Re: Using evidence to build a better justice system: The challenge of rising prison costs

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1 17 September 2018 Professor Juliet Gerrard Chief Science Advisor Department of Prime Minister and Cabinet PO Box Auckland 1023 By Dear Professor Gerrard Re: : The challenge of rising prison costs The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is pleased to provide feedback on the above paper published by your Office and commend you on developing an insightful and well-reasoned document. The New Zealand Faculty for Forensic Psychiatry, supported by the New Zealand Faculty of Addiction Psychiatry and the Faculty of Psychiatry of Old Age have reviewed the paper. We strongly endorse the key principles outlined in the document including: We welcome the paper s discussion articulating the link between the media and public lobbying, the subsequent political approach of being tough on crime in New Zealand and the significant rise in the prison population. We support the paper s recommendation for early intervention to address the social determinants of health to reduce the risk of criminal behaviour. We agree with the paper s view that the justice system s resources should be directed towards prevention rather than punishment. We note the paper s cost-benefit commentary on the impact of increased government funding towards punitive and often ineffective measures rather than evidence-based prevention and early intervention initiatives The paper acknowledges the negative impacts of prison environments and we support this view. We support the paper s focus on the utility of New Zealand-based research across the justice system to inform future system change. Box 10669, Wellington 6143 New Zealand T F ranzcp.nz@ranzcp.org

2 We trust you will find this submission useful in developing future policy relating to justice system reforms. The RANZCP recommends the report be widely disseminated as it makes a major contribution to the debate on how we might implement effective strategies to reduce criminal offending. If you require further information please contact the National Manager, New Zealand, Rosemary Matthews, who supports the New Zealand-based Committees. Rosemary can be contacted on or by Rosemary.Matthews@ranzcp.org. Ngā mihi nui Dr Mark Lawrence FRANZCP Chair, New Zealand National Committee Tu Te Akaaka Roa Dr Julie Norris FRANZCP Chair, Dr Justin Barry- Walsh, FRANZCP Chair, Bi-national Faculty of Forensic Psychiatry

3 Submission to Office of the Prime Minister s Chief Science Advisor Response to the Office of the Prime Minister s Chief Science Advisor - : The challenge of rising prison costs September 2018 Responding to the mental health needs of prisoners

4 About the Royal Australian and New Zealand College of Psychiatrists The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is a membership organisation that prepares doctors to be medical specialists in the field of psychiatry and addiction, supports and enhances clinical practice, advocates for people affected by mental illness and advises government on mental health care. The RANZCP has more than 5,000 members, including around 3,700 fully qualified psychiatrists and almost 1,200 members who are training to qualify as psychiatrists. Psychiatrists are clinical leaders in the provision of mental health care in the community and use a range of evidence-based treatments to support people in recovery including pharmacotherapy and psychotherapy. About the Faculty of Forensic Psychiatry The Faculty of Forensic Psychiatry is a specialist area within the RANZCP whose role is to provide mental health care to people who have come to the attention of criminal justice services. Forensic psychiatrists provide voluntary mental health assessment and treatment to people in prison. They also provide voluntary and involuntary care and treatment to mentally unwell people admitted to hospital from prison or court. The term mentally disordered offender (MDO) will be used to cover both groups. Introduction The RANZCP welcomes the recently published paper : The challenge of rising prison costs (the paper) as this document makes a major contribution to revising the current justice system. As health professionals committed to evidence-based practice, it is encouraging to see the paper explicitly detailing the futility of the punitive approach taken to crime in New Zealand and the lack of evidence that prisons reduce reoffending. We also support the focus on a public health and social equity framework to improve the factors associated with future criminal offending. This submission has been developed by the (FFP) in consultation with the New Zealand Faculty of Addiction Psychiatry and the New Zealand Faculty of Psychiatry of Old Age. The Paper s Key Principles supported by the RANZCP 1. The FFP welcomes the paper s discussion articulating the link between the media and public lobbying, the subsequent political approach of being tough on crime in New Zealand and the significant rise in the prison population. The FFP agrees these approaches to offending must change although appreciates that the complex reasons for criminality cannot be reduced with one single policy approach. Royal Australian and New Zealand College of Psychiatrists submission to the PMCSA Page 1

