One of the unfortunate taboos in disability is that people steer very clear of any discussion of the intersection between disability (particularly intellectual disability) and mental health. As part of a general campaign to wear down this barrier I regularly invite the very wonderful Masuma Rahim to write on mental health issues for my chiefly disability-focused audience. If you’d like to hear from Masuma more regularly (and who wouldn’t) I strongly recommend her blog over at http://masumarahim.wordpress.com/.
I like working with offenders. I haven’t done it in a while, since I’ve spent the last three years training as a clinical psychologist, but I miss it enormously. It’s perhaps odd that I find anxiety harder to work with than things like personality disorder (though words like ‘easy’ and ‘hard’ are both crude and relative). Still, someone has to do it, and I’d far rather play to (what I see as) my strengths.
I have issues with the treatment of both offenders and those with mental health issues. On the whole, practitioners are dedicated and compassionate; be they social workers, nurses or support staff. I’m not so keen on psychiatry, though I have met and worked with some psychiatrists who are fantastic. I suppose it’s not psychiatrists per se I am wary of but the tendency to see mental health through a psychiatric lens. But that is probably a topic for another day.
In mental health, we are rightly very concerned with good and bad practice when working with offenders who are also in contact with psychiatric services. Of the 85 000 people in British prisons, an estimated 70% have mental health problems (MHP). Furthermore, 4000 people are held in the ‘special’ hospitals – Broadmoor, Ashworth and Rampton, and, in Scotland, Carstairs. These patients tend to be the ones thought of as ‘untreatable’ and are invariably seen as extremely dangerous – Peter Sutcliffe, David Copeland, Charles Bronson, Robert Maudsley, Ronald Kray, Ian Brady. Interestingly, 87% of the patients at such institutions are male.
There is little doubt that prison is bad for your mental health. The WHO pinpoints the greater risk of isolation, loss of privacy, aggression from others and the loss of control. Add on the stigma and the pressure to engage in illicit activities and the situation is certainly bleak.
And the effects? For a start, each year, 17 000 children are placed in care after their mothers have been remanded at Her Majesty’s Pleasure. Then there is the problem of life after prison. Prisons are very good places to find work, whatever that may be. Some are very good at giving you skills (literacy and numeracy being a case in point; though Chris Grayling has put an end to that) necessary for any hope of a life on the outside. The problem is that there is no support upon release. A release grant of £47.50 is given to all those going back into the community. But, let’s be realistic. £47.50 is not going to get you much. The average person (not the average offender, note), would perhaps buy some cigarettes and then go to the pub. That will leave you with little to buy food and find accommodation. Benefits exist, of course, but, as anyone who has ever dealt with them will know, the DWP is very good at stopping payments when you’re remanded and very bad at reinstating them upon release. It can take weeks. No Housing Benefit can mean nowhere to live. Without other allowances it can be virtually impossible to survive. It’s not uncommon for people to shoplift and then end up back in jail when all they were trying to do was feed themselves. Prison may be unpleasant, but at least you’re provided with the basics. In addition, even if you make it out of prison and get somewhere to live and something to eat, who’s going to employ you with a criminal record? Research shows, unsurprisingly, that those who have been imprisoned are more likely to reoffend. The likelihood increases with each extra spell spent behind bars.
Now imagine the situation if you’re an ex-offender with MHP. The difficulties are magnified – 40% of prisoners with MHP are homeless; 60% have no work outside the prison. It can be hard to manage psychosis in prison. There are few specialist services and trying to get someone in the midst of a breakdown referred is never simple. There are targets in place: a person breaking down should be referred to an appropriate service immediately and transferred within fourteen days. What actually happens is that the person is referred and it can take months before a bed becomes available. They continue to deteriorate. In 2013, there were 70 suicides in custody; the highest figure in six years. There have been increases in recent years in the number of adolescents killing themselves. But the target for transfer is met through the back door – many services start counting the fourteen days form the date a bed becomes available, not the date the referral was made.
