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Ruth Martin
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Ruth Martin
2010-03-16 15:41
Thank you, Mr. Chairman and members of the committee, for inviting me to be a witness.
I come wearing three hats. I juggle a few hats, but these are the ones I'm wearing today.
As a prison family physician, I've worked in corrections systems for 16 years, mostly with women and mostly in the provincial system, but I do have some experience with men's facilities and federal systems.
The second hat I wear is as a clinical professor in the UBC department of family practice. Amber has talked about some of the research in which I'm involved.
My third hat, more recently acquired, is as director of the Collaborating Centre for Prison Health and Education. It is a group of academics and community organizations--actually anybody who wants to join--that is looking at ways to facilitate collaborative opportunities for health education research service and advocacy for people in custody, their families, and communities.
I'd like to share with you five personal reflections that I formulated about mental health, primarily in female corrections. These personal reflections are consistent with prison health publications, which I've footnoted in my written submission to you. I'd be happy to supply any of the documents to you if you'd like to read them further at a later stage. Don't hesitate to ask me.
It's well established that prison populations throughout the world suffer more ill health than the general population, and that female prison populations suffer more ill health than male prison populations. As a prison physician I've witnessed this over the years. As I've witnessed women cycle in and out of the system over the years, I've come to learn that most women are incarcerated because of crimes due to their disordered health and social lives. Therefore I've come to realize and reflect that the key to women's successful reintegration into society lies with figuring out how to empower incarcerated women to improve their health.
The second reflection pertains to the aboriginal people, who are tragically overrepresented in our systems. Over the years I've listened to aboriginal patients and aboriginal colleagues explain to me about their understanding of health. They've taught me that mental health is not a stand-alone thing. It is closely interwoven with a person's physical, emotional, and spiritual health. I realize that I started off in my career with a very Eurocentric or western-centric view of health, and I've come to appreciate that in order to engage incarcerated people to improve their health, we all need to improve our cultural knowledge and sensitivity.
My third reflection that I wish to share with you is that women with incarceration experience are experts about their own health. This was reinforced for me during this participatory health research project that we started in prison. I thought we would focus our research on HIV, hepatitis C, and addictions, but in fact when we asked women in prison what they would like to research in order to improve their health they told us they wanted to become better mothers. They wanted to become involved in meaningful work. They wanted to improve their community support and have safe housing.
The goals that women in prison identified that were important to improving their health were very similar to my own goals and probably to your goals. They are consistent with the public literature that pertains to mental health, social inclusion, and health promotion. All of these published studies agree that in order to improve the mental health of a population we have to affirm people's self-confidence, engage people in decision-making processes, and focus on people's strengths rather than their deficits. Doing so will enhance their sense of hope and their belief that they can succeed and change.
A fourth reflection that I've learned through my work with the collaborating centre is that numerous multi-sector organizations are keen and eager to collaborate with prisons to foster health. In fact, they recognize that they should be playing a role, particularly in two components of service.
First, individuals in prison should be offered the best multidisciplinary, patient-centred prison services that we can, including health. The second component is that during their transition to the outside community, individuals should be offered well-coordinated continuity of care. I can share three examples of that: inter-ministerial collaborations in other countries on health, academic collaborations on health, and collaborations at the local prison community level, if you wish.
The final reflection I wish to address is that most of the incarcerated people I've met are not mentally healthy. The prevalence rates, as you know, vary, depending on how you diagnose mental illness or how you measure it. In the literature it varies from 12% up to between 76% and 80%, and you've heard those figures in the statements of your previous witnesses.
Most of the women I see in prison clinics do not fall into a mentally ill psychiatric diagnosis, nor do they warrant transfer to a psychiatric hospital or treatment centre. However, the majority of people I have met in prison suffer from mental health difficulties such as anxiety, insomnia, flashbacks to previous trauma, depressive episodes, interpersonal conflicts, and poor impulse control. Many also have substance dependence, which is associated with their mental health difficulties. Some may be related to an under-diagnosed or under-screened condition such as a learning difficulty or fetal alcohol syndrome.
