The idea that prison should be a place where a person recovers or is rehabilitated is a complex issue. Many people see prison as a place of punishment, where people who have done things wrong should be segregated from society. There is an increasing awareness, however, that abandoning 'criminals' to the prison system is not really in the interests of society.
Encouraging recovery in prisons is not only the right thing to do from an humanitarian perspective, but it is necessary if the huge increases in prison population are to be curbed. Mental illness is now recognised as a huge problem within prisons and government policy is just beginning to tackle it. This essay will examine the prevalence of mental illness in prisons and then go on to discuss how those with mental illness are identified and what services and treatments are made available.
It has long been recognised that prisoners are at a higher risk of suffering from serious mental health problems than the general population. Fazel & Danesh (2002) examined the literature on serious mental disorder in prison populations that have been studied around the world. They reviewed the results from 12 countries, comprising 62 surveys and produced some consistent findings. In western countries about one in seven members of the prison population have a major depression or psychotic illness. Looking then at less serious problems, half of all men and one fifth of women have antisocial personality disorders. Fazel & Danesh (2002) compare these rates to the general British and American populations, showing that being in prison raises the chances of having a major depression or psychosis by between 200% and 400%. Fazel & Danesh (2002) conclude that this indicates that there is almost certainly a huge number of these people going untreated.
These figures represent a birds-eye view, but taking a closer look at the subgroups provides further alarming trends. Gunn, Maden & Swinton (1991) and Maden, Taylor, Brooke & Gunn (1995) compared mental health problems in sentenced and prisoners on remand respectively. Levels in those sentenced who were male, were at 37%, and female 57%. For those on remand the levels were even higher, 63% male and 76% female. Birmingham (2004) reports on evidence gathered by Singleton, Meltzer & Gatward (1998) which finds that, looking at psychosis, levels among males were at 10% compared to 0.4% in the general population (Meltzer, Gill & Petticrew, 1995). These figures show the prevalence of the most serious mental disorders is worryingly high.
Considering the high levels of prevalence of serious mental health problems in prisons, then, what are the levels of need existing within these institutions? The Howard League for Penal Reform (2005) examined the statistics on suicide in prisons and found that, despite the prison population increasing by 61% from 1985 to 2005, the number of suicides has increased by 228%. Part of this problem, they ascribe to the high level of people in prison who have serious mental health problems.
Evidence from Birmingham (2004) cites Harty, Tighe, Leese, Parrott & Thornicroft (2003) who used the Camberwell Assessment of Needs schedule to compare psychotic male patients in the community with those who had been transferred from prison. They found significantly higher levels of unmet needs in the prison population in, for example, levels of psychological distress, psychotic symptoms and welfare benefits.
These findings, however, represent levels of need that have actually been identified. There is evidence from studies that preliminary screenings of new prisoners fails to find a fair proportion of serious mental illness. Parsons, Walker & Grubin (2001), in particular, examined the levels of mental disorder amongst female remand prisoners. This study compared the results of those screened by the standard check with another screening at reception to the prison. The standard screening process failed to identify the majority of female remand prisoners with mental health problems.
For example, of 42 women deemed psychotic by the reception screening, only 9 were identified by the standard prison screen. Similarly, Birmingham, Mason & Grubin (1996) carried out a study at Durham prison which found that 26% of remand prisoners had a current mental disorder, and, of these, one-third had a serious mental disorder. Again, the majority of these prisoners on remand had not been identified by the standard prison screening process. Birmingham et al. (1996) argue that, despite the limited sample, it is possible to generalise their results to the overall prison population.
The implication of these studies is that many remand prisoners, going unidentified, are at a significantly greater risk, especially those suffering from the most serious mental health problems. Moreover, these people are unlikely to receive treatment unless they are particularly disruptive. This is clearly a longstanding problem, with previous studies having pointed it out (Mitchison, Rix, Renvoize & Schweiger, 1994).
Birmingham (2004) describes changes that have been made to the way in which prisoners with mental health problems have been treated in British prisons over the last decade. Originally, care for prisoners was provided by doctors employed by the prison service. As a result of reforms, the NHS have been given greater responsibility in the treatment of prisoners so that psychiatrists working in general adult services will be treating prisoners. This should provide a significant improvement as, currently, many prisoners are treated by doctors with no specialist psychiatric training.
Having considered the prevalence of mental illness in prison and its identification, or rather lack of identification, it is necessary to move onto the service delivery. What kind of treatment is being received by prisoners? Wilson (2004) points out the principle of equivalence of care that has been reiterated by a number of bodies, including HM Prison Service & NHS Executive (1999), before analysing the current situation in prison hospital wings. Wilson (2004) explains that psychiatric in-reach teams work in two main areas in prisons: the healthcare wings of prisons and the prisoners who are in their ordinary cells or the main areas of the prison. Wilson (2004) argues that for those in ordinary areas of the prison, there is no problem providing reasonably effective mental health services, but the healthcare wings, conversely, are not so easily serviced.