5 2. When working with MDOs in prison, forensic psychiatrists see the detrimental and cumulative impacts prison can have on their patients; 1 often compounded by a lack of timely, effective treatment and care required to meet the complex needs of this population group We support the paper s recommendation for early intervention to address the social determinants of health to reduce the risk of criminal behaviour. 4. The FFP strongly endorses the paper s focus on life-course and multifactorial reasons for people entering the justice system including poverty, poor educational outcomes, childhood trauma, violence, exposure to and/or dependency on drugs and alcohol and poor emotional resilience. We agree with the paper s view that the justice system s resources should be directed towards prevention rather than punishment. 5. The paper provides a cost-benefit commentary on the impact of increased government funding towards punitive and often ineffective measures rather than evidence-based prevention and early intervention initiatives. The FFP supports the need for Government investment in appropriate social programmes to address the drivers of criminality including literacy, parenting education, enhancing cultural connectedness and specific support for families living in poverty and social deprivation. 6. The paper acknowledges the negative impacts of prison environments. 3 The FPP considers that the money being spent on building new prisons should be diverted to social programmes that improve people s health and life chances. 7. The FFP supports the paper s focus on the utility of New Zealand-based research across the justice system 4 to inform future system change. We maintain there is a specific need for investment in clinical and epidemiological research that can contribute to better treatment options for MDOs. Research from Sullivan (2006) reveals that current funding is based on prevention of adverse publicity and risk containment. Instead it should be focussed on improving the management of high risk patients on entry to the justice system and examining potential preventative strategies to reduce mental health risk factors. Additional Comments Improving the justice system response to prisoners mental health needs Whilst the paper identifies the high prevalence of complex, co-morbid mental health and addiction issues for the prison population and lack of effective treatment models; it does not fully address the current role of Forensic Mental Health Service (FMHS) whose services are significantly under resourced. 1 Including exacerbating their symptoms and increasing the risk of self-harm and suicide (Bradley, 2009; Department of Corrections, 2018.) 2 Including exacerbating their symptoms and increasing the risk of self-harm and suicide (Bradley, 2009; Department of Corrections, 2018.) 3 Specifically, that: prisons may be expensive training grounds for further offending and building offenders criminal careers (p.4) 4 Including the role investment in research may have in reduced incarceration rates in Finland, for example (p.8) Royal Australian and New Zealand College of Psychiatrists submission to the PMCSA Page 2

6 The core FMHS inpatient and outpatient work is the assessment, treatment and rehabilitation of people who have committed serious crimes in the context of their illness. Many mentally ill people within FMHS are classed as special patients 5 and require specialist risk management as part of clinical care. Special patients spend long periods of time in hospital. However, there are limited numbers of inpatient beds and few community rehabilitation options available when the person is ready to leave hospital. Forensic psychiatrists provide expert input to courts to help determine criminal responsibility, assist in relevant civil matters and assess issues such as the risk of violence and reoffending. Aspects of forensic psychiatry include involuntary treatment, juvenile offending, competence, diversion of offenders from court to treatment and the provision of medico-legal opinions and expert evidence (RANZCP, 2016). Forensic psychiatrists also provide assessment and treatment of MDOs in custody through prison clinics. People who require admission to hospital from custody for treatment of their mental illness are currently admitted to FMHS hospitals and there are no separate beds available for people being admitted from prison. In addition, mentally unwell people who are charged with serious crimes and require inpatient assessment can also be directed to hospital from court, often at very short notice. All these situations provide further pressure on the existing inpatient FMHS beds. There has been no significant change in forensic bed numbers, resourcing or staffing since FMHS was created in the 1990s despite the increasing prison muster (Lunt, 2017). There has also been no notable growth in either general or the Department of Corrections 6 -based accommodation or community support with the muster increase. FMHS are chronically under-resourced in all areas where they provide assessment, care and treatment. The pressure to provide adequate mental health services for MDOs has been well documented in the Controller and Auditor General s report Mental Health Services For Prisoners (Controller and Auditor General, 2008). The situation has worsened since this report was published. Inpatient FMHS are often at or close to capacity therefore mentally unwell patients are spending longer in prison waiting for admission into forensic care. Less unwell patients, who nevertheless have unmet mental health needs, have minimal chance for admission (Controller and Auditor General, 2008). We strongly argue that MDOs, like any other population group, must receive appropriate interventions before their condition deteriorates. There is a legislative requirement that the standard of healthcare that is available to prisoners in a prison must be reasonably equivalent to the standard of health care available to the public. 7 It will not, however, be possible for FMHS to provide optimal services based on principles of recovery and rehabilitation without greater resource for all areas of care including inpatient and outpatient services, prisons and courts. In addition we contend that MDOs should be afforded the same care as the general population, therefore, specialist mental health care for MDOs should be provided by health organisations (District 5 See Ministry of Health 6 The Department of Corrections, within the Ministry of Justice, referred to as Corrections in this document. 7 Corrections Act 2004 s75(2) Royal Australian and New Zealand College of Psychiatrists submission to the PMCSA Page 3

