Introduction
The Correctional Service of Canada utilizes the multi-level Aboriginal Corrections Continuum of Care Model to address the unique cultural needs of Aboriginal inmates in federal correctional facilities. This paper will provide some background on occurrences, at the federal level, that influenced the creation of this model and the concept of importance of addressing social determinants of health will be apparent throughout. It will briefly compare the model to the similar but better-known socio-economic model and expand on how CSC went one step further to include the four parts of the self and the cultural significance this model holds for Aboriginal offenders. Each level of the model will be discussed and finally, a case study illustrating an intervention with the spiritual part of the self will be shared to help illustrate this model’s use in intervention of a suicidal crisis.
Background
In 1991, four Aboriginal and three non-Aboriginal commissioners were appointed to investigate, and to propose solutions to, the issues affecting Aboriginal peoples in Canada and advise the government on their findings (Canada, 2008). The result of the investigation was the Royal Commission on Aboriginal Peoples (1996). “The Commission concluded that ‘the justice system has failed Aboriginal peoples’ and the key indicator of this failure was the steadily increasing over-representation in Canadian penitentiaries and prisons” (CSC, 2013).
The Correctional Service of Canada (CSC) was aware of the over representation of Aboriginal offenders in the federal correctional system. “Aboriginal people represented 16.7% of federally-sentenced offenders compared to 1.7% of the Canadian adult population” (CSC, 2013). In 1992, four years prior to the publication of the Commission, CSC introduced The Corrections and Conditional Release Act (CCRA) and “for the first time, the law gave Aboriginal peoples a place in the development and delivery of federal correctional policies, programs and services and a place for Aboriginal spirituality and culture in the correctional environment” (CSC, 2013).
Policy and procedure, in CSC called Commissioner’s Directives, were finalized in 1995. Commissioner’s Directive 702: Aboriginal Offenders (CD702) detailed the implementation of “operational practices and interventions respect the specific needs of Aboriginal offenders in the Continuum of Care” from sentencing to reintegration into the community (CSC, 2013).
Other changes at the federal level, following the Commission, were occurring as well. An amendment to the Criminal Code Section 718.2(e) “specifically required that sentencing judges take into consideration all available sanctions other than imprisonment for all offenders, with particular attention to the circumstances of Aboriginal offenders” (CSC, 2013). In 1999, the Supreme Court of Canada, in Regina vs Gladue ruled that Section 718.2(e) was to be applied to Aboriginal offenders living both on and off reserves (CSC, 2013).
“Justice Rowles wrote a strong dissenting opinion on the extent of systemic discrimination in the criminal justice system” (CSC, 2013). “The Court further stated that the unbalanced ratio of imprisonment for Aboriginal offenders flows from a number of sources including low incomes, high unemployment, lack of opportunities and options, lack or irrelevance of education, substance abuse, loneliness and community fragmentation" (FASD Justice Committee. n.d.). Gladue Considerations are now included in the sentencing of Aboriginal offenders in Canada and their Aboriginal Social History (ASH), is taken heavily into account in any treatment they receive while incarcerated (CSC, 2013).
“CSC's first priority was to develop a policy to accommodate the practice of Aboriginal spirituality and culture within federal penitentiaries” (CSC, 2013). “The Aboriginal Corrections Continuum of Care model, introduced in 2003, was developed in consultation with Aboriginal stakeholders working with CSC to develop new approaches to addressing Aboriginal offender needs” and is the multi-level approach used to address the needs of Aboriginal offenders. Within the Continuum of Care model, the focus is twofold. First, Aboriginal offenders would be connected to their culture, families and communities; Second, Aboriginal culture, spirituality, community support would be integrated within the overall operations of CSC beginning at intake and continuing into the community. This paper will discuss how this approach is utilized by the Institutional Mental Health Team in working with offenders seeking help with depression in federal correctional institutions.
CSC’s Continuum of Care Model
The Continuum is, essentially, a socio-economic model (SEM) addressing the individual at the core, surrounded by their interpersonal relationships and community, within the organizational structure of the correctional institution, as influenced by policy and law. “The SEM states that health is affected by the interaction between the characteristics of the individual, the community, and the environment that includes the physical, social, and political components” (Kilanowski, 2017).
