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You are here: Cabinet PapersReview of the Interface between Mental Health and Alcohol and Other Drug Services and the Criminal Justice System Paper Five: Population Groups: Maori, Pacific Peoples, Women and Youth

Paper 27: Review of the Interface between Mental Health and Alcohol and Other Drug Services and the Criminal Justice System Paper Five: Population Groups: Māori, Pacific Peoples, Women and Youth

PURPOSE

  1. The purpose of this paper is to provide Cabinet with background information, and an overview of the key issues relating to vulnerable offender population groups. It outlines four proposals relating to each of the population groups examined, and invites Cabinet to note the recommendations in Cabinet Paper One: Overview.

EXECUTIVE SUMMARY

  1. This is the last of five papers proposing initiatives that aim to:
  • enhance the social functioning and mental health of offenders
  • assist in reducing their rate of AOD addiction and addiction-related harm
  • assist in reducing their re-offending.
  1. The terms of reference for the review included a requirement to focus particularly on the needs of specific offender population groups: Māori, Pacific peoples, women and youth.
  1. The proposals in this paper for population groups are, however, reasonably narrow in as far as they focus most particularly on the mental health and AOD needs of these offenders. Cabinet papers that focus on the causes of the offending of these populations are due shortly.
  1. Māori sustain poor criminal justice outcomes and constitute more than 50% of the sentenced prison population. Recent research also indicates that Māori have higher mental health and addiction needs than other ethnic groups. There is a limited number of Māori AOD programmes for Māori and little evaluative material demonstrating their effectiveness. Consequently, there is limited understanding about what works for Māori, and why. We propose an evaluation of an AOD programme that has a kaupapa Māori focus, and an evaluation of a mainstream treatment programme so that an assessment on the differences they have on their Māori clients can be made.
  1. Pacific peoples are over represented in violent offending. There are also serious issues about their use of alcohol. Pacific peoples should be treated in a manner that is empathetic to their social profile, cultural values and beliefs. We propose an internship / training programme to increase the effectiveness of treating Pacific peoples in a manner that is appropriate to their cultures.
  1. Women are a small proportion of New Zealand's prison population (6%), however, their proportion is rapidly increasing. Female criminal and mental health profiles and the relevance of substance abuse to their offending means that the rehabilitative needs of female offenders/prisoners are different to those of men. They require different responses from policy-makers. We propose to undertake a feasibility study to establish a bicultural dual-diagnosis (mental health and AOD), community-based treatment programme in the Auckland region to address the complex specific needs of female offenders.
  1. Children and young people account for about 22% of police apprehensions, however, of this number 80% commit only one offence, the remaining 20% who re-offend are often significant repeat offenders. Advice from Judges indicated that there is insufficient early screening and assessment in youth courts for the mental health and AOD needs of young offenders. We propose piloting a mental health clinician with experience in AOD issues in a youth court to provide advice to the Court about young offenders' mental health and AOD needs.
  1. All these proposals to address some specific aspects of mental health / AOD needs of vulnerable groups rely on the success of the proposal in the Cabinet Paper One: Overview relating to measures to improve and enhance the AOD / mental health workforce. The proposals will also complement the work underway in the Ministry of Justice and population ministries on the causes of offending.

BACKGROUND

  1. The background to the interface review is detailed in Cabinet Paper One: Overview.
  1. Offenders are not a homogeneous group. As part of the interface review, the Ministries of Health and Justice were directed by Cabinet to examine issues relating to Māori, Pacific peoples, youth and women with mental health and/or AOD issues in the different settings of the criminal justice system.
  1. The recommendations of the other four papers also apply to these offender groups. However, Cabinet considered it was necessary to enhance the Effective Interventions project by supplementing various mainstream programmes with tailored interventions for these particular vulnerable population groups.
  1. Under the original terms of reference these Cabinet papers were to have followed a number of papers being prepared in the Ministry of Justice and population based Ministries about the causes of offending by these population groups. The revised timeframe, however, means that this paper must precede those. By necessity the recommendations of this paper represent a very narrow set of proposals for these population groups relating most particularly to their mental health / AOD needs and complement the general AOD and Mental Health initiatives. Later papers will have a broader focus on the needs of these groups and will provide more opportunities for action on the justice-related issues these population groups face.
  1. The following summarises the Ministries' findings and include proposals regarding Māori, Pacific peoples, women and youth.

