Offenders with Mental Health Needs:

The Effectiveness of Correctional Service Canada’s Community

Mental Health Initiative in the Successful Reintegration of

Offenders into the CommunityLuong, D., Allegri, N., Delveaux, K., & Yates, P. M.

Evaluation Branch, Policy Sector, Correctional Service Canada

International Corrections and Prisons Association

Barbados, October 28, 2009

Acknowledgements

• Evaluation Team at National Headquarters

• Research Unit at the Regional Psychiatric Centre in Saskatoon, Saskatchewan, Canada

• All staff, offenders, and community service providers who took time to share their thoughts on the Community Mental Health Initiative (CMHI) by completing a survey or agreeing to participate in an interview as well as all the staff members who helped to coordinate correctional site visits

• Members of the Executive Steering Committee and Evaluation Consultative Group

Overview

• Introduction• Correctional context in Canada• Legislation and Correctional Service Canada (CSC) Policy• Mental Health and CSC

• Community Mental Health Initiative: Program Description• Evaluation

• Logic Model• Strategy and Methodology

• Results• Discussion• Limitations• Conclusions

Correctional Context in Canada

• Criminal Code of Canada (1985)

• Provincial/Territorial and Federal correctional systems

• The majority of adult convictions do not result in incarceration in federal institutions• e.g., in 2005/06, estimated adult convictions was

244,572 in Canada • 4,787 resulted in admissions to federal custody

• 78,081 admitted to provincial/territorial custody

• In 2008, there were a total of 22,831 offenders under the federal system• 31% were under active supervision in the community*

* Federal offenders on day parole, full parole, and statutory release as well as those in the community on long-term supervision orders

Total Federal Admissions

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Legislation and CSC Policy:Health and Mental Health

Corrections and Conditional Release Act [1992, 86(1)]:

The Service shall provide every inmate with

(a) essential health care; and

(b) reasonable access to non-essential mental health care that will contribute to the inmate’s rehabilitation and successful reintegration into the community

Commissioner’s Directive (CD) 850: Mental Health Services (CSC, 2002)

To ensure appropriate access to professional mental health services. These services contribute to the improvement and maintenance of the inmate's mental health and adjustment to incarceration and assist them in becoming law-abiding citizens.

Departmental Priorities

• Strengthening CSC’s strategy to treat and effectively manage offenders with mental disorders was highlighted in the Report of the Correctional Service of Canada Review Panel: Roadmap to Community Safety Report (2007)

• The 2006 report of the Standing Senate Committee on Social Affairs, Science and Technology on Mental Health Care in Canada, Out of the Shadows at Last, also recommended that CSC take responsibility for ensuring the continuity of mental health care post-release

• Addressing mental health of offenders is one of the five strategic priorities of the CSC

Mental Health and CSC

• The prevalence of mental disorders is higher among offenders than among the general population

• Since 1996/97:• The prevalence of mental health problems at

intake among men and women federal offenders have increased by 67% and 69%, respectively

• Almost 80% increase in offenders who were on prescribed medication at the time of admission

• Overall, 10% of men offenders and 22% of women offenders are identified as having a mental health disorder at intake

Community Mental Health Initiative (CMHI)

• The CMHI was designed to aid offenders with serious mental disorders (OMDs) to reintegrate into the community by providing care through clinical discharge planning, support from mental health professionals in the community, training of CSC and mental health resource staff in the community, and assisting OMDs to access specialized services such as psychiatric care.

• Four main components :• Clinical Discharge Planning (CDP)• Community Mental Health Specialists (CMHS)• Community Partnerships through Contract Services• Mental Health Training for Community Correctional

Staff

Clinical Discharge Planning

• Transitional service that supports OMDs being released from the institution to the community

• The primary goal of clinical discharge planning services is to ensure the continuity of mental health care for released offenders

• Offenders who meet the eligibility criteria are referred by the institutional parole officer to clinical social workers (CSWs) for CDP services nine-months prior to their expected release date.

