A man with severe mental illness is caught between the legal and health systems, bounced between healthcare and prison because he can't get accommodation and treatment. A leading forensic psychiatrist says his and hundreds of similar cases are a human rights violation. Why are we incarcerating our most seriously ill people when it's the worst possible place for them?
A couple of years ago, Joshua*, a man with schizoaffective disorder, suddenly realised he didn't have to take his medication if he didn't want to. At the time, he was in prison on remand, waiting to be sentenced for an assault - and in prison, the court order requiring him to take medication couldn't be enforced.
He was off his meds for six weeks before he completely unravelled, becoming manic and "wildly, wildly psychotic", according to his mother Hannah*. She wasn't told much, except that he was restrained and taken to a specialist psychiatric inpatient unit, where he spent four weeks getting the help he needed before returning to prison.
Eventually, Joshua was released from prison and the back-and-forth between the justice and health systems continued. He was placed in accommodation in the community, where he deteriorated again. He was again admitted to hospital, where he assaulted a nurse and damaged hospital property. He's now back in prison on remand, because there was nowhere safe to bail him to.
Because of court suppression orders, and because being the subject of a media story would cause him a great deal of distress, RNZ learned of Joshua's case via his family and his lawyer, on condition of anonymity.
Although the schizoaffective disorder means he hallucinates and has delusions, one of his most difficult symptoms is anosognosia, which means he's unaware of his condition and doesn't think he's unwell. In his world, he's being closely monitored and persecuted by his family, healthcare staff, lawyer, and judicial authorities. He believes their attempts to help, including medication, are injustices he must fight.
Of all the months he's spent inside, Hannah says, none of them were because he was sentenced to be there. It was because there was nowhere else to remand him to. The cumulative effect of all the moves has been both destabilising and traumatic.
But his illness still isn't deemed bad enough for ongoing forensic inpatient mental health care, when demand for that care is so great, both in terms of space and staff.
Oliver Lewis, a journalist who extensively investigated our inpatient mental health facilities last year, described them as "Dickensian" in an interview with RNZ/Newsroom's The Detail, pointing out that a 2019 stocktake of 24 units - about half the total number in the country - showed nearly a third were in 'poor' or 'very poor' shape, requiring urgent repair or replacement.
An Association of Salaried Medical Specialists paper published in 2021 reports that our DHBs' mental health and addiction inpatient beds frequently exceed 100 percent occupancy levels, well above the 85 percent occupancy considered clinically safe.
It says the number of inpatient mental health and addiction beds per population has actually fallen by nearly 10 percent in the past five years, with our number of psychiatric beds per head of population among the lowest in the OECD. And in 2018, New Zealand had the lowest number of practising psychiatrists per capita compared with 10 other countries, including Australia, the UK, and Canada.
Although some builds are under way at places like Waikeria Prison, which will have a new 100-bed mental health and addiction service, that will only serve people in the Central regions - and only those in prison.
Other builds the government has embarked upon, such as an extension to mental health services at Christchurch's Hillmorton Hospital, will take years to come to fruition - and don't include forensic beds. RNZ asked the Ministry of Health for more information on this, and the spokesperson says the size of the future forensic inpatient unit and the programme to deliver it is yet to be determined.
"Decisions around the sequence of the Hillmorton campus upgrade have yet to be finalised. The Health Infrastructure Unit is working with the DHB and we expect a decision on the first tranche to be confirmed in June."
With demand for care stretched around the country, people like Joshua are in limbo; everyone holding their breath until his behaviour deteriorates again and he is considered bad enough to be admitted. It's an ambulance-at-the-bottom-of-the-cliff approach that puts Joshua, the community, and mental health and prison staff at risk.
Hannah calls it an "endless, self-perpetuating Catch-22".
"It's a bizarre cycle where nothing makes sense, nothing seems to get better, and it snowballs out of control."
Watching it all happen, helplessly, she has been left with the abiding conviction that no matter what happens to her son, the holes between the justice and health systems mean he's being set up to fail.
"I hate this illness. I just hate it," she says. "I feel like it's stolen my son."
Joshua should be getting healthcare. Instead, she says, he's jailed for being sick.
