Letter to the Editor Offering group mental health programs in a maximum-security correctional facility: Observations, outcomes, and recommendations

In the following article, I discuss psychoeducational groups offered in a men’s maximum security prison by the Centre for Addiction and Mental Health’s (CAMH) Forensic Early Intervention Service (FEIS) in partnership with correctional services staff.  I share observations and experiences facilitating mental health programs with clients in custody and explore related challenges, risks and opportunities. Outcomes and feedback from group participants are reviewed and recommendations for others interested in offering similar programs are presented.

Dear Editor, Individuals with serious mental illness (SMI) are overrepresented in Canadian correctional facilities and make up an estimated 15% to 20% of the prison population [1].To address the needs of this population, the Ontario Ministry of Community Safety and Correctional Services and the Ministry of Health and Long-Term Care partnered in 2015 with the Centre for Addiction and Mental Health (CAMH) to establish the Forensic Early Intervention Service (FEIS).The FEIS is a multidisciplinary psychiatric team that offers triage, assessment, and rehabilitative services for clients within a men's maximum-security detention facility in Toronto, Ontario, Canada.As part of the partnership, the FEIS has worked alongside correctional officers and health-care staff since 2016 to provide group programs for clients with mental health and addiction challenges.These programs have evolved to occur weekly in a high-security supportive care unit.
The FEIS team intentionally offers services on units where clients with the most persistent SMI are housed.Access to psychiatric support in Ontario prisons is limited due to heavy demands on resources, high turnover of inmates, and other structural factors [2].In addition, clients may be reluctant to accept care and treatment in custody for a variety of reasons [3].These factors present unique challenges when formulating and delivering mental health services in custody.

Therapeutic Approaches and Process
Group programs facilitated by the FEIS are designed to address the immediate mental health needs of participants.Materials are psychoeducational in nature, about one hour in length, and emphasize practical skill development.The subject matter focuses on stress management, goal setting, release planning, understanding psychosis, relapse prevention, anger regulation, medication, and other related areas.The FEIS uses therapeutic approaches that have demonstrated effectiveness in prison settings, including motivational interviewing (MI) and dialectical behaviour therapy (DBT), and integrate them into programming to address ambivalence regarding change and reduce impulsiveness [4,5].
Coordination with and input from correctional officers (COs) are essential, as they are tasked with ensuring the safety and security of all clients and staff on units.COs retain the most updated information regarding client behaviour, sleep, social tensions, and risk factors.As a result, they can most effectively identify clients suitable to be offered the opportunity to attend the program.Details regarding the physical location of the group and other security protocols are reviewed regularly with security staff to maintain the safety of all involved.
Three to eight participants typically attend each group, depending on client interest and staff consultation.Participants change from week to week as clients are released from custody or transferred to other units, though a core group of two to three usually attend regularly.

Ghelani
IJRR 2020;3 (1) Limits to confidentiality, attendance, and information regarding health record processes are reviewed at the onset of each session.Group rules are discussed at this time and participants are given an opportunity to provide thoughts on appropriate guidelines.At the end of each session, voluntary feedback forms are distributed to gain participant perspectives regarding services offered.

Observations, Challenges, and Opportunities
From In addition to managing tensions, complex group processes require close attention.Participant sharing or side conversations often deviate from the material and may require guidance toward the rehabilitative subject matter.Grievances related to the legal system, medication distribution, and other issues unrelated to programming may require validation or redirection, depending on the relevance of the concern.Inappropriate laughter or disorganized thought processes need to be selectively addressed or ignored.
Clients who find they are unable to tolerate the social environment may require space to leave the group as needed.
The FEIS has observed that motivation for change among clients attending rehabilitative programs in custody occurs on a continuum.Participants may be pre-contemplative regarding recovery and demonstrate limited insight toward the impact of their substance use.Some may attend out of a mistaken belief that engaging with services can provide an opportunity for early release.Clients who have been isolated for periods of time may be seeking opportunities to socialize.Despite the range of motivations, staff believe all participants can benefit from engaging in a pro-social group activity.This is especially true when evidence-based information is presented, a safe space for peer support is provided, and discussions create opportunities to consider alternative methods for coping.
Participants did not like, some participants expressed frustration regarding prison processes, others who spoke out of turn, and some material being difficult to comprehend.As outcomes and feedback continue to be evaluated, programming can be adapted to meet the changing needs of clients attending these psychoeducational programs.Responses may be disproportionately positive due to selection bias, as those who may not have been satisfied with services might not have submitted feedback forms.Furthermore, the final sample may not be fully representative of the targeted population due to group attrition.Ongoing evaluation of FEIS groups and broader programming will include efforts to obtain feedback from individuals who disengage from our services.Future research may be able to establish a correlation between positive group experiences and reduced recidivism, likely mediated through improved relapse prevention planning, medication compliance, and amenability to community support.

Recommendations
For clinicians interested in providing mental health programs in correctional facilities, we recommend fostering open communication and collaborative partnerships with COs and healthcare staff.
Having correctional staff set the time and location of groups is important, as they may have schedules for meals, medication distribution, and other activities.
Protocols for ethical decision-making must be established for addressing participant healthcare or safety concerns should they arise during groups [6].
Consistency around processes can reinforce staff and client expectations.
Flexibility is required when groups are rescheduled due to institutional issues and persistence is sometimes needed to keep programs operational.The FEIS encourages patience and empathy when supporting this population, as we may not be aware of the multiple stressors clients are coping with.
A calm, non-confrontational, and validating approach is recommended when de-escalating agitated clients, and clear boundaries should be set at the onset of sessions.
Keeping language simple and information practical is useful for maintaining group focus, as literacy levels and language barriers may affect engagement.
Finally, explicit commitments to creating a mutually respectful environment can set the foundation for productive group programs.
the FEIS's experience, facilitating programs in high-security settings poses a variety of challenges.Due to limited space, this program takes place outside client cells in the open area of the supportive care unit.Issues of security and staffing are often in flux and incidents in other areas of the facility (i. e., institutional searches or physical altercations) can affect the availability of staff to monitor the program.Inmates not attending the program can cause disruption by yelling or banging on cell doors.Tension among clients may be elevated and increased levels of CO monitoring are sporadically needed to reduce the risk of conflict.Client agitation can occasionally escalate to threats of violence between group members or frustration toward the facilitator, which may require CO support.