Regardless, women in prison across the board tell me that if they could figure out how to improve their mental health while they're inside prison, they will have a better chance of succeeding when they leave prison. I have reflected on about six suggestions--probably more--over my experience of working with people in prison, and also reading the prison literature.
The first one would be that incarceration in this country should be viewed as an opportunity for individuals to improve their mental health and to turn their lives around. Therefore, we should be doing everything we can to nurture processes inside prison that demonstrate success in improving health.
The second one is that we should be incorporating into every correctional system participatory processes that listen to and act upon the voice of individuals with incarceration experience about ways to improve mental health.
The third one is that prisons are really stressful places to work. There's a real tension that staff experience between nurture versus security and it's very wearing on prison staff. The mental health of inmates is really influenced and impacted by the morale of prison staff. Therefore, prisons should adopt what the literature calls a “whole prison settings approach” for health promotion that engages staff and inmates, because then prisons will become more effective in helping the mental health of inmates.
The fourth suggestion is that healthy prison environments should be fostered, because healthy environments will reinforce the educational benefits of inmates who participate in prison educational programs. By contrast, unhealthy prison environments will negate and undermine the benefits of these programs.
The fifth one is that prisons that use creative alternatives to solitary confinement foster healthier mental health both for the staff and for the incarcerated individuals. The use of solitary confinement does not enhance an individual's mental health. It worsens it, especially among those with pre-existing mental health difficulties. In Canada, therefore, we should support and commend prison management teams that do not use solitary confinement. In fact, we should discourage the use of solitary confinement in Canada.
The sixth suggestion is that because the overall prison ethos influences the mental health of inmates and staff, we should do everything we can, from top ministerial levels all the way down the chain, to support prison management teams that create and sustain a healthy prison ethos.
Thank you very much for listening to my reflections, and I welcome your questions.
Brenda Tole
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Brenda Tole
2010-03-16 15:49
Mr. Chair and committee members, I am very pleased to be here and to have this opportunity to speak to you regarding these very important issues within corrections.
My experience is in the British Columbia corrections system. I spent 36 years in this field, both in community and custody settings, and have worked with youth, men, and women. The last position I held was warden of the Alouette Correctional Centre for Women.
British Columbia has benefited over the years from its relationship with Correctional Service of Canada. CSC is generous and resourceful when sharing research and program and policy information. The provincial system houses remanded and sentenced offenders and immigration detainees. The maximum sentence length is two years less one day in the provincial system. However, people often spend long periods, sometimes several years, remanded and awaiting trial. All offenders who are admitted to CSC have been in the provincial correctional system prior to their admission. In B.C. there are approximately 2,500 in custody and 25,000 supervised in the community on bail or probation on any given day. The difference in sentence length has huge implications for program and service delivery and community reintegration, but both systems face many similar challenges. Corrections has a mandate to ensure public safety while exercising humane control. Balancing public attitudes to offenders with research and best correctional practice is a very difficult process.
This committee is focused on offenders with mental health disorders and offender programming. I'd like to talk a bit about interventions and initiatives that I have found to have a positive outcome for staff, contractors, and offenders in a custody setting. I'm going to focus on women offenders, which is the area of my most recent experience, but many of these issues are relevant to both populations.
Women make up approximately 10% of the custody population and due to the small numbers have been greatly influenced by the larger male population in areas of physical plant design, security, classification, risk needs assessment, and programs. When we opened Alouette Correctional Centre for Women, we had an opportunity to slowly move away from a model focused on security and control towards a more pro-social offender responsibility model. It is very difficult to move away from long-standing attitudes and ideas around safety and security. However, we found the more normalized environment made the centre safer for staff and inmates, and institutional violence and use of force incidents were greatly reduced.
I am mindful of time, so I will briefly list some of the factors I felt contributed to positive change at this centre.
