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Rapid Responses: Rapid Responses published:
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Mentaly disordered offenders
- Peter O'Loughlin (9 June 2007)
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Mentally disordered offenders
- Ciaran E C Regan (14 June 2007)
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Dostoyevsky said it first
- Nisha I Shah, Dartmouth Park Hill, London, N19 5JG (14 June 2007)
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Mentally Disordered Offenders - experience elsewhere in the UK
- Andrew Fraser, Dr Lindsay D G Thomson, Medical Director, The Forensic Network and the State Hospitals Board, Lanark/Senior Lecturer in Forensic Psychiatry, The University of Edinburgh; Dr L J Graham, Public Health Specialist, Information Services Division/Scottish Priso (15 June 2007)
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The questions remain unanswered.
- Peter R. O'Loughlin (15 June 2007)
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Personality Disorders - "potentially untreatable"?
- Martin Zinkler (17 June 2007)
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A bin is a bin by any other name
- John Alexander McFadyen (23 March 2009)
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Peter O'Loughlin, Principal: Alcohol & Drug Addiction Recovery Beckenham BR3 3AT
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The authors clearly believe that the above do not belong in prison. A view that is difficult to disagree with. However since many of the mentally disordered have a serious substance abuse problem, either arising from, aggravated,or induced by such abuse, is it not the case that the majority are in prison for criminal offences arising from the latter,including violent offences carried out in order to fund their addiction? If that is the case,are the authors suggesting, or implying that they should be found not guilty of their criminal activities, possibly on the grounds of 'insanity'? If these offenders are not to be imprisoned for their criminal activities, what proposals do the authors have for protecting the public from the harm they inflict on them?. In our desire to be merciful and compassionate, we should not overlook the fact that in London alone for the fiscal year 2005-6, the police recorded 197,000 violent crimes, an eye watering increase on 2004- 5, when the figure was 34,000. We should not pretend that most violent crime is not related to alcohol and drug abuse, or the fact that addiction to either or both are classified as mental disorders. I think it was John Stuart Mill, regarded by many as the father of liberty, who in his classic text 'On Liberty' said: " the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others" Competing interests: None |
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Ciaran E C Regan, Psychiatric specialist registrar HM Prison Pentonville
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Dr Sales and Dr McKenzie are making an important point with their article. Working in the prison environment can be disheartening as there is a lack of access to psychiatric beds especially for those who require specialist forensic care. Many of the offenders who are referred to the in-reach team do have substance misuse problems but there are a significant number with severe disorders such psychosis secondary to schizophrenia who remain in prison without appropriate care and medical treatment. Although the healthcare wing can provide a degree of nursing care and containment, the inability to use the mental health act to allow treatment often ties our hands in improving patients mental states. The recent Capacity Act could provide a structure for in-reach teams to manage people with mental health problems who require treatment and we wait to see the provisions made by changes to the current Mental Health Act. The limited provision of mental health care to offenders due to pressure on in -patient services enforces the perception that people with mental health disorders require only detention from the general population reinforcing the disparity that exists between physical and mental health care. Competing interests: None declared |
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Nisha I Shah, locum consultant psychiatrist Highgate Mental Health Centre, Dartmouth Park Hill, London, N19 5JG
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The desire for equitable care for mentally disordered offenders is commendable but, as ever, a lack of political impetus will be the cause of pragmatic blocks to change. Dostoyevsky's assertation that one can judge a civilisation by the way in which it treats its prisoners is surely the case. We incarcerate too many, some of whom have their psychotic illness triggered by imprisonment, but we show limited political will to improve their mental health care. It seems unlikely that equity of care will be incorporated into new mental health legislation as this would force funding for their treatment to be identified, possibly by diversion from an already hard pressed service. Mental health service users are stigmatised enough outside the criminal justice system: it seems likely that negative attitudes towards them will be accentuated by imprisonment, particularly the high proportion with substance misuse problems. Changes in legislation are necessary, but may not win votes. Competing interests: None declared |
