Is A Prison Sentence Appropriate For Mentally Disordered Offenders?

There is much concern and criticism regarding the mental health care within prisons in the UK (APG, 2006; Sainsbury Centre Mental Health (SCMH), 2007; Okasha, 2004). Howitt (2011) explains that mental disorder incorporates the mental illnesses which are regarded as treatable and changing but includes, in addition, long-term and unchangeable conditions such as learning disorder. It is important to stress early on that mental illness and mental disorder are not identical. Prison Reform Trust (2013) highlighted that 20% of prisoners have four of the five major mental health disorders; “autism, ADHD, bipolar disorder, major depression and schizophrenia” (Asher, 2013). Much research demonstrates high psychiatric morbidity and substance misuse within prisons (Unit S. E, 2004; Reed, 2003; Singleton et al, 1998).

According to Michael Spurr, NOMS Chief Operating Officer, at any one time 10% of the prison population has ‘serious mental health problems’ (SCMH, 2007).  More than 70% of the prison population has at least two mental health disorders (Mental Health Foundation, 2013). Furthermore, male prisoners are 14 times more likely to have two or more disorders than males in general, and female prisoners are 35 times more likely than women in general (Unit, S. E, 2004). Additionally, they emphasized 10% of men and 30% of women have had a previous psychiatric admission before they come into prison. Neurotic and personality disorders are particularly prevalent with 40% of male and 63% of female sentenced prisoners have a neurotic disorder, over three times the level in the general population. 62% of male and 57% of female sentenced prisoners have a personality disorder (Prison Reform Trust, 2013). Suicide rates in prison reach almost 15 times higher than in general population (Appleby, 2004).

The above statistics highlight the magnitude of mental health problems within the UK prisons; they prompt urgency for a more effective plan to address these issues based on an understanding of the different reasons leading to mental health by creating a more equivalent system in order to administer treatment. The Government has acknowledged these figures and attempted to provide a much more “equivalent” level of service, research into the health care provided within the prison system has concluded to be “frequently poor” (SCMH, 2007; APG, 2006). This report believes that that it is un-ethical to incarcerate an offender in prison with severe mental health issues when the critical help required is not an acceptable standard and simply not good enough.


2.1 – Schizophrenia: Punishment or Treatment

Mental Health and Schizophrenia has been synonymous with violent behaviour and criminal activity. “Public opinion surveys indicate that mentally ill people (especially those with schizophrenia) are perceived as violent and dangerous” (Howitt, 2011). British Mental hospital admissions correlate negatively with rates of prison admissions. (Weller & Weller, 1988). This supports the notion that mental health and violent behaviour are linked as the Criminal Justice System believes prison reduces the risk management.

Characteristics particularly associated to schizophrenics.

Schizophrenics: Sharp and blunt weapons are used more often than guns perhaps because their crimes are more impulsive; they injured their victims face more frequently than the other group of mentally ill offenders possibly because the face is symbolically the essence of a person or because they find facial expressions threatening; their attacks were less likely to follow arguments; mostly they suffered from hallucinations/delusions at the time of the attack; their victims were frequently relatives.

Hakkanen and Laajasalo (2006)

What needs to be understood, not only by prison staff, but also Judges, police and the CJS in general, is the context of the violent behaviour by schizophrenics. Mental Disorders can develop as a result of traumatic injuries or events and even disease (Howitt, 2011). It is widely accepted that damage to temporal and predominantly frontal lobes of the brain can induce more violent, anti-social behaviour (Raine, 2002), for example; Phineas Gage, whose personality and everyday behaviour changed when an accident at work led to his frontal lobes being pierced with an iron rod. Schizophrenic patients experiencing frequent intense symptoms are more violent than groups of patients with a different psychiatric classification (Howitt, 2011). For example, Command Hallucinations (hearing voices commanding the patients to perform violent tasks against another person) were believed to inspire the Yorkshire Ripper who murdered at least 13 women, generally prostitutes, featured such hallucinations (Ainsworth, 2000).

When prison staff are not trained to deal with or understand this behaviour it seems rational enough to conclude that the treatment needed is not found within prisons.


3.1 – Implementation of “in-reach” teams

It is important to remember that individuals who are in prison have broken the law. Prison isolates an offender and takes away their civil rights but preserves their dignity. Yet for prisoners with mental health disorders, the current healthcare system within UK prisons is also taking away their human rights. This is demonstrated by the lack of equivalent healthcare support. In an effort to ensure that prisoners with mental health disorders get the equivalent attention to treatment as in a hospital setting, Government policy introduced specialist “In-reach” teams. Most Prisons in England and Wales now have a mental health in-reach team. These teams are intended to support those prisoners with the most serious mental health problems (DH & HMPS, 2001).

In-reach Team Main Duties;

  • Reaching out to the wings of the prison where the prisoners reside
  • Focusing on prisoners with severe and enduring mental health problems
  • Working with health care and primary care practitioners in prisons
  • Raising mental health awareness, particularly among prison staff
  • Offering evidence based interventions (such as behavioural therapy)
  • Offering similar multidisciplinary service and model of care to which a community mental health team provides outside prison.

Durcan & Knowles (2006)

3.2 – Problems facing in-reach teams – No regulation of standards 

The creation of in-reach teams has shaped a significant movement towards the healthcare provided in prisons. APG (2006) argue that although it’s a step forward to addressing the issue, there are several flaws limiting their role and prohibit the in-reach teams functioning effectively. Unlike teams in the community there is no implementation guidance for in-reach teams and those that commission them (Durcan & Knowles, 2006). This presents a problem, it allows every prison a view of subjective flexibility in standards of how in-reach teams can function and operate. Durcan and Knowles (2006) continue that these teams should consist of; psychiatrists, social workers, mental health nurses and other nurses. The issue is that in most prisons teams are made up of nurses with varying degrees of medical support.