'You could not design a more deleterious environment'
Prisons weren't designed for people with mental health problems, says specialist forensic psychiatrist Erik Monasterio, the former director and clinical director of Canterbury DHB area mental health. In fact, he says the conditions and lack of regular psychiatric care means you could hardly design a worse place to house people with illnesses like Joshua's.
"The environment [in prison] will almost guarantee a poor outcome," he says. "Families will tell you there is a trajectory of doing poorly once you've been in custody, because the experience is not good for your mental health, or your risk of recidivism."
Monasterio estimates there are hundreds of people like Joshua across New Zealand, locked up awaiting treatment because of a lack of beds in appropriate mental health facilities. The accommodation and treatment they need is greater than what the government has built, or funds.
First, there is the issue of staying on your medication uninterrupted. Then, he says, if you're mentally unwell and placed in the main prison environment, you're far more vulnerable to abuse and exploitation.
"You'll enter into an environment where intimidation, often, is a way to deal with conflict… you will learn strategies to cope with stress and frustration, [which are] not going to be in your best interest… you'll have an experience that is not pro-social or normalising.
But Monasterio says one of the most damaging aspects of being incarcerated is the time patients spend in intervention and support units when their behaviour deteriorates.
"You'll be subjected to lockdown for 23 to 24 hours a day, in situations of sensory deprivation, where you have no access to fresh air, where you have no natural light, where, if you're unwell enough, will not have access to a toilet, where you will be simply sleeping on the ground on a mattress," he says.
"Where even though Corrections staff, because I've worked alongside them, work very hard [to] help you, they're not trained. Where [you] have some access to specialist mental health care [through external health staff visiting], but not 24 hours a day."
For someone suffering from a serious mental disorder, he says "you could not design a more deleterious environment" than being placed in such a sensory-deprived setting, without access to specialised care.
"And that's likely to cause long-term damage for a large number of people."
From his position at Canterbury DHB, Monasterio watched situations like Joshua's play out again and again for more than 20 years.
"It's really regrettable that had seen this train wreck occurring over an extended period of time," he says. "And no matter how much we've worked from an academic perspective, from a clinical perspective, from a leadership perspective, it's just continued down this negative road to where we are now.
"My life is full of terrible individual stories that I have to provide care to," he says. "I think the public would have sympathy and they'd be aghast if they understand what happens personally … to hundreds of psychiatric patients that are held in a situation which does not meet even the basic standards of human dignity."
With Covid-19 stretching the health system, causing staff shortages and chronic stress, he says the pandemic will have made things worse.
"First and foremost, the effect of Covid on those with serious mental illness is going to be disproportionately worse, so their situation is likely to get worse.
"Second, all of the factors that have led to this crisis have been present for a long time, so they can't be explained away by Covid. This has been foreseen for a long time."
Monasterio says the current government, though it campaigned on kindness, has made things even worse. In fact, he tells RNZ that the crisis of caring for mentally ill people in prison demands an investigation equal to the Royal Commission of Inquiry into Abuse in Care.
"The parallels are startling," he says. "The abuse in state care occurred over a period of time with knowledge, as we now know, from various very influential people. And it occurred for a long time before action was taken. The same thing is happening now.
"This is a government that's always proposed that they were going to be a kind government, they were going to look after the most vulnerable, and they put central to their agenda - this is part of their political platform - that they were going to assist those with mental illness.".
"Sadly, I can unequivocally tell you that the situation for those with serious mental disorder, since the government's been in power, it's worse, not better than previous governments."
'The Ministry have all known about this'
A 2016 paper in the Australian and New Zealand Journal of Psychiatry by Monasterio and University of Otago associate professor of psychiatry James Foulds pointed out how remand prisoners held in custody while awaiting sentencing or trial were stretching prison health services to the limit. They warned of a looming public health crisis as prison numbers grew.
Defendants who had access to stable housing were more likely to be granted bail, Monasterio and Foulds wrote. But they added that affordable housing was increasingly out of reach for those of low socioeconomic status and with chronic mental and physical illnesses, so many more in these vulnerable groups were likely to be remanded to prison.
Since 2016, prisoner numbers have dropped, but the number of people on remand continues to rise, a warning bell experts sounded on Newsroom recently.