7 Health Boards, Primary Care Organisations) rather than Corrections. This is consistent with the recommendations from the Mason Report 1988 (Mason et al.,1988). We are concerned that the paper s statement in paragraph 70: some people in prison with severe personality disorder and chronic self-harm behaviour would potentially have their needs better catered for in the forensic mental health system conflates mental health, substance use and personality disorders as being able to be treated together within FMHS. The examples referred to in Germany and the Netherlands are associated with low incarceration rates for both nations and based on the importance of rehabilitation and reintegration. We are concerned the paper overlooks the failed UK Serious Personality Disorder experiment (Appelbaum, 2005), and that the extrapolation of these models into New Zealand is both inappropriate and unrealistic within current FMHS resource constraints. The FFP also recognises that discrimination 8 impacts on the ability for MDOs to return to the community. Many MDOs are unable to successfully obtain appropriate and safe accommodation and with limited social support available, they often reoffend. Forensic psychiatrists and FMHS need Government commitment and resourcing in order to advocate for the needs of this highly vulnerable population. We also suggest that in order to reduce pressure on the current prison system, the concept of Mental Health Courts proposed by Lunt (2017) is explored further. There is an opportunity to pilot these courts in New Zealand whereby some mentally ill people can be diverted from prison and into treatment so they do not experience the negative impacts of incarceration. Specific Populations Who Require Consideration Prisoners with addictions The RANZCP notes there is no specific focus in the paper on alcohol and other drug issues, despite the high prevalence of substance use disorder and co-morbidity amongst prisoners (Indig et al., 2016) and their association to criminality (Young et al., 2011). We maintain the need for improved quality and provision of care to meet the complex needs of this group, appreciating the significant impact addictions can have in mental health treatment outcomes and the successful rehabilitation and reintegration into the community. The RANZCP welcomes Corrections recent investment in AOD treatment and support, specifically focused on post-prison rehabilitation and community reintegration, and the Ministry of Justice s AOD Pilot Courts initiative. We maintain, however, that there is a need to strengthen the AOD clinician role across the justice system by appreciating the complex needs of this population group and the associated expertise required. There is also the requirement to externally assess the efficacy of AOD rehabilitation programmes and increase equity of access to ensure consistent service provision. Furthermore, we support the recommendations for improving and expanding the services provided by AOD clinicians in Court made by the Ministry of Justice (2016) and corroborated by Lunt (2017)9. 8 Both the discrimination experienced from having a mental illness and a criminal record. 9 Including improved: data collection for service evaluation and improvement; awareness and service uptake; resources available; evaluations of all charged individuals; training to AOD clinicians and culturally appropriate service provision; and record-keeping, communication and information sharing. Royal Australian and New Zealand College of Psychiatrists submission to the PMCSA Page 4

