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. 2021 Jan 29;28(5):774–784. doi: 10.1080/13218719.2020.1855269

Prison mental health in-reach teams in Aotearoa New Zealand: A national survey

Brian McKenna a,b,c,✉, Jeremy Skipworth b, Andrew Forrester d,e, Jenny Shaw e
PMCID: PMC9103505  PMID: 35571595

Abstract

The STAIR in-reach model of care for prisoners with serious mental illness focuses on screening, triage, assessment, interventions and reintegration by using the principles of assertive community treatment. An evidence base exists for the efficacy for its use in Aotearoa New Zealand. However, little is known about its adoption throughout the country. This national survey of managers of in-reach teams to all prisons (N = 19) aimed to determine the pattern of in-reach service delivery. It compared STAIR in-reach teams with other teams regarding service structure, staffing, interventions, reintegration strategies and training needs. This study signals gains made by adopting the STAIR model (multi-disciplinary team service delivery, ‘through the wire’ support and use of technologies to assist discharge planning) and potential areas of improvement (further use of psychosocial interventions and training needs). To assist national adoption of STAIR, a review is required to consider the cultural responsivity, gender-responsivity and recovery-orientated characteristics of the model.

Key words: assessment, in-reach, intervention, prison, reintegration, screening, triage

Introduction

Internationally, the pooled prevalence rates of serious mental illness (SMI; lifetime diagnosis of schizophrenia or bipolar disorder, or current diagnosis of major depression) in prisons are substantial, at 13.8% of male prisoners and 18% of female prisoners (Fazel et al., 2016). The provision of appropriate mental health services to prisons in many jurisdictions is challenging (Davidson et al., 2020). It has taken national inquiries, such as the Butler Report (1975) in the United Kingdom and the Mason Report (1988) in Aotearoa New Zealand, to realise that the responsibility for meeting the mental health needs of this population lies with a health responsibility model, rather than correction’s, response (Brinded & Evans, 2007).

The shift to a health responsibility has placed an emphasis on equivalency: that prisoners should receive the same level and quality of mental health care as that provided in the community. Equivalency is viewed as pivotal to improving prison mental health services and was included in the revision of the United Nations minimum standards for the treatment of prisoners in 2015. However, current evidence suggests equivalency has yet to be fully realised, and the need for service improvement is ongoing (Forrester et al., 2013).

Prison ‘in-reach’ teams provide one mechanism to achieve such equivalency. In-reach teams provide multi-disciplinary (MDT) specialist secondary services, adapted from an integrated, community-based approach (Senior et al., 2013). Ideally, such teams provide wrap-around, holistic services from initial screening through to reintegration to the community. They provide treatments, including medication, and evidence-based psychological therapies, such as social skills training, psycho-education and cognitive rehabilitation, proven in both community and prison settings (Nicholls et al., 2018).

Recent developments in the prison in-reach model of care emphasise a ‘modified’ assertive community treatment model following the principles of assertive engagement, continuity of care, MDT service delivery and a small case load. There are five key elements within service provision: (a) screening, (b) triage, (c) assessment, (d) intervention and (e) reintegration (STAIR model; Forrester et al., 2018; Nicholls et al., 2018). Screening prisoners upon reception to prison is considered best practice internationally in order to address immediate safety issues and quickly identify prisoners’ mental health needs to facilitate early intervention and/or transfer to secure hospital care (Dressing & Salize, 2009). Triage is about prioritising mental health resources to those with greatest need. Assessment then provides a more in-depth clinical view of the prisoner’s mental health needs than can be achieved in the prior steps. Interventions should then follow evidence-based best practice guidelines and standards, so as to provide equivalent services to community care (Nicholls et al., 2018).

There is sound evidence that the period of transition from prison to community living is a vulnerable period, with the potential for problematic health engagement and increased morbidity and mortality. An emphasis on reintegration in prison in-reach service delivery is thus crucial. Release planning, pre-release engagement with post-release care providers, continuity of care beyond the gates of the prison (‘through the gate’ care) and coordination of support post release all offer potential improvements in reintegration (Hancock et al., 2018; Hopkin et al., 2018; Pearsall, 2016; Smith-Merry et al., 2019).