But it's not only about mentally ill prisoners on remand. On 13 March, 2020, Monasterio and the six other directors of every area mental health service in New Zealand took the very unusual step of strongly and publicly condemning the government in the pages of the New Zealand Medical Journal.
Together, they wrote a scathing article titled "Mentally ill people in New Zealand prisons are suffering human rights violations". Forensic psychiatry services were "unsafely stretched", they said, with the growth in prison populations contributing to a serious, "arguably scandalous mental health crisis, with few relief options in sight".
Because medication orders couldn't be enforced in prison, they said, it led to prisoners becoming "acutely unwell", and then waiting untreated for weeks. With a disproportionately high number of Māori in the prison population, the seven authors said the government had breached its obligation under Te Tiriti O Waitangi to address the inequalities that incarcerated them in a place where they were dislocated from whanau and faced added barriers to healthcare.
They argued New Zealand was also breaching international human rights agreements, such as the 2008 United Nations convention on the rights of persons with disabilities, which means the government has a duty to enable access to healthcare services for people with a disability, including serious mental illness, in custody.
They concluded that a specialist mental health court, like those that exist in the United States and some Australian states, would help take care of the increasing number of people with serious mental illness who are remanded to prison on minor charges. Courts such as these typically have a multidisciplinary team across health and justice, who work with the defendant to court to develop a community-based programme for them.
"In many cases offending in this group can be traced to general adult mental health services' lack of resources to assertively treat these people or provide the level of care necessary for successful diversion, as a result of decades of decay from under-funding," they said.
But the article was published on the Friday before Covid-19 closed New Zealand's borders and just a week before the first alert level system was introduced. The doctors didn't get the media or political traction they were hoping for.
"We don't believe we were being overly dramatic about the situation; the scale is enormous," Monasterio says now. "And sadly, successive governments, and the Ministry have all known about this, the extent of the problem has been well laid out for 20 years. It's getting worse. And all people in management and leadership know this, yet they ignore the problem.
"It's a lack of resources and the unwillingness to address what is a public health crisis of extraordinary proportions affecting the most vulnerable in New Zealand."
None of this is a particularly palatable to the public or politicians, Monasterio says - and ensuring prisoners have mental health care, or questioning if they should be in prison at all, aren't popular topics either.
"It's still very easy to ignore people with serious mental illness, particularly if they're in prison, because the public view is that they're less deserving," he says.
"The politics of incarceration… has been one to stigmatise and demonise those who offend. From whichever angle you attack it, the public sentiment is not on the side of the offender, even when the offender does not offend seriously and they're offending because they're either addicted to drugs and alcohol, or they suffer from mental disorders.
"So it's really, really difficult to be an advocate for this group of people. It's a terrible reality and an indictment of our value system and our modern society."
Hillmorton Hospital. Photo / RNZ
No new funding for forensic mental health in Budget
The Ministry of Health would not provide RNZ with anyone to interview about these issues. In a written response, an unnamed Ministry of Health spokesperson says the Ministry "acknowledges there is pressure on inpatient mental health services and is working to address them through capacity, infrastructure and workforce programmes".
The spokesperson also says the ministry is "improving services in the community so people can access support before people become acutely unwell".
In response to questions on how the new health system might address the issue of demand on forensic mental health services, the spokesperson says the ministry is "aware that prisoners often experience wait times to transfer to a forensic bed due to availability, and are working to address pressures on inpatient mental health services across the country".
The spokesperson adds there are "several initiatives under way to grow and upskill the workforce supporting forensic mental health inpatients, as well a focus on transforming the way mental health and addiction services are provided in New Zealand to focus on early intervention so people are supported to stay well".
As well as the Hillmorton build, they say investment has been approved and work is underway on redeveloping the Mason Clinic, a mental health facility in Auckland, which currently has seven forensic beds.
They also say "a programme of work to better understand current and future need for forensic mental health is underway", which will "inform prioritisation of infrastructure planning and investment".
RNZ asked the ministry if it can assure the public that general community mental health services have the capacity to accept referrals to ensure safe community transition and reintegration after prison relapse. The MoH spokesperson says general community health services always prioritise access for those with the most urgent needs to help manage demand for services.
"There is substantial work under way to ease the pressure on mental health services, including expanding the workforce."