The actual physical plant design and centre environment have a significant impact on staff and offenders, particularly those offenders suffering from mental health disorders. All benefit from access to natural light, fresh air, regular physical activity, and non-controlled movement whenever possible. It is important to note that this type of building is generally much cheaper to build and to maintain. Classification of women to the least restrictive setting needs to be a high priority. Women, particularly aboriginal women, tend to be classified to higher security levels than required. Placing people at the least restrictive setting using a good classification process immediately rather than making them apply for or earn the placement is a much more consistent and efficient process. All offenders, particularly those with mental health disorders, manage much better in a less restrictive and therapeutic setting.
For example, we had a number of offenders at Alouette who were on remand prior to moving to Correctional Services of Canada. They managed for periods of over a year at a medium open centre, which is what we had. When they were sentenced they moved to the federal system, and then were required to stay in a maximum security setting for two years due to policy. That's an example of how, from the viewpoint of classification, you can have a huge impact. Policy has no flexibility. It makes it very difficult to actually do what's in the best interests of everybody.
Offenders have a huge interest in programs and services in a correctional centre and if engaged can contribute to defining their needs. Open communication with staff and administration can reduce the development of a negative subculture, which often operates in a correctional centre. Offenders, supervised by staff, should be encouraged to take responsibility for appropriate aspects of programs and operations. Aboriginal women seem to be even more impacted by the isolation from their family and community. Programs that facilitate the return of these women to their community, under supervision of band or community justice components whenever possible, seem to present the most positive outcome. The ever-increasing over-representation of aboriginal women in custody continues to be of grave concern. It is a tragedy, and I do not think that more aboriginal programming and services within our present correctional environment will impact the situation.
Supporting aboriginal governments, organizations, and service providers to assume more responsibility for the management of aboriginal offenders presents the most promise.
Mutual respect between staff and offenders is critical for a safe and secure environment. Staff who engage offenders with respect and who focus on being professional and helpful contribute to an environment that is pro-social. A better working environment affects staff recruitment and retention and lowers rates of staff absenteeism. The positive aspects of good staff-offender relations are seen in program interest and participation. It needs to be recognized that the negative effects of being in custody increase with sentence length.
Good health services are one of the most important components of the correctional centre. Physical and mental health professionals who work in coordination with corrections in delivering consistent and timely health services, including preventive education, are essential. Providing health services to a community standard is an ongoing struggle. There is also a need for continuity of care upon reintegration into the community. Partnerships with provincial health authorities could provide continuity of care and community standards and would promote a “patient first, offender second” approach. Staff training from forensic mental health services has helped our staff, in the past, understand mental health symptoms and non-compliant behaviours from a different perspective. It has also exposed them to hospital model interventions for dealing with offenders who have mental health disorders.
The use of segregation, other than for serious disciplinary matters, has a very negative effect on offenders, particularly women and those with mental health disorders. I have not seen any benefit from isolating an individual from support, comforts, and human contact for extended periods of time. If anything, this procedure tends to escalate problem behaviours. What has benefited these offenders is not isolation but rather extra staff or contractors to engage with them and close attention from health professionals.
Self-harm is a very complex and difficult issue. In four years at Alouette, we had one minor incident of self-harm occur, and it was not repeated. I think it's important, when looking at self-harm, to see it not in isolation but to see it basically in the environment in which it happens. It's really a symptom of extreme emotional distress.
On women and their children, a high percentage of women in custody have dependent children. Women are often in centres that are large distances from their children and families. This should be a major consideration in any administrative transfer. Initiatives that promote and foster contact between women and their children is beneficial to both. These include enhanced visits, email, tapes, telephone calls, and letters. Research shows that the children of incarcerated women are more negatively impacted if the contact with their mothers is limited or absent. One of the most compelling factors for women to change their behaviour or lifestyle is pregnancy and having children. Having a supportive mother-baby program at Alouette had an amazing, positive impact on the mothers involved and on the other inmates and staff. This initiative was basically a health initiative, and it was done in conjunction with the Vancouver Women's Hospital, which had requested that we give consideration to it. They worked very closely with us on that program.
