Abstract
The overrepresentation of persons with mental illness in carceral settings has led to justifiable concerns about their wellbeing and the appropriateness of their care. Correctional officers may be the first point of recognition and management for incarcerated persons experiencing mental illness. Correctional officers thus unknowingly participate in mental health care without a formally recognized mental health care role or knowledge of mental health educational best practice standards. This article reviews the small literature linking specific factors in mental health educational interventions for correctional officers to improvement in knowledge, skills, attitudes, and potentially to incarcerated persons’ mental health outcomes. Synthesizing that literature with the authors’ experience in creating a mental health educational program for correctional officers at a large provincial detention center in Ontario, Canada, we propose a five-principle framework to guide such programs. We propose such programs be intentionally designed and evaluated with educational and quality improvement best practices in mind, an inclusive attitude toward participants and the intersectional factors in mental health in carceral settings, the use of interactive teaching methods, consideration of instructor relatability, and integration of educational programs into broader philosophical changes in carceral institutions.
- correctional officers
- incarcerated persons’ mental health
- correctional mental health education
- continuing professional development
For many years, there have been justifiable concerns about persons with mental illness behind bars.1 Challenges have arisen over the proper identification of mental disorders in carceral settings, about the accuracy of medical and psychological assessment, and about the quality of available treatment.2,3 More broadly, the inadequacies of community-based mental health services have contributed to the overrepresentation of individuals with serious mental illness in the criminal justice system, a trend that has been linked to the criminalization of mental illness.4 At the operational level, carceral staff must also manage behavioral risk and ensure institutional safety in environments where stress and burnout are common.5,6 In Canada, there is an increasing overrepresentation of individuals experiencing mental illnesses in such settings,7 and the results of their incarceration are often tragic. Prominent individual cases highlight the humanitarian challenge facing individuals experiencing mental illness in carceral facilities.8,–,12 There is evident room for improvement in the care of incarcerated persons with mental illness.
Front-line correctional officers (COs) play a central role in managing mental health struggles of incarcerated persons,13,14 but the education that COs receive in mental health has been described as inadequate.15 This is problematic, because COs implicitly serve a health care professional role within their facilities,16 a role that is at odds with their disciplinary training and culture. This gap between their training and their role puts both incarcerated persons and COs at risk, because the protective mechanisms available to other health care workers, such as best practice guidelines or accredited mental health education programs, are not available to them. There is limited standardization in available programs: for example, an analysis of 52 U.S. jurisdictions found that programs varied widely in their duration (from 1.5 hours in Tennessee to 80 hours in Florida).17
Here, we summarize the available evidence supporting the use of mental health educational interventions for COs, although some are more effective than others. We review a case study of the implementation of a relevant educational program at a large carceral facility in Canada. Synthesizing the literature with our personal experiences in that implementation, we later propose a framework to guide future mental health educational programs for COs.
Evidence for Educational Interventions
Our group previously published a review of the literature of existing mental health education programs for COs16 to identify what elements made them effective (or ineffective). We looked broadly for mental health education programs delivered to COs that resulted in tangible outcomes for either COs or individuals in their custody. The literature was limited. We were only able to identify 11, generally small, studies. The programs described were generally brief in duration (typically, minicourses of several hours or, at most, days). Most programs were modular, outlining theories of mental illness and generally acknowledged risk factors and common symptoms. Some programs focused more or less exclusively on either suicide prevention or on enhancing counseling skills. Outcome measures were most often changes in the knowledge, skills, or attitudes held by the COs, although one study linked CO education to reducing the frequency of incarcerated persons throwing bodily waste.18
All studies reviewed were considered to be of relatively low quality (i.e., level four on the Oxford Centre for Evidence-Based Medicine Levels of Evidence Scale). This scale rates study quality from strongest (level one) to weakest (level five), based on vulnerability to bias and study design quality. It is also worth considering the risk of publication bias. Despite the limited evidence, however, the published studies all suggested that mental health education was beneficial in improving the knowledge, skills, and attitudes of COs.
