support for the research, authorship, and/or publication of this article.