The conditions within prison healthcare wings are described by Reed & Lyne (2000). In their research Reed & Lyne (2000) carried out semi-structured inspections of 13 prisons that have inpatient beds in England and Wales. The study found a number of endemic problems, starting at the organisational level. Of the thirteen wings examined, nine of them were managed by healthcare officers with no nurse healthcare training. The general condition of the wings was criticised, with a very poor standard of fixtures and fittings.
The staff providing the care on the prison wing were generally not properly qualified (Reed & Lyne, 2000). None of the doctors providing care were psychiatrists, although some had a little psychiatric training. This is clearly not in line with the healthcare standards that have been set. Of the nursing staff in the healthcare wings, only 24% had received mental health training. Of the remaining healthcare staff, 44% were general nurses and 32% untrained. The situation during the nights was also lamentable with generally only one person on duty - because of security, at night, accessing a prisoner took ten minutes and any kind of other emergency in the main prison would leave the wing unattended.
Further, therapeutic treatments are criticised by Reed & Lyne (2000). Healthcare standards set state that prisoners should be engaged in therapeutic activities for six hours each day and should be unlocked and out of their cells for 12 hours each day. Again, no prisons were found to meet these standards. The average was that prisoners were unlocked for about 3.5 hours a day and that the therapeutic activities available can barely be described as therapeutic. Cleaning, playing pool and watching television hardly have strong evidence bases within the psychological literature!
Providing a critical analysis of these standards, Reed & Lyne (2000) make the point that treating prisoners for mental health problems provides an excellent opportunity to benefit society - these are people who are unlikely to engage with health services of their own volition. Overall, Reed & Lyne (2000) found little evidence that any attempt was being made to reach the standards of service that are required.
Despite the principle of equivalence discussed earlier, and taking into account the research by Reed & Lyne (2000), comparing prison healthcare wings with NHS hospitals still reveals other important differences. Transfer to an NHS hospital for even the most severe of cases is likely to be protracted process, because of lack of resources as well as the risk assessment that has to be carried out. In the meantime the mentally disordered prisoner must wait on the prison wing, receiving little treatment of benefit.
Isherwood & Parrott (2002), examining transfers of prisoners into NHS hospitals, found that long delays were the norm and this was usually the result of a lack suitable beds in the NHS. Statistics collected at that time - between 1997 and 1998 - showed that there was a lack of beds in the NHS at all levels of security. Wilson (2004) points out that in a prison healthcare wing a person cannot be given medications against their wishes, such as might be carried out in an NHS hospital.
One aspect of more recent practice that is showing an improvement in the identification of offenders with serious mental health problems is in-reach nursing (Reed & Lyne, 2000). Armitage, Fitzgerald & Cheong (2003) describe the introduction of an in-reach service at HMP Leicester, similar to those being instigated nationwide. The two mental health nurses in this prison provide a range of support services to prisoners on the wings including mental health promotion, counselling, and support for other members of staff. Anecdotal evidence is provided that the nurses are reducing levels of self-harm, reducing the stigma of mental health problems as well as facilitating some therapeutic activities.
Meiklejohn, Hodges & Capon (2004) describe similar efforts to develop in-reach services at HMP Gloucester. While this report is similarly optimistic about the potential for in-reach, it strikes a more balanced judgement. Meiklejohn et al. (2004) identify the same lack of therapeutic opportunities within prisons described previously. This means that, for nurses working within prisons as part of in-reach teams, while they may be able to identify those with mental health problems, they cannot necessarily provide much in the way of treatment. Prisoners are, for example, often referred to counselling schemes run voluntarily by other prisoners who have been trained by the Samaritans.
Similar problems are identified in young offenders institutions. Harrington, Bailey, Chitsabesan, Kroll, Macdonald, Sneider, Kenning, Taylor, Byford & Barrett (2005), for example, identify screening problems including a reliance on routine screening carried out by youth offender teams. Even when young people with mental health problems were identified, the authors find a lack of options for treatment. Young offender's institutes, however, sometimes had some professional provision for mental health problems. This study nevertheless makes clear that these services are patchy across the country. Research carried out by Nicol, Stretch, Whitney, Jones, Garfield, Turner & Stanion (2000) also looked at the young people being held in penal institutions and found that their needs were clearly not being met as they received little or no treatment for, sometimes, very severe mental illness.
