The Madness Inside: Offender
Mental Health
Richard Luck
Senior Lecturer/Mental Health Nurse
Question?
Are Prisons the right place for
mental health care?
And
Should all those with mental
health issues in prison be
moved to the NHS?
Routine care of the insane
•
•
•
•
•
•
Poorhouses
Bridewells
Prisons
Private houses
Family
Bedlam – 12 months only…and only if
“curable”
History
King of Babylon: Nebuchandzar
“put to pasture” after behaving like a Mad
man….
Discuss the a “wild man wandering in the
wilderness naked amongst the tombstones,
having broke free of his chains.”
“Bedlam”
Hogarth: Rakes Progress
James “William”
Norris
1863 Broadmoor
Rampton 1912; Ashworth 1970’s
“High-security prison unit criticised
for holding mentally ill inmates”
Manager of Woodhill close supervision centre admits mental disorders 'not
uncommon' in unit where inmate cut own ears off
Tuesday 25 October 2011
The Derry Journal (2014)
• Sean Lynch (23): on remand in Maghaberry Prison in June
attempted to slit his own throat and wrists with a plastic
knife, taken to Craigavon Hospital where his wounds were
treated but on release from hospital he was returned to the
same prison cell.
• It is claimed that Sean found a sharp object, believed to be
a piece off a broken flask, and proceeded to cut at his
genitals.
• Again given medical treatment, it is claimed he was
returned to his cell by prison staff. It was at this stage
that Sean then used his own fingers to gouge his
eyeballs from their sockets and as a result is now
permanently blind.
Setting the Scene
November prison stats 2014
Total
Population
85,625
Male population
81,723
Female population
3,902
Useable Operational Capacity
87,879
Home Detention Curfew caseload
October 2013 :-
2,068
85,340
(m)81,374
(f)3,996
Bromley Briefings - 2014
• Psychosis – 14% women, 7%
males.
• 10% men/ 30% women
previous psychiatric admission.
• 26%women/16% men
received treatment in yr prior
to.
• PD: 62% male/57% female
sentenced prisoners
• 49% women /23% male
assessed as suffering from
anxiety and depression.
(general UK population 16%).
Rates of functional psychoses 10 x greater than
the general population!!
Population by year
Reasons for growth
• tougher sentencing and
enforcement outcomes.
• a more serious mix of offence
groups coming before the
courts.
• VTAP – more, more custodial,
longer sentences.
• Drug offences. More, more
custodial, longer sentences,
more stable since 2001
• Sexual offences: more
following offences act 2003,
ave. sentence increase by 13
mths, leading to continued rise
in the sentenced population
for sexual offences.
• Aug 2011: sharp increase due
to the remanding and
sentencing of people alleged
to have been involved in the
riots in England.
• Decline and stabilisation since
2012.
Biopsychosocial influences analogous
Criminal Behaviour:
Genetics, Chemical
Environmental
Social, Psychological
Mental Illness:
Genetics, Chemical
Environmental
Social, Psychological
Typical Profile
young men, usually single, unemployed, reliant
on state benefits and with a previous criminal
record, insecurely housed and with drug or
alcohol as well as mental health problems.
Women
• Held at long distances (60100 miles).
• Single Parents
• First time in custody
• First time away from
children
• Greater risk of MI and
Substance Misuse
• Lose accommodation
• DSH/Suicide - 37% of
females attempted suicide,
24,000+ recorded incidents
of DSH.
Young people 18-23yrs
• held on average of 50 miles
away.
• 12% physical abuse from
other prisoners.
• 38% feel unsafe at some
point.
• Mental health problems/drug
and alcohol abuse common
amongst young people
• more likely than adults to
suffer from mental health
problems.
• More likely to take, or try to
take, their own life.
• 20% young male (remand)/ 33% of young
female (sentenced) attempted suicide at some
point in their lives.
• 27% arrive with an alcohol problem
• 23% believe they will leave with an alcohol
problem.
