The Madness Inside: Offender Mental Health

Richard LuckSenior 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 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%).

October 2013 :- 85,340(m)81,374 (f)3,996

Total

Population 85,625

Male population 81,723

Female population 3,902

Useable Operational Capacity 87,879

Home Detention Curfew caseload 2,068

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 oralcohol as well as mental health problems.

Women• Held at long distances (60-100

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

The ProcessMental Health Nurses accompanying police on “call outs”.Access to Liaison nurses at police stations.Use of “place of safety”Lack of training

Prison in-reach servicesCommunity based modelProvided by the NHSWorking in partnerships“challenges”.Prison officers lack of training

Diversion Services at CourtsAccess to sessional crisis team input.“piecemeal” still under funded increases by 2017

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 committee1974/5 Home Office:Too many ill in prisonNeed to divertNot enough places.1990’s: Reed ReportToo many ill in prisonNeed to divertNot enough places

2000:Too many ill in prisonNeed to divertNot enough places.2009: Bradley2010:Too many ill in prisonNeed to divertNot 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??