A particular challenge to the treatment of serious mental illness in prisons is dual diagnosis. Dual diagnosis describes a patient who has both a mental illness as well as having a substance abuse disorder. Singleton, Meltzer & Gatward (1998), in examining co-morbidity in prisoners, found that while only one in ten were free of any mental disorders, only two in ten only had one disorder. This means that the large majority of prisoners would be considered to have a dual diagnosis. O’Grady (2001) makes the point that these kinds of prisoners, with dual diagnosis, face even greater problems to getting the right treatment, partly because of the system, and partly because of the difficulties in treating dual diagnosis.
One part of the The Models of Care (DoH, 2002b) document that is relevant for dual diagnosis patients is the Counselling Assessment Referral Advice and Throughcare (CARAT) services. This service is aimed at the treatment of those with substance misuse disorders, from which many dually diagnosed prisoners suffer. These services are to be provided by specialists external to the prison system who work on identifying needs, talking to a variety of agencies and using counselling as a therapeutic intervention with the prisoner. While this step forward is better than nothing, there are two reasons for the inadequacy of this programme.
As O’Grady (2001) points out, one of the most significant omissions is the abuse of alcohol, perhaps unsurprisingly, a very common substance misuse disorder amongst prisoners. The second flaw is that the Department of Health (2002a) calls for the use of integrated care pathways - a single clinician dealing with a patient's dual diagnosis - the CARAT scheme is failing to address this, and in fact working in the opposite direction. O’Grady (2001) cites Drake, Mercer-McFadden, Mueser, McHugo & Bond (1998) who argue that while the evidence is not yet strong for integrated care pathways, the evidence, such as it is, suggests that this will provide the best outcomes in the long term.
The other main type of rehabilitation going on in prisons, as described by O’Grady (2003), is that aimed at reducing re-offending. The advantages of these sort of programmes are clear, if they are effective, but the problem is that, as can be clearly seen from the evidence here, many of the prisoners have quite severe mental health problems and are probably unable to benefit effectively from these programmes. O’Grady (2003) provides some examples of those groups: those with personality disorder make up a large percentage of those with mental health problems, and this can limit the group work that can be carried out. Similar problems - social, cognitive and learning disabilities - will also limit the benefits of these programmes to many other prisoners.
The treatment of prisoners with dual diagnosis, is as O’Grady (2001) points out, still an unknown quantity with the lack of evidence-based research to rely on. Integrated care pathways have been quoted by the Department of Health (2002a) as providing the best method of dealing with dual diagnosis. This approach focuses on one clinician dealing with one patient rather than being dealt with separately. This approach, while having some positive evidence to support it, has also been criticised. Drake, Yovetich, Bebout, Harris & McHugo (1997), for example, found positive effects, while Hellerstein, Rosenthal & Milner (1995) did not find any support. These kinds of ideas about the treatment of dual diagnosis will be far from many prisoner's realities, however, because, as has been already shown, prisoners are unlikely to receive any specialist care at all.
Central to providing integrated treatment is the Care Programme Approach (CPA) which has two levels, standard and enhanced. Pyszora & Telfer (2003) examined how this would operate in HMP Belmarsh. They found that with the current resources available it was only those who met the criteria for an enhanced CPA that would be covered. Similarly, Knowles & Durcan (2005) point out that while government policy supports the idea of an integrated care policy, the reality in prisons and the community is quite different. Anecdotal evidence suggests that while entering prison, for many offenders, is distressing, leaving prison to return to the same circumstances from which they came, is even worse.
Any gains made in prison are lost almost immediately on return to the community, making work done in prison feel pointless. Links between community and prison services are not always the strongest. Anecdotal evidence suggests that community mental health teams appeared reluctant to continue their responsibility for a patient after they have gone into prison - although these authors admit this could be a matter of resources. Further, there are often disputes over which catchment area a prisoner belongs within. The government is attempting to address some of these issues with the 'Offender Mental Health Care Pathway' (DoH, 2005) which lays out the steps that should be taken at each stage.
It is clear from the studies of prevalence that the rates of mental ill-health in prisons are extremely high. Rates of very serious mental health problems are many times higher than that occurring in the general population. There are also, clearly, very high levels of unmet needs within prisons, although there are many practical changes that are being implemented as a result of government policy. It is still too early, however, to gauge the effect of these changes. The research into the delivery of services shows that there are many problem areas: the transfer of prisoners to NHS hospitals, the identification of prisoners with mental health needs and the actual therapeutic treatment given to prisoners all have serious deficiencies.
Dual diagnosis provides a particular problem for prison services, especially in their attempt to provide integrated care pathways. Rehabilitation schemes that do run within prisons may not be benefiting many with mental health problems. Overall, the picture is not good and it is clear that the levels of availability of wellness approaches are extremely low and of a fragmented nature. Government policy is currently addressing many of these issues, but without the proper funding for expanded services, it will be difficult for the improvements to move off the paper and into reality. At present, for the majority of prisoners with mental health problems, recovery in prison certainly is a contradiction in terms.
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