Life Through The Prison Bars
Taken at Fort Steele Heritage Park this photograph is of a street actor “Brent Gill” looking through the prison bars of the towns jail house. My wife Laurie was also working as an actor, I love this area of our province.
The crime of mental illness
Noni MacDonald, MD MSc, Stephen J. Hucker, MD and Paul C. Hébert, MD MHSc
Section Editor, Public Health, CMAJ
Consulting Forensic Psychiatrist, Professor, Law & Mental Health Program, University of Toronto, Toronto, Ont.
Editor-in-Chief, CMAJ, With the editorial advisory team: Ken Flegel MDCM MSc and Matthew B. Stanbrook MD PhD
The current push to get tough on crime will likely increaserates of incarceration behind the prison bars 1 — and consequently increase thenumbers of prisoners with mental illnesses. If we want to stopjails and prisons from becoming mental health warehouses, wehave an urgent medical–legal–societal conundrumto solve.
Correctional facilities have long been known to contain manymore people with serious mental problems than the general population2 — as many as three times more, according to a recentCanadian study. 3 One major reason for this is the lack of awarenessof the needs of and support for people with manageable, or curable,mental illnesses in the community.
And there’s the crux: People with difficult but potentiallymanageable medical conditions — such as chronic schizophrenia,depression, or mood and anxiety disorders, made worse by abuse,neglect or ignorance — who have no support systems canact out in ways society deems unacceptable and even come tobe viewed as criminal.
Consider Ashley Smith. The New Brunswick teen committed a seriesof minor offences over several years that took her through theprovincial jail system and, because of escalating behaviouralproblems, into the federal prison system. In 2007, Ashley, age19, killed herself while in custody behind the prison bars. Her unsuitable behaviourbecame a death sentence.
This isn’t about the court system. It does what it canwithin the confines of legal definitions and pretrial diversionprograms. But it cannot address clinical needs or determinebest placement for the mentally ill. If we accept the premisethat serious illnesses should be treated, the only questionleft is where: in correctional institutions, the community orboth?
The Mental Health Commission of Canada has proposed a frameworkthat aspires to destigmatize mental illness, provide comprehensive,accessible person-centred prevention and care programs for all,and justify these programs with appropriate evidence. 4 Forthe mentally ill who commit crimes, this framework should leadto programs focused on people rather than on institutions, keeping them behind prison bars.
As a next step, strong advocacy and support from the medicalcommunity would go a long way to raise awareness, thus leadingto concrete plans and resources to address this complex issue.
To understand exactly what needs to be done, governments mustmandate the collection of accurate and comprehensive data onthe prevalence and consequences of mental health problems amongthe incarcerated; people behind prison bars— not only behavioural problems well-knownto correctional personnel but also all mental illnesses.
Corrections staff need training on how to care for prisonerswith mental illness. Whether in a remand centre, a provincialjail or a federal prison, the staff needs to know how to recognizesymptoms so they can quickly identify distressed inmates withpoorly controlled mental health problems. The acting-out behaviorthat can escalate if symptoms are not addressed can destabilizecell block routines, frustrate guards, irritate other inmatesand lead to serious confrontations behing the prison bars.
More research and novel approaches to treatment and care ofmentally ill prisoners are needed. Whether within existing systemsor in pilot programs, evaluation of short- and long-term outcomesmust focus on success of treatment and reintegration into society.The evaluation should include cost-effectiveness —to advancesound public policy based on evidence not ideology.
Part of the solution is outside the justice system: incarcerationwould not be the only solution if prevention programs were availablethat tackle problems long before someone gets in trouble withthe law. Reintegration programs could stop, or at least slowdown, the revolving door that leads people back into the correctionalsystem. Integrated community-based care could try to deal withthe many issues after release. These programs could be far morecost-effective than building more prisons.
At present, there are few peer-reviewed evaluations of mentalhealth courts, diversion programs, and community treatment ordersand programs, such as British Columbia’s integrated forensicmental health system, which is designed to enhance service deliveryto mentally ill inmates. 2 Without proper studies, how are weto determine best practices, especially with ever-escalatingcosts?
Having people with treatable mental health disorders fall intothe criminal justice system serves neither society nor the individual.That so many inmates in jails and prisons have mental healthdisorders — often untreated — is an indictment ofsociety’s values and understanding of mental health disorders.