Correctional Investigator Critiques Mental Health Care in Prisons

Post #293

1300 words; 5 minutes to read

Summary: The most recent report of Canada’s Correctional Investigator points out serious problems in the treatment of the many prisoners with mental health issues, leading to many issues after release from prison.

Audio summary courtesy of volunteer Kimberly Duong.

The reports of Canada’s Correctional Investigator are one of the most important independent sources of public information about what happens in our federal prisons.  This blog has previously referenced a number of those reports, both annual reports (such as from 2021-22) and special reports (such as this one on education).  All these reports are available on the OCI website.  They are models of solid research, careful presentation of evidence, and reasonable recommendations.

In his latest annual report, for 2024-25, Correctional Investigator Ivan Zinger also announced his retirement and his frustration with the failure of the Correctional Services to respond meaningfully to many of the recommendations, often made repeatedly, during his years with the OCI.

The report also reviewed findings from six national investigations into access to and quality of various aspects of mental health care for federally sentenced individuals – an important issue given the high proportion of federal prisoners who do have serious mental health issues.

Mental health care has many problems

The conclusion: There is no question that lack of access to timely, adequate, and appropriate mental health care is a human rights issue… it is abundantly clear that CSC is fundamentally ill-equipped to provide long-term mental health care to individuals with serious mental illness.

The report found serious deficiencies in many aspects of mental health provision in Canadian prisons.  It isn’t just these limitations that are significant; any large institution will struggle to keep up with the constant changes in a field of service like that.   As the report puts it,

The lack of transparency and failure to consult more broadly is indicative of how the CSC continues to prioritize what is best for the Service, and not what is best for those in their custody or supervision… many of the issues previously raised by this Office and the Service itself, remain and progress has seemingly stagnated. Our investigation… confirmed a long-standing issue – the priority continues to be the resourcing of mainstream, custodial corrections.

The report finds some consistent problems across many areas of mental health delivery.

• Weak, vague, outdated, and/or absent national policies have led to ineffective, confusing, and inconsistent direction and implementation of mental health services.

For example, careful policy is lacking in areas such as who should be placed in regional psychiatric facilities (Regional Treatment Centres), where 30% of individuals at RTCs do not actually meet CSC’s own criteria for admission… These individuals have been admitted as  … individuals with serious physical disabilities who require 24-hour nursing or other clinical care not available in the region.

Poor training, not enough skilled personnel

Similarly, despite nearly all incarcerated women having experienced some form of trauma in their lives, little is done in the way of screening and assessment of newly sentenced women for trauma.

• Insufficient training is provided to staff on how to work effectively and humanely with individuals with mental health issues’ coupled with insufficient specialized staff to provide services.
• An absence of effective screening and assessment of mental health issues has created a domino effect of poor identification and access to services, thus excluding many who need such enhanced forms of care.

…for Indigenous peoples serving federal sentences, trauma- and culturally-informed mental health and wellness services were found to be severely lacking, despite the significant needs of this population and their well-documented over-representation in the system.

Even when procedures or policies exist, implementation is ‘Overly focused on compliance issues (e.g., completion of tasks in accordance with policy) and proper placement of documentation in an individual’s file, to the exclusion of assessing the quality of treatment or interventions.’

Failure to deal with past trauma

In the absence of formal screening, both incarcerated women and CSC staff [said] that traumatic life experiences are typically brought up during intake or programming. However, these discussions are primarily focused on the link to criminal behaviour and used for assessing risk and need and not for therapeutic purposes. Consequently, many women reported reluctance to disclose trauma due to fears that the information could appear in official reports or be used against them.

• Prioritization of security measures, responses (including the use of force), and physical structures prevails over more dynamic, human-centred, and therapeutic forms of interaction

For example, one area of mental health care in prisons used to be staffed by 50 guards and 100 nurses, which has gradually shifted to 130 guards and fewer than 50 nurses.  More ranges seem to rely on cameras and intercom compared to actual personal interaction between prisoners and staff.

The pervasive reminders that one is in a prison are not only visual, but also extend to the language used by institutional staff in reference to those residing there for treatment.  All of which has negative effects on the welfare of prisoners.

Another instance of the security focus is too much use of force.  The report documents extensive use of force (e.g. pepper spray, restraints of different kinds) on vulnerable individuals, including those suffering from mental health issues.

The report further indicates that the compulsory reviews of serious incidents and deaths among prisoners with serious mental health issues has led to very little in the way of change in practice or policy.

Poor preparation for life in the community

• Adapted and/or specialized options for programming, treatment, or opportunities for skill acquisition that would support preparations for successful release are inconsistent or unavailable.

The entire prison system, according to the report, has only 4 positions for discharge planners even though it releases several thousand people each year.

Although total spending on… community mental health services had remained relatively stable since its first year of full funding in 2007-2008, we found a 39% decrease from $13.8M in 2009-2010 to $8.4M in 2024-2025 when adjusted for inflation. During the same period, CSC’s overall annual expenditures have been relatively stable, keeping up with inflation. However, its corporate focus remains on institutional corrections; despite accounting for roughly 40% of the federally sentenced population in 2024-2025 (8,713 out of 23,516), Community Corrections received just 12% of CSC’s $3.2 billion budget and 9% of its staff.

Compared to other people in Canada, federally sentenced persons enter the correctional system with disproportionately high rates of housing and financial instability, poor employment and economic outcomes, low education and literacy, childhood trauma, and a high prevalence of mental disorders and cognitive deficits. Add to this the intersection of race, gender, or the stigma of having a criminal record, and it should be no surprise that sentenced individuals face tremendous barriers to reintegration, including access to mental health care.

One issue that complicates release is the urgency to transition responsibility for the individual back to the provincial or territorial health authority. Consequently, the transition from institutional to community mental health services can be delayed or derailed by the change in responsibility over health services, sometimes with devastating effects.

The report notes poor engagement between CSC and community agencies, and the continuing problem of people leaving prison without the documents, such as health cards, required for them to function in the community.

Of 761 releases between 2022 and 2024 where people had significant mental health need, more than half upon release had no health card.  More released prisoners extend their stay in halfway houses or move to Community Correction Centres (run by CSC) in the absence of anywhere else to live.

The work of the Correctional Investigator is essential to maintaining any kind of reasonable prison system in Canada.

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