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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 Four: The Corrections Setting

Paper 26: Review of the Interface between Mental Health and Alcohol and Other Drug Services and the Criminal Justice System, Paper Four: The Corrections Setting

PURPOSE

  1. The purpose of this paper is to provide Cabinet with a discussion of the issues that relate to the mental health and alcohol and other drug (AOD) needs of prisoners and of offenders in the community.
  1. It outlines a proposal to increase the number of intensive residential beds in the 2007/08 financial year by 15 to address gaps in existing services in Auckland/Northland and the southern South Island. It suggests that a feasibility study be undertaken to establish a residential treatment service in the south of the North Island.
  1. It also proposes that a specialist AOD offender team should be established in the Auckland area to enhance the efficiency and effectiveness of providing AOD treatment to prisoners, and to offenders in the community, and to ensure continuity of care for prisoners with AOD needs who are transitioning from prison into the community.
  1. Finally the paper invites Cabinet to note the recommendations relating to the Corrections setting contained in Cabinet Paper One: Overview.

EXECUTIVE SUMMARY

  1. This is the fourth 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 AOD related harm
  • assist in reducing their re-offending.
  1. The review of the interface between mental health and AOD services and the criminal justice system revealed issues about the treatment of offenders' AOD problems in the Corrections setting (in prison and in the community). Issues in the prison setting include:
  • insufficient treatment overall for prisoners with AOD problems
  • few AOD service providers operating AOD programmes in prisons
  • long waiting lists for treatment.
  1. As directed, Health and Corrections officials reported back to the Ministers of Health and Corrections on 30 March 2007 on offenders' access to AOD treatment in the community. This report found that, despite data limitations, a substantial AOD treatment gap for offenders exists in the community, and that there are clear areas of pressing need. These needs must be addressed if efforts to reduce re-offending rates are to be effective.

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"First Steps" set of proposals have been incorporated into this Cabinet paper. They include:

  • funding 15 additional intensive residential beds in the 2007/08 financial year to address gaps in existing services in Auckland/Northland, and the southern South Island
  • investigating the feasibility of establishing similar services in the lower North Island
  • a range of workforce development initiatives, given that workforce is the primary constraint on developing AOD services
  • developing a better sense of the prevalence of AOD needs of offenders in the community by improving data and knowledge.
  1. In order to improve offenders' access to treatment, this paper also discusses whether funding should be invested in prioritising offenders for AOD treatment over the general population, or provide specific AOD treatment programmes to offenders. We consider, in principle, that offender specific treatment programmes are likely to be more acceptable to the public and to service providers, and better able to address the complex needs of offenders.
  1. We propose piloting a specialist AOD offender team in Auckland to provide AOD treatment to prisoners and offenders in the community. The aim of this pilot is to enhance the efficiency and effectiveness of providing AOD treatment to prisoners, and to offenders in the community, and to ensure continuity of care for prisoners with AOD needs transitioning from prison into the community.
  1. In regard to mental health, it is clear that there is a higher prevalence of mental illness in offender populations than in the general community in New Zealand. Offenders should receive adequate mental health care in prison and in the community. Research suggests that treating offenders' mental health issues can improve overall well-being and reduce re-offending.
  1. The increase in the prisoner muster over the last ten years has placed forensic mental health services under increasing pressure, and has reduced the number of prisoners with mental health problems (as a percentage of the total prison population) that the services are able to treat.
  1. The issues about the need for and the availability of mental health services for offenders are currently being addressed by projects that are already underway in the Ministry of Health and the Department of Corrections.

BACKGROUND

  1. The background to the interface review is detailed in Cabinet Paper One: Overview.

The Corrections Setting

  1. The Department of Corrections manages offenders serving custodial sentences (imprisonment) and non-custodial sentences and orders (e.g. supervision, community work and parole) imposed by the Courts. Corrections also provides information to assist judicial decision making in regard to sentencing offenders (such as pre-sentence reports), and provides support services to the New Zealand Parole Board.
  1. The Public Prisons Service operates 19[1] public prisons and manages around 7,700 prisoners at any one time. Of these, approximately 94% are male and 6% are female. The Community Probation Service manages approximately 40,000 new community-based sentences and orders per annum (around 23,800 offenders at any one time), and with the Psychological Service, provides information and reports to Judges and the New Zealand Parole Board to assist them in making sentencing and release decisions.