Māori

  1. While 14.5% of New Zealand's population identify themselves as Māori, Māori men and women comprise approximately 51% and 58% of their respective prison populations. The Māori population is also a young population, i.e. 37% of the Maori population is aged 0 to 14, compared to 23% of the general population aged 0 to 14. Maori are expected to comprise 17% of the total population in 2021, up from 15% in 2001. Māori are disproportionately represented in convictions for violent crimes (47% of total convictions) and property crimes (48%). They are most commonly convicted for traffic, and property offences.
  1. Recent research indicates that Māori have higher mental health and addiction needs than the rest of the population. Te Rau Hinengaro: The New Zealand Mental Health Survey indicated that Māori have a higher rate of lifetime mental disorders compared with other ethnic groups, and particularly suffer from mood disorders, substance abuse disorders, and suicidal behaviours.
  1. Māori are less likely to drink alcohol as frequently as non-Māori, but are more likely to consume a large amount of alcohol at least weekly, than non-Maori. Their abuse of illegal substances is also high compared to the general population. For example, the NZ Arrestee Drug and Alcohol Monitoring report (see Cabinet Paper Two: the Police Setting) found that Māori arrestees were significantly more involved with methamphetamine than any other group.
  1. In terms of enhancing justice sector responsiveness to Māori, and addressing the persistence of high levels of offending and imprisonment among Māori, Cabinet has directed Te Puni Kōkiri and the Ministry of Justice to develop a programme of action for Māori [CAB Min (06) 27/3A refers].

Issues

  1. When addressing the health needs of Māori including their mental health and AOD needs, it is important to consider their status socio-economic variables such as, for example, income, housing and education; their youthfulness; and their harmful use of drugs and alcohol. Moreover, Māori are generally less likely to access health services, including mental health or AOD services, and have lower treatment follow-up rates than non-Māori.
  1. There is a general concern internationally and in New Zealand, that current western-based treatment models may not be appropriate for different cultural groups. Re-orienting existing models of health, treatment, and care, and identifying specific Māori healing processes and outcomes, has been integral to Māori attempting to improve their own health care. Many Māori argue for increased delivery of services and treatment, including AOD services, to Māori by Māori.
  1. In the AOD treatment sector, kaupapa Māori services have been established. These services are based on traditional and contemporary models of Māori wellbeing. The services can be delivered separately or incorporated into 'mainstream' services.
  1. Some evidence suggests that, when delivered in conjunction with programmes that address criminal behaviour, culturally specific interventions, processes and practices, including those involving AOD or mental health, may influence the responsiveness of Māori offenders to address their behaviours that underpin their criminal offending. Examples include the the New Life Akoranga programme for Māori offenders, and the Department of Corrections' Te Piriti Special Treatment Programme for male offenders imprisoned for sexual offences against children. However, while these may be useful examples, there is in fact is limited evidence on what AOD programmes work for Māori, and why.

Proposal

  1. Unlike other treatments, programmes based on Kaupapa Māori are exclusive to New Zealand. There is no international evidence available on the effectiveness of such programmes because they are unique. We propose that the Ministry of Health undertake an evaluation of an AOD programme that has a kaupapa Māori focus, and a mainstream treatment programme attended by Māori participants that does not have a kaupapa Māori focus. The aim would be to:
  • evaluate the effectiveness of both programmes against key indicators, such as AOD misuse among Māori participants, including those who are also offenders, and the changes to negative behaviours that may underpin potential offending
  • analyse the cultural aspects of the Kaupapa Māori programme, to ascertain what works best for Māori in terms of AOD treatment programmes.