Introduced and implemented in 2003, the Aboriginal Corrections Continuum of Care Model is designed as a multi-level system of engagement addressing the unique needs of the Aboriginal offender (CSC, 2013). The Continuum is described in CSC’s Commissioner’s Directive 702: Aboriginal Offenders (2013):
The Medicine Wheel, found at the centre of the Continuum of Care, reflects research findings that culture, teachings and ceremonies (core aspects of Aboriginal identity) appear critical to the healing process. Representing the cycle of life from conception to return to the Spirit World, the Medicine Wheel is a reminder that correctional interventions developed and implemented for Aboriginal offenders must take into consideration the past, the present and the future direction of Aboriginal peoples as a whole and of the Aboriginal person as an individual.
Surrounding the Medicine Wheel is the Aboriginal community, which includes both on- reserve and urban communities made up of First Nations, Métis and Inuit peoples. The Continuum of Care recognizes that Aboriginal communities must be involved in supporting Aboriginal offenders during their healing journey and reintegration, as they link offenders to their history, culture and spirituality. The Continuum of Care also reflects the importance of community support at every step during administration of the sentence.
In the Continuum model, the representation of the individual as a medicine wheel, increases the cultural appropriateness of the model, by recognizing the Aboriginal as a whole person consisting of the physical, mental, emotional and spiritual self. It also lends to the purposed idea of the healing journey- the time from sentencing until warrant expiry where the individual will reconnect with their culture and spirituality as they move through the correctional system. With the addition of this micro focus, the Continuum Model goes one step further than traditional socio-economic models. At CSC, Elders utilize these four central parts of the self, again utilizing the symbolism of the medicine wheel, when addressing the Aboriginal Social History (ASH) of inmates. The following is an example of an Elder’s report as described in CD702 (CSC, 2013):
1. PHYSICAL ASPECT (East): focuses on learning to value the physical self and becoming comfortable within one’s own body. Interventions to balance the various areas of the physical self may include addressing addictions, healthy eating habits, physical exercise, the infliction of physical pain to oneself and others, and treating the physical self as the sacred gift the Creator has provided.
2. EMOTIONAL ASPECT (South): involves examining an individual’s emotional state of mind and ability to fulfill one’s emotional needs. Interventions may involve examining stressful areas of life, impediments to one’s learning and growth, healing unresolved abuse issues, learning to respect one’s own feelings, accepting responsibility for actions and words, understanding both the positive and negative aspects of oneself and learning to make both work.
3. SPIRITUAL ASPECT (West): understanding that all things on Mother Earth are related, that life is a gift from the Creator, and that we must learn to live to the best of our ability and respect all living things that we encounter upon our journey. Through ceremonies and Elder teachings, the spirit is healed.
4. MENTAL ASPECT (North): focuses on the individual’s cognitive capacities, the ability to learn from the past and to develop new ways of thinking. With knowledge comes wisdom, with wisdom comes compassion, and with compassion comes understanding.
Social determinants of health are described as “the broad range of personal, social, economic and environmental factors that determine individual and population health” (Canada, 2001) and include: “1. Aboriginal status, 2. Gender, 3. Disability, 4. Housing, 5. Early life, 6. Income and Income Distribution, 7. Education, 8. Race, 9. Employment and Working Conditions, 10. Social Exclusion, 11. Food Insecurity, 12. Social Safety, 13. Net Health Services, 14. Unemployment and Job Security” (Raphael, 2009). By addressing the individual as parts of the wholistic self, the Continuum of Care model is able to incorporate the social determinants of health from the macro level of influence, to the most micro level. The model also validates past experiences, heath inequities and intergenerational trauma, works with the offenders in the here and now and focuses on restorative justice and healing of their entire community as a future goal.
Depression in the Aboriginal Male Federal Inmate
Depression is a psychiatric condition affecting about 1 in 10 Canadians and can manifest itself as emotional, physical, behavioural and cognitive symptoms (Mood Disorders Society of Canada, n.d.).
Addressing mental health issues in inmate populations is of critical importance. A study by Kouyoumdjian et al. (2016) highlighted that “men in federal detention in British Columbia in 1999 had lifetime rates 2 to 3 times greater than men in a community sample with respect to mood disorders, schizophrenia, anxiety disorders, substance use disorders, and eating disorders.” The most serious consequence of depression, and other mental health disorders in CSC, is that “more than 1 in 5 persons in custody have attempted suicide” (Kouyoumdjian et al, 2016).
