Slow decline: The social organization of mental health care in a prison-hospital
Dieleman Grass, Crystal
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Within Canada’s federal correctional system, prison-hospitals provide both in-patient and ambulatory services to incarcerated male offenders. With at least 12% of incarcerated men being identified at intake as having a mental health disorder, the need for these services is significant (Sampson, Gascon, Glen, Louie & Rosenfeldt, 2007). While some description of the mental health services provided, internal operational reviews, and external health services accreditation surveys of these prison-hospitals are available, there has been very little attention paid to the challenge of trying to balance the dual correctional and mental health mandates of these facilities. Research in comparable facilities and services in the United States describe mental health care as a ‘non-system’ of care and state that mental health staff receive very little system-wide direction regarding the provision of services (Cruser & Diamond, 1996; Elliot, 1997). This is a study that critically analyses how mental health care has become subordinated to correctional and security priorities in a Canadian prison-hospital. Five key elements identified in the policy implementation literature are used to explicate the everyday experiences of frontline staff as they work to provide mental health services in this correctional environment. The thesis argues that the mental health work of frontline prison staff is subverted by a lack of vision for mental health care within organizational policy structures, allowing the detailed correctional policy structures to become the dominant force in implementation and decision making. Using the theory and method of institutional ethnography developed by sociologist Dorothy Smith, the analysis displays how the everyday activities of frontline staff are systematically organized by routine organizational policy structures to advance the correctional mandate of the prison-hospital while mental health care has slowly declined. The study finds that mental health care is socially organized as a ‘zero-sum game’. As policy texts have concerted and coordinated the everyday activities of frontline staff in predictable ways, gains for the correctional and security priorities of the prison-hospital have meant significant and repeated losses for mental health care. However, there are ‘windows of opportunity’ for frontline staff to advance the mental health mandate of the prison-hospital if they work together.