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Andrew Fraser, Director of Health and Care Scottish Prison Service, Calton House, 5 Redheugh Riggs, Edinburgh, EH12 9HW, Dr Lindsay D G Thomson, Medical Director, The Forensic Network and the State Hospitals Board, Lanark/Senior Lecturer in Forensic Psychiatry, The University of Edinburgh; Dr L J Graham, Public Health Specialist, Information Services Division/Scottish Priso
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We welcome the attention that the recent Personal View (BMJ 2007;334:1222 (9 June)) by Doctors Sales and McKenzie devotes to mentally disordered offenders. Prisons are the unfortunate and involuntary receiving unit for people with mental and many other health problems. In a recent audit of prisoners who were transferred under the new Mental Health (Care and Treatment) (Scotland) Act 2003 over a seven month period to secure psychiatric care, over half of those on remand were recognisably ill on reception into prison. Nurses and prison officers were the first to notice and refer the patient for expert assessment. These patients should never reach prison, but even the most forward-thinking legislation will not prevent such a lack of care occurring unless diversion from prosecution by police and courts is effective across the country. Scottish prisons in the public sector have no in-patient accommodation. Such prison hospitals as there were could only act as clearing stations and intermediate primary care units, and they were closed in the past 4 years. Recent improvements in the prison service offer limited day-care but do not provide intensive mental health care. Nor should they. Hospital is the correct place for very sick patients. Our audit shows that, with few exceptions, people who came to the notice of mental health services in prison transferred promptly - 16 out of 22 had complete documentation in three days or less, with a further 3 within one week. 16 out of 22 then waited three days or less to transfer to hospital. So what are the possible differences between Scotland and England that may account for such a difference in waiting times before transfer to hospital. We offer four possible explanations: 1) The prison population in England (139/100,000 population) is greater than in Scotland (126/100,000 population) although it is only in this decade that this has occurred (Home Office, 2003). This may result in proportionately more prisoners in England requiring placement in psychiatric hospital. 2) The prevalence of major mental illness likely to require transfer of an individual to psychiatric hospital may be greater in the English prison population. Some evidence for this can be found in prevalence studies of remand prisoners in Scotland and England where rates of psychosis were found to be 2.3% and 10% respectively (Davidson et al, 1995, Singleton et al, 1998). Given that there is no difference in the general prevalence rates of major mental disorder throughout the UK and that crime rates are higher in Scotland (196/100,000 population; Scottish Executive, 2006) than in England (104/100,000 population; Walker et al, 2006), this suggests that more patients are diverted from prison within the Scottish system. 3) The number of psychiatric beds (general adult psychiatry and secure care) per 100,000 population was greater in Scotland (614; Information and Services Division, 2007) than in England (374; Department of Health, 2006) in 2006. 4) The configuration of secure psychiatric services is different North and South of the Border. There is a strong tradition of local prisons being served by local mental health services with access to secure beds in Scotland. Prisons with a national role are often served by forensic psychiatrists from the national high secure facility at the State Hospital and this again provides access to beds in an appropriate level of security. It is likely that the scale of both prison and psychiatric services in Scotland and the personal contacts that this promotes, will ease the path to transfer. There is undoubted pressure on secure mental health facilities. Diluting the effort by dividing care between prison and secure hospital is no solution for people with serious and treatable disorders. Building the capacity of good community alternatives for custody or care, with mental health at the core, will serve much better the community that such institutions are there to protect, as well the human rights of mentally disordered offenders. Legal duties can assist, but there is no substitute for clear purpose and good understanding between prisons and secure hospitals, and adequate services in the correct places for our most vulnerable patients. Yours faithfully, Dr Andrew K Fraser, Director of Health and Care, Scottish Prison Service, GMC No 2551766 Dr Lindsay D G Thomson, Medical Director, The Forensic Network and the State Hospitals Board, Lanark/Senior Lecturer in Forensic Psychiatry, The University of Edinburgh Dr L J Graham, Public Health Specialist, Information Services Division/Scottish Prison Service (on secondment) References: Davidson, M; Humphreys, M.S., Johnstone, E.C., Cunningham Owens, D.G. (1995) Prevalence of psychiatric morbidity among remand prisoners in Scotland, British Journal of Psychiatry, 167, 545-548. Department of Health (2006) Information from Form KH03 www.performance.doh.gov.uk/hospitalactivity/ Home Office (2003) World Prison Population Statistics (4th edition) Research, Development and Statistics Directorate, Findings 188, London. Information and Services Division (ISD, 2007) Scottish Health Statistics www.isdscotland.org/isd/ Scottish Executive (2006) Recorded Crime in Scotland 2005/06, Statistical Bulletin, Criminal Justice Series CrJ/2005/6. Singleton, N., Meltzer, H., Gatward, R. (1998) Psychiatric morbidity among prisoners in England and Wales. The Office of National Statistics, The Stationary Office, London. Walker, A., Kershaw, C. and Nicholas, S. (2006) Crime in England and Wales 2005/2006, Research Development Statistics, Home Office, London. Competing interests: None declared |