One recent additional study19 identified that COs who participated in a Crisis Intervention Team educational program also developed a better understanding of their options in managing problematic behavior. This may be particularly relevant, given that CO discretion regarding use of force has been linked to improved relationships between staff and incarcerated persons experiencing mental illness.20
Our review identified several factors that contributed to CO education program effectiveness. These included their applicability to all COs, the quality of program facilitators, the excellence of teaching methods, and the ability of COs to retain the information received. All COs, regardless of their level of experience, their preexisting attitudes or knowledge about mental illness, or their level of education, appeared to benefit. Generally speaking, COs were more receptive to course facilitators who had carceral experience than to medical staff. Educational programs that featured interactive teaching methods, such as role-play or group feedback sessions, were preferred over more traditional didactic sessions. Importantly, multiple studies noted that, in follow-up evaluations, CO knowledge, skills, and attitudes returned to baseline with the passage of time. Recommendations were made to increase the frequency of education sessions and to increase the practical, interactive teaching components of the program.
Educational Program Case Study
We next present a case study of an educational program our team developed and implemented for COs in two Ontario institutions. The structure and outcomes of this program highlight key themes that informed the development of our proposed framework.
Background
There is general recognition that carceral settings are unique environments that develop their own internal systems and cultures beyond that which is prescribed by the managing authority. Goffman21 described them as “total institutions.”A total institution is a place of work and residence where a great number of similarly situated people, cut off from the wider community for a considerable time, together lead an enclosed, formally administered round of life. Privacy is limited in total institutions, as all aspects of life including sleep, play, and work, are conducted in the same place (Ref. 21, p 1).
Within this construct, it can become difficult for new ideas to be introduced and for those not accepted as “one of us” to struggle to make their voices heard, let alone to enact change. In awareness of these challenges, our group identified specific training needs within an identified institution and developed a bespoke educational intervention tailored to the needs of COs and to the realities of their day-to-day practice.
The educational curriculum focused on three priorities: increasing understanding of how mental disorders present in carceral settings; developing an awareness and understanding of suicide and violence risk; and applying communication strategies to effectively support prisoners with mental health disorders.
Methods
The education program was developed by a planning committee encompassing an interprofessional team of individuals (social worker, occupational therapist, forensic psychiatrists) who had experience working in forensic mental health in both hospital and carceral settings, with close consultation and collaboration from carceral and health care leaders and subject matter experts from the Toronto South Detention Centre (TSDC), the largest male provincial carceral center in Ontario, and the Vanier Centre for Women, the largest equivalent female facility in Ontario. A needs assessment, conducted with the COs at the TSDC, also informed the design of the curriculum.
The delivery of the education program, which included didactic, small group, and simulation modalities, was undertaken by a multidisciplinary team of individuals with experience working in forensic mental health inpatient, outpatient, and carceral settings. That lived experience and the multidisciplinarity approach contributed to the uptake of the program.
Practically, the course occurred over an eight-hour workday in the carceral institution (either TSDC or the Vanier Centre). The course was delivered to groups of 15 to 17 COs at a time. COs were generally keen to attend, which we attributed to their familiarity with the correctional health care team, their engagement in the needs assessment, and their desire to improve their skills. They were supported by institutional leadership to attend during working hours.
Consistent with continuing professional development (CPD) practices, the teaching curriculum was highly interactive. It included a variety of teaching modalities and was informed by educational learning theories. Learning activities were informed by Miller’s pyramid for the assessment of clinical competence,22 a framework used to assess students in health care settings that aligns learning outcomes (clinical competencies) with what learners are expected to be able to do at various stages of their learning. Learning activities allowed learners to move from knowledge (“knows”) to performance or “shows how”22 over the course of the day. By the end of the day, learners had an opportunity to apply knowledge and practice skills through case-based learning and a live simulation. Experiential learning was also incorporated, with Kolb’s experiential learning cycle23 (a model describing how individuals learn through a continuous cycle of experiencing, reflecting, conceptualizing, and experimenting), informing the design of the curriculum. For example, a paid actor portrayed the role of a distressed incarcerated person in a cell for the simulation component. Scenarios and cases were developed by professionals with lived experience and, as such, reflected the day-to-day realities of COs’ practice. Approximately a quarter of the day was dedicated to each component (didactic, group discussion, case-based learning, and simulation training) with a midday lunch break.