In Aotearoa New Zealand, a 2015 study found that over the previous 12-month period, 62% of prisoners had been diagnosed with a mental illness or substance misuse disorder; 14% had thought about or attempted suicide; 31% had diagnoses of two or more disorders; and 16% had a diagnosis of post-traumatic stress disorder (Indig et al., 2016). Furthermore, 10% of the New Zealand prison population has moderate to severe traumatic brain injury; and there is an over-representation of foetal alcohol spectrum disorder, cognitive impairment/intellectual disability, communication disorders, attention deficit hyperactivity disorder (ADHD), learning difficulties, dyslexia and autism spectrum disorder (Lambie, 2020).

In Aotearoa New Zealand, primary mental health needs are managed through correctional facilities, under the auspicious of Ara Poutama Aotearoa (the Department of Corrections; Frame-Reid & Thurston, 2016). In-reach teams managed by publicly funded regional forensic mental health services (FMHS) have been established to meet the needs of those prisoners with SMI. Two of the country’s five regional FMHS developed the STAIR model in 2011 (Pillai et al., 2016). This model of care requires a collaborative relationship with correctional health services and related external agencies. Given the over-representation of Māori, the indigenous people of Aotearoa New Zealand, in prisons, cultural expertise is integrated into the MDT response (Cavney & Hatters Friedman, 2018; for full explanation of the model of care, see Pillai et al., 2016).

Implementation of this model of care reflected an increase in the detection of people with SMI in prison (Pillai et al., 2016); improvements in the use of holistic interventions to address mental-health-related needs (McKenna et al., 2018); and improvements in engagement with community mental health services and reduction in reoffending rates (McKenna et al., 2015).

The aim of this study was to determine the pattern of in-reach service delivery to all the prisons in Aotearoa New Zealand and compare service provision between the two regions that use the STAIR model and other regions where this model does not exist. Secondary objectives were to explore any gaps in service delivery and workforce training needs.

Method

Design and participants

A descriptive, electronic survey eliciting both quantitative and qualitative responses was sent to the manager of each regional forensic mental health in-reach team servicing each correctional facility in Aotearoa New Zealand (N = 19), in early 2019. The two regional forensic mental health services that used the STAIR model cover eight of the 19 prisons, allowing a comparison between those prisons where the model exists and those where it does not.

Survey

The survey covered six sections and consisted of closed tick box responses and the ability to comment on survey items as required. The first section asked general information about the prison that the in-reach team served. This included the size, security level, remand verses sentenced status and prisoner gender.

Section 2 focused on the in-reach service structure to each of the prisons, primarily the extent to which it was integrated with prison health processes and related agencies, including drug and alcohol services.

The third section focused on the staffing levels of the in-reach team to each prison. This considered the specific membership of the team and the actual numbers of full-time equivalents for each discipline.

Section 4 focused on the interventions undertaken to meet the needs of prisoners with SMI. General queries were asked regarding the model of service provision (care co-ordination and/or care management), the use of psycho-social interventions and the provision of psycho-education programmes. The focus then turned to interventions for specific diagnostic groupings, including schizophrenia, depression, anxiety, personality disorder, ADHD, dementia, autism spectrum disorder and intellectual disability. A focus was also placed on specific psychosocial interventions to meet holistic mental health needs, including anger management, anxiety management, problem-solving and coping strategies, and counselling.

The fifth section focused on support to prisoners with SMI at the time of reintegration to the community, including involvement of other agencies in discharge planning prior to release, referral processes and ‘through the gate’ support, including the provision of medication on release.

The final section focused on staff training needs emphasising those conditions previously mentioned; risk management of harm to self and others; and skill acquisition of psycho-social interventions such as cognitive behavioural therapy.

Recruitment

The e-mail address of the manager of each of the prison in-reach teams was accessed via the five regional FMHS following permission from the New Zealand Forensic Psychiatry Advisory Group to the Ministry of Health. Two reminders were sent to managers at monthly intervals. Data collection was completed by June 2019.

