Prison/Probation service and Forensic
Psychiatry in Sweden
Maria Hägerstrand
Health Care Development Administration
Swedish Prison and Probation Service HQ
Prison and Probation Service in Sweden
• The Prison and Probation Service
is part of the legal system.
• The main tasks of the Prison and
Probation Service are to
implement sentences of prison
and probation, to supervise
conditionally released persons, to
implement instructions for
community service, and to carry
out pre-sentence investigations in
criminal cases.
The organisation of the Swedish Prison- and Probation Service
Ministry of Justice
National Parole Board
Transport Service
Head Office
30 Probation Enforcement Board
Northern
region
Stockholm
region
Central
region
Eastern
region
Western
region
Southern
region
9 Prisons
5 Remand prisons
10 Prisons
2 Remand prisons
9 Prisons
5 Remand prisons
9 Prisons
6 Remand prisons
12 Prisons
5 Remand prisons
7 Probation authorities
3 Probation auth.
6 Probation auth.
7 Probation auth.
7 Probation auth.
8 Prisons
5 Remand prisons
6 Probation auth.
The Health Care system in the Swedish
Prison- and Probation Service
Health Care Developer
Committee for
Correctional Medicin
Regional
Manager
for the
Northern
region
Health Care
Coordinator
Regional
Nurses
Consultant
physicians
Nurses
Consultant
Manager
for the
Stockholm
region
Health Care
Coordinator
physicians.
General Director
Senior Medical Advisor
Regional
Manager
for the
Central
region
Health Care
Coordinator
Nurses
Consultant
physicians.
Regional
Manager
for the
Regional
Manager
for the
Regional
Manager
for the
Eastern
region
Health Care
Coordinator
Western
region
Health Care
Coordinator
Southern
region
Health Care
Coordinator
Nurses
Consultant
physicians
Nurses
Consultant
physicians
Nurses
Consultant
physicians
The clients - in prison
During their time in prison, it
is the responsibility of the
Prison and Probation Service
to prepare the inmate for a
better life in freedom
afterwards, through training,
work and various
programmes.
Most clients are men. Just
over half of those who are
sent to prison have been in
prison before.
A very high percentage of the clients suffer from mental illness and severe drug
problems. According to recent drugstatistic 40 of 100 inmates are under treatment
with antidepressiv drugs. About 70% suffer from personality disorder and 25% from
ADHD. Over half of them have experience of injecting narcotics. Many have no
homes and poor finances. Inmates are people of all ages.
The Prison system
• 5099 beds of which 261 are for women
• 10-11.000 new enrolled every year of which
>700 are women
• 19% of the newly enrolled are <25 years
• 60% are judged to sentences under 6 months
• Just under 50% have earlier judgements to
prison
MEDICAL SERVICES AND MENTAL
HEALTH CARE IN PRISON
• The Right to medical services for inmates are regulated by law.
• An inmate has the same right to medical service as other persons
living in Sweden (The normalization principle)
• For practical reasons and due to security medical care is available in
all prisons and remand prisons in Sweden. This service is provided
by nurses (on duty during normal working hours and in some
remand prisons there is a nurse on duty also at weekends and on
public holidays) and consulting physicians (general medicine).
• Some facilities also have access to psychiatrists and about one third
of the nurses have psychiatric training.
Prison and mental illness
• All offenders, even if psychotic or mentally retarded, are legally
responsible for there actions. Since 1965 Sweden do not deal with
the concept of accountability/responsibility.
• If an offender at the time of the crime suffers from a “severe
mental disorder” the court cannot sentence him/her to prison
• If the offender is still suffering from a “severe mental disorder” and
is in need of psychiatric care at the time of the trial he/she can be
sentenced to in-patient forensic psychiatric care.