Of the 12 mothers who brought babies back from the hospital and were released to the community with their babies, 11 have remained out of custody. The initiative was also a partnership with several other ministries, community agencies, and women offenders and their families. It was based on the best interests of the child.
The one thing that is not in my notes that I would like to make a comment on is reintegration. Integration is really a combination of having the community involved inside the centre and with offenders outside the centre. The community is a very interested group that is quite willing to participate inside the centre. It will provide expertise and the standards of the community. That applies to a number of areas, including what Dr. Martin has talked about in terms of health, but also in terms of education and job preparation and vocational courses. There is an amazing source of information and program availability actually sitting right in the community.
I think it's really important for the community to have involvement in the centres. It's a way for the public to gain an education on what actually works for offenders and not necessarily the public perception we sometimes have, which is quite negative. It also reduces the fear factor.
In terms of increasing the number of temporary absences and the ability for offenders to return to the community, I think that supportive transitional housing in the community, particularly accommodation for women and children, is essential.
It's important to recognize that women tend to be associated with the same risk that men present to public safety, which is simply inaccurate. When it comes to release into the community, for that population, I think it presents an opportunity to really increase the access that women offenders have to the community.
I want to thank you for this opportunity. I'd be happy to answer questions the committee has.
Thank you.
Peter Ford
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Peter Ford
2009-11-05 12:28
My name is Peter Ford. I am a physician recently retired from the department of medicine at Queen's.
For the past quarter of a century I have been looking after patients with HIV and associated diseases. Also for about a quarter of a century I have been looking after federal prisoners with HIV, which I do by going into the prisons on a regular basis.
At any one time I have 35 to 50 patients in the eastern Ontario area with HIV. Ninety-five percent of these have hepatitis C, which is, in this particular context, a marker of intravenous drug use.
Because of this high prevalence of hepatitis C in the HIV population, we did some studies back in the nineties--the first one was in 1994--to see what the prevalence of HIV and hepatitis C was in the institutions generally. We looked at a medium security institution in the Kingston area and did an anonymous study, which showed us that 28% of the inmates had hepatitis C and 1% had HIV.
We repeated that study in 1998, by which time 33% of the inmates had hepatitis C and 2% had HIV. With the second study we did a detailed questionnaire, which could be linked to the blood samples anonymously. What we discovered was that almost everybody who had hepatitis C had a history of intravenous drug use. The people who gave a history of sharing injection equipment had the highest incidence of hepatitis C. But the most alarming thing that came out of that study was that there was a group of people who had not injected outside prison but had shared injection equipment in prison, and two-thirds of these people were positive for hepatitis C.
So what we're looking at is a problem with a communicable blood-borne disease, which is being imported into the prisons and is proliferating within the prisons. That has some very serious public health overtones, because these folks are going to get out and they're going to go on doing what got them infected in the first place. In addition, hepatitis C can be spread by sexual transmission--just under 10% is spread by sexual transmission--so the risk is going to move beyond the intravenous drug users to their sexual partners.
The long-term health costs of this are very considerable. It costs about $20,000 to treat somebody with hepatitis C. The treatment is not always successful. The treatment is not always possible because the patients don't identify themselves or because they're not suitable for treatment--and there are some reasons why people do not get treated.
The end product of hepatitis C is liver failure. Liver transplantation due to liver failure from hepatitis C is now the largest cause of liver transplantation in North America, and we're only in the early stages of this epidemic. The epidemic of hepatitis C infection has blossomed with the increase in intravenous drug use, but it takes 20 years to get to end-stage liver failure. So the big bulk of this problem is not going to arrive for quite some time yet.
Corrections is going to find itself looking after people with terminal liver failure, and this is a very expensive prospect. As a physician, I am very concerned about the amount of hepatitis C, and to some extent HIV, that is related to intravenous drug use in our institutions.
I have brought with me something that can be passed around, but if it is going to be passed around I would really asked that you don't open this container. This contains a syringe that was brought into our clinic in Kingston by a very frightened guard who had just stuck himself on it while doing a cell search. This syringe was probably the only syringe on the range from which it came. It's probably been used by at least 10 to 15 different people, several of whom would have been infected with hepatitis C and some of whom would have been infected with HIV.