Data analysis

Descriptive statistical analyses were undertaken on closed items in the survey, to determine the frequencies of responses to nominal variables, using the statistical programme IBM SPSS 26. In comparing STAIR in-reach teams with other teams, variables were dichotomised where possible, and the Fisher’s Exact Test was applied to determine statistical significance (given the small sample size). A 10% significance rather than 5% significance was accepted in such comparisons, with a p < .10 rather than < .05.

Thematic analysis was undertaken of responses to open-ended items in the survey, using the processes of immersion, coding, creating categories and identifying themes (Green et al., 2007).

Ethics

Ethical approval was obtained from the Auckland University of Technology Ethics Committee (number: 18/124).

Results

Sample description

Regional FMHS in-reach teams provided services to each of the 19 prisons in Aotearoa New Zealand at the time of the study. All in-reach teams responded to the survey (response rate = 100%). One response combined data from Whanganui Prison and the New Plymouth Remand Centre, in a manner that prevented the two facilities being separated. Therefore 18 responses were analysed. The in-reach teams to the eight prisons in the northern and midlands FMHS used the STAIR model of care.

Over half of the prisons (n = 11; 61%) covered the full range of security levels from low to high, with two of these also indicating they housed maximum secure prisoners. The majority (n = 14; 78%) indicated they managed both remand and sentenced prisoners. There were three sentenced prisoner specific facilities and one remand specific facility. The majority were male-only facilities (n = 14; 78%), with three female-only facilities and the before-mentioned Remand Centre covering both genders. The maximum capacity of each prison ranged from 103 to 1046 (excluding the New Plymouth Remand Centre), with the median size being 616. Total capacity over all prisons was calculated from the responses as 10,764.

Integration

The majority of in-reach teams were involved in multi-agency reviews of complex cases (n = 15; 83%) and suicide risk (n = 17; 94%). In the majority of these cases, management was jointly led by the in-reach team and prison health staff (n = 12; 67%), with in-reach representatives in attendance at reviews on 75–100% of occasions. However, integration with substance misuse services was less evident (n = 8; 44%). There was no significance difference in the levels of integration between STAIR in-reach teams (n = 2 of 8) and others (n = 6 of 10).

In detailing the nature of integration with substance misuse services, three approaches were evident. Some in-reach teams accessed substance misuse programmes provided to all prisoners by the correctional facility, but this access was difficult:

The prison has a corrections-based Drug Treatment Unit and shorter courses. These are only for sentenced prisoners and a large number who could benefit do not get the opportunity.

Other in-reach teams accessed the services provided by external providers, such as Community Alcohol and Drug Services, and an ‘Opioid recovery service’. Finally, two in-reach teams mentioned integration through the employment of substance misuse expertise within their MDT team: ‘Our social worker has training in substance misuse.’

Staffing

In considering the MDT structure of the in-reach teams, every team had a psychiatrist attached in various fulltime equivalent (FTE) proportions, while only one did not have a mental health nurse as part of their team. The majority had ‘as needed’ access to psychologists (n = 12; 67%), social workers (n = 9; 50%) and cultural expertise (n = 11; 61%). No occupational therapists were part of the MDT.

All STAIR in-reach teams were multi-disciplinary (n = 8 of 8), while half of the other teams were not (n = 5 of 10; p = .03). Of these five, three were composed of only a psychiatrist, a nurse and a cultural expert; one of a psychiatrist and a cultural expert; and one of a psychiatrist and a nurse. Although the FTE numbers of each discipline were asked for in the survey, non-specific responses (such as ‘as required’) meant it was impossible to determine the actual discipline FTE with any degree of accuracy.

Interventions

Overall, most in-reach teams practised case management (n = 14; 78%) and/or care co-ordination (n = 16; 89%). The majority had access to psycho-social interventions (n = 14; 78%) and provided psycho-education programmes for prisoners with SMI (n = 11 of 17; missing value = 1; 65%). There were no significant differences in these variables between the STAIR teams and other teams.

Thematic analysis determined two ways in which psycho-social interventions were accessed. The first was via referral to other services sometimes existing in the prison concerned: ‘Corrections has hired a trauma counsellor who accepts referrals.’ However, this popular approach was often difficult ‘due to their long waiting list’.

