Rivlin - Prisoner of mind

ADRIENNE RIVLIN speaks out for mentally ill inmates let down by the penal system

The prison service is in turmoil. Massive inflation in both the number of people in custody and the lengths of their sentences has led to unprecedented overcrowding in the male and female estate. In the last decade, the prison population has almost doubled in size from 45,000 in 1993 to over 81,000 today bringing with it a complicated range of problems including rising numbers of self-inflicted deaths.

To address this issue and free up much needed places for supposedly more dangerous criminals, the government pledged earlier this year to step up plans to build 8,000 new prison places and, controversially, to release around 25,500 prisoners eighteen days early, an action that has caused hysteria in both the broadsheets and the tabloids. A further blow came in the form of illegal industrial action by the Prison Officers’ Association in August this year protesting against significantly harder working conditions caused by the massive extra numbers of violent and dangerous prisoners in their custody and the increasing numbers of serious attacks on staff (an average of eight per day).

Whilst Britain’s prisons brim to capacity, its staff become increasingly dissatisfied in their jobs and a lot of (very loud) noise is made about all this in the press, there is a silent scandal festering away in the background: massive numbers of mentally ill individuals are finding themselves behind bars. It is perhaps one of the most shameful secrets of modern penal history that those who are most in need of medical care have been scurrilously ignored by successive governments wishing to “streamline” the prison service or make “efficiency savings”.

Here are the facts according to the Office for National Statistics: 78% of male remand, 64% of male sentenced and 50% of female prisoners have a diagnosable personality disorder. 10% of male remand, 7% of male sentenced and 14% of female prisoners have a psychotic disorder. Neurotic disorders were prevalent in 59% of male remand and 76% of female remand, and in 40% of male and 63% of female sentenced prisoners. Similarly, levels of drug and alcohol misuse and dependence and suicidal and self-harming behaviours were also extraordinarily high. To put things very clearly indeed, as many as nine out of every ten prisoners have at least one mental health disorder.

How did unprecedented numbers of mentally ill individuals end up behind bars rather than in another more appropriate setting? The most significant factor has been the reduction in the number of places within high secure units, to which mentally ill offenders historically have been – and should continue to be – referred. This has been for two reasons. First, the accelerated discharge programme which came into effect following the review of security at high security hospitals in 2000 by Sir Richard Tilt recommended that around one third of patients in high secure units could be accommodated in medium- or low-security. Second, there have been consistent efforts to house the mentally ill in the community rather than in institutions.

The traditional theoretical debate over whether prison “selects in” those who are more likely to be mentally ill or whether prison itself has a role to play in inducing psychiatric morbidity is largely settled. As usual it is a bit of both. Prisoners do import their pathological problems but at the same time countless sociological studies have highlighted the result of at-risk individuals’ incarceration in a brutal and terrifying environment where fears for physical safety, a loss of autonomy and familial and social support networks often drive already-vulnerable prisoners to exhibit signs of mental distress.

But the resolution of this academic debate is of no interest, help or comfort to the hugely disproportionate numbers of individuals currently locked within our criminal justice system who are psychiatrically disturbed. I think it is extremely important at this point to make one thing clear: I am not an apologist for any crime or indeed criminal behaviour. I stop short of the “lock ‘em up and let ‘em up rot” brigade but I do believe that prison should be punishment. It should also provide a decent, humane environment where accredited rehabilitation programs such as the SOTP (sex offender treatment programme) and CALM (controlling anger and learning to manage it) can flourish and those who wish to better themselves can have access to education and training in order to facilitate their reintegration back into civil society.

Clearly, one of the principles of a just penal system should be that those who have the most serious mental illnesses should not be locked in the same violent establishments where their vulnerabilities are exploited intentionally by other criminals and un-intentionally or indirectly by the system in which they are incarcerated. And if a compulsion on humanitarian, moral or ethical grounds cannot help sway the argument then perhaps consider the economic costs of releasing back into the community an even more frustrated, angry and vulnerable young person or adult. It is not anything but common sense to recognise that if mentally ill prisoners do not get the help they need to address their problems and offending behaviours, recidivism rates are likely to remain high. Indeed, according to the Royal College of Psychiatrists, between 50 and 55 murders each year are perpetrated by those considered mentally ill at the time of the homicide, many of whom will have been known previously to the prison service.

The prison service cannot, however, be accused of having done nothing to help with the growing numbers of offenders incarcerated with mental health issues. A massive recent shake-up of the way in which psychiatric services were provided resulted in NHS mental health in-reach teams working alongside the prison service to supply skilled staff to help with the detection of mental health problems upon reception and the management of those with psychiatric disorders throughout their sentence. Without a doubt this has been a step in the right direction for mental health provision in prisons; it has at least highlighted psychiatric morbidity among prisoners as an issue.

But there are some problems with the approach. First, the in-reach teams require more funding to provide a service which is wide enough to be comparable to mental health provision in the community. Second, the mental health in-reach staff do not necessarily have any forensic training – a serious problem in the prison population as the extent, variety and distribution of psychiatric morbidity among offenders is very different to community populations. Third, and perhaps most worryingly, there seems to be the perception that the introduction of in-reach teams is a sufficient response to the crisis of mental health morbidity in prisons. In fact, in-reach teams are necessary but they are not sufficient; those with serious mental health issues should not be in prison at all.

So if the psychiatrically vulnerable should not be in prison where should they be accommodated? Those who have been convicted of an offence and who have been assessed as having psychiatric problems should be housed in a secure unit run by professional medical staff instead of sent to prison where most prison officers only have very basic, if any, training in mental health issues.

But there are two main impediments to the re-establishment of enough high-secure beds to satisfy demand. The first is financial: the average cost of a high-secure bed is significantly higher than the cost of a prison place estimated at around £4,400 per bed per week compared to approximately £800 per bed per week. This appears to be a huge discrepancy but the problem with these figures is that they neglect to take into account the wider costs to society of failing to manage or rehabilitate offenders. When these are factored into the equation, £4,400 per bed per week may actually seem like a bargain. The second is political: it is not very fashionable to be seen to be “soft” on crime. No political party wants to admit to the public that it would like to lock away fewer offenders in prison. Here is where we need braver leadership. Politicians need to point out the shockingly high levels of psychiatric morbidity among prisoners and they need to campaign as part of their law and order reforms to do something constructive about levels of recidivism, especially in those who are mentally ill.

It is often suggested that the best indicator of the moral integrity of society is the way in which it treats those whom it takes into its custody. Considering the evidence, it is time to reconsider the purpose, management and direction of our judicial and penal institutions.

Adrienne Rivlin is a doctoral research student in Psychiatry based at Linacre College. In association with Oxford's Centre for Suicide Research, Adrienne and her colleague, Lisa Marzano, are researching near-lethal suicide attempts in prisons, thus assisting NHS mental health in-reach teams and other key workers in the prison system.