The Mood Disorders Society of Canada (n.d.) recognizes that the causes of depression include family history, an imbalance of chemicals in the brain, difficult life events, traumatic childhood events, abuse, neglect, divorce, family violence, gender, work demands, chronic illness, low income and substance misuse. This list mirrors social determinants of health, as well as common factors seen in Aboriginal Social Histories, and clearly indicates the need for multifaceted, multilevel solution to this multifaceted and multilevel problem.
Applying CSC’s Continuum of Care
Treating depression in the Aboriginal inmate requires a culturally competent approach if the treatment is going to be effective. The fist step is to acknowledge Canada’s genocidal history of colonization. Aboriginal individuals are victims of more than 500 years of colonization and for generations have endured crimes including, but not limited to, theft of territory, identity, economy, lifestyle, culture, language, family, health, freedom, spirituality, and autonomy (First Nations Health Authority, n.d.). In the era of the Residential School System, Aboriginal culture was essentially criminalized, and the crimes enacted upon individuals, communities and entire Aboriginal nations has resulted in intergenerational trauma that affects an Aboriginal individual’s social determinants of health so profoundly that “Aboriginal Status” is, itself, considered a social determinant of health (Raphael, 2009).
Starting from the most macro level of influence, CSC’s Continuum of Care is directed by law and policy, at the federal level. Statistical analysis, research and evaluation of historical outcomes challenging Aboriginal peoples are described in the Royal Commission on Aboriginal Peoples (1996). This Commission influenced reforms in the federal legal system, as seen in the Supreme Court of Canada’s Gladue Decision (1999) and the Criminal Code of Canada, specifically Criminal Code Section 718.2(e).
The next level in the institutional level. The Correctional Service of Canada is a federal institution which is overseen by a Commissioner, appointed by the Prime Minister, who reports directly to the Minister of Public Safety and Emergency Preparedness and is accountable to the public via the Parliament (CSC, 2018). Implementation of policy and procedure that reflect the law of Canada is one of the roles of the Commissioner, hence CSC’s policy and procedure called Commissioner’s Directives. Commissioner’s Directive 702 Aboriginal Offenders (1995) as well as The Corrections and Conditional Release Act (1992) address “operational practices and interventions respect the specific needs of Aboriginal offenders in the Continuum of Care” from sentencing to reintegration into the community (CSC, 2013). Commissioner’s Directive 800 outlines Health and Mental Health Service (CSC, 2015) and Commissioner’s Directive 843 outlines the Interventions to Preserve Life and Prevent Serious Bodily Harm in the suicidal or self injurious inmate (CSC, 2002).
The implantation of CD702 influences the community level of the model and the resources available. There are two communities to be considered, the community that is a federal institution as well as the outside community of origin that an Aboriginal federal inmate has come from. Some examples of CD702 implementation include institutional staff resources such as Aboriginal Elders, Aboriginal Liaison officers and Aboriginal Programs Officers employed at all federal institutions. These staffs address the cultural, spiritual, educational, correctional, and emotional needs of inmates and assist in restorative justice with offenders in their home communities, so that offenders may return to their community of origin when released. Another example is the assessment and documentation of an offender’s Aboriginal Social History (ASH), as described earlier in the paper, identifying the community, family, and individual factors that influence the offender both in life and in their commission of their index offence (CSC, 2013). Non-cultural specific staff, including health care staff and institutional mental health staff, provide screening and interventions to individuals with health and mental health concerns.
At the individual level, depression is treated by interventions that acknowledge all parts of self. The Continuum is helpful in treating Aboriginal inmates and addresses many of the social determinants of health that contribute to depression. Physically, the body is treated for ailments and pain, concerns with addictions are addressed, sleep and appetite dysregulation are assessed, and pharmacological interventions are offered. Emotionally, a sense of community, contribution, purpose and growth are fostered- all of which produce hope and resiliency and are protective factors in mitigating depression. Spiritually, individuals are encouraged to engage in spirit work, in their culture and religion and find healing here as well a sense of interconnectedness to all living things and their own inherent value as a living being. Mentally, cognitive concerns are addressed, learning through schooling and correctional programming and psychotherapy help the individual engage with, and learn from, others to develop new and healthier ways of thinking and pro-social ways of living. Multi-disciplinary staffs in correctional facilities collaborate as a force of wellness in identifying, and intervening, with inmates experiencing depression utilizing the Continuum as a plan of engagement at the individual, community, institutional and policy levels.