Alcohol and Other Drugs

  1. The National Study of Psychiatric Morbidity in New Zealand Prisons (1999) showed that 83% of prisoners in New Zealand have had a substance misuse disorder at some time in their lives, compared with 32% of the general population. These figures are reasonably consistent with experiences in Australia and the United States.
  1. Corrections operate 21 drug-free prison units for prisoners who profess not to use drugs or wish to break the drug using cycle while in prison. Prisoners entering these units sign a behaviour agreement that commits them to remaining drug-free. Random drug tests indicate that the drug units are highly successful in keeping prisoners drug-free compared to the wider prison population.
  1. Three drug treatment units currently operate in New Zealand prisons.[2] The units provide intensive treatment for prisoners with moderate to severe drug and alcohol problems. The programmes are full-time for six months and are based on the therapeutic community model.[3] The programmes are designed to address AOD addictions, addictive behaviours, and related offending patterns.
  1. Research has shown the units to be effective in reducing AOD abuse and criminal behaviour in the long term. In one study, the drug treatment units achieved a 13% reduction in re-imprisonment rate for participants in the 24 months after release from prison. In another, the drug treatment units demonstrated up to 16% reduction in participants' re-offending rates compared to similar prisoners who did not undertake the programmes.
  1. International literature has indicated that continuity of care is essential for drug abusers re-entering the community - any treatment in prison must be continued on release.[4] Continuing substance abuse treatment helps recently released offenders deal with problems that become relevant at re-entry, such as learning how to live drug-free in the community or developing a drug-free peer support network.
  1. After serving their prison sentence, prisoners can be released on parole to one of three residential AOD programmes that operate in New Zealand, Odyssey House[5] in Auckland and Christchurch, and Moana House[6] in Dunedin.
  1. There is an absence of reliable data on the prevalence of AOD addiction among offenders on community-based sentences. However, the Ministry of Health considers that the rates are likely to be comparable to the prison population.

Mental Health

  1. Under section 75 of the Corrections Act 2004, a prisoner is entitled to receive medical treatment that is reasonably necessary, and the standard of health care available to prisoners must be equivalent to the standard available to members of the public. It is particularly important that prisoners receive adequate mental health care in prison because research suggests that, in some cases, the stressful conditions within prison can cause a mental illness to develop, or exacerbate existing mild mental disorders.
  1. The higher prevalence of mental illness in offender populations than in the general community has been well documented both in New Zealand and internationally. Major mental disorders, for example, occur at a rate of two to four times more within the prison population, compared to the general population. One study found that typically one in seven prisoners in western countries have psychotic illnesses or major depression, and about one in two male prisoners and about one in five female prisoners have antisocial personality disorders. In the United States it has been reported that 10-15% of people in prison have severe mental illness.
  1. In New Zealand specialist psychiatric services to offenders with secondary and tertiary level mental health problems in prison and in the community is delivered by DHBs through Regional Forensic Mental Health Services. Each service consists of inpatient services in forensic hospitals, a Court liaison team, a forensic prison team and community forensic services. The Community Forensic team provides clinical care for clients transitioning from forensic inpatient care to community living.
  1. There is an absence of reliable data on the prevalence of mental health problems among offenders on community-based sentences. However, the Ministry of Health considers that the rates would be comparable to the prison population.

ISSUES

Alcohol and Other Drug Issues for Prisoners

Insufficient treatment available and long waiting lists

  1. A significant issue for prisoners with AOD needs is that there is insufficient therapy or treatment for AOD addictions in prison and long waiting lists for treatment including for the drug treatment units. Another three drug treatment units will be opened in 2007/08 to total six. These will partially meet the demand for AOD treatment in prison, but there remains a large, unmet need for less intensive, DHB-funded AOD treatment services.
  1. Few DHB Community Alcohol and Drug Services (CADS) and other AOD service providers run AOD programmes in prisons. Reasons for this include:
  • some DHBs are reluctant to accept responsibility for providing prisoners with secondary and tertiary AOD services
  • access to prisoners by CADS depends upon prison routine, security considerations, and the availability of prison staff to supervise prisoners
  • some service providers estimate that providing AOD services in prison may cost four times as much as providing the same service in the community.[7] This is due to the service needing to go into prisons, the security requirements of Corrections, and the time factors involved
  • many prisoners have severe AOD problems and complex co-morbid needs, including behavioural and psychiatric disorders. Many AOD clinicians are either not sufficiently trained or are unwilling to deal with such a difficult client group.
  1. The limited availability of AOD treatment in prisons is of concern. Untreated substance abusing offenders are likely to relapse to drug abuse and return to criminal behaviour upon release, incurring re-arrest and re-incarceration. Treatment provides the best alternative for interrupting the drug abuse/criminal justice cycle for offenders with substance abuse problems.

