The Australian and New Zealand prison crisis: Cultural and clinical issues

Foulds and Monastario’s (2018) paper in this journal reveals deeply disturbing aspects of our societies’ approach to crime. Successive law and policy changes over recent decades appear in practice to be both racially discriminatory and socially marginalising of mentally ill and intellectually disabled people.

The internationally high rates of incarceration in both New Zealand and Australia cited by Foulds and Monastario (2018) are terribly sobering from an indigenous perspective. In 2017, official statistics from New Zealand (New Zealand Department of Corrections, 2017) reveal that Maori experienced 7.5 times the risk of imprisonment when compared to New Zealanders of European heritage (704 vs 93 per 100,000 population). During the same time period, the Australian Bureau of Statistics (2017) reported that Aboriginal and Torres Strait Islanders experienced a relative risk of imprisonment 15.2 times the non-indigenous population, with a staggering imprisonment rate of 2434/100,000 population (2434 vs 160 per 100,000 population). Incarceration at these levels profoundly disrupts the structure of those societies, with significant impacts on future generations. Evidence for racially mediated biases at all levels of the criminal justice system has been reported, from arrest, to detention, to conviction and sentence (Gluckman, 2018). Gluckman (2018) clarifies that these imprisonment rates do not reflect high levels of crime. Instead, they reflect a retributive rather than restorative approach to crime, which does nothing to protect or advance our societies’ interests.

The variables leading to the unprecedented rise in prison muster in Australasia are well summarised by Foulds and Monasterio: legislative changes (affecting bail laws, sentence length and parole eligibility), community changes (shortage of housing and reduced tolerance for risk) and effective lobbying from groups representing victims’ interests. To that, I would add the effect that risk-averse executive policy decisions can have – such as the virtual cancellation of temporary releases from prisons in New Zealand following a high-profile escape in 2014. Without the ability to test potential parolees in the community before release, parole boards are asked to take a leap of faith, which clinicians would only reluctantly contemplate from a hospital setting.

Prisons are toxic environments in which many people experience mental health deterioration. Prisoners’ substance abuse and dependency often worsens, and their criminal behaviours are reinforced by association with criminally minded peers. It is easy to forget that prisoners are often victims themselves, of violence and of sexual abuse. At least 10% require specialist mental health care, and the prevalence of primary mental health and addictions problems is substantially higher and more complex than a typical community General Practice might be expected to cope with.

Foulds and Monasterio suggest that political solutions are needed, which may indeed be the case. However, while we remain the ambulance at the bottom of this cliff of social failure, it may also be true that clinical solutions are more likely to have immediate impact. What can be done to avert, or at least moderate, the looming crisis from a mental health perspective?

Many evidence-based, fiscally sensible approaches are suggested in Gluckman’s (2018) report, though I would like to focus on four clinical areas which, as clinicians, we may be able to influence directly.

First, as mental health providers, we must remain concerned with the development of effective, evidence-based mental health and addiction screening at reception into prison, followed by mental health triage of positive screens, so that effective treatment and release planning can be properly supported. These elements of a comprehensive prison model of mental health care are all gaining an increasing evidence base.

Second, we must maintain sufficient forensic hospital beds to enable hospital transfer for those acutely unwell prisoners who cannot be safely managed in prison. Rapidly rising prison numbers have not been matched by forensic hospital bed numbers in Australasia over the last decade, and greater coordination between government agencies is needed to ensure our societal obligations to this group are not forgotten in the rush to build more prisons. To not do so risks the spectre of compulsory treatment in prison-based mental health units.

Third, in jurisdictions where prison health care is still provided under the umbrella of Correctional Services (such as New Zealand), alternative health-driven models of care should be explored, as these have generally been shown to yield superior health outcomes.

Finally, but perhaps most importantly, mental health care in correctional and forensic inpatient settings needs to embrace cultural dimensions to treatment delivery. Early research into culturally informed models in forensic settings has shown promising results, but much more work in this area is needed (Gutierrez et al., 2018).