Another obstacle is funding. Because prisoners are moved around the country so much, a Londoner may find themselves in HMP Wakefield, in Yorkshire. So, who pays for the psychiatric care? The London Borough of Lambeth (for example) or the Wakefield Primary Care NHS Trust? Invariably, wrangling ensues. Contrast this with the prisoner who’s had a heart attack. In general, an ambulance will draw up within ten minutes and no one will dare question their financial liability.
Prisons are, unfortunately, not places steeped in morality. On average, there is an assault every other day at most prisons. Robbery and violence are commonplace; the atmosphere is brutalising, to say the least.
As for the money, it costs £40 000 to incarcerate a person for a year. It costs £170 000 to build a prison cell. In these times of economic hardship, £2bn is being spent on new prisons. And, each year, budgets are cut by around 3%. The first to go is the rehab work, the work that actually can turn lives around.
There are alternatives. This isn’t about being a woolly liberal. This is about common sense and humanity.
The Sainsbury Centre for Mental Health advises the government on mental health policy. Their strategy is ‘diversion’ and it is simply based on identifying those individuals at risk of entering the criminal justice system and intervening appropriately. That may involve parenting classes or community sentences. It’s surely better to give someone a community sentence rather than sending them to prison for four months for a minor offence. Realistically, they’ll be out in two but the fact of the remand will count against them for quite some time. And the research supports it: people ‘diverted’ from the prison system tend to re-offend less. On average, the saving is £20 000 per individual. And that’s just for adults; successfully ‘diverting’ a juvenile could potentially save a lot more money. Factor in the benefits to society and surely there is compelling evidence?
As ever, there is apparently a shortage of money. 150 of these ‘diversion’ units have been set up but we need more like 300. Will the Coalition government put more money towards it? Given past form, probably not.
Then there’s the example of HMP Dovegate, a therapeutic community (TC). Dovegate is a prison but operates in a different way. A therapeutic community works on the basis of individual control, autonomy and group cohesion. You are encouraged to take responsibility for what you have done and learn new ways of coping and interacting with others. Again, the research is promising. After as little as six months, self-esteem has increased and inroads have been made into previously disturbed though processes. With time, hostility reduces and self-awareness increases. Again, people who are placed in the TC tend to re-offend less than those placed in a mainstream prison.
This all sounds like a manifest for spending billions on violent, dangerous people. It’s not. It’s a manifesto for realising that the system is failing many vulnerable people and that something has to change. So I end with two stories, both completely factual.
Petra was taken into care at the age of nine as her mother was abusive towards her. She was repeatedly raped by staff at the children’s home she lived in and began to self-harm. At sixteen she had a son but, diagnosed with borderline personality disorder, common in those who were raped in childhood, she was unable to cope. She was deemed ‘untreatable’ and left to her own devices. Her self-harm escalated. One day, she phoned the community mental health team and asked to be assessed as she felt she was deteriorating. They refused. She set fire to herself and, rather than being assessed for psychiatric care, she was charged with arson with intent to harm. She was imprisoned and, within 130 days, there were 90 incidents of self-harm involving burning, cutting, overdosing and ligatures. No action was taken to address her obviously deteriorating state. She eventually hanged herself, aged nineteen.
Petra had a twin sister whose experiences during childhood had been similar. Her sister was placed in a therapeutic community and is now a well-adjusted member of society. In her words, if Petra had been given the same chance, she would probably still be alive.
Ashley Smith had her first contact with psychiatric services aged thirteen. They decided she was too difficult to handle and sent her home. She was diagnosed, after assessment, as having ADHD and a learning disability, as well as a borderline personality disorder and narcissistic traits. By the age of fifteen, she was in prison and began to harm herself. The crime? Throwing apples at a postal worker. She was troublesome and she was punished for it; repeatedly tasered and put in isolation. Canadian law states that you cannot be put in seclusion for more than sixty days at a time. The prisons side-stepped this by transferring her to another prison after sixty days and having her secluded again. In twelve months, there were 150 incidents recorded. At the age of nineteen she too hanged herself. The only difference was that there were seven prison guards watching her. They had been instructed not to intervene if she tied a ligature as that would be ‘giving in to her manipulative behaviour’.
If that doesn’t indicate we need to rethink how we treat mentally ill offenders, what does?