3.3 – Problems facing in-reach teams – Prison Routine vs. Patient Care

One of the biggest challenges for the in-reach teams is actually being able to implement the treatment available. A review by the Sainsbury Centre for Mental Health (SCMH; 2007) found that working in an environment in which security precedes health impacted on the success of clinical interventions. It was emphasized that there is a 30-35% of non-attendance to the in-reach appointments. The reason for this is due to the security and prison routine.  Prison staff should acknowledge the importance of attendance to mental health clinical interventions of the in-reach appointments. There is a serious human rights violation as prisoners are not receiving the treatment they need. This lack of care supports the fact that prisons are clearly no place for mentally disordered offenders.



3.4 – Problems facing in-reach teams – The Prison Healthcare “Dogs-Body”

Another issue that faces the in-reach teams is that other services may not be fully aware of their role. Inappropriate referrals put added pressure on in-reach teams and restrict the time they can give to each person (SCMH, 2007). This is because prisoners with common mental health disorders are not given any treatment from other services of health, therefor are being referred to in-reach teams (SCMH, 2007). Furthermore, APG (2006) identified that at any one time there can be up to 8,000 prisoners on the move within the prison system, this is a complex and time consuming task. This presents the problem of little to no time available to administer medical treatment the prisoners on the wings.


4.1 – The Problems within the Prison Healthcare system – Lack of Communication

Although the switch over to the NHS is a step in the right direction, there seems to be a significant lack of communication between inter-departments and external services. This is also recognised by Executive NHS (1999) who argues that there is a need for stronger partnerships between the NHS and Prison Healthcare Service. This is detrimental to ensuring that the level of prison healthcare matches the standard of the hospitals. SCMH (2007) claim that due to services working independently of each other it’s possible for patients to be assessed multiple times. If there were more communication between services they would save more time and would be able to apply more time to those that need the treatment. This lack of communication is supported by Grounds (2005) who argues that the relationship between forensic and general health services is strained because of the pressures to move more higher-risk patients from general services. Furthermore, he states that there can be reluctance and lack of capacity to take on patients who no longer need specialist care.


4.2 – The problems within the Prison Healthcare system – Transport to Treatment

“Transport arrangements to take prisoners to hospital need to be improved and escort arrangements need to be available when necessary” (APG, 2006). The development of medium secure forensic units has been uncoordinated, leading to patchy and under-provision (Coid et al, 2001). Currently transport to facilities is a large problem facing patients. HMPS (2004) estimated that around 40% of prisoners held on health care wings were awaiting transfer to NHS secure accommodation. DH (2005) found “Unacceptable delays in the transfer of acutely mentally ill prisoners to and from hospital under sections 47 and 48 of the Mental Health Act 1983”. Reed (2003) presents an example of the “unacceptable delays” in that HM Inspectorate found that a prisoner waiting for admission to a high security hospital 5 years after the transfer had been recommended by a special hospital consultant. There is absolutely no excuse for a delay of 5 years to be transferred. This demonstrates the need for a more communicative link between different services. Finally, Julie Saggers, Health Policy Manager at Winchester Prison (APG, 2006), believes links between prison mental health services and those outside must undergo rapid and radical improvement. People who need compulsory treatment should be taken to hospital; not kept in prison until a bed becomes available. The difficulty in getting secure beds is because of apparent reluctance by NHS providers to accept responsibility (Durcan & Knowles, 2006).


4.3 – The Problems with the Prison Healthcare system – Short Staffed and Lack of adequate training

One problem in administering treatment to prisoners with mental illness is due to a lack of psychiatrists employed in the prison medical service. Up until 1999, it was not required for doctors to hold appropriate specialist training equivalent to those employed in the NHS, so long as they were “registered medical practitioners” (Reed, 2003). “Prisons are overcrowded and lack staff skilled in dealing with mental health problems” (SCMH, 2007). The lack of staff creates problems for prisoners as soon as they arrive in prison. The Don Grublin screening tool is the standardized screening tool assessing prisoners (Carson et al, 2003) and conducted by health care staff and may not possess mental health training (SCMH,2007). This is problematic as prisoner’s mental health disorders may not be identified and consequently accommodated incorrectly (Parsons et al, 2001). Furthermore, due to the behavioural nature of other offenders in a particular area of prison, a mental health disorder may become transparent (Birmingham et al, 1998). It may be worth implementing a member of the in-reach team to assist in identifying mental health disorders in the screening process.


5.0 – Conclusion and Recommendation

Currently, there are no national guidelines for the way in-reach teams should be ran. This impact’s heavily on the treatment mentally disordered prisoners receive. Prisons can run their in-reach teams however they want and often put their priorities over the healthcare priorities of the offender. It is recommended that national guidelines be set so healthcare is a priority within these prisons and that it sets a high national standard of care that is equivalent to hospital treatment. If this cannot be achieved, then there is no place for mentally disordered prisoners in a prison.

There needs to be a stronger communication developed throughout the Mental Health services in the UK. If this could be achieved the services could utilize their time spent on treating prisoners, rather than spending time assessing a patient multiple times. Furthermore, a priority shift geared towards the transfer of patients to medical facilities should be implemented. A failure to do so is not only breaching the Mental Health Act 1984 but also disenfranchising the patients’ human rights.

Finally, each prisoner costs the tax payer £37,000 a year, yet more than 70% of young offenders and more than 60% of adults re-offend within two years of their release (Sieghart, 2006), and with 70% prison population owning two or more mental health disorders (Social Exclusion Unit, 2004).  This demonstrates a clear picture that prisons are not only unsuccessfully rehabilitating offenders they are not providing adequate healthcare treatment they are legally required to receive.


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