Short term sentences inhibit AOD treatment options

  1. A large volume of prisoners serve short-term (less than 12 months) sentences. Short-term prisoners make up the majority of prison receptions[8] and up to 32% of the prison population on any one day. Under the Sentencing Act 2002 short-term prisoners are released automatically after serving half of their sentence. These prisoners often will not access interventions in prison due to the short length of incarceration and the relative duration of rehabilitation programmes.
  1. Of most concern are prisoners sentenced to up to 12 months imprisonment (who will serve up to six months). While some of this group of prisoners may be directed for an AOD assessment and/or treatment on release as part of their release conditions, some will be released back into the community without Community Probation oversight. Many of these offenders will return to the community without having had any treatment for their addictions.

Alcohol and Other Drug Issues for Offenders on Community-Based Sentences

  1. On 9 October 2006, Cabinet requested officials to investigate and report to the Ministers of Health and Corrections by 30 March 2007 on investment in intensive AOD treatment services for offenders in the community, including an increase in further residential service capacity. Cabinet also requested a similar report on the gap between need and availability of services (insofar as it is possible from available data), and feasible options for expanding the following aspects of AOD treatment services for all offenders in the community:
  • assessment and referral;
  • non-residential AOD services, including case management; and
  • withdrawal management (medical and social).

[CAB Min (06) 37/5]

  1. The findings of the investigation about the gap between the need for and availability of services and the subsequent recommendations arrived at for AOD service expansion for offenders in the community are discussed in this paper from paragraph 54.
  1. Officials reviewed a range of New Zealand information and data resources to see if better data exists than was sourced in September 2006 (when the last review was undertaken). More robust data is necessary to enable a more accurate estimate of the gap between the need for and availability of AOD services for offenders in the community. Useful data remains elusive, and the range of estimates of costs to fill the gap remains wide. Nevertheless, officials are agreed that a substantial AOD treatment gap exists and that there are areas of pressing need that should be addressed if efforts to reduce the prison population are to be effective.

Improving Offenders' Access to AOD Treatment

  1. It is important for Judges to be able to respond to an offender's AOD treatment needs and incorporate AOD treatment as a condition of an offender's sentence. However, offenders are prioritised according to health need alongside members of the community, including when they are referred to services from the Court. Although this approach is appropriate from a health outcomes perspective, it fails to capture the social benefits that stem from treating offenders (e.g. greater public safety, reduced re-offending and imprisonment rates), and can undermine the effectiveness of sentences (either in the community or post-release from prison).
  1. To assist Judges incorporate AOD treatment into offenders' sentence conditions offenders could be prioritised for AOD treatment over the general population, or offender-specific AOD treatment programmes could be developed beyond the services currently offered in the community. Both options would improve the timeliness of offenders' access to AOD services, which may reduce their AOD misuse and re-offending rates. However, the following issues are associated with prioritising offenders over the general population:
  • without additional funding, access to AOD services for the general population could reduce, and waiting times may increase
  • AOD services would need to change their prioritisation criteria and develop a rating system based on clinical need and risk of re-offending
  • while unlikely, it may establish a perverse incentive to commit a crime in order to access earlier AOD treatment
  • the public and some service providers may object to the prioritisation of offenders over law-abiding citizens.
  1. Specific offender programmes raises the following issues:
  • the public may object to the creation of extra offender AOD services
  • without additional funding money may need to be taken from other areas of Vote: Health to fund the new services
  • it could be difficult to attract AOD clinicians to work in services that cater exclusively for offenders.
  1. On balance we consider that, in principle, funding specific services/programme placements for offenders, rather than prioritising offenders over the general population for services is the best approach.