There was no funding for forensic mental health in the 2022 Budget announced last month.
However, a ministry spokesperson pointed out, $34m over four years was assigned in the 2019 Budget, which at the time included an increase in the number of clinical psychology internships funded and more specialist places for nurses, social workers and occupational therapists in addiction and mental health services.
The spokesperson added that 46 new bursaries for Māori students and 30 scholarships for Pacific students were added in the 2019 Budget as well.
They also say money assigned to crisis services in this year's Budget will relieve some of the pressure on inpatient mental health services, which includes forensic services.
The Government has also earmarked $78.3m for the 80-bed adult acute inpatient mental health unit at Hillmorton Hospital, one of the units journalist Oliver Lewis described as "Dickensian" and desperately needing attention.
It also budgeted $202m for mental health services, $100m of which the Government said was for trialling "new models of specialist mental health and addiction services and increased availability for people with specific needs in targeted areas across the country".
That includes $27.5 million for community-based crisis services that the government says will deliver "a variety of intensive supports" such as residential and home-based crisis respite, community crisis teams, co-response teams (involving police, a paramedic and mental health staff responding to mental health callouts together), and peer-led services in the community and as part of care teams.
It also includes $10m "for workforce development to build the capability and capacity of the specialist services workforce", and $18.7m to enhance existing specialist child and adolescent mental health.
The ministry spokesperson says the Government has developed a recruitment campaign to attract more people into mental health and addiction nursing, which launched in March this year and will run for two years.
'I feel like the grief and stress will kill me'
Budgets and promises are all very well, but talk of rebuilds and new beds that are years in the future mean little to Hannah right now. Her main concern is finding somewhere for Joshua to live when he gets out of jail. He's been trespassed from many of the usual accommodation options and she has no idea where he's going to go.
Stress triggers episodes of psychosis and mood disorder for him, and as anyone who's been there knows, not having somewhere stable to live is one of the biggest stressors you can face, even if you're well.
"The longer he goes without stable accommodation the more unwell he becomes," she says. "The more unwell he becomes the harder it is to house him.
"I don't know if I can take another round of it. I feel like the grief and stress will kill me."
He can't stay with her anymore; because he's threatened her in the past, she's already been forced to do the unthinkable and get a trespass order against him, as well as a police panic button installed when he wasn't in prison.
Looking for help, she has approached Work and Income, Kāinga Ora, a local housing trust, a local hardship trust, the Salvation Army, Habitat for Humanity, and Housing First. She has a letter from a senior psychiatrist stating that without stable, suitable accommodation he is likely to end up in hospital - again.
She has talked to the general manager of her area's mental health services; they contacted housing agencies on her behalf. Joshua has been on and off the social housing list for five years, and nothing has ever been offered. Her local housing organisation, set up to give transitional accommodation to people with mental health conditions, is unable to house someone with his level of illness.
"Not that they have any beds available," she says.
She has made formal complaints about Joshua's care to the local DHB, and contacted the Health and Disability Commission, the Ombudsman, the Director of Mental Health, the Health Minister, the Corrections Minister, her local MP, and the local council.
She knows exactly what has the best chance of helping him long-term, because it has helped before - going back to the specialist forensic psychiatric unit. But he can't get in there; they're frequently full.
"There are judges, police, lawyers, doctors, nurses, friends and family that can all see this needs to happen," she says. "But my son is still lost in the gaping holes between the mental health system and the justice system.
"We need something like [the forensic inpatient unit to which Joshua was admitted], but pre-forensic, so people don't have to commit crimes to get in there," she says. "Where people can get proper treatment and rehabilitation. Not cutting people off from their families and nature, and the world."
Last year, Joshua was put in supported accommodation at a local motel. Hannah knew it wouldn't work for him, and it didn't; he assaulted one of the staff members. The day before the assault, Hannah had texted his nurse saying 'Joshua is not well'.
"And he was charged with that. He did prison time for that because he didn't reach this criteria of being sick enough to get help. It's infuriating. It's also really unfair on staff who have to deal with this. It's putting them at risk."
The other peculiarity that's hard for families and laypeople to understand is that despite Joshua's illness and delusions, he is deemed sane enough to instruct his lawyer and weather the consequences of those instructions.