You will see that this syringe, which is made from a ballpoint pen, tape, and a needle that probably came from an insulin syringe, is dirty. It's not possible to clean it. There is no way you can clean this syringe, even with the best intentions. These syringes are not only responsible for transmission of hepatitis C, HIV, and hepatitis B, but they are also responsible for a large number of rather nasty injection site abscesses that I see in the course of my work in the prison. I think this is a problem that also needs to be addressed.
Thank you, sir.
Graham Stewart
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Graham Stewart
2009-10-27 11:12
Good morning.
I'm here today as a co-author of A Flawed Compass: A Human Rights Analysis of the Roadmap to Strengthening Public Safety. A Flawed Compass is the work of Michael Jackson, professor of law at the University of British Columbia, and me alone.
Having retired over two years ago from the John Howard Society of Canada, I am not a representative of, nor do I speak for, the John Howard Society of Canada. Craig Jones has that responsibility.
Leading up to the adoption of the CCRA in 1992, the office of the Solicitor General produced nine important papers that explored issues facing Canadian prison law, particularly in the context of the new charter. Those papers formed the substance of eight years of active public consultation. It is worth noting that the correctional law review analysis was based on a human rights perspective.
In 2007, the Minister of Public Safety created a panel to advise the minister on various important issues facing the Correctional Service. Chaired by Rob Sampson, the panel's report, along with all its recommendations, was accepted immediately by the government, without public consultation. It is now the transformative agenda for CSC, the Correctional Service of Canada.
I should begin by stating that Michael Jackson and I agree with the recommendations of the Sampson report with respect to mental health. They largely endorse the mental health strategy developed by CSC in 2004, which we also support. The important observation, however, is that mental health services are very much part of, and are influenced by, the overall correctional setting. Other correctional policies and practices can completely undermine the best plans for mental health and the noblest intentions of staff. In that respect, many of the panel's recommendations for mental health are severely compromised by other recommendations. In part, the lack of coherence has occurred because the approach of the panel completely ignored human rights.
Why are human rights essential as the foundation of correctional policy? One reason is that the purpose of human rights is to protect all citizens from abuse by the state. A prison system that is not respectful of human rights is one that necessarily tolerates abuse. We know of no evidence that abusive, arbitrary, or unfair treatment improves a prisoner's prospects for success after release. Abuse teaches that might is right, the very values that often lead to criminal acts in the first place. Effective corrections cannot occur outside a human rights framework.
The road map ignored the report the CSC commissioned in 1997 by Max Yalden, former chief commissioner of the Canadian Human Rights Commission. In doing so, it also ignored his caution. He said:
It is particularly important to recognize the fundamental nature of Canada's commitments in light of the fact that some members of Canadian society, including some CSC employees, do not necessarily share the values underlying the Service's human rights framework. In that context, it is essential to make it clear that the principles and provisions incorporated in the CCRA derive from universal human rights standards supported by all the advanced democracies with which Canada compares itself, that the Service holds itself accountable to those standards, and that it is actively committed to making them work in federal correctional institutions.
Yet this is the response given in a CFRB interview by Minister Van Loan to questions about the criticism contained in A Flawed Compass:
Prisoners have the full protection of the Charter of Rights. They have the Office of the Correctional Investigator to look into complaints. That's not the issue here. The issue is, how do we protect the rights of the people in the community, Canadians, to be safe from the threat of criminals?
There is no totalitarian regime in the world that does not espouse human rights, so long as they do not threaten whatever they define as public safety.
Our system invests tremendous resources in preserving the right to be free from crime through police, prosecution, courts, imprisonment, supervision, and so on, all without cost to the individual. But there is virtually no publicly supported mechanisms that help us preserve our right to be free from abuse by the state.