8 The presence of a substance use disorder is a strong predictor of increased mortality among prisoners after release (Chang et al, 2015). Effective treatment for substance use disorders might reduce the excess mortality in prisoners. Where addiction treatment is offered, it should span the period before and after release, ideally with continuity from the same treatment provider, but at a minimum with close integration between prison-based and community services. Currently, substance use disorder treatment within prisons is mainly targeted towards sentenced offenders. There needs to be more opportunities for remand prisoners to be offered assessment and treatment, particularly as these people are likely to be experiencing more acute medical and psychosocial problems related to their substance use. In summary, there needs to be good integration between forensic and addiction specialty care. Older prisoners who may have cognitive decline The number of people in New Zealand living with dementia will double between 2026 and 2050 (Alzheimers New Zealand, 2010). A recent Australian research paper demonstrated that the number of older people in custody living with dementia is increasing (Alzheimers Australia, NSW, 2014). In general, prisons are not specifically equipped to manage physically frail, older-aged prisoners and those with cognitive impairment (Sullivan, 2006). It is acknowledged that older-aged prisoners experience accelerated ageing due to the effects of substance use, poor nutrition and neglect of their health (Reutens, 2015). The high level of mental and physical needs of the ageing prisoner requires greater collaboration between all health and justice systems to adequately accommodate these MDOs. The RANZCP supports the Government s recent commitment to establishing units to accommodate the needs of special MDO groups including older prisoners. We are, however, concerned that the number of units available are insufficient to cater for the needs of this burgeoning population group. We call for ongoing research to improve services for this small but vulnerable population and note that research is underway in Australia to establish best-practice frameworks for offenders with dementia. (Alzheimers Australia, NSW 2014). Māori prisoners high levels of mental health issues and addiction As stated in the paper, the RANZCP asserts that the disproportionate numbers of Māori in the prison population is highly concerning. Evidence indicates that recidivism rates remain a significant issue for Māori released from prison. Five years after release from prison 77% of Māori were reconvicted and 58% were back in prison (Department of Corrections, 2009). Māori prisoner numbers continue to grow and psychiatrists have a role in ensuring Māori prisoners are treated in a culturally appropriate way and their mental health and addiction needs are addressed. Research reveals that Māori prisoners have the highest prevalence of two or more mental health or addiction disorders, indicating they require a greater level of intervention to address their needs (Indig et al., 2016). It has also been reported that Māori living with psychotic illness in forensic units do not receive optimal treatment (Rangihuna, 2018). Royal Australian and New Zealand College of Psychiatrists submission to the PMCSA Page 5

9 We refer to a 2015 Waitangi Tribunal Claim (Ministry of Justice, 2015) in which the claimant alleges that the Crown has breached the principles of the Treaty by failing to make a long term commitment to bring the number of Māori serving sentences in line with the general Māori population; to have an overall strategy to reduce reoffending by Māori; and to engage with Māori at a strategic level. The Claimant also states that the current Government rehabilitative programmes are not developed in a manner that contributes to successful outcomes for Māori. Accordingly, the RANZCP maintains that Corrections and the Ministry of Health need to embed a Te Ao Māori approach to address Māori prisoners health needs. Modelling the innovative kaupapa Māori service response to mental health currently being developed in Gisborne could prove effective in prisons (Rangihuna, 2018). We support further research to develop evidenced-based approaches to establish culturally appropriate frameworks to improve mental health outcomes for Māori in prison. We also need to understand those structures within the criminal justice system that lead to higher rates of Māori imprisonment. Colonisation and alienation from their land have resulted in Māori experiencing high levels of poverty, poor education and increased substance dependency which in turn has contributed to high rates of Māori imprisonment. We concur with the paper s acknowledgement that solutions to these wide-ranging issues require a partnership with Māori to develop cross-sectorial strategies. Forensic psychiatrists are able to contribute to this dialogue by providing research around best practice for Māori in the criminal justice system and promoting activities that contribute to improved whānau mental wellbeing. We also note that Māori prisoners have the highest prevalence of lifetime drug dependency so we argue substance disorder treatment for Māori must be made a priority to reduce reoffending and improve their mental wellbeing (Indig et al., 2016). Conclusion Many prisoners with serious mental illness in New Zealand remain in prison, only being able to access hospital level care when acutely unwell, and then return to prison with persisting mental illness symptoms. This situation means that they are neither eligible for, nor able to benefit from, the limited rehabilitation options for mainstream prisoners. This position has arisen from the disproportionate growth in the prison population over the last decade without a commensurate increase in funding for Forensic Mental Health Services. We are cognizant that implementing social programmes would take a generation before they showed positive outcomes. However, action needs to be taken to reduce the prison population and resolve the current burden experienced by FMHS and rising punitive views held by the wider New Zealand population. References Alzheimer s Australia, NSW (2014) Dementia in prison, Discussion Paper No. 9. Alzheimer s New Zealand (2010) National Dementia Strategy Appelbaum P (2005) Law & Psychiatry: Dangerous Severe Personality Disorders: England's Experiment in Using Psychiatry for Public Protection. Psychiatric Services 56 (4): Royal Australian and New Zealand College of Psychiatrists submission to the PMCSA Page 6