Pacific peoples

  1. Pacific peoples constitute 6.5% of the general population and are largely located in the Auckland region. It is a predominately young population with 38.2% under 15 years of age. The proportion of Pacific people of the total New Zealand population may reach 13% by 2016.
  1. Pacific peoples constitute 11% of the prison population, and are over-represented in violent offences (13% of convicted cases). However, the most common offences Pacific peoples are convicted for are traffic and violent offences. The violent feature of their offending will be addressed in the proposed Action Plan for Pacific peoples referred to below in paragraph 27.
  1. In the past 12 months the prevalence of mental disorders for Pacific peoples was 24.4% compared to 20.7% for the general population. They have a higher than average prevalence of bipolar disorders, and a lower than average prevalence of depression.
  1. The proportion of Pacific drinkers (57%) is less than the proportion of drinkers in the general New Zealand population (85%). However, Pacific drinkers consume larger volumes of alcohol on drinking occasions compared to drinkers in the general New Zealand population. No specific issues were found in regard to Pacific peoples' use of other drugs.
  1. To enhance justice sector responsiveness to Pacific peoples, Cabinet has directed the Ministry of Justice and the Ministry of Pacific Island Affairs to develop a programme of action for Pacific peoples to address the causes of their offending, including violent offending. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxs9(2)(f)(iv)xxxxxxxxxxxxxx
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Issues

  1. Several unique features of the Pacific population need to be taken into account when delivering AOD or mental health services, for example Pacific peoples':
  • youthfulness, and their general negative status against socio-economic characteristics such as income, education, employment, and housing
  • geographical spread
  • generally low levels of engagement with AOD and/or mental health treatment in the community. Overall Pacific people are less likely than the total population to use these services, and proportionately more of them are referred to mental health services by the justice sector
  • traditional understanding of mental health (held particularly by Island-born peoples). These beliefs are not easily accommodated in the way New Zealand's mental health services are generally delivered
  • harmful drinking patterns. A greater proportion of Pacific peoples report violence and injury from other peoples' drinking; and also problems from violence and serious arguments as a result of their own drinking
  • need for a well trained, specialist workforce that is competent in dealing with Pacific peoples in a culturally appropriate manner.
  1. The notion that mainstream interventions may not work as well as they could for non-mainstream populations is as material to Pacific peoples as it is to Māori.
  1. The Alcohol Advisory Council (ALAC) has two projects underway to address the cultural responsiveness of treatment for Pacific peoples in general. One is to provide support for a Pacific treatment worker in the Auckland Regional Alcohol and Drug Service to develop a tool to enable Pacific AOD providers to assess and evaluate their effectiveness and responsiveness to Pacific clients and carers. This will enable them to identify where improvements are needed to provide the most clinically optimal and culturally appropriate care for Pacific peoples. The other ALAC project is the "Le Ala Project". In collaboration with the Accident Compensation Corporation and the Health Research Council, this project aims to ensure that community-based alcohol interventions and services for Pacific people will improve their health and well-being.
  1. At a meeting of Pacific AOD providers in Auckland officials from the Ministries of Health and Justice canvassed proposals to address current Pacific peoples' needs. The meeting highlighted the necessity for Pacific peoples' AOD treatment to be delivered in a culturally sensitive and holistic manner. The providers suggested that there were too many different referrals, and that some assessments were not addressing the cultural influences or needs of the individual. Concern was expressed that re-integration or continued support for offenders during and after treatment was weak. The providers noted that for Pacific peoples a stronger focus on the role that families could play to assist offenders was essential. The providers were acutely aware of the workforce development issues, and noted that it would be better to strengthen current Pacific services rather than create new services that would inevitably be too stretched to deliver effective treatment.

Proposal
  1. We propose that an established AOD Pacific provider be funded to provide for up to two AOD trainees / interns each year to develop their clinical competency and cultural awareness of the specific needs of Pacific peoples. This proposal is included in the workforce proposal discussed in Cabinet Paper One: Overview.

