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Feeling at home in forensic mental health: working in an all-female prison offers challenges, as well as opportunities, as one nurse helps turn around some chaotic lives.

When director Kenji Kohan decides to introduce a mental health perspective to his popular American TV prison drama Orange is the New Black, Christchurch forensic mental health nurse Shannon Christie is well positioned to be his adviser. Holding weekly in-reach clinics at Christchurch Women's Prison, while working for the Canterbury regional forensic community team, gives her first-hand insight into the psychological health and lives of the women incarcerated there--"a population desperate to talk".

A key part of Christie's role is carrying out mental health screening assessments. On admission to prison, each inmate is screened for mental health concerns using the national mental health screening tool. A positive result means automatic referral to the regional forensic mental health team. Using this screening tool, Christie says, "catches lots of mental health issues that otherwise would be missed. It hits on the major issues we want to target, including suicide/self-harm risk, mood disorders and psychosis".

Managing suicide risk

Some women will need ongoing follow-up by specialist mental health services; others can be referred for brief intervention counselling through packages of care provided by the Department of Corrections. Suicide/self-harm assessments are a core aspect of Christie's work and "working with Corrections staff to manage this risk is key". Suicide rates in prisons are up to 10 times higher than those in the general population, (1) and the rate is higher among women prisoners than male prisoners. This contrasts with suicide rates in the general population, which tend to be higher among men. (2)

Christie knows prison is a fertile ground for mental illness, with women prisoners being two to four times as likely to have a psychotic illness or major depression as the general population. (3) Worldwide, 42 per cent of women prisoners have a personality disorder, about 10 times the prevalence in the general population. (3) Any behaviours of concern during incarceration can generate a referral from the internal prison health-care team for her team's input. Pre-existing mental health disorders can be exacerbated in prison. Fear of assault from peers can fuel an already existing anxiety disorder and having to eat in communal settings can make life harrowing for somebody with a crippling social phobia.

As the Mental Health Act is not enforceable in prison, some prisoners with chronic mental illness choose to discontinue vital medication, Christie says. This can result in acute mental health deterioration. Some disorders take a while to uncover in a prison setting, while others are layered and interconnected. "Female mental health needs in prison are complex, and complicated by high levels of drug and alcohol misuse and significant trauma histories, including sexual abuse and domestic violence," Christie said. Up to 90 per cent of those she sees have active alcohol and substance issues up to the time of incarceration.

Addressing trauma histories

"You can't separate out any one issue for these women--so many have horrific personal histories. While psychological input is available to address their cycle of offending, it's particularly frustrating there is no such input to address trauma histories. It's a huge gap in resources, which means they cycle through the justice system again and again, without their underlying mental health concerns being addressed."

The need for gender-responsive programmes and treatment, which Christie observes at the coal face, may now be gaining traction at parliamentary level. In June 2016, close to $14 million was granted to fund extra mental health services in prisons. An additional $877,000 was ring-fenced to address trauma-related work with female inmates. This financial contribution, however small, supports international research which concludes female-specific factors greatly influence women's entry into crime. (4,5) New Zealand-based research also shows post-traumatic stress disorder is the second most common psychiatric disorder among women referred to psychiatric services in New Zealand prisons. (6)

Female offending is on the rise. Women's prison populations in New Zealand have increased by about 400 per cent since the mid-1980s (7) and Christie experienced a 50 per cent increase in referrals during her first year in the role. It's engagement, rather than these staggering statistics, that she focuses on when doing an initial assessment.

"It's important to structure the interview and emphasise the voluntary aspect of it. A relaxed approach and sense of humour help. A too straight-up-and-down approach doesn't always work. I carefully explain my role, what will be done with the notes I take and with whom the information will be shared. I am also clear about my limitations, as there is often an expectation I will facilitate prescriptions for medications some women seek."

Time constraints can lead to ethical conflict. "Often the time allocated doesn't match the time needed, especially when discussing trauma histories, when women need to be given all the time they require. Disengagement can be difficult in these circumstances."

The reality of prison life means valuable time can be lost waiting for custodial staff to bring women from other parts of the prison to the health clinic, where Christie does her assessments. As a result, appointments often have to be rescheduled. Barriers unique to custodial settings need to be factored into Christie's assessments. "When I do brief intervention work addressing sleep difficulties, for example, I have to remember mattresses are only two inches thick, their plastic covers can be hot/sweaty and only one pillow is allowed."

