As a result of the initial Immediate Needs Assessment at the time of first entry into an institution, all women believed to have mental health problems should undergo a standardized comprehensive mental health assessment resulting in a written report. The assessment should specifically address mental health needs as well as other relevant needs and be culturally sensitive (CD 840, Psychological Services - Appendix I). The assessment should also integrate mental health needs with other correctional objectives into a single, comprehensive treatment plan. The assessment should determine the level and intensity of mental health intervention required, as well as the women’s willingness to participate in various forms of treatment. This information will eventually comprise the treatment plan with the input of the other members of the mental health interdisciplinary team. If a woman appears to have serious mental health problems she may be referred to a psychiatrist or other specialists for further evaluation and assessment.
The written assessment report should be shared with the mental health interdisciplinary team with due regard for confidentiality, to ensure an interdisciplinary team approach to the management of those offenders requiring mental health support.
Psychopathy - Practice Guidelines
CSC does not support research on the issue of psychopathy in women offenders, regardless of how it is measured. This is, in part, due to the extremely low base rate of recidivism within the federally sentenced women's population and the virtual non-existence of violent recidivism. Further, the assessment of psychopathy provides little direction with regard to treatment planning, and there is no evidence that measures of psychopathy are useful for predicting risk. Consequently, it is not considered appropriate to use measures of psychopathy to inform decisions about individual women offenders; this is in accordance with the CCRA sections 4(h) and 77. Moreover, the assessment of psychopathy may impose divisive and diminutive stigma that contradict Principle 1 of the Strategy regarding wellness and the avoidance of labels.
Intensive care may be required to assess and treat women with acute mental disorders (schizophrenia, bipolar mood disorders, etc.). The goal is to address serious and deteriorating mental health problems. Most often the primary treatment target is symptom stabilization which may require the use of psychotropic medications. Once symptoms are stabilized, the offender may be able to benefit from psycho-educational approaches to understand and manage her condition.
This level of psychiatric/psychological intervention is best provided in an intensive residential treatment setting such as the Churchill Unit of the Regional Psychiatric Centre or a secure mental health facility in the community. However, with respect to community mental health facilities, it should be noted that the services and resources that can be offered to women are dependent on what is available. Further, the operation and type of programs and approaches used by these non-CSC facilities may not necessarily be consistent with the Strategy.
The Churchill Unit
The Churchill Unit is CSC's primary option for the intensive care of women offenders. The unit has continuously evolved since its inception. The Intensive Healing Program (IHP) of the Churchill Unit was originally designed to address the needs of those women who had historically been difficult to manage in regular facilities due to their mental health problems.
The IHP was created by CSC (no similar program had ever previously been offered either in CSC or to incarcerated women elsewhere), and has been operational at the Regional Psychiatric Centre in Saskatoon, Saskatchewan since September 1996. Treatment focuses on understanding and transforming the thoughts and behaviours that often are the source of the women’s problems. Key to reinforcing these transformations is the acquisition of new skills and coping strategies. This happens both formally through the program components and informally through interactions and the positive role modelling of the behaviour by staff (therapeutic milieu).
The Churchill Unit has twelve treatment beds in order to serve CSC's women offenders who require the services of a psychiatric hospital either on a voluntary basis or if they have been deemed certifiable for psychiatric care. In ranked order, the current admission priorities for Churchill Unit are: (a) emergency psychiatric care, (b) ongoing psychiatric care, (c) comprehensive assessment and specialized treatment, and (d) special requests for assistance from regional facilities. The treatment approach is highly individualized and a personalized treatment agreement is developed with each patient. Treatment is implemented through the use of short-term behavioural agreements, and treatment progress is monitored on a daily basis and aggregated across time. When treatment goals have been reached or when treatment has been maximized for the time being, women are discharged to a regular institution.
Structured Living Environment*
The Structured Living Environment (SLE) is a model of intervention that falls between intermediate and intensive care. The SLE provides a treatment option for minimum and medium security women with significant cognitive limitations or behavioural mental health concerns in order that their needs can be met at the regional facilities.