CDP Referral Criteria

• Major mental disorder• Schizophrenia and other psychotic disorders• Mood disorders (e.g., major depression, bipolar

disorder)• Other disorders (e.g., obsessive-compulsive disorder)

• Moderate to severe impairment from:• Personality disorder excluding antisocial personality

disorder (e.g., paranoid, borderline, schizoid)• Acquired brain injury or organic brain dysfunction (e.g.,

FASD)• Developmental disability or intellectual impairment

Community Mental Health Specialist (CMHS)

• The key services offered are comprehensive assessment and intervention planning, direct service provision; advocacy, coordination and support, implementation, monitoring and evaluation, and community capacity building

• The CMHS (either a clinical social worker or a community mental health nurse) works with the offender’s parole officer, community services, and support workers to further enhance integrated offender management

• Work to remove barriers to service delivery and contribute to community capacity building

• Same referral criteria as CDP

Community Partnerships through Contract Services

• To develop links or working relationships between CSC and non-CSC organizations that will provide OMDs with necessary support and resources after release

• Contracts for services are arranged by the regions, and are not limited to the 16 existing CMHI sites

• Services range in nature but are frequently provided by psychiatrists, psychologists, and community service agencies providing bed space for offenders to reside at their facilities, and personal aid workers assisting with daily functioning needs and socialization

Mental Health Training for Community Correctional Staff

• The objective is to provide mental health training to staff members and community partners involved in the supervision or management of offenders at sites targeted to receive new community mental health positions (Champagne et al., 2008).

• Includes correctional service, parole offices, Community Residential Facilities, and contract service providers

• 2-day training consisting of 9 modules:•Introduction •Risk and mental disorder

•Myths and realities •Effective strategies

•What is mental disorder •Resources

•Mental disorders •Legislation

•Fetal alcohol spectrum disorder

Correctional Service Canada’sCommunity Mental Health Initiative – Logic Model

Ultimate Outcomes

The Community Mental Health Initiative contributes to the safe accommodation and reintegration of offenders into Canadian communities by providing them with reasonable access to mental health care.

Activities

Outputs

Immediate Outcomes

Discharge Planning

Establishing contracts and agreements for enhanced services for community OMDs

Staff training

Community Mental Health Nurses and Clinical Social Workers hiredCommunity care plans developed for targeted offenders

Contracts and agreements established

Standardized national mental health training package.Qualified trainers in each region.Trained front-line staff at identified sites.

Offenders are accessing available services

Staff has increased awareness of mental health issues

Discharge Planners hired Discharge plans developed for targeted offenders

Improved services for offenders with mental disorders

Improved correctional outcomes for offenders with mental disorders

Improved quality of life for offenders with mental disorders

Increased availability of services and support for offenders with mental disorders being released and in the community

Standardized provision of services

Hiring of mental health staff for community sites

Intermediate Outcomes

Evaluation Objectives

• To provide information required to make investment decisions in the area of community mental health

• To examine the continued relevance, implementation, success, cost-effectiveness, and unintended outcomes of the CMHI

• For the purpose of the presentation, results are discussed for each of the four components of the CMHI

Evaluation Methodology

• A multi-method approach incorporating qualitative and quantitative methodology • A review of program documentation and reports (e.g.,

CMHI Guidelines)• Surveys with CSC staff and community service

providers• Face-to-face interviews with offenders who were

participating in the CMHI• Offender data extracted from the Offender

Management System (OMS) and CMHI-specific databases maintained by the Regional Psychiatric Centre in Saskatoon (Prairies Region) and Health Services (HS) at NHQ

Measures

• Mental Health Training Evaluation Questionnaire, Mental Health Knowledge Quiz, Self-Perceived Competency Scale

• Staff and community service provider surveys

• Offender interviews

• Alberta Continuity of Service Scale for Mental Health (Adair et al., 2004)

• Data from the CSC’s Offender Management System

• Community outcomes (i.e., suspensions and revocations) compared to a historical control group

Samples

• Clinical discharge planning recipients (CDP)

• Community mental health specialist service recipients (CMHS)

• Comparison group (CMHI Comparison). • generated by using a historical cohort of offenders who

were eligible for release between April 1, 2003 and March 31, 2005, and who had the Offender Intake Assessment (OIA) indicator “diagnosed as disordered currently” (CSC, 2008d)

Demographic, Criminal History, Risk Variables and Security Level at Release for the CDP, CMHS

and CMHI Comparison Groups

CDP (n = 53)

CMHS (n = 79)

Comparison Group(n =95)

