Concerns are growing about the number of mentally unwell people spending repeated time in prison and then falling through the cracks when they return to the community, sometimes with tragic results. Bruce Munro looks at the statistics and talks to those affected and those calling for change.
Prisons are New Zealand's largest mental-health institutions.
The streets are our second largest.Once upon a time we locked up everyone who was not "normal" and "good".
They were the "mad", the "bad", the "sick" and the "disabled". And we had a different place for each of them - asylums, prisons, hospitals and infirmaries.
But then we closed most of our mental hospitals and sent the vast majority of the residents on their way. The cracks in care yawned wide, people with mental illness got into trouble or did terrible things, and we often put them in the only place left - prison.
Today, mental illness is rife among the more than 8600 men and women in our country's 19 prisons. More than half have lifetime psychotic, mood or anxiety disorders. Twenty percent are "thinking a lot about suicide", and nearly 60% have mild to severe personality disorders. The vast majority of prisoners with mental illness have the added complication of long-term substance abuse.And when they have done their time, we send them out again.
Vincent [surname withheld] was released from prison for the eighth time earlier this year.
Of Ngati Porou descent but raised by a Pakeha family in Otago, he has been incarcerated for 17 of his 39 years. That does not include two years in Cherry Farm psychiatric hospital, north of Dunedin, where he was diagnosed with paranoid schizophrenia at the age of 15.
Nor the year spent at Dunedin's Wakari psychiatric hospital after Cherry Farm was closed in 1992. Nor a year at Hillmorton Hospital in Christchurch ...
With nowhere to live when he was released from Milburn's Otago Corrections Facility in February, Vincent slept under bridges and in Dunedin car parks for about a month and a-half, until he got into trouble again.
"There were meds in prison, but I stopped taking them," he said.
"I suppose I was fighting the system. I was angry, not sleeping, not taking my meds.
"I thought I could be well but I wasn't ... I came out a mess."After several weeks living rough, and in an agitated state, Vincent wanted to be admitted to Wakari Hospital but was told there was no room. He was given some medication and told to come back the next day. He took all the pills at once and then, sometime after 5pm, entered the yard behind the South Community Mental Health premises and used rocks and a chair to do $50,000 worth of damage to vehicles parked there.
"Whenever I do my crime, I've always showed remorse and done my time," he said.
"I'm just really pleased those cars weren't people that day."
The judge ordered Vincent to pay $3000 reparation and gave him a six-month home detention sentence so he could continue a community drug treatment programme.
Since then he has been living in a boarding house off High St, in Dunedin, with about 13 other tenants who are former prisoners, former mental-health patients or both.
In the late 1800s this part of town was known as the Devil's Half-Acre, a notorious triangle formed by Princes, Maclaggan and Maitland Sts where slumming, sweated labour, prostitution and drugs were commonplace.
More than a century later its legacy continues in the form of sometimes squalid rental properties housing dozens of ex-inmates and former psychiatric patients.
It is where community worker Carol Frost witnesses poverty and despair on a daily basis."It gets you down. The hopelessness of it is soul-destroying," she said.
"We see the same people over and over, and try to help them.
"If they have family support it's difficult but not impossible.
But if you have no-one to support you and make sure you take your medication and pay your rent, you deteriorate.
"If you are living in a dive and all the people around you are drunks and drug addicts, what chance do you have?
" It was a catch-22 situation, she said. They find it hard to get accommodation, and at least the landlords give them a roof over their heads. Some of the houses are run down, but if they were spruced up their present tenants would have nowhere to stay.
New Zealand "threw out the baby with the bathwater" when it closed most of its mental hospitals during the 1990s, Mrs Frost said.
She lists the problems her clients face. There is not enough support and care in the community for people with mental illness, Wakari Hospital's emergency psychiatric beds are almost always full, and the wait for help from the Community Alcohol and Drug Service can take weeks, she says.
Add to that discrimination by prospective employers and you truly have "a vicious cycle".