Other in-reach teams favoured accessing such interventions through expertise within their MDT. Part-time psychologists were the preference in this regard, though it was conceded that this resource was limited, as ‘psychologists are there only one half day a week and can [only] see up to four people’.

The clear majority of in-reach teams served all cases of schizophrenia in the prisons (n = 15; 83%). However, of the 15 in-reach teams, only a minority (n = 6; 40%) were using innovative evidence-based interventions to treat this condition, such as cognitive behavioural therapy, psychodynamic psychotherapy or cognitive remedial therapy. As regards depression, a half of the teams (n = 9; 50%) were using interpersonal therapy, psychodynamic therapy or cognitive behavioural therapy as treatment strategies. The innovative responses to depression were more likely to occur in the teams adopting the STAIR model (see Table 1).

Table 1.

Significant differences in the interventions used.

Item STAIR
(n = 8 )		 Other
(n = 10)		 p
Depression 6 3 .08
Anxiety 6 2 .03
Problem-solving interventions 8 5 .03
CBT 4 1 .09
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Note: CBT = cognitive behavioural therapy.

In relation to the other conditions surveyed, over half the teams indicated a focus on the management of ADHD (n = 15; 83%), autism (n = 10; 56%) and intellectual disability (n = 10; 56%). However, only a minority focused on anxiety conditions (n = 8; 44%); dementia (n = 6; 33%) and personality disorder (n = 3; 17%). A focus on anxiety was more likely to occur in the teams adopting the STAIR model (see Table 1), while a personality disorder clinical pathway was only acknowledged by three non-STAIR in-reach teams.

Qualitative responses indicated that the treatment foci for ADHD, dementia and intellectual disability were confined to diagnostic formulation (‘assessment and diagnosis’); medication; and ‘referral to relevant placements’.

In meeting the holistic needs of service users, the majority of in-reach teams provided one-to-one assistance with anger management (n = 10; 56%); anxiety management (n = 16; 89%); relaxation (n = 15; 83%); sleep therapy (n = 16; 89%); problem-solving interventions (n = 13; 72%), counselling (n = 10; 56%) and cultural interventions (n = 13; 72%). Only one example of group facilitation of any of these interventions was indicated (a group anger management approach). Of all these interventions, problem-solving interventions and CBT were more likely to occur in STAIR in-reach teams (see Table 1).

Reintegration

Involvement of other agencies in discharge planning prior to release was mixed. Only community mental health teams (n = 14; 78%), probation services (n = 10; 56%), resettlement services (n = 13; 72%) and prison staff (n = 10; 56%) attended pre-discharge planning with the majority of in-reach teams. In comparing attendance between STAIR teams and other teams, counter-intuitively, family attendance only occurred in five non-STAIR in-reach teams (p = .03).

Contact relating to discharge planning was more likely to occur via phone or e-mail. In comparing STAIR in-reach teams and other teams, STAIR teams were more likely to contact families on 50% or more occasions (STAIR n = 8 of 8; non-STAIR n = 5 of 10; p = .03) and also community mental health teams (STAIR n = 5 of 8; non-STAIR n = 2 of 10; p = .09).

‘Through the gate’ support out into the community was offered by six of the eight STAIR in-reach teams, and no non-STAIR teams. However, even then, it was only provided to less than a quarter of the caseload (for five out of these six STAIR teams). Managers of all prison in-reach teams were aware of other agencies that were offering such support. Such services were primarily offered by substance misuse services (n = 13; 72%), resettlement services (n = 13; 72%), probation services (n = 9; 50%) and/or primary health organisations (n = 9; 50%). Three of these four ‘through the gate’ services (substance use services, resettlement services and primary care services) were more likely to occur in prisons with STAIR in-reach teams. ‘Through the gate’ support involving family was also more likely to occur in prisons with STAIR in-reach teams (see Table 2).

Table 2.

Presence of ‘through the gate services’ alongside in-reach teams.