10 Controller and Auditor General (2008) Mental Health Services For Prisoners. Chang Z et al (2015) Substance use disorders, psychiatric disorders and mortality after release from prison: a nationwide longitudinal cohort study. Lancet Psychiatry 2015 (2) Department of Corrections (2009) Reconviction Patterns of Released Prisoner: A 60 Month follow-up analysis. Available at: data/assets/pdf_file/0005/672764/complete- Recidivism-Report-2009-DOC.pdf (Accessed 9 June 2018). Department of Corrections (2016) Change Lives Shape Futures: Investing in better mental health for offenders. Available at: data/assets/pdf_file/0009/880650/investing_in_better_mental_health_f or_offenders.pdf (Accessed 9 June 2018). Indig D, Gear C & Wilhelm K (2016) Comorbid substance use disorders and mental health disorders among New Zealand prisoners. Wellington: Department of Corrections. Lunt L (2017) Preserving the Dignity of the Mentally Unwell: Therapeutic Opportunities For the Criminal Courts of New Zealand. Ian Axford Fellowships in Public Policy. Available from: Unwell-Therapeutic-Opportunities-for-the-Criminal-Courts-of-New-Zealand-.pdf (Accessed 9 June 2018). Mason K et al. (1988) Report of the Committee of Inquiry into Procedures Used in Certain Psychiatric Hospitals in Relation to Admission, Discharge or Release on Leave of Certain Classes of Patient. Wellington, New Zealand: Ministry of Health. Available at: ason%20report.pdf (accessed 31 May 2018). Ministry of Justice (2016) Alcohol and other drug (AOD) clinicians in court Research report. Wellington: Research and Evaluation Team Sector Group Ministry of Justice Rangihuna D, Kopua M, Tipene-Leach D (2018). Mahi a Atua: a pathway forward for Māori mental health? NZMJ 131 (1471): Reutens S, Nielssen O, Large M (2015) Homicides by older offenders in New South Wales between 1993 and Australasian Psychiatry, 23 (5): Sullivan D & Mullen P (2006) Forensic Mental Health. Australian and New Zealand Journal of Psychiatry 40: The Royal Australian and New Zealand College of Psychiatrists (2016) Position Statement 90: Principles for the treatment of persons found not criminally responsible or not fit for trial due to mental illness or cognitive disability. Available at: (Accessed 10 June 2018). Royal Australian and New Zealand College of Psychiatrists submission to the PMCSA Page 7

11 Young S, Wells J, Gudjonsson GH. (2011) Predictors of offending among prisoners: the role of attentiondeficit hyperactivity disorder and substance use. Journal of Psychopharmacology 25(11): Royal Australian and New Zealand College of Psychiatrists submission to the PMCSA Page 8