Mental Health Issues for Prisoners

  1. The following issues have been identified regarding regional forensic psychiatry services:
  • The increasing prison muster has placed forensic services under pressure, and has reduced the number of prisoners (as a percentage of the total prison population) that services are able to care for.
  • There is high demand for forensic beds for prisoners, particularly in the Auckland region. In March 2006, an additional 15 forensic beds became available at the Mason clinic. While this reduced the need for Corrections to hold acutely mentally unwell prisoners in prison, the demand for beds continues to exceed supply.[9] Waiting for a forensic hospital bed in prison can exacerbate offenders' mental health conditions and is potentially damaging in terms of their long-term rehabilitation.
  • There are no dedicated forensic psychiatric units for female prisoners. This is a concern because female offenders have different treatment needs from male offenders. Also a high proportion of female offenders have been victims of violence and sexual abuse. It is generally inappropriate to place them in the same forensic units as male offenders.
  • People with severe personality disorders[10] are not usually eligible for compulsory treatment under the Mental Health (Compulsory Assessment and Treatment) Act 1992, however, they cannot be properly managed in prisons. These prisoners often spend lengthy periods of time in At Risk Units, which can lead to deterioration in their condition. At Risk Units are not designed for long term stay and are staffed by Corrections Officers, not health professionals. Forensic care for severe personality disordered prisoners is usually only offered as respite for crisis management.

Review of Forensic Psychiatric Services

  1. The current forensic services framework was developed in 2001. The Ministry of Health is developing a new framework that aims to:
  • present a picture of the current state of the forensic mental health sector
  • identify and analyse issues of national significance in forensic services
  • identify and analyse region-specific issues
  • clarify the future funding and planning issues for the ongoing development of regional forensic mental health services.
  1. The new framework will identify those forensic services that require attention over the next five years, for example, for children and young persons; specialised management programmes for women in forensic care; forensic services' reach into prisons; and agreed assessment and reporting criteria. The framework will be finalised this year. Future funding for forensic services will be considered after the framework has been completed.

Management of Prisoners with High and Complex Behavioural Needs and Personality Disorders

  1. This year the Department of Corrections will complete a project that focuses on prisoners with high and complex behavioural needs. These prisoners are very difficult to safely manage in a prison environment and are often excluded from services due to the complex nature of their severe behavioural issues.
  1. The Department of Corrections and the Ministry of Health are working through the issues regarding prisoners with severe personality disorders, focusing on service delivery and attaining the best service for these prisoners. Possible solutions being considered include developing management plans that provide these prisoners with time in a forensic mental health setting, and using forensic reintegration units to assist them with their reintegration needs.

Prisoner Mental Health Screening Tool

  1. Research conducted by the Department of Corrections and the Ministry of Health in 2003 identified that New Zealand prisoner referral rates to secondary mental health services were significantly lower than that experienced in overseas jurisdictions. As a consequence, both agencies have developed, and plan to introduce, a validated mental health screening tool as part of the prisoner health assessment process.
  1. A trial of the newly developed tool began in July 2006 at Christchurch Men's prison. A further trial at Auckland Central Remand Prison will commence in May 2007, to test the validity of the tool for Māori. If the trial is successful and the tool is fully implemented at all prisons, there is an expectation that it will improve the identification of mental health problems in the New Zealand prison population. This will contribute to better mental health service delivery for these prisoners.

PROPOSALS

Specialist AOD Offender Team

  1. We propose piloting a specialist AOD offender team based in the Community Alcohol & Drugs Services (CADS) in Auckland. The aim of this initiative would be to enhance the efficiency and effectiveness of providing AOD treatment to prisoners, and to offenders in the community, and to ensure continuity of care for prisoners with AOD needs who are transitioning from prison into the community.
  1. The specialist team would comprise a lead co-ordinator, liaison person/s, and offender-focussed clinicians. Access to psychiatric advice and expertise in cultural issues will be readily available. We propose that two FTE co-ordinating liaison positions be established. The clinicians would be based in probably five of the current CAD service sites. The main functions of the teams would be to:
  • provide regular AOD treatment and relapse prevention programmes in prison
  • offer one-to-one counseling to prisoners where needed and appropriate
  • provide regular AOD treatment and relapse prevention programmes to offenders in the community
  • work with Corrections staff so that prisoners needing AOD treatment while on a community-based sentence, or on release from prison will be appropriately referred.
  1. The role of the Co-ordinator would be to:
  • liaise with Corrections to ensure that the treatment provided to prisoners is delivered in an efficient and effective manner
  • ensure the offenders are linked into appropriate AOD services and that the treatment continues over all transition points
  • train the clinicians in regard to the broad needs of offenders and the needs of the Department of Corrections
  • train Department of Corrections staff in prisons and in the community as to how to ensure AOD treatment meets the needs of offenders and is successful
  • administer the teams and collate information
  1. There are advantages with the proposal's focus on offenders. It will ensure that the treatment providers can spend the time to follow offenders through the various transition points and not to lose track of them.
  1. We propose that the specialist offender team be piloted over a three year period. A progress report will be completed before the pilot commences in consultation with CADs. The report would canvass the proposal further, provide more detailed costings, and outline the next steps. After the initial three years the pilot will be evaluated by the Ministry of Health in consultation with the Department of Corrections and the Ministry of Justice.
  1. The project will be led and funded by the Ministry of Health. A progress report will be referred to the Ministers of Health, Corrections and Justice by 31 August 2007.