Demographic Variables Mean (SD)Age at Index Offence (years) 29.5 (8.6) a 31.5 (9.3) a 35.2 (9.7) b

Age at Release (years) a 32.2 (8.5) a 36.3 (10.3) b 37.8 (10.0) b

Number (%)Marital Status - Married/CL 13 (24.5%) 19 (24.1%) 22 (23.2%)Gender - Male 42 (79.2%) 64 (81.0%) 85 (89.5%)Race – Aboriginal 23 (43.4%) a 18 (22.8%) b 16 (16.8%) b

Sentence and Criminal History Mean (SD)Index Sentence Length (years) 4.3 (3.1) a 6.2 (7.2) b 3.6 (2.8) a

Number of Prior Convictions:Non-Violent 22.6 (17.0) a 15.8 (16.8) b 16.9 (16.1) b

Violent 3.6 (2.6) a 2.6 (2.7) b 3.2 (2.9)Sexual 0.2 (0.7) 0.6 (1.6) 0.6 (1.2)Total 26.4 (17.5) a 19.0 (17.9) b 20.7 (16.5)

Note. Statistically significant differences between the groups are identified with an a, b, at p < .05.

CDP (n = 53)

CMHS (n = 79)

Comparison Group(n =95)

Criminal History & Risk Variables Number (%)Index Offence Type:

Schedule I 39 (73.6%) 46 (58.2%) a 72 (75.8%) b

Sexual 4 (7.5%) 12 (15.2%) 13 (13.7%)Security Classification at 1st Release 1:

Maximum 12 (22.6%) a 6 (7.6%) 7 (7.4%) b

Medium 31 (58.5%) 50 (63.3%) 60 (63.2%)Minimum 6 (11.3%) a 19 (24.1%) 25 (26.3%) b

Missing Data/Prov/Unknown 4 (7.5%) 4 (5.2%) 3 (3.2%)Reintegration Potential 1:

Low 30 (56.6%) 24 (30.4%) a 43 (45.3%) b

Medium 18 (34.0%) 36 (45.6%) 35 (36.8%)High 5 (9.4%) 19 (24.1%) 17 (17.9%)

Demographic, Criminal History, Risk Variables and Security Level at Release for the CDP, CMHS

and CMHI Comparison Groups

Notes. Statistically significant differences between the groups are identified with an a, b, at p < .05. 1 Security classification and reintegration potential each had three levels. In order to minimize the chance of erroneously finding a difference (i.e., family-wise error), comparisons were completed for CDP vs. comparison and CMHS vs. comparison groups only

Results – Mental Health Training

• Three formats of training: generic, train-the-trainer, and women offenders

• Mental health training was provided to:• 830 individuals in the community• 352 CSC institutional staff members who worked with

individuals with mental disorders (primarily CSC nurses)

• Training was effective in improving community personnel’s mental health knowledge and self-perceived competency to work with offenders with mental disorders

Average Pre- and Post-Training Mental Health Quiz Scores

M (SD) t (df)%

Improvement

Training Package Pre-Training

Post-Training

Total (n = 616) 8.63 (3.47) 13.69 (2.84)-39.15***

(615)58.63%

Generic (n = 420) 8.17 (3.41) 13.28 (2.93)-33.35***

(416)62.55%

Train the Trainer (n = 60)

11.35 (2.54) 14.60 (1.86)-9.65***

(59)28.63%

Women Offenders (n = 136)

8.88 (3.44) 14.55 (2.64)-19.67***

(135)63.96%

Note. *** p< .001.

Self-Perceived Competence in Working with Offenders with Mental Disorders

• Participants’ self-perceived competency ratings improved significantly after training (average improvement of 31%).

• Mean competency rating:• Pre-training: 32.35 (SD = 9.23)• Post-training: 42.36 (SD = 9.37)

• Results from the CSC staff survey administered for the present evaluation indicated that CSC staff members who participated in the mental health training rated their competence to work with offenders with mental disorders significantly higher than CSC staff members who did not receive training

CDP and CMHS Services

• Offenders referred to, and accepted for, CMHI services, including discharge planning and community mental health specialist services, are receiving these services.