Implementing the SLE concept required the construction of a purpose-built duplex at each of the four regional women's facilities that included living space, program space, two therapeutic quiet spaces, and staff offices. Staff were hired to be members of a mental health interdisciplinary team and trained to provide intensive support and supervision as well as specialized correctional, rehabilitation, and mental health programming on a twenty-four hour basis.
Women are placed in the SLE on a voluntary basis once they have been assessed as meeting the criteria for placement and when it has been determined that this is the most suitable treatment option to meet their mental health needs. Women in the SLE have access to the rest of the facility, activities, and programs. Where appropriate, women with special needs who are living in the general population may benefit from attending the specialized programming at the SLE. The SLE administrative and support services are shared with the rest of the facility.
Overall, the SLE operates as a therapeutic environment incorporating the principles and practices of Dialectical Behavior Therapy (DBT) and Psychosocial Rehabilitation (PSR). The dual emphasis of interaction and treatment presents unique opportunities for the application of behavioural contingencies, vicarious learning, and high quality care through effective rapport and consistency. The two key interventions provided in the SLE are as follows:
Dialectical Behavior Therapy (DBT)
Dialectical Behavior Therapy (DBT) is a psychotherapeutic treatment regime suitable for individuals with high emotional distress and exhibiting a combination of difficulties characterized by self-destructive and/or suicidal behaviour, emotional dysregulation, severe interpersonal relationship problems, unstable and low self-image, and cognitive disturbances and distortions. It is a treatment whose efficacy has been well established for use with individuals diagnosed with borderline personality disorder (Linehan, 1993).
DBT targets skill development to address dysregulation in the sphere of emotions, relationships, cognitions, and behaviours. The goal of DBT is for individuals to learn and refine skills to identify and change their behavioural, emotional, and thinking patterns associated with significant problems in daily living.
CSC has extensively adapted DBT for application with a forensic, incarcerated population (including modifying published DBT materials and the development of CSC-specific materials). Two primary models have been developed and implemented by the Service: CSC Comprehensive Model of DBT (for use in the SLE) and CSC General Model of DBT (for use in the general population). In addition, the Service has developed a hybrid model of DBT for implementation in the Secure Units of the regional women's facilities.
To support the implementation of forensic DBT, CSC has also developed a national training curriculum in DBT, with specialized training specific to each of the models. This training, as well as follow-up consultation, is provided by NHQ, Health Services staff. Comprehensive assessment and evaluation packages have been developed for ongoing monitoring of the efficacy of this treatment.
The Comprehensive Model offers an intensive and coordinated approach to assessment and treatment. Within the context of a therapeutic environment, the following four essential treatment components are included: individual psychotherapy; DBT Skills Training Program; 24 hour DBT support/coaching; and DBT Team Consultations. The General Model has two main components: individual psychotherapy and DBT Skills Training. The Secure DBT model adds DBT support/coaching as a treatment component and the modules in the Skills Training Program are condensed and discrete.
Psychosocial Rehabilitation (PSR)
Psychiatric Rehabilitation, also known as Psychosocial Rehabilitation (PSR) is a comprehensive strategy for meeting the needs of persons with severe and persistent mental illness including those with basic skill needs and cognitive challenges. The goals of PSR are to assist individuals in the identification of their own particular needs, to build on their strengths, and to maximize their potential through encouraging occupational, social, and personal independence. PSR has its conceptual roots in a response to the failure of the mental health system to assist individuals in coping with the psychosocial devastation brought on by severe mental or emotional illness, severe behavioural problems, and traditional treatment methods, (i.e. institutionalization and medication) (Nel, 1994). The successful return to the community of women offenders with basic skill needs and cognitive challenges is enhanced through:
The development of skills to deal with problematic behaviours as well as skills for daily living; and
The development of a network of supports and community living opportunities.
Staff of National Headquarters monitor and support, both on site and through ongoing training, consultations, and correspondence, the implementation of the DBT and PSR interventions. Attention is paid to the implementation of an effective therapeutic environment in general, and to adherence to the treatment models. This monitoring process distinguishes itself from the evaluation component insofar as it is directed specifically at the congruence between the program philosophies and actual clinical application/intervention.