In real terms, the charter offers no significant protections in the face of a government that chooses to disregard human rights when it suits them. We need to know that our government understands human rights. We need to know that our leaders believe in human rights. We need to know that they appreciate that defence of our human rights is at the very core of democracy and, as such, it is their fundamental obligation to safeguard them, both in law and in practice. A road map for the future of corrections in Canada and its treatment of prisoners that cannot devote a single footnote to human rights, and a Minister of Public Safety who tells us that human rights are incompatible with public safety, is not a good start.
A human rights analysis of corrections and the treatment of the mentally ill within correctional settings leads to many fundamental questions that might guide the work of this committee. Some of those questions would include the following.
Can a system that is respectful of human rights and the decent treatment of those in its care place the severely mentally ill in segregation for long periods of time without even providing a thorough psychological assessment or treatment activity?
And could it refuse to implement the minimal safeguards of independent adjudication for those placed in administrative segregation or pretend that the charter and the correctional investigator could protect their human rights?
Would we tolerate a system where we pretend that the mentally ill have ready access to effective grievance and redress systems, particularly where their literacy and mental condition often make such grievances impossible to prepare?
Could a system that is respectful of human rights accept that while the Sampson panel is pending its recommendations to remove some of the residual rights for those in segregation, a 19-year-old mentally ill girl in segregation strangles herself to death in front of guards, who have instructions not to intervene unless she stops breathing?
Can we accept a correctional system that acknowledges that most of their population has serious mental health and/or addiction issues, and yet spends only 2% of revenue on programs?
Given that addictions in prisons consume most of the population and commonly co-exist with mental illness, can we accept that none of the Sampson panel recommendations relating to drugs addressed prevention, harm reduction, or treatment, while 13 recommendations would toughen enforcement, often by further restricting visits? Would we accept recommendations that see family and community support only as security problems, without any acknowledgement that both the prisoner and the family are entitled to visit and are dependent on those visits to maintain their crucial relationships?
Would a human rights approach allow for more correctional officers than nursing staff on psychiatric ranges? In contrast are the many community forensic facilities where there are no correctional staff on the ranges at all. Could we accept correctional treatment facilities that have a fraction of the treatment staff-to-patient ratios that community forensic facilities have? Could we accept huge waiting lists for programs while the Sampson panel asserts that we need to deprive people of their rights in order to motivate them to take these programs?
Could we endorse recommendations to abolish statutory release, the only gradual release option that is sometimes available to the mentally ill and the otherwise disadvantaged, while knowing that thousands would be released to the community without support, supervision, resource, or follow-up treatment? Could we tolerate a system that keeps seriously ill or disadvantaged people in prison as long as possible, all the while telling them and the public that they can earn parole?
Would we accept broad-ranging, indeed dramatic, changes to corrections without evidence of effectiveness, and in the face of contrary evidence posted on the ministry's own website?
Would we tolerate the removal from the CCRA of the long-held principle of least restrictive measure for the use of criminal sanctions in administration of prisons?
Would we accept vague promises for improvements to our prisons, when sentencing and gradual release policies will inevitably strangle the capacity of the system to deliver on them through huge population increases, inadequate space, and shortage of adequately trained staff?
Would we accept the recommendations that CSC build super-prisons, a complex of prisons within prisons, containing all levels of security and special populations, without justifying carefully how it is possible to actually deliver diverse environments and programs in such a monolithic structure?
If we were concerned about the decent and effective treatment of people in our institutions, would we turn over the planning for the future of federal corrections to a panel of non-experts chaired by an obviously politically partisan chair, with an all-embracing mandate, minimal resources, an impossible 50-day timeframe, and no provision for public consultation on their recommendations? Would we do that with defence, health, or policing?
Would we accept a correctional transformation agenda that is based on a report that never mentions human rights or acknowledges the necessity for human rights to be at the foundation of effective corrections?
We believe strongly that the important work of this committee will fail if it does not reflect in its principles, decisions, and recommendations an unequivocal endorsement of human rights as the foundation for effective corrections and for the treatment of the mentally ill in prisons.
Thank you for your attention.
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