Additional AOD Services for Offenders on Community-Based Sentences[11]

  1. For offenders on community-based sentences of supervision with AOD needs, the proposed way forward over the next two years is to fund additional intensive residential beds to address gaps in existing services in Auckland/Northland and the southern South Island. Service development needs to:
  • take into account the needs of Māori, women and young people
  • ensure services are flexible enough to handle issues of co-morbidity and offending behaviour
  • if possible with available funds, grow associated services, especially assessment and counselling/case management.[12]
  1. Apart from the specialist offending team proposal, further investments will include:
  • 15 new intensive residential beds and/or intensive day programmes
  • investigating the feasibility of establishing similar services in the lower North Island
  • funding two additional medical detoxification beds
  1. As noted in Cabinet Paper One: Overview, officials also need to improve data collection and the knowledge base on the AOD needs of offenders across all population groups, in order to develop a better sense of addiction prevalence and the ability for offenders to access services.

Population Group Considerations

  1. As part of the interface review, officials have examined the needs of Māori, Pacific peoples, youth and women with mental health and/or AOD issues in the criminal justice system. Paper Five: Population Groups examines the needs of specific population groups across the criminal justice system. However, as the proposals in this paper cover all persons in Corrections settings it applies to all of the above population groups.

Consultation

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

Financial Implications

  1. Funding for all the proposals in this paper will be met from Vote: Health. We estimate the cost of the key elements of the proposals (summarised in paragraph 54 of this paper) are as follows:
Item 2007/08 2008/09 Vote

Piloting a Specialist AOD Offender Team from Auckland CADS

s9(2)(j)

s9(2)(j)

Health

Investing in additional services for offenders on community services

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 Right Implications

  1. The proposals of this paper do not pose implications for human rights.

Gender Implications

  1. The proposals will be of greater advantage to males as they compromise around 90% of offenders in the Corrections setting. However, female offenders who have their AOD addiction needs met will also benefit.

Disability Perspective

  1. The proposals will benefit offenders with disabilities in the Corrections setting who are also affected by mental health or AOD problems.

Publicity

  1. A communications strategy will be developed to support decisions made by Cabinet.

Recommendation

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

Footnotes

1 The Otago Corrections Facility will open in 2007 raising the total number of prisons to 20

2 The units are located Arohata Women's Prison in Wellington, Waikeria Prison in Waikato, and Christchurch Men's Prison. Additional units are planned for Hawkes's Bay Regional Prison, Rimutaka Prison in Wellington, and the new Springhill Corrections Facility in northern Waikato.

3 The therapeutic community is a well-established treatment model for substance abuse and addictions.

4 Ex-prisoners have an increased relative risk of mortality. Death from all causes in some groups was found to be 17 times higher than in the general population in the two weeks following release. The main causes of death are associated with AOD misuse.

5 Odyssey House is available to men and women in both locations. It is a psychiatrically oriented therapeutic community with the primary objective of fostering personal growth and change. It requires that no more than 25% of its residents be offenders.

6 Moana House is a residential bicultural therapeutic community in Dunedin that caters for up to 11 male offenders. Residents may have been directed to attend Moana House as a condition of supervision, or be on parole or home detention.

7 Officials have been unable to verify this estimate of increased costs.

8 In 2004/05, 90% of sentenced female receptions were for short terms of imprisonment and 84% of sentenced male receptions received short-term sentences.

9 On 30 March 2007 the overall waiting list reached 21; only one short of the peak of 22, reached in August 2005. However, the average waiting time for acute patients has reduced from 55 days in August 2005 to 36 days in March 2007. The main reason for the large waiting list is likely to be that the prisoner population also rose to a new high of 7,916 in March 2007.

10 Personality disorders are pervasive patterns of thinking, feeling, interacting or behaving that are fixed and inflexible and result in impairment in the person's ability to function in one or more key aspects of their life.

11 These proposals have been carried forward from the 30 March 2007 report-back to the Ministers of Health and Corrections on the Cabinet paper 'Effective Interventions: Offender Access to Alcohol and Other Drug Services'.

12 The numbers involved are relatively small and this will not be particularly costly.