Women
  1. In New Zealand there are approximately 450 women in prison, i.e. about 6% of the total prison population. Of these 58% are Māori women. The imprisonment of women has become more common, and the size of the women's prison population is growing at a higher rate than for men. There has been a four-fold increase in the female prison population over the past ten years. This is similar to trends in Australia, England, Canada and the United States.
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  1. The 1999 National Study of Psychiatric Morbidity Study in New Zealand Prisons found that 41.8% of women had past treatment for a mental health problem prior to entering prison and 37.6% had treatment in prison. Twenty two percent of women prisoners had AOD treatment, and 29.2% were on medication. The study also found that lifetime prevalence of post traumatic stress disorder for women prisoners was 37% and one-month prevalence was 16%. This figure is significantly higher than for the community in general and is more in keeping with victims of violent crimes and combat veterans.
  1. In 2006 the Ministry of Health reported that 18.8% of female prisoners had seen a general practitioner before prison for mental or emotional health, and 15% had seen a counsellor for AOD or gambling problems since imprisonment. Of those taking medication, 26.9% took anti-psychotic or anti-depressant medications. The report found that females have a higher prevalence of anxiety disorder, major depression and eating disorders than males, and high levels of co-morbidity between conditions.

Issues

  1. The literature review completed for the causes of female offending project found international evidence that certain life experiences such as childhood and adult sexual and physical abuse, mental health issues and AOD abuse, are associated with women who offend and are closely linked to their offending. Because a large number of female offenders have suffered sexual and physical abuse, mixed gender treatment facilities to address mental health and AOD needs are not generally appropriate.
  1. There is also widespread recognition in the literature that the criminal profiles and pathways, and the rehabilitative needs of female offenders are different to those of men. For example, alcohol and drug abuse is significantly more likely to precede offending by females than for males and is more closely linked to certain types of offending in females, such as property offences. Many women self-medicate to mask the trauma of childhood abuse and adult victimisation and offending often takes place to support the addictions.
  1. Understanding the differences between male and female offenders is essential to meeting the distinct rehabilitative and re-integrative needs of female offenders and addressing the underlying causes of offending. Equal treatment of female and male offenders will not result in equal outcomes. International evidence supports the proposition that programmes must be designed specifically for the distinct needs of female offenders. The research also suggests that for programmes to be effective they must also be culturally appropriate.

Proposal

  1. We propose that the Ministry of Health in consultation with the Department of Corrections and the Ministry of Justice undertake a feasibility study on establishing a new dual-diagnosis (mental health and AOD) community treatment programme to address the needs of female offenders on community-based sentences. The programme would:
  • probably be based on the therapeutic community model for residential treatment, however, other models such as intensive day programmes may be more suitable. All options will be assessed
  • take a holistic approach to addressing the mental health, AOD and offending behaviours of female offenders
  • co-ordinate with other social sector agencies such as housing and employment, so that all offending risk-factors can be addressed
  • be designed specifically for women, and be culturally responsive to the needs of Māori and other ethnic groups
  • provide another option for a sentence condition for judges when sentencing female offenders with mental health / AOD problems
  • be family/whānau based so that young children can visit and/or stay with their mothers during the programme.
  1. If approved, the study should be completed and referred to the Ministers of Health, Corrections and Justice by 31 October 2007.

Youth

  1. Police apprehensions are the best indication of child and young person offending. On average, children and young persons account for about 22% of police apprehensions. Over 60% involve property or dishonesty offences. Of the total children and young people apprehended by Police, 26% are warned, 56% are diverted by the use of alternative actions, 7% are referred for an Intention to Charge family group conference, and 11% appear in the Youth Court. Māori and males are significantly over-represented, with 85% of youth offenders being male.
  1. Of all the children and young people who offend, 80% commit only one offence. The 20% who re-offend are often significant repeat offenders. A small group of 'high-risk, life course persistent offenders' are responsible for a disproportionate number of offences committed by young people. There is a link between these offenders and mental health problems including substance abuse, suicidal ideation, self harming behaviours and conduct disorders. A common impression formed by Youth Court Judges is that around 80% of young offenders have an AOD dependency, and that this dependency has a direct relationship to the offending. Police also consider that 70-80% of youth offending is related to alcohol and drugs.
  1. Alcohol is the most commonly used drug by youth with 55.7% of youth aged 12-17 years reporting they had consumed alcohol in the last 12 months. Cannabis is the most widely used (illegal) drug by youth. Approximately 20% of young people aged 13 to 17 years reported cannabis use in the past 12 months. An analysis of the Christchurch Youth Drug Court pilot showed that all the participants in the pilot were diagnosed as having either moderate or moderate-severe alcohol and/or cannabis dependence.