• A total of 176 offenders were accepted for clinical discharge planning services and 190 offenders were accepted for community mental health specialist services nationally from the start of the initiative until June 2008

Contracted Services

2006/07

Apr - Sept

2006/07

Oct - Mar

2007/08

Apr - Sept

F2007/08

Oct - Mar

Total

Number of services requested

20 175 394 384 973

Types of Services

Addictions 0 11 16 16 43 (4.4%)

Employment 0 24 0 0 24 (2.5%)

Leisure/Daily Living 0 66 122 147 335 (34.4%)

Psychiatric Services 11 74 256 215 556 (57.1%)

Women Specific Services

9 0 0 6 15 (1.5%)

National Community Capacity Building for CDP and CMHS Services in 2007/08

FY 2007/08

TotalTotal Number of Contacts a 1755Information Sharing with Organizations 1057Internal 388Psychiatric/Psychological Services 115Housing 109Non-government organizations (e.g., Elizabeth Fry) 56Correctional (CRF/Provincial) 51Mental Health Information and Referral 41Employment 37Addictions 34Other b 226

Notes. a excludes 47 entries on the Community Capacity Building records that were not appropriate capacity building activities. b includes categories that had small frequencies such as Aboriginal culture-specific services, provincial/municipal government agency, and education

National Community Capacity Building for CDP and CMHS Services in 2007/08

FY 2007/08

TotalActivities with Organizations 698Psychiatric/Psychological services 158Housing 77Mental Health information/referral 68Non-government organizations (e.g., Elizabeth Fry) 56Addictions 53Employment 53Other c 233

Note. c includes categories such as physical health, CSC (internal), and Aboriginal culture-specific services.

Offender Perception of the Continuity of Services as Rated Using the Alberta Continuity of Services

Scale for Mental Health

Mean (SD) Observed Possible

System Fragmentation

84 (10.2) 62 to 105 21 to 105

Relationship Base 39 (4.1) 32 to 45 9 to 45

Responsive Treatment

31 (4.5) 24 to 40 8 to 40

Total 154 (17.1) 124 to 190 38 to 190

Results – Suspensions

After controlling for pre-existing differences in age at release, functional impairment, and reintegration potential, there was a significant group effect on survival. Specifically, the CMHS group was 34% less likely to be suspended than the comparison group and the CMHS group was 42% less likely to be suspended than the CDP group. There was no significant difference between the CDP and comparison group.

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Results – Technical Revocations

After controlling for pre-existing differences in age at release, functional impairment, and reintegration potential, there was a significant group effect on survival when examining likelihood of revocation of release Specifically, the CMHS group was 59% less likely to have their release revoked than the comparison group and the CMHS group was 60% less likely to be revoked than the CDP group. There was no significant difference between the CDP and comparison groups on likelihood of revocation.

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Results – Community Outcome

• The majority of offenders received either clinical discharge planning (CDP) or community mental health specialist (CMHS) services, but not both.

• Offenders receiving CMHS services were less likely to be suspended or revoked than the comparison group, after statistically controlling for pre-existing group differences.

• There was no evidence to suggest that the CDP group differed from the comparison group with respect to suspensions or revocations.

• These preliminary findings should be interpreted with caution due to small sample sizes and short follow-up times

Limitations

• Use of a historical comparison group

• Lengthy implementation delays

• An inability to identify offenders who may have had their CMHI services terminated shortly after accepting their referrals

• The small number of offenders who received both CDP and CMHS services to date

Conclusions and Lessons Learned

• There is a continued need to provide services to OMDs to address their mental health needs and assist them to successfully reintegrate into the community

• Delays in implementation were attributed primarily to staffing challenges

• Challenges related to information sharing across institutional and community mental health and case management teams were identified

• Increased mental health training, particularly for institutional staff members, was recommended

Conclusions and Lessons Learned

• Preliminary results suggest that community mental health specialist services are associated with decreased likelihood of suspensions and technical revocations compared to the comparison group and clinical discharge planning group

• Future evaluations and research should examine community outcome using a longer follow-up time and examine an additional group of offenders who receive both CDP and CMHS services

Contacts for Additional Information

Duyen Luong

Senior Evaluator

Evaluation Branch, Policy Sector

Correctional Service Canada

duyen.luong@csc-scc.gc.ca

Dr. Pamela M. Yates

Director General

Evaluation Branch, Policy Sector

Correctional Service Canada

pamela.yates@csc-scc.gc.ca