Item STAIR
(n = 8 )		 Other
(n = 10)		 p
Substance misuse services 8 5 .03
Resettlement services 8 5 .03
Primary care services 6 3 .03
Family 5 0 .002
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Other means of facilitating reintegration for prisoners with SMI were considered in the survey. In the majority of cases, prison clinical records were sent to community mental health teams (n = 12; 67%); prisoners with SMI were referred to mental health services (n = 18; 100%); and prisoners were released with medication if required (n = 15; 83%) . Non-STAIR in-reach teams were more likely to send prison clinical notes to community mental health teams (non-STAIR n = 10 of 10; STAIR n = 2 of 8; p = .002).

Analysis of qualitative data on perceptions of an ideal community re-integration service on release for prisoners with SMI emphasised the provision of continuity of care to enable a ‘seamless transition’; strong collaborative links and transparent communication with interfacing agencies; and service provision, which was ‘well organised’. Collaboration needed to occur with social care agencies in order to advance ‘finding housing, supported accommodation, Work and Income New Zealand support, budget advice, and family support’. A time limit was also placed on support at around 3 months: ‘Close follow up to transition over the risk period (100 days post release) with stepped gradual reintegration to the community.’

Three STAIR in-reach teams in one regional FMHS actually discussed the development of a reintegration team:

The Prison Adult Transition (PAT) team which is run by our FMHS. This consists of a nurse and a part time social worker and psychologist that help people make the links back to general mental health services.

Training

The majority of services provided the following training for their prison in-reach teams; violence risk management (n = 15; 83%), suicide and self-harm risk management (n = 14; 78%), personality disorder (n = 11; 61%), intellectual disability (n = 9; 50%) and ADHD (n = 9; 50%). A minority provided training in autism (n = 8; 44%), dementia (n = 7; 39%) and talking therapies such as CBT (n = 4; 22%). There was no significant difference in any of these training provisions between the STAIR in-reach teams and other teams.

All of the prison in-reach teams acknowledged gaps in training, except one. In qualitative analysis two themes arose: ‘access difficulties’ and ‘desired content.’ Accessing training opportunity was difficult on several counts. First, there was no training available to some in-reach teams: ‘There is little educational opportunity offered to us.’ Second, the timing and location of training were inconvenient to busy, off-site teams. One manager described ‘Missing the opportunity to attend most programmes due to being busy and most training programmes are happening in [the home base of the in-reach team]’. Furthermore, the mode of training inhibited participation when service provision was off-site: ‘[only] mandatory training is available on line.’ The responsibility was then placed on the individual to source external training opportunity: ‘The onus is very much upon the individual team member . . . to find suitable courses or training activities to enrol in.’

Regarding the ‘desired content’, training in the use of psycho-social interventions was a strong theme, as was training to understand the ‘effect and treatment of illicit substances currently in the community’.

Discussion

The STAIR model of care for in-reach mental health services for prisoners with SMI has an evidence base for its efficacy in Aotearoa New Zealand (McKenna et al., 2015, 2018; Pillai et al., 2016). This study indicates that there has been no national adoption of this best practice alternative. Even a multi-disciplinary focus is absent from some non-STAIR in-reach teams.

The STAIR model of care defines each required care element in service delivery. Multi-disciplinary requirements can be sized in relation to these elements. An algorithm based on epidemiological research has been developed to calculate full-time equivalent MDT involvement in screening, triage and assessment activities, case management and reintegration (Simpson & Jones, 2020). Such calculations could be used to determine the resource required to initiate and sustain STAIR in-reach teams to every prison in the country.

In-reach teams require strong collaborative relationships with the prison and other key agencies assisting in meeting prisoners’ mental health and addictions needs (Pillai et al., 2016). Continuity of care explicit in the STAIR model implies limiting the latter in favour of MDT engagement. For instance, this study revealed diverse approaches in addressing substance misuse, including prison-based services, external providers and in some cases the in-reach team. Evidence exists for best practice in meeting the substance misuse needs of prisoners (Mullen, 2016). Access barriers to other services could be avoided through resourcing such best practice within STAIR in-reach teams.