The evaluation of participants’ knowledge and confidence in their ability to identify and assist persons with mental illness was carried out using pre- and postintervention measures at the TSDC site. A survey was administered before and after the training, evaluating three domains: participant knowledge of mental health topics (12 questions), confidence in identifying persons with mental illness in carceral settings (nine questions), and confidence in working with persons with mental illness in such settings (10 questions). Participant satisfaction was assessed in the postsurvey, which also included an opportunity for open-ended feedback. Each quantitative question was rated on a Likert scale to indicate participant level of knowledge or satisfaction (1: poor, 2: fair, 3: good, 4: excellent, 5: not applicable). Descriptive statistics and paired sample t-tests were conducted using SPSS 25 to analyze the survey data. An a priori significance level of p < .05 was used for all statistical tests.
Follow-up surveys administered three months after the intervention asked participants if they had applied what they learned in their practice. (The options included to a small extent, to some extent, to a moderate extent, to a great extent, or not applicable). Additionally, focus groups were conducted nine months postintervention, where participants were asked open-ended questions exploring two areas: changes made in their work because of the intervention and additional support needed to enhance their knowledge, skills, and confidence going forward. Thematic analysis,24 conducted by an education research assistant, was used to interpret the transcribed focus group content and better understand participants’ needs and the educational program’s impact.
The University of Toronto Research Ethics Board granted an exemption for this project from formal review, which was considered a program evaluation.
Results
The results were generally positive, indicating the intervention was effective in improving knowledge transfer and was viewed favorably by participants. Here, we report results from the TSDC CO cohort. At the TSDC, 57 COs participated in the mental health educational program. Completion rates for pre- and postintervention surveys varied by domain: 89 percent (51 of 57) completed both surveys for the knowledge domain, 96 percent (55 of 57) for the confidence in identifying domain, and 81 percent (46 of 57) for the confidence in working with persons with mental illness domain. Respondents’ self-reported knowledge of mental illness increased from a mean of 33.7 to 41.6 of 48, t(50) = 8.97, p < .001, 95 percent confidence interval (CI) (6.13, 9.67). Confidence in detecting mental illness improved from 21.7 to 27.3 of 36, t(54) = 9.46, p < .001, 95 percent CI (4.46, 6.85). Confidence in working with individuals with mental illness rose from 22.8 to 30.0 of 40, t(45) = 9.71, p < .001, 95 percent CI (5.70, 8.69).
Based on postintervention survey data completed by 51 participants, 92 percent reported high satisfaction with the program. Furthermore, 61.8 percent indicated an intention to change their practices based on the training, whereas 36.4 percent reported that the content was already integrated into their work. Open-ended feedback responses indicated several COs found the simulation and case discussions most applicable to their work. Several COs also suggested that more information relating to mental health self-care would be beneficial.
Twenty-three of the original participants (approximately 40%) responded to the survey three months postintervention. Of these respondents, 75 percent indicated they had applied their learning to a moderate or great extent.
Twelve participants (21%) engaged in focus groups nine months after the training. There were two separate groups, each lasting approximately one hour. Participants reported feeling better able to understand and identify incarcerated persons experiencing mental illness. They described attitudinal changes, such as increased patience, understanding, and compassion. Additionally, participants reported changes in their communication styles, including speaking more slowly and concisely, asking more questions, and remaining flexible based on individual behavior. Participants also noted improved communication with health care colleagues in the institution. Finally, they suggested that more frequent refresher training, delivered broadly across the institution, would help maintain knowledge and support a broader cultural shift in the workplace.
Discussion
Our results, especially those from the three-month survey and focus groups, are vulnerable to self-selection bias and small sample sizes. Additionally, changes in practice were self-reported by participants; we lacked objective data evaluating possible impact on incarcerated persons.
Collectively, the results suggest that the intervention had its intended educational impact and was valued by participants. We believe the positive reception was supported by the relationships, and thus credibility, of health care staff with COs within the carceral institution and the engagement of COs and institutional leadership during the needs assessment. Additionally, as described in our literature review, certain course characteristics, such as interactive teaching methods, likely enhanced learning. We also concluded that education programs should not be single events but ongoing processes to maintain skills and attitudes over time. This view is supported by focus group participants and is consistent with previous studies noted in our literature review, although we acknowledge that only a small number of the original participants contributed to this feedback. We also recognize that sustaining CO participation in refresher training may be a challenge, which could potentially be mitigated by integrating such education into routine institutional practice.