Two reports by two independent psychiatrists have found he is fit to stand trial, and doesn't reach the criteria for an insanity plea (an earlier report by a third psychiatrist reached different conclusions, finding he wasn't fit to stand trial, and did reach the criteria for an insanity plea).
In fact, Joshua has pleaded not guilty for his upcoming trial for assault, because, as part of his anosognosia, he believes his actions were justified. He was defending himself against mental health professionals who he felt were persecuting him.
He is awaiting his day in court, his mother says, so he can finally reveal the injustices he believes are being inflicted upon him; he finally gets his say. But pleading not guilty means he must wait for a trial, and that could take up to 18 months, meaning he will likely be in prison much longer.
"How can a man making decisions coming directly from a symptom of his disease be deemed fit to stand trial?" Hannah says. "It does my head in."
Joshua's lawyer, Stephen, has been working the mental health circuit for decades. Although Joshua keeps firing him, Stephen is experienced; he will get back onside with him to continue his legal representation.
He has several mentally ill clients in prison at the moment, waiting for beds to become available in forensic mental health facilities.
"The poor guy shouldn't be in jail," Stephen says. "They can get beaten up at the drop of a hat.
"He's a really intelligent guy. A really likeable person, quite a nice man. But he's a hard case - a hot potato."
He says people like Joshua keep "falling through the gaps" in the system, but says everyone involved in the healthcare and justice systems has no energy left to complain.
"You just plod on knowing that you're captured and working within a broken system.
"There's just no beds. There are no safe beds with proper staff," he says. "It's just bizarre… Joshua is in the cluster of some of the most vulnerable people you can get. Poor bugger; hearing voices and all sorts of shit, and he's stuck in there [prison].
"He should be in the secure facility. That's the guts of it."
'To think he's in jail - it's the most ridiculous thing in the world'
Joshua wasn't always this sick. A schoolmate remembers him as "a handsome genius", quiet at first, but hilarious once you got to know him, as well as popular. Years later, she would bump into him on the street while he was in the middle of a manic episode, and he laughingly told her he hadn't slept for days.
"Wacky ol' Josh," she thought - but there was a lot more going on than she realised.
Another friend, a close family connection, recalls that as a boy, Joshua was "a delightful child".
"He was quite shy, but smart, a great sense of humour. Happy, as sharp as anything - a lovely kid," he says. "Just a little sweetie, really."
Joshua was into reading and politics, and would hold intellectual conversations with adults about subjects that seemed way above his head.
"He was always into detail - he really loved doing intricate things."
His illness snuck up on everyone.
"This whole thing is so sad. It absolutely breaks my heart. To think he's in jail - it's the most ridiculous thing in the world. It's so far from the kid I knew. It's absolutely unbelievable."
It's also had a terrible impact on Hannah, the friend says.
"I think it's had as much an effect on her as it has on him."
Although Hannah doesn't want to downplay the impact of Joshua's actions on those he's hurt - she feels "awful" for them - she can't help but think that his disjointed care and lack of safe, stable accommodation in the last few years has exacerbated his symptoms.
"If his needs are met, then he's safe and the people around him are safe."
No criminal charges were laid against him for more than a decade after he became sick, but, she says, every time he's been left undertreated in the community, he's done "great damage" to his life, burning bridges and seeing opportunities for change go up in smoke. Sometimes it seems there's been so much destruction and chaos that his life is irreparable.
Because he's been held accountable by the justice system for his actions, he now won't be eligible for emergency housing, for example.
He hasn't always been 'bad'; hasn't always had things reach the crisis point of assaults and criminal charges. He just had no place to get well, she says.
"All this while he needed sanctuary and somewhere to heal and receive the therapy he deserves. He has untold trauma from 15 years of hospitalisations, restraints, forced injections, weeks of seclusion at a time and the best we can do is put him in prison."
Lately, he's been on a new medication regime, and things have been better. He's had no problems with aggression, his mother says - no problems with his behaviour at all.
"He's not thumping people. He's not aggressive."
She can't easily contact him in prison, and the medication means that although he's not agitated, he doesn't really talk.
But when they do connect, he's calmer and able to speak to her, even though his delusions persist. She's able to catch glimpses of her son through the shifting curtain of his illness.
