Law and policy framework
The Prison Service Offender Management Manual (Part 1.Ch1.1) establishes a ‘functional support’ category of prisoner. This category covers prisoners with ‘severe behavioural problems or disability’, including those with psychiatric illness, intellectual disability, personality disorder and complex medical conditions. The manual focuses on how these prisoners can be managed, to increase the frequency of desirable behaviour and conversely to decrease undesirable behaviour.
Corrections indicate that prisoners with complex health needs are managed in partnership with Regional Forensic Psychiatric Services. Such prisoners may also be placed in ‘at risk’ units on a short-term basis.
Applications for the compulsory assessment or treatment of prisoners, or their hospital detention, must meet the requirements of the Mental Health (Compulsory Assessment and Treatment) Act 1992. The Mental Health Act 1992 notes that it is an offence for a person concerned with the care, oversight and control of mentally disordered people to neglect or ill-treat them.
Responsibility for mental health provisions are split between the Department of Corrections (for primary care) and District Health Boards (for specialist care through Regional Forensic Services). The Ministry of Health guides strategic direction.
Issues
Recently, good-practice initiatives have included the opening of a 13-bed ‘At Risk Unit’ at Hawkes Bay Prison in 2008. This Unit is staffed by on-site registered nurses with mental health training as well as a forensic nurse from Hastings DHB. Prisoners can also access a psychiatrist on a weekly basis. This Unit, like others, is a useful tool for short-term stays.
In addition, it is clear that certain practices – such as the use of Forensic Mental Health Services (FMHS) to work with those with serious mental illness – provide very good service delivery. As Simpson et al (2006) have identified, these services are costly but offer very good outcomes in terms of lowering offending rates. Their study, of 105 patients (many of whom had psychotic disorders and a history of violent offending), demonstrated that at the end of the study, half were in independent living and half were in employment. Only five were reimprisoned. This illustrates that committed mental health services can produce high level outcomes. This is something that is not evidenced in other forms of care.
Despite these advances, there remain a range of concerns about provision for those with mental illness within the prisons:
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Capacity – Over recent years, forensic services have been operating at full capacity (and beyond). Still, many prisoners do not receive the treatment they need in a timely manner and prisoners who require urgent treatment for mental illness often have to remain in prison and wait for an available bed. This puts pressure on prison services, that are already stretched through prisoner numbers, to look after disturbed individuals (Brinded et al, 2001; Fennell, 2006; Office of the Auditor-General, 2008; Simpson et al, 2006). The Office of the Auditor-General (2008) detailed the situation of 59 prisoners on the Auckland prison waiting list (between July 2006-June 2007). Of the 59 prisoners, 34 waited ten days or less, 10 for 41-80 days, 15 waited longer than 80 days, and 10 prisoners waited more than 100 days for treatment.
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Limited funding for Primary or Preventive Care – There are few services for prisoners with mild to moderate mental health illness. More basic treatment options, such as counselling or therapeutic treatment, are not available (Office of the Auditor-General, 2008). The lack of effective primary services loses an opportunity for a ‘fence at the top of the cliff rather than an ambulance at the bottom’ for prisoners who struggle with mental health concerns and who may well deteriorate within the prison environment.
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Dual Diagnosis Provisions – Evidence suggests that a large proportion (over 80%) of prisoners have both mental health and substance abuse issues (Department of Corrections, 1999). This dual diagnosis requires specialised, and integrated, services in which drug teams can work closely with mental health services. A range of best practice standards have been advanced on these issues elsewhere (see Livingston, 2009).
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Treatment and Diagnosis Issues – The pyschiatric profession have been reluctant to treat ‘those whom they do not believe are likely to respond to treatment’ (Fennell, 2006:247). Those who are cast as ‘untreatable’ – principally those with personality disorders – are not ‘well served’ (Office of the Auditor-General, 2008:3.31). Those with severe personality disorders can pose considerable risk to themselves and others, however there is no policy on this group (ibid). The Department of Corrections and Ministry of Health are working to address this gap (Human Rights Commission, 2009).
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Specific Group Issues – It has also been observed that particular groups – notably Māori, women, young people or those with learning difficulties – may not have their needs met by current practices (Office of the Auditor-General, 2008). For instance, there is no specialist inpatient youth forensic facility in New Zealand. More monitoring, evaluation and expansion of services is required.
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Staffing – Concerns have also been raised about staff provisions and training. The Office of the Auditor-General (2008) detailed that some Corrections staff can provide very good support services to those with mental illness. Staff attend relevant education days, and can gather knowledge from other professionals in their interactions. Nonetheless, they do remain Corrections staff rather than mental-health specialists. Literature (Human Rights Commission, 2009; Office of the Auditor-General, 2008) has continually called for further staff training on mental health issues as well as increased levels of trained specialists.
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Tensions between Institutional and Individual Concerns – the Office of the Auditor-General (2008) highlighted concerns of the dominance of Correctional interests over prisoner health interests. For example, there are cases in which prisoners are transferred (to deal with overcrowding issues) and consequently miss their treatment. Similarly, prisoners may struggle to receive ‘medication outside the usual prison routines or there can be delays in getting prisoners to clinics because there are not enough officers available for escort duties’ (ibid:1.6). There are also concerns that prisoners’ families are not always told when a prisoner’s mental health deteriorates. Further planning and consultation, to focus on prisoners’ needs for rehabilitation, is required.
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Fragmented Data – It has been noted that data on prisoners with mental health needs could be recorded by Corrections in a more systematic way. Information systems could also be improved in terms of prisoner transfer – as prisoners can lose information between prisons (Office of the Auditor-General, 2008). A mental health screening tool has been developed and trialled, and its implementation will begin during 2011/12. This, together with further periodic screening of those held for more than one year, could improve quality data issues (Human Rights Commission, 2009).
Overall, those with mental health concerns do not have their needs adequately addressed by the prison service. In addition, prisoners with mental illness ‘are more likely to violate prison rules leading to disciplinary hearings, inappropriate sanctions and segregation’ (Birgden and Perlin, 2008). This can mean that these prisoners are more likely to be regarded as a ‘control problem’ rather than a population ‘in need’. Many staff will however spend their working lives engaged in supporting and providing crisis management for prisoners with mental illness. Nonetheless, despite their best efforts, prisons are not essentially therapeutic places.
Prisons are, of course, a cheaper option than providing specialist care; however, they regularly do not offer the right kind of care that is required for many sick and ill people (Owers, 2006b). Many of those with mental health problems would have their needs (health, psychological and re-offending) addressed in a more effective way through a medical or social environment (Roberts and Cobb, 2008).
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