• 25% thought they would leave with a drug
problem.
• Young adults account for 18% of all self-harm
incidents although they represent 9% of the
population in custody
Ageing prison population
• fastest growing age group.
• more than three times the
number in 1996.
• women prisoners has more
than trebled.
• Over half suffer from a
mental illness, most
common being depression.
• health status of ten years
older than their
contemporaries on the
outside.
Prisons are bad for mental health:
•
•
•
•
•
•
•
overcrowding,
various forms of violence
enforced solitude or conversely, lack of privacy
lack of meaningful activity
isolation from social networks,
insecurity about future prospects (work, relationships, etc),
inadequate health services, especially mental health services,
in prisons.
• The increased risk of suicide in prisons (often related to
depression) is, unfortunately, one common manifestation of
the cumulative effects of these factors.
www.euro.who.int/Document/MNH/WHO_ICRC_InfoSht
_MNH_Prisons.pdf 2008
Understanding How The Prison Environment Influences the Mental
Health of Prisoners and Prison Staff
(Nurse et al 2003)
• Reduced time with visitors
• Reduced monitoring of bullying
• Increased prisoner time locked
up
• Increased staff shortages
• Increased sickness level of
prison staff
• Increased stress levels of
prisoners and staff
• Negative relationships
between prisoners and
staff
• Misuse of drugs
• Increased anger,
frustration and anxiety
• Little mental stimulus
• Long periods of isolation
Mental Health Nurses
accompanying police on “call
outs”.
Access to Liaison nurses at police
stations.
Use of “place of safety”
Lack of training
Diversion Services at Courts
Access to sessional crisis team
input.
“piecemeal” still under funded
increases by 2017
Prison in-reach services
Community based model
Provided by the NHS
Working in partnerships
“challenges”.
Prison officers lack of training
The Process
What is the aim of Prison Inreach?
• Asses – Illness – severe or primary, risk, need.
• Plan - treatment, aftercare(CPA linked to
sentence planning)
• Implement – treatments interventions
• Divert – from custody where able
• Support – social inclusion, prognosis,
reduction in offending.
How does inreach work?
What are the difficulties?
•
•
•
•
•
•
Isolation
Geography
Lack of treatment
Lack of training
Provision of diversion
High risk groups
•
•
•
•
•
Ageing population
Womens needs
Transfer
Substance Misuse
Liaison/ Diversion
Juliet Lyon, Director of the Prison
Reform Trust
“Turning prisons into hospitals is not the answer
to the growing number of people behind bars
with a mental health need. Wherever possible,
people who are mentally ill should be diverted
into care and treatment in the community, not
locked up in a bleak prison cell. Prison is an
important place of last resort for the most
serious and violent offenders, not a capacious
health and social service."
Issues for Care
• Effects of Recognition and
identification.
• NHS England Moratorium
on funding specialist beds.
• Transfer Timescales – 14
days is DOH standard…can
be 3 mths or more.
• The Chief Inspector of
Prisons has estimated that
four out of ten of people in
HC should be in secure bed
• Stigma in Mainstream
Services.
• Treatment in Prison
• Seamless services lacking :
CPA
• Diversion should be
national and agreed service
model
• Funding for
diversion/liaison
• Ageing Population.
Echo through time!
1802: select committee
1974/5 Home Office:
Too many ill in prison
Need to divert
Not enough places.
1990’s: Reed Report
Too many ill in prison
Need to divert
Not enough places
2000:
Too many ill in prison
Need to divert
Not enough places.
2009: Bradley
2010:
Too many ill in prison
Need to divert
Not enough places
No Health Without Mental Health
• Improved contact with
MH services by 2014.
• Early intervention in CJS
– Bradley 2009.
• Parenting interventions
and there effect directly
on education and CJS
improving life chances.
Finger points at NHS & CJS
Are the issues more wider social policy
issues??