• The definition of “severe mental disorder” is legal and not a
medical term. It includes psychotic disorders, severe depressive
disorders with risk of suicide, and in some cases severe
personality disorders, but not mental retardation. Persons with
severe autistic disorders have also been excluded from criminal
liability
Psychiatric service in prison vs Forensic Psychiatry
• The psychiatrists who consults are mostly specialists in
general psychiatry and not forensic psychiatry. Their ordinary
service are in General psychiatric clinics or Addiction
Centers
• There is no formal cooperation between The Prison and
Probation Service and The National Board of Forensic
Medicine or the forensic care in the different counties
• There are no prison hospitals in Sweden. If an inmate needs
inpatient treatment, he/she is referred to the Psychiatric
Emergency Unit at the nearest Hospital.
Committee for Correctional Medicine
• The Swedish Prison and Probation Service has had a
Committee for Prison Medicine since 1981.
• The reason for the establishment of this committee was the
unexplainable differences in the prescription of the
medications used as drugs (benzodiazepines, opiates).
• Since 1983 the Committee has published Essential medicines
in the Prison and Probation Service; a booklet with
recommendations for medication for the most common
symptoms and diseases in the prison population.
• The latest edition is named Correction medicine – manual and
essential medicines, and is completed with care programs for
some of the most common psychiatric disorders
Health screening
• There is a health screening program for inmates in remand
prisons. This is carried out by nurses.
• This screening program is for both mental and somatic
problems.
• The security staff in Swedish remand prisons are trained to
recognize deviant behavior and contact the health services.
• Many of The security staff are specially trained to recognize
suicidal behavior. The risk of parasuicide or suicide is
highest in the remand prisons.
Screening for suicide risks
• All persons arriving at a remand prison are asked about risk factors
for suicide and if they have present suicide thoughts (so called
suicide screening) by the correctional staff according to a special
questionnaire
• If they give positive answers they also should be investigated by the
medical staff (all nurses are trained in suicidology). In anticipation of
such they can be monitored either constant or intermittent.
• Some cases are transported to a Psychiatric Emergency Unit for
investigation
Psychiatric treatment in prison
• Inmates that needs out-patient treatment can have that treatment in
prison.
• The quality of psychiatric care in a prison is likely to meet the
general mental health standards.
• Most of the consulting psychiatrists are very experienced with
inmates and are well equipped to handle their problems.
• Almost all medication is administered under supervision; the
treatment in prisons is in that way followed much more closely than
outside.
• Compulsory treatment is not possible
Cooperation projects toghether with the Counties
• Common out-patient treatment (Forensic out-patient clinic
in Stockholm, Järntorgsmottagningen i Gothenburg and an
out-patient clinic in Malmoe)
• Screening for Adhd in Norrtälje and Storboda
• ITOK (Integrated team for opiateaddicts in Kriminalvården)
and similar program in Malmoe
• ITOK-NPF (Integreted team for treatment of inmates with
neuropsychiatric disorders
• Seperate wards for adjustment of maintenance treatment
for opiatedependence (Fosie, Högsbo, Storboda and
Täby)
New laws for compulsary psychiatric treatment
• Accountability/responsibility imposed as a condition for
legal action
• Persons with severe mental illness will be sentenced to
prison, but must start their enforcement in hospital
• Former forensic psychiatric clinics will be clinics with
certain agreement with the prison system
• Persons with dementia and mental retardation will
execute their sentence at separate wards suited to their
needs
• Inmates with severe mental illness, could after the
sentence, if there is a risk for relapse, be forced by court
to live in sheltered accommodations
Forensic psychiatry in the future
• Expanded investigation activities (accountability, severe
mental illness, dementia/retardation
• No certain clinics, but clinics with agreement with The
Prison system
• Need for the competence for both follow-up and
assessment of recurrence-risk
• Establishment of out-patient clinics where inmates with
mental illness can be refered
Responsibility of Forensic psychiatry (Optimistic)
Prevention
Prison-
In-patient
Out-patient
Cuntinued
support
services
care
care
support
Present
Future