Case Study
With permission, and with gratitude, I would like to share my experience in applying CSC’s Continuum of Care Model to an Aboriginal offender at risk of suicide. Application of the Continuum incorporates law, restorative justice, health care, and policy. The name of the offender has been changed to respect confidentiality. It is written from my first-hand experience as a Registered Psychiatric Nurse working at a medium security correctional center.
It was 3pm on a Friday afternoon and I was preparing to wrap up my work week. A call came in about an inmate in crisis requiring immediate mental health intervention. The inmate, who will be referred to as Chris, was escorted to my office.
Chris, a 29 year old Aboriginal inmate, explained that he had told his programs coordinator that he had purchased a large amount of drugs with the intention of intentionally overdosing. He was distraught, crying and voicing suicidal ideation with plan and intent. He had a previous suicide attempt history, mental health diagnosis and was considered high risk for completing this plan.
Chris explained to me that the following Wednesday would be the three year anniversary of the murder of his best friend. He further explained that this was the first year he was sober for the anniversary and he was not coping. Although he was not directly responsible, he blamed himself for the death and was overwhelmed by grief and shame.
When it comes to death and the grief associated with loss, all aspects of self (physical, emotional, mental and spiritual) are affected, but the spiritual aspect, in many cultures, is where the healing work has the most profound effect; This can be seen cross-culturally in religious ceremonies that follow death. Recognizing that there were no pharmacological or psychological interventions that would provide immediate protection against suicide for this man, with Chris’ permission, I invited an Elder to attend the interview.
Chris and the Elder planned a ceremony to commemorate the loss of his friend that would include a culturally significant ritual of hair cutting to symbolize Chris letting go of his grief and shame. Chris, now future orientated and validated in his experience of grief and suffering, had some hope. I now felt comfortable that Chris was no longer at imminent risk of suicide over the weekend and did not activate high risk suicide precautions which would have required he be placed in an observation cell, in segregation, for his own protection. In my opinion, this isolation would have reinforced his pain, guilt, shame and feelings that he should be punished. Instead, he was on a healing journey, supported by staff.
Wednesday came and Chris invited writer and several other staff to attend the ceremony. There were Elders, Aboriginal Liaison Officers, Aboriginal Programs Facilitators, mental health staff and inmates in attendance. Many empty chairs were included in the great circle, inviting Chris’ ancestors to attend and provide their strength and guidance in his time of need. The ceremony opened with prayer and song. All in attendance, Aboriginal and non-Aboriginal, smudged to purify ourselves. An eagle feather was passed around and each person spoke to Chris, except for Chris who spoke to his departed friend. Another inmate sang several songs and beat his drum while Chris had his hair cut and wrapped in sacred cloth. Each person, and ancestor, in attendance gave their medicine to Chris, whether it was prayer, song, dance, or simply their presence. Many tears were shed, and a strong sense of connection and community was felt by all.
In a decade of professional practice, this single intervention had the most profound effect that I have ever seen. Had CSC not had policies and staff in place to address the cultural and spiritual needs of Aboriginal offenders, the outcome would been detrimental, if not tragic. Each person who attended Chris’ ceremony gained connection to the others in that room. Each contributed their gift, or medicine, to all in attendance. All were empowered by giving and receiving. Instead of a tragedy, which would have had a ripple effect through the institution and through Chris’ home community, there was healing, and the effects were felt broadly.
Conclusion
CSC’s Aboriginal Corrections Continuum of Care Model is a multi-level model utilized by interdisciplinary staff to address the needs of Aboriginal offenders in Canada’s correctional facilities. From the most macro level influences of federal law to the most micro parts of the self, this model encompasses interrelated factors the address all an individual’s social determinants of health. Just as this multi-level approach impacts the individual, the individual, in turn, impacts society. “Improving health in people who experience detention and incarceration is an important goal, and could lead to valuable secondary benefits for society, such as decreasing health care costs, improving health in the general population, improving public safety, and decreasing re-incarceration” (Kouyoumdjian et al, 2016). A weakness in this model lies in obtaining measurable outcomes however. There are not yet outcome measures specific to Aboriginal offenders and therefore comparing them directly to non-Aboriginal offenders they continue to have poorer outcome. For example, the outcome measure of employment following release cannot be reasonable compared to a non-Aboriginal offender released to an urban city and an Aboriginal offender returning to a rural reserve, where many social determinants of health rank significantly lower. More research is needed to measure the effectiveness of this model moving forward.
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