Christie strikes a careful balance when talking about offending histories. "I don't seek any more detail than what is necessary to complete solid, risk-based assessments. Offending is not the only hat prisoners wear. I look at the whole person, their abilities and interests, seeking out the things they are good at. This doesn't minimise the gravity of their offending, of course." But she believes sustaining hope is crucial. "It may be reminding them of previous accomplishments or adversities they've overcome. Hope can come with taking small steps."

As New Zealand has only three female prisons, women are often held far from families and communities of origin. More than half those Christie sees are mothers, which adds additional stress. "Being a parent is a big issue and often on their minds. It can take up to two weeks for phone calls to be approved. This is a significant stressor, especially when these women are already overloaded dealing with court proceedings and detoxing at the same time.

"Remand can be a vulnerable and testing time, as they don't know what their future holds. Feelings of isolation, alienation and hopelessness are common. Legal proceedings can be a barrier to rapport-building. I may not see them again and this needs to be taken into account when doing my assessment."

Christie values having her practice based in Hillmorton Hospital, as opposed to the prison itself. "Being based outside the prison means fewer preconceived ideas and less risk of enmeshment and prejudice. It makes it easier to stand behind solid mental health frameworks."

A sense of humour is essential for coping in her specialised role. She once got denied entry to a prison facility when her underwear triggered the security scanner alert, much to the mirth of nursing colleagues, who affectionately dubbed it "bra gate".

A comprehensive forensic nursing apprenticeship also helps. After graduating in 2008, Christie spent four years working at the medium secure regional forensic inpatient unit at Hillmorton Hospital. This, she says, "exposed me to the depth and breadth of offending. This experience helped me gain an understanding of the overlap between the health and justice systems, and where forensic nursing fits into the overall system. I developed well-honed interviewing skills, as these patients are often guarded and don't always want to be interviewed."

Working with youth offenders

Christie gained a sound working knowledge of the "nuances of court proceedings" while working as a forensic liaison nurse at Christchurch Youth Court. Time spent as a visiting community forensic nurse to the youth justice residential facility, Te Puna Wai o Tuhinapo in Christchurch, helped her grasp how layered forensic presentations can be. "These youth presentations often involved abuse, alcohol/drugs problems, care and protection issues, behavioural difficulties and sometimes mental illness."

But it's what drives female offending that particular interests to her. "It's complex. There's so much more beneath the surface than what you see on a charge sheet. In addition, a slanted media focus means the public rarely gets to hear the story behind the offending."

Christie knows change is possible in a custodial setting. "Many of the women have had chaotic lifestyles and, following imprisonment, they get detoxed, do some correspondence study, even sit their drivers' licence. They develop confidence in their own abilities, gain a sense of pride and can see a future."

The "realness" of the women she deals with appeals to her. "Here is a group who make no apology for who they are, which can be refreshing. I feel at home in forensic mental health."

* Shannon Christie is now working as a community forensic youth nurse, based at Princess Margaret Hospital.

Bernie Burns, RN, is a staff nurse at Hillmorton Hospital, Christchurch


(1) World Health Organization. (2008). Trencin Statement on prisons and mental health. Copenhagen: Regional Office for Europe.

(2) Marzano, L., Hawton, K., Rivlin, A., & Fazel, S. (2001). Psychosocial influences on prisoner suicide: a case control study of nearlethal self-harm in women prisoners. Social Science & Medicine, 72(6), 874-883.

(3) Fazel, S., & Danesh, J. (2002). Serious mental disorder in 23,000 prisoners: a systematic review of 62 surveys. The Lancet, 359(9306), 545-550.

(4) Van Voorhis, P., Wright, E. M., Salisburn, E., & Bauman, A. (2010). Women's risk factors and their contributions to existing risk/ needs assessment: the current status of a gender responsive supplement. Criminal Justice Behaviour, 37, 261.

(5) Giordano, P., Deines, J. A., & Cernkovich, S. (2006). In and out of crime: A life course perspective on girls' delinquency. In Heimer, K. and Kruttschnitt, C. (Eds.) Gender and Crime. New York University Press.

(6) Collier, S., & Friedman, S. H. (2016). Mental illness among women referred for psychiatric services in a New Zealand women's prison. Behavioral Sciences & the Law, 4(4), 539-50. doi: 10.1002/bsl.2238

(7) Newbold, G. (2016). Crime, Law and Justice in New Zealand. United Kingdom: Routledge.

Caption: Shannon Christie enjoys 'the realness' of the women she deals with.
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Title Annotation:profiles; Christchurch Women's Prison forensic mental health nurse, Shannon Christie
Author:Burns, Bernie
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Sep 1, 2017
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