A Proposed Framework
In considering the available evidence exploring factors that determine effective educational interventions, combined with the experience of implementing and evaluating the education program at the Toronto South Detention Centre, we are able to propose a framework that can assist in guiding future educational interventions in this area. Examples of the specific principles are available in Table 1.
A Five-Principle Framework for Developing Mental Health Educational Interventions for Correctional Officers
Intentional Design
Carceral settings are currently one of the largest providers for mental health care, according to numbers treated, in North America. As academic psychiatrists with an interest in improving the health of patients everywhere, we have a vested interest in improving the quality of that care. A need to pursue a quality improvement (QI) process has been identified as an “essential component of an adequate correctional mental health system” (Ref. 25, p S7). Academics involved in developing education programs for COs should be intentional about incorporating best practices while implementing and validating new, potentially improved interventions.
Incorporating CPD best practices, program development should ideally begin with a needs assessment of the target learners, both subjective (from the target audience) and based on objective evidence, when available (for example, suicide and behavioral incident data, although we acknowledge this information may be challenging to acquire in some carceral contexts). Embarking on developing new programs should involve intentionally setting learning goals and education outcome measures, evaluating performance, and contributing to the development of a body of best practices, informed by ever higher quality evidence.
Inclusivity
Educational programs should promote equitable and inclusive learning environments, which, in turn, foster a sense of belonging and empathy. Mental health education programs for COs should be inclusive in their outlook, perspective, and intended audience.
Until now, we focused specifically on the problem of high prevalence of incarcerated persons with mental illness. Taking a wider view, however, mental illness is but one of several factors of social disadvantage that intersect in our carceral institutions. These include, but are not limited to, matters of race, gender, sexuality, trauma, poverty, and other socioeconomic and psychosocial factors. Programs may also include content about the identification and management of conditions other than, or comorbid with, major mental disorders, including neurodevelopmental and substance-related disorders, for example. Curricula designed to address the educational needs of COs should include content on the nature and role of those social determinants. These should include opportunities to explore the link between those factors and behaviors COs may encounter, including impulsivity, affect dysregulation, maladaptive coping strategies, and substance use.
In addition, COs may vary in their level of interest and expectations of education programs. Programs need to be tailored to a specialized adult audience with significant experience in security, but not necessarily mental health care. The discipline-oriented culture of carceral institutions may contribute to cynicism about persons experiencing mental illness. But the literature suggests that the attitudes, skills, and knowledge of all COs benefit from educational interventions, regardless of their levels of experience or cynicism.16
Furthermore, COs benefit from recognition and validation of the impact of their work on their own mental health and identification of strategies and supports that they could access for help. COs participating in our educational intervention provided feedback that they would have liked to have even more information on self-care at the end of the program.
Interactivity
Several studies have found that COs view interactive teaching methods as more useful than traditional didactic lectures.16 This is consistent with the overall thrust of educational best practices in health care26 and this may be an area where academic psychiatrists have unique skills to bring to the table.
Interactive methods described as helpful include role-play, case discussions, watching videos of psychotherapeutic or de-escalation interventions, and group feedback sessions. Adult learners with varying levels of experience and previous education benefit particularly from simulation training that incorporates learning into familiar scenarios to practice skills. This can help turn cognitive learning into new procedural memory. Our own experience in this area bears the same principle out: COs in our intervention rated group discussions and simulations among the most relevant to their experience.
Instructor Relatability
Instructor selection appears to be particularly important in the uptake of mental health education for COs. The literature suggests that officers were more receptive to content delivered by individuals with carceral experience.27,28 Content delivered by individuals with lived experience, such as consumers of mental health services and their family members, may also be helpful.18,29 Taken together, the findings suggest instructors who are perceived as relatable and relevant are more likely to be effective at delivering content.