Although this study detected improvements in the use of some psycho-social interventions in STAIR teams, the scope for improvement was evident. Psychosocial interventions are necessary to address the high and complex needs of prisoners with SMI including post-traumatic stress disorder (PTSD; Dempster-Rivett, 2018; McGlue, 2016) and to provide rehabilitative options to mainstream programmes, which prisoners with SMI have difficulty accessing (Skipworth et al., 2019). Such needs could be readily addressed by the MDT in the STAIR in-reach teams being up-skilled in psycho-social interventions, including group interventions where feasible.

There is irrefutable evidence that a focus on reintegration strategies assists in improving prisoner morbidity and mortality post release and in reducing recidivism (Hancock et al., 2018; Hopkin et al., 2018; Pearsall, 2016; Smith-Merry et al., 2019). In this study, the STAIR in-reach teams were more likely to use technologies to involve support agencies in discharge planning such as Community Mental Health Teams rather than face-to-face contact, while ‘through the gate supports’ were more likely to be evident in those prisons served by STAIR in-reach teams. Further research is required to determine the cause and effect relationship between the presence of these strategies and positive outcomes for prisoners in the community.

The incremental gains identified in the use of the STAIR model rely on a highly skilled, dedicated workforce. Given the isolation and complexity of the prison workplace, up-skilling of this workforce requires innovative training solutions. Extensive orientation training (Choudhry et al., 2017); joint health and correction staff training (Giblin et al., 2012); and academic and health partnerships in workforce preparation (Hale et al., 2015) are all approaches worthy of further consideration as up-skilling options.

The STAIR model of in-reach care was first developed in Aotearoa New Zealand in 2011 (Pillai et al., 2016). In-reach care in this country faces unique contextual challenges. The growth of the prison remand population is projected to rise to 53% of the total prison population by 2029 (Ministry of Justice, 2020). Inequity is reflected in the gross over-representation of Māori and ethnic minorities in prison, and in a burgeoning female prison population (McKenna & Sweetman, 2020). The latter experience higher levels of all types of mental illness, including PTSD, psychotic disorders and major mood disorders (Collier & Friedman, 2016; Indig et al., 2016). The extent to which the STAIR model of care is culturally responsive (Cavney & Hatters Friedman, 2018) and gender responsive and fit for a remand population (Bartlett et al., 2014) requires review.

Review is also required regarding the integration of a recovery-orientated approach into the STAIR model. Recovery models focus on the provision of person-centred, collaborative care to empower prisoners’ self-determination (Nicholls et al., 2018). Recovery approaches are less developed for prisons, largely due to an environment ‘not conducive to mental well-being’ (Völlm et al., 2018, p. 65). This represents a potential area of improvement of the STAIR model.

This study is limited by the descriptive nature of the survey undertaken. Closed responses to some survey items and limited space for clarification place caveats on the depth of understanding. This understanding was also confined by surveys of team managers, which were devoid of the descriptions of other stakeholders involved in the delivery and receipt of services. Although confined to a description at one point in time, a strength of the study is the 100% responses rate from all the in-reach teams in the country.

Conclusion

There are a range of service delivery models for prisoners with SMI, and variances persist within and between jurisdictions (Davidson et al., 2020; Forrester et al., 2013). Prisoners with mental health needs require a reliable system for treatment under the challenging conditions that prevail in most prisons. Current evidence suggests that prisoners with SMI derive benefit from a model of care, which supports continuity of care from initial screening through to discharge planning and transition to the community (Nicholls et al., 2018). The STAIR model of in-reach service delivery supports this approach, without the need for additional funding (Pillai et al., 2016). Although this study signals the gains made by adapting this model, on-going review is required in order to best position the introduction of this model in every prison in the country.

Acknowledgments

We acknowledge the New Zealand Forensic Psychiatry Advisory Group to the Ministry of Health and Ara Poutama Aotearoa (the New Zealand Department of Corrections) who approved this research.

Ethical standards

Disclosure of interest

Brian McKenna has declared no conflicts of interest

Jeremy Skipworth has declared no conflicts of interest

Andrew Forrester has declared no conflicts of interest

Jenny Shaw has declared no conflicts of interest

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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