Issues

  1. Judges have indicated the importance of identifying the mental health and AOD needs of all offenders, not just those who are high risk offenders. This approach aligns with the direction of the youth justice system. This information is not only necessary to ensure the young person is referred to appropriate treatment, but is also helpful in providing advice to Judges on the culpability of young offender and the most appropriate way to manage the case.
  1. There are potentially four levels of screening and assessment.
  1. First, Child, Youth and Families' Towards Wellbeing Tools are applied usually prior to a Family Group Conference (FGC). They include screening for drug and alcohol misuse, psychological distress and suicide risk, and are followed by a general wellbeing assessment.
  1. Secondly, a Youth Justice Co-ordinator can arrange a primary health care and/or education assessment, for consenting and eligible young offenders, prior to holding a Family Group Conference. This assessment is the Youth Justice Health and Education Programme jointly funded by CYF and the Ministries of Health and Education. The Judges' experience is that these do not adequately identify mental health needs or AOD needs.
  1. Thirdly, a proposed Court Liaison approach (Health funded). There is a lack of early screening and assessment in youth courts for young offenders with AOD issues and most particularly with mental health issues. Although on-site mental health assessments are available in adult courts nationally through regional forensic services, the same service does not exist for youth. Around the country, DHBs are identifying this need and starting to respond.
  1. In the process of this review officials were informed that three DHB providers are providing, or in the process of providing, screening services to the youth courts in Auckland, Wellington and the Waikato. The need for such services nation-wide was the key recommendation emerging from the participants at a Health Forensic Workshop held by the Ministry of Health in February this year.
  1. Fourthly, Court ordered specialist section 333 assessments which are Court funded. Sentencing Judges can request a section 333 report under the Children, Young Persons and their Families Act 1989. Section 333 provides that a Judge can order medical, psychiatric and psychological reports at any time during proceeding to determine:
  • whether a young person is unfit to stand trial due to mental impairment
  • if a young person is insane
  • the type and duration of any order that it is empowered to make
  • the nature of any requirement that it might impose as a condition of any order
  1. It is desirable that a section 333 report be undertaken and delivered to the Court within 21 days of receipt of referral. However, because of the shortage of practitioners able to carry out this work the standard waiting time is usually six weeks and can be up to six months. The effect of these delays on a young person can be significant, as the time a young person spends on remand does not count towards their eventual sentence. Added to this concern is the fact that a significant proportion of the young people held on remand awaiting a section 333 report eventually receive a community placement and no Court-order time in a residence. Lengthy delays in section 333 reports also place pressure on youth justice residential capacity, and can necessitate some young people being remanded into Police cells for unacceptable lengths of time. This delay creates problems for organising Court schedules and reduces judges' willingness to request a report
  1. These reports are funded by the Courts on a fee-for-service basis, and where provided by Health providers, they are additional to the Health funding for that provider. There may need to be further discussion between Health and Courts about contracting and funding implications to provide better services.

Proposal

  1. The three DHB initiatives that are underway have been developed in response to the specific needs of those communities. The extent and scope of these initiatives is unclear, and they may vary both in their scope and approach. We propose that the Ministries of Health and Justice, in consultation with the Ministry of Social Development review these initiatives to examine the focus and extent of the assessments, how these are working in practice, and other relevant issues.
  1. This review will inform the need for and the most effective and efficient use of a mental health and AOD clinician, who has specialised in the needs of youth, in the Youth Court. Other improvements to the delivery of forensic services in the Youth Court may also emerge.
  1. Having established best practice a pilot building on these three initiatives could be implemented quickly. It may be that more than one pilot could be undertaken as Youth Courts may not require full time clinicians. However, in terms of resources, the pilot or pilots will be limited to one full time equivalent. It is envisaged that the pilot/s would be based on the forensic health model currently operating in the adult jurisdiction, but would also incorporate AOD screening. The pilot/s would operate for three years, and be reviewed six months after the first year, to ensure it benefits judges' and Family Group Conference decision making and addresses the needs of young offenders.