The cases she knows of, involving people with mental illness who have been in prison, are as plentiful as they are sad: someone living under bushes near Dunedin's Otago Settlers Museum during the past winter until the bushes were removed; a man presently living under trees in the city's Town Belt; another recently returned to prison for parole breaches ...
"When he takes his medication he feels good," she says of the man sent back to prison.
"So then he feels he shouldn't have to take it and so he gets in trouble.
"A number of mental-health people are thrown in jail because there is nowhere else to keep them and others safe.
"At another time they would have been in a secure place, where they would feel secure." Mrs Frost thinks an effective solution would require "lots of money and a change of attitude from government and society".
"But that won't happen. We've become too selfish," she adds.Dr Warwick Brunton, of the University of Otago's department of social and preventive medicine, said that for more than 100 years we locked up an increasingly wide variety of people who threatened or concerned us.
But by the 1970s there was a growing realisation that a proportion of those in mental hospitals did not need to be there.
"A 1974 survey showed a quarter of all patients with a psychiatric diagnosis, and 45% of those with an intellectual handicap diagnosis, were capable of independent living," Dr Brunton, who is a mental-health policy researcher, said.
This late-blooming tolerance did not result in much change at the time, but was used by those promoting fiscal austerity in the 1980s to help justify the wholesale closures of the 1990s.
In the course of a few decades New Zealand went from 10,000 state psychiatric hospital beds to fewer than 1000.
The aim, since the mid-1990s, has been for the Ministry of Health's specialised mental-health services to care for the 3% of the population with the most severe mental illness, while primary health services cater to the remaining 17% with mild to severe mental illness.
It is often community organisations, such as the New Zealand Prisoners Aid and Rehabilitation Society and churches, who end up having the most regular contact with the more unwell component of this larger cohort.
The Rev David Brown, of Church of Christ Community, says "mental-health difficulties" are common among the 40 to 70 people who turn up to the Dunedin church's St Andrew St drop-in centre on Friday evenings. Some of the regulars have been in and out of prison several times.
"You often see them function well for a while and then go downhill and get in trouble and go to Wakari [hospital] or prison, and then it all starts again."
They have become the detritus of 21st-century life, he says.
People with mental illness living in the community used to be able to find work, often low-skilled, which gave them something useful to do and a group of people to keep an eye on them.
"But now there is no place where they fit and no sense of dignity. How do you feel hope?" Mr Brown asked.
"Society runs on this super-efficient model. But it means we leave a whole lot of people behind. We need to provide them not just with benefits but also a place in society."
This month, in response to the pressing need for more supervised care, the Dunedin Night Shelter Trust, of which Mr Brown is chairman, has opened Phoenix Lodge. The supervised, rental accommodation takes ex-prisoners for three months, giving them a stable, supportive place to live while they are helped to reintegrate into society. But it has only six beds.
Today, with so many people with mental illness falling into the criminal justice system, their health care, including mental health, is split between the Department of Corrections, which runs prisons, and the Ministry of Health through district health boards (DHBs).
The department employs nurses and contracts others such as dentists to provide primary health care. The DHBs run public health promotion and preventive services such as communicable disease control, as well as secondary and tertiary health care including specialist mental-health services and alcohol and drug services.
But problems and critics abound.
Even what would seem to be basic - effectively identifying which prisoners have mental illness - has taken 13 years to materialise.
In 1999, Corrections commissioned a report which for the first time quantified the high rates of mental illness in New Zealand prisons.
Compared with the general population, inmates are 23 times more likely to have a schizophrenic disorder and 18 times as likely to be suffering from post-traumatic stress disorder. The stress disorder rates are 28 times more prevalent among women in prison.
The report said the high level of need was "quite beyond the capacity" of the prisoner mental-health services that then existed. It called for a "significant increase in mental health provision" and recommended screening techniques be introduced to identify who had mental illness and to what degree.
Eight years later a screening tool was given a trial, and Corrections said although it wanted to implement it nationwide the funds were not there to do so.
In June this year the department rolled out its mental-health screening tool, which it said "lifts Corrections' ability to detect mild or moderate mental illness in prisoners".