A psychiatrist from an academic institution can be perceived as relatable and relevant in the unique carceral context; in our experience, potential challenges can be mitigated by engaging with COs prior to program development. In line with the principles of being intentional and inclusive, we recommend engaging COs in an open-minded process of needs assessment and program planning at the outset of curriculum development. Such a process facilitates CO agency and ownership over any subsequent educational interventions. Fostering long-term relationships outside of discrete educational interventions improves trust, respect, and, ultimately, educational engagement, particularly when psychiatrists approach COs with humility and a willingness to learn their culture. In addition, if psychiatrists associated with academic institutions are regularly consulting with and have professional relationships with COs in which they are perceived as helpful generally, they may come to be accepted into the group and thus have standing in delivering educational interventions. Such relationships allow subsequent knowledge and skills transfer to be valued and more likely to be embedded into future practice.
Integration
Studies30,31 have signaled an unfortunate trajectory to the mental health educational programs for COs described thus far. The initial gains in CO knowledge, skills, and attitudes appear to decline on repeat measurement several months later. Authors have provided different explanations and possible solutions to this, including a need for refresher education and more frequent education sessions.
In our view, cultural factors are likely at play here as well. Well-meaning education may leave staff feeling more optimistic and empowered in the classroom, only to return to their daily work in the at times adversarial carceral arena. Chronic understaffing, scrutiny, and predictable burnout take their toll on COs, who may no longer be able to psychologically access the knowledge and skills they gained from mental health education. Negative attitudes toward incarcerated persons may be understood as maladaptive defenses against distress, which we should recognize. Creating more positive attitudes and skills is not likely to happen overnight.
Changing the culture of carceral institutions is a daunting task and beyond the scope of academic clinicians alone. But change is possible. For example, broad philosophical and policy reforms in the North Dakota correctional service led to a near 75 percent reduction in solitary confinement use in the five years after they were implemented in 2015.32 These included an increased focus on mental health screening and relevant services. Any successful educational strategy has to be integrated into a broader cultural shift in our institutions, supported by the principles outlined above. A “one-and-done” education strategy is unlikely to be successful. Rather, a philosophy of continuing education is more appropriate, recognizing the health professional role COs play in recognizing mental health symptoms and referring for health care services. Repeated education following the aforementioned principles, including self-care for COs, will be required to truly make a difference in the lives of incarcerated individuals with mental illness.
Conclusion and Future Directions
The development of evidence-based educational interventions for COs is an important task, given the increasing prevalence of persons with mental illness in custodial settings. Our proposed 5-I Framework, composed of the principles of Intentional Design, Inclusivity, Interactivity, Instructor Relatability, and Integration, represents a set of principles intended to guide such interventions, rooted in both the existing literature and our program development experience.
Looking ahead, several considerations emerge for future development and implementation of CO education. Sustaining educational gains will require more than one-time events. Several authors have suggested refresher training to improve skill retention and attitudinal shifts, ranging from every nine to 18 months.18,31,33 More research is needed to determine the nature of refresher training and the optimal spacing of sessions. A reassessment of ongoing learning needs at a given institution would likely be beneficial in guiding such interventions. In our experience, ongoing engagement between health care staff (including psychiatrists and allied professional staff) and CO staff is beneficial in supporting learning and attitudinal changes. We believe that having a presence at institutional forums and discussions, engaging in active mental health screening procedures, and responding promptly to consultation requests from CO staff both before and after formal educational interventions has been helpful in establishing and maintaining credibility. Such relationships may improve CO openness toward working with persons experiencing mental illness.
Although we have described COs as health care professionals by circumstance, there is a lingering question as to the ultimate role that would best serve in this regard. As a society, we need to consider if we want COs to function as compassionate police, as fledgling therapists, or as members in a mental health care team. The answer to that question would guide whether or not programs should focus on determinants of health, on intervention and counseling skills, or on some combination of both.
Finally, when taking a long, critical view of the situation of incarcerated persons with mental illness, we acknowledge that carceral institutions may not be the correct environment for them to be receiving care. But that is where a very large number of persons with mental illness in North America currently receive care. We recommend that mental health professionals advocate for optimal standards of care wherever individuals find themselves. The field of mental health educational interventions for COs is in its infancy but needs to rapidly grow. Our hope is that our framework will empower COs to recognize the important role they play in the lives of the vulnerable individuals they serve and, at the same time, that it will improve the quality of care for incarcerated persons with mental illness.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2025 American Academy of Psychiatry and the Law