Intermediate care is designed to allow inmates with significant mental health problems to live in the general population by providing treatment services through one-to-one counselling, treatment groups, or a combination of interventions. However, group intervention targetted at this population is unlikely in some institutions given the insufficient numbers of women requiring this form of intervention.
The role of the mental health interdisciplinary team established in every institution (CD 850, Mental Health Services - Appendix H) is to oversee the mental health needs of women who require this level of care. The mental health interdisciplinary team will identify needs and service requirements, and monitor and document the clinical progress of individual women on a regular basis. To ensure appropriate monitoring, it is advisable to have one member of the mental health interdisciplinary team assigned as the coordinator of the mental health aspects of the case for every woman requiring this level of care.
Intermediate care interventions can include:
Symptom stabilization and management
Skills Training - social, interpersonal, cognitive, educational (e.g., Dialectical Behavior Therapy and Psychosocial Rehabilitation)
Therapeutic groups* (e.g., medication education, support and compliance, survivors of abuse, eating disorders, self destructive behaviour, and anger and stress management)
Dual disorders treatment (mental health and substance abuse)
*For incarcerated women, groups with a psycho-educational focus appear to be the preferred option, that is, those that make the psychological connections in an educational way versus probing into the women’s individual traumas.
Follow-up and relapse prevention for those offenders in the SLE or the RPC Intensive Healing Program is critical to ensure that changes made in treatment are supported and maintained.
Ambulatory care includes therapeutic groups, maintenance, relapse prevention, and psycho-educational services. These services are designed to provide both therapy directed at specific ongoing issues (e.g., eating disorders) and short term interventions to women experiencing significant psychological distress related to situational phenomenon that may impair their ability to function on a temporary basis (e.g., death in the family, losing a custody hearing, or interpersonal conflicts).
The mental health interdisciplinary team should coordinate ambulatory care services. The individual plan for a woman may be developed between her and her psychologist or primary worker, in conjunction with the team.
Treatment can include:
Targetted group treatment programs (e.g., anger and stress management, conflict resolution, survivors of abuse and trauma*, substance abuse, eating disorders, self-esteem, parenting skills, self-destructive behaviour, relapse prevention, Elders therapeutic circle meetings)
* The survivors of abuse and trauma group is one of the Core Programs offered in the women’s facilities. It is designed to be psycho-educational in context and delivery. It is listed here because this group may play an integral role in addressing women’s mental well-being.
Some institutions have provided these groups based on the needs of a number of inmates at a point in time. The nature of the groups offered at any point in time may also vary according to the community expertise available to deliver a particular program in an institution.
As with intensive care, follow-up and relapse prevention for those who were in the Intensive Healing Program or SLE will be essential in ambulatory care to ensure that changes made in treatment are supported and maintained. Women requiring intensive care could participate in the group treatment programs dependent on their suitability for group work, the numbers of women, group dynamics, and operational considerations.
Psychological and individual counselling services should be available on a voluntary basis to deal with personal issues (CD 840, Psychological Services - Appendix I). The role of counselling is critical for women dealing with various personal and other traumatic issues that they are not able to deal with in other ways. The psychologists work with the women to increase their awareness of how past issues are affecting current behaviour and to increase their coping skills with a view to enhancing mental well-being. If the issue is one for which an appropriate group exists, the woman may be encouraged to deal with her issue by attending the group. However, the small size of some facilities may mitigate against participation in therapeutic groups due to issues of confidentiality.* Psychotherapy and counselling may also be an important adjunct for those involved in the group components of intermediate or ambulatory care.
* Some research suggests that it is possibly contraindicated to be undertaking intensive therapeutic work on issues such as sexual abuse inside prison and also, contraindicated if they do not yet have the containment skills and other skills to deal with the emerging memories and issues.
Aboriginal Components/Elder Services
The importance of access to Elder Services for the healing and mental well-being of Aboriginal women is critical (Appendix J). At the Okimaw Ohci Healing Lodge contact with Elders is viewed as the most integral part of their mental health services and an Elder is permanently on site. Western mental health services are provided in the form of counselling offered by a psychologist, and psychiatric services are also available. There appears to be an easy integration of Western mental health services with Traditional Aboriginal Elder teachings and other services, and women are encouraged to utilize the best that they believe each has to offer.