Consultation

  1. The following agencies have been consulted on this paper: Department of Corrections, New Zealand Police, Treasury, Department of Prime Minister & Cabinet, Ministry of Social Development, Te Puni Kōkiri, Ministry of Pacific Island Affairs, and the Ministry of Women's Affairs. In addition, DHB representatives and the Law Commission have been informed.

Financial Implications

  1. The estimated costs of the proposals are as follows:

Item

2007/08

2008/09

Vote

Evaluation of an AOD programme that has a kaupapa Māori focus and a mainstream programme attended by Māori

s9(2)(j)

s9(2)(j)

Health

Internship project for Pacific peoples

s9(2)(j)

  

Health

Feasibility study on establishing a dual-diagnosis community treatment programme for female offenders on community-based sentences

s9(2)(j)

s9(2)(j)

Health

One mental health clinician with experience in AOD issues in a Youth Court

s9(2)(j)

s9(2)(j)

Health

Legislative Implications

  1. This Cabinet paper has no legislative implications.

Regulatory Impact and Business Compliance Cost Statement

  1. A regulatory impact and business compliance cost statement is not necessary.

Human Rights Implications

  1. Disparity of outcomes for Māori and young persons in the criminal justice system raises concerns about the right to be free from discrimination under section 19 of the New Zealand Bill of Rights Act 1990. The proposals in this paper are intended to eliminate or reduce such disparities over time and are consistent with the Bill of Rights Act and the Human Rights Act 1993.

Gender Implications

  1. This Cabinet paper proposes a new initiative that would benefit female offenders (see paragraph 43).

Disability Perspective

  1. The proposals will benefit people with disabilities who are also affected by mental illness.

Publicity

  1. Cabinet decisions will be supported by a communications strategy.

RECOMMENDATION

  1. We recommend that the Committee
  1. note that the recommendations that relate to this paper are contained in Paper One: Overview.
Hon Pete Hodgson
Minister of Health 		Hon Mark Burton
Minister of Justice

Footnotes

1 Ministry of Justice (2006) - Conviction and Sentencing of Offenders in New Zealand 1996-2005.

2 New Zealand Medical Journal, Vol 119, No 1244 (2006) Alcohol and Drug Treatment Population Profile: a Comparison of 1998 and 2004 Data in New Zealand, Simon Adamson, Doug Sellman, Dargyle Deering, Paul Robertson, Karen de Zwart

3 Ministry of Justice (2003) Research on the New Life Akoranga Programme of the Mahi Tahi Trust.

4 Ministry of Health (2006) - Te Rau Hinengaro: The New Zealand Mental Health Survey

5 New Zealand Medical Journal, vol 118 No 1216 ISSN 1175 8716 (2005) New Zealand Pacific peoples drinking style: too much or nothing at all? John Huakau, Lanuola Asiasiga, Michael Ford, Megan Pledger, Sally Casswell, Tamasailau Suaalii-Sauni, Leti Lima

6 Ministry of Health (2005) - Te Orau Ora: Pacific Mental Health Profile, P.24

7 Women and Punishment: the struggle for justice, edited by Pat Carlen, published 2002. Bryne, M. & Howells, K. (2002). The Psychological Needs of Women Prisoners: Implications for Rehabilitation and Management. Psychiatry, Psychology and Law, vol. 9, no. 1, p34-43. Johnson, H. (2004). Drugs and Crime: A Study in Incarcerated Female Offenders. Research and Public Policy Series, No. 63. Australian Institute of Criminology. Willis, K. & Rushforth, C. (2003). The Female Criminal: An Overview of Women's Drug Use and Offending Behaviour. Trends and Issues, No. 264. Australian Institute of Criminology.

8 Alternative actions may involve the child or young person paying reparation to the victim, writing a letter of apology, or undertaking community work.

9 Ministry of Health 2004 Health Behaviours Survey

10 Ministry of Justice 2006 Process Evaluation of the Christchurch Youth Drug Court Pilot