The department has been unable to say how effective the tool has been since it was introduced.
Corrections' director of offender health Bronwyn Donaldson said the department had made "significant progress" since the 1999 report.
All prisoners with significant health needs have a health-treatment plan which can include, if needed, placement and care in a forensic psychiatric facility.
Corrections worked closely with district health boards to ensure the care prisoners received was "equivalent to that provided in the community", she said.
But others disagree.
Two years ago the Ministry of Health's National Health Committee said "service gaps are built into the [prison health care] system and people cannot help but fall through" both inside prison and when they are released.
The committee said its investigation had "raised the question of whether any agency charged with custody can or should be a health provider". It believed there was a "strong case for transferring responsibility for prison primary health care from the Department of Corrections to the health sector".
The call was repeated this year by Wellington-based Dr Paula King, who said such a transfer of responsibilities had led to better health care for prisoners in England, Wales, France, Norway and several states in Australia.
Dr King said New Zealand's Child, Youth and Family service handed responsibility for primary health care of its charges to DHBs in 2009 and had since seen health outcomes "significantly improved".
But as seems to be the way when it comes to prisoners, it is unlikely to happen any time soon.
Minister of Corrections Anne Tolley and acting Minister of Health Jo Goodhew both said they favoured the status quo.
At the same time, however, the call from various quarters to effectively tackle the causes and repercussions of mental illness among prisoners and former inmates is growing louder.
Kim Workman, executive director of Rethinking Crime and Punishment, which promotes debate about the justice system and alternative forms of punishment, says significant change is needed if we want prisoners who, when they are released, are not a burden on or danger to society.
A former head of the prison service, Mr Workman said an article in the Otago Daily Times earlier this year highlighting 23 murders committed by offenders on bail since 2006 had caught his attention.
He obtained the judges' notes on 20 of the cases, which revealed "nearly all had mental health and drug and alcohol issues", Wellington-based Mr Workman said.
"If someone had said 'Let's deal with the causes', some of these murders could have been prevented.
"Our prisons have become de facto institutions for the mentally ill ... and those with serious drug and alcohol issues."
He wants to see more money spent on treatment and support of prisoners and their families, greater investment in early intervention drug and alcohol treatment, and a trial of mental-health courts similar to the two drug and alcohol courts opened in Auckland this month.
Pushing the cost of incarcerating and treating a prisoner from $94,000 to more than $100,000 a year would save money in the long-term, Mr Workman believes.
"We would be putting back in to the community a functioning human who won't be a burden on society and instead would be a productive member of it."
Equally concerned, but coming from a different perspective, is Garth McVicar, spokesman of the Sensible Sentencing Trust, which advocates policies it believes will reduce crime.
Napier-based Mr McVicar says his organisation wants the number of psychiatric hospital beds increased and will be calling for a government inquiry into the mental-health system.
The number of police callouts that had a mental-health component had risen from 6860 in 2002 to 10,734 in 2011. And the number of acquittals due to insanity had risen 300% in the past decade, he said.
"In the whole area of mental health, something is going seriously astray," Mr McVicar said.
In the meantime, while the poor mental-health of prisoners and former inmates is not in anyone's interest, the complexity and paucity of solutions remains, foremost, the stark, moment-to-moment reality of those living under its shadow.
When Vincent first got out of prison earlier this year he wanted to go straight back inside.
"I admit I've been institutionalised," he said.
"It's in my comfort zone. I feel safe in there, locked away where no-one can get at me." And without support on the outside it is too easy to get into trouble again, he says.
"A lot, when they get out, say stuff it, I'm going to get on the juice and drugs." But Vincent says he wants a future that is "out of jail, crime-free and mentally well".
He has interests and aspirations. He quite enjoyed being a cook in the Air Training Corps as a teenager. And he earned some maritime certificates through Otago Polytechnic after his time at Cherry Farm and before he "went off the rails".
Two weeks ago he moved into Phoenix Lodge.
"A friend of mine, he's there. He's doing well. We want to help each other."