All staff working with women offenders should be aware of the importance of Elder services to the healing process of Aboriginal women. Further, access to Elders should be ensured and they should be part of the mental health interdisciplinary team in every facility with Aboriginal women.
In addition to those programs specifically targetting mental wellness or mental health needs, women may also require programs directed at other issues such as social and cognitive skills. However, as previously noted, it is essential to ensure that all programs and services are inter-connected.
There are four core programs, as identified by the Correctional Program Strategy for Federally Sentenced Women (1994), that are essential to women's programming and are offered to women as needed/required. These programs are:
Living Skills Programs (including anger management, cognitive skills);
Survivors of abuse and trauma; and
Education and literacy.
Suicide and Self-Injury
Consistent with CD 843, Prevention, Management, and Response to Suicide and Self-Injury, (Appendix K) each institution must have procedures in place to ensure appropriate responses to suicide and self-injury and staff education and awareness.
Staff training must take the specific needs and issues of women offenders into consideration including appropriate intervention. Self-injurious behaviour should not be viewed as a security issue unless there are extenuating circumstances, such as the involvement of weapons. Given that self-injury and aggression have been found to be linked in those with personality disorders (Swinton and Hopkins, 1996), staff should pay close attention to the increased probability of these incidents amongst women with personality disorders.
There are a variety of types of women sex offenders and their treatment and supervision needs vary depending upon personal characteristics, the nature of their sexual offending, and their particular release plans. However, in the North American literature mental disorders have seldom been found to be a significant problem in this group.
To address the specialized needs of this group, an assessment and treatment protocol was developed in 2001 by the NHQ, Offender Programs and Reintegration Division. According to the Protocol for the Assessment and Treatment of Women Offenders who Sexually Offend, the role of the institutional or community psychologist is as follows:
The assessment of each case, regardless of who is directly delivering the treatment;
Coordinating the involvement of the mental health interdisciplinary team with respect to the treatment and delivery of the modules;
Administering any psychological tests that may be required;
Administering any assessment required for the evaluation of risk.
Further, the staff person(s) or psychologists trained to deliver the treatment to women who sexually offend are responsible for:
Delivery of the treatment modules under the direction of the institutional or community psychologist (direction from the psychologist is required when the staff person is not a psychologist); and
Completion of post program reports in accordance with national guidelines.
The substance abuse program for women currently being developed is a multi-dimensional and gender-responsive model that will include: an educational and motivational component for all women, a core treatment module that addresses both therapeutic needs and cognitive learning (primarily designed for women assessed as having moderate to severe substance abuse problems), and a maintenance program that begins in the institution and continues into the community. Maintenance will be provided to the entire population and is based on a broad application of relapse prevention principles. The model also addresses the environment and incorporates a variety of venues to foster the concept of 'community building'. The model proposes close collaboration with Health Services and the core treatment module, in particular, may require referral or consultation with psychology where indicated.
Peer support is a component of the mental health continuum of care to provide women with short-term support services delivered by peers. Peer support services are intended to provide non-judgmental support, information, and referrals when an inmate requests the service. In addition, the peer support programs may supplement the counselling capabilities of the facility in the following situations:
When women are not amenable to staff intervention;
In post crisis intervention situations; and
When professional counsellors are not available i.e., evenings and weekends.
In 2000, the Research Branch evaluated the Peer Support Program at the sites where it was being delivered. One of the recommendations was to develop national guidelines, which were completed in 2002. The program manuals were also revised to include a session on grief and loss.
Offenders with mental health needs should be linked to community services to ensure treatment gains are maintained and risks of recidivism are reduced.
Services could include the establishment of linkages with appropriate community institutions such as mental health agencies, supportive housing, employment, social assistance, educational programs, substance abuse services, and Aboriginal communities/services.
Variations in the type and number of community services available are in many cases dependent on the size of the community. Community reintegration staff should be assigned to monitor and coordinate the links between women with mental health needs and the community. Strategies for encouraging community involvement to support the reintegration of incarcerated women require ongoing development.