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Peter R. O'Loughlin, Principal: Alcohol & Drug Addiction Recovery Beckenham BR3 3AT
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Drs Reagan and Shah, are correct in what they say, as indeed were the authors of the article. However the fact remains that many of those with mental disorders do have a serious alcohol and/or drug problem both of which give rise to violent ciminal activity. The questions I raised remain unanswered. Are they to be allowed their liberty, with the attendant danger to the public? Are they to be set free without retribution for their crimes? who amongst is willing to take responsibility for the release of a mentally disordered drug addict, with a history of violence, who then goes on to re-offend? Is it not a fact that at present there are people in the community who have been sectioned, and who represent a threat to the public, but due to 'lack of police resources' have still not been detained? Is it not also true that of the few psychiatric beds there are available, a number are occupied by people with cannabis related disorders? We already have a situation where offenders on Drug Treatment and Testing Orders,(DTTOs) instead of being imprisoned, (an excellent concept) go on to re-offend, a situation that has increased year on year, with the latest sanitised statistics putting the rate of re-offending at 92%. A major contributory factor to the problem of both the mentally disordered drug addicts in prison, and those on DTTOs is that so called interventions for their addiction is rarely, if ever, abstinence focused. Nor for that matter is the comorbity that can be discerned in the majority of such cases. Instead we have what is referred to as 'harm reduction' wherein Government funded and misguided drug treatment agencies, with the approval of the National Treatment Agency, seek to persuade addicts to reduce their drug intake,either by quantity or frequency. Apparently those responsible for such a futile activity, are unaware, or unwilling to accept, that neither are relevant to the condition of addiction, or that addiction is irreversible, or for that matter that any reduction is transient. Addiction is either in remission or active. 'Interventions', where tacit permission is given for continued use keeps it active. Addiction can only be arrested by abstinence, which in turn can lead to recovery. So called research that purports to show otherwise, is mainly based on self reported ancedotal evidence from 'selected' subjects, conducted over a relatively brief period of time, together with alterations to the universally recognised criteria for addiction Whilst the National Treatment Agency allow such a situation to continue, our prisons will continue to have a high percentage of mentally disordered and violent addicts, and those on DTTOs will continue to re- offend. It is also true that the cost to taxpayers of the latter's treatment, together with the cost to society, and the distress of the victims will continue to rise. Competing interests: None declared |
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Martin Zinkler, Consultant Psychiatrist East London and City Mental Health Trust, Newham Centre for Mental Health, London E13 8SP
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Sales and McKenzie refer to personality disorders as "potentially untreatable" disorders as opposed to acute psychosis as a treatable disorder. With emerging evidence on the outcome of personality disorders this distinction appears questionable. Zanarini et al. (Am J Psychiatry 163:827-832, May 2006) found in cohort of people with Borderline personality disorder that after 10 years 88% achieved remission. Labelling personality disorders as potentially untreatable can however increase stigma and the feeling of hopelessness that surrounds so many of these patients. Competing interests: None declared |
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John Alexander McFadyen, Director, Mental Health Consultancy (Midlands) Limited, Telephone: 01604 889135 Brixworth, Northamptonshire, NN6 9JW
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I must say that this argument has been raging for a couple of decades now as the prison service creaks under the weight of the demands upon its services. Likewise mental health services are not doing any better except someone somewhere has cleverly put the breaks on the hospital closure programme by using prisons as defacto mental health institutions and recreating institutions in the form of the now complex and expanding network of forensic services (Priebe et al, 2004). Recent discourse on the matter has suggested that it is a waste of public money keeping mentally ill individuals in prison but the economic arguments are false as it is more expensive to treat them in forensic services. The real questions are: Is it morally right to incarcerate in prison those seen as mentally ill? If not can the overstretched and inadequate mental health system cope with treating them and at the same time maintain the safety of the public? As Peter O'Loughlin argues, is it morally right to use mental illness as a reason to excuse criminal activity and circumvent the normal judicial process? Stein and Test (1980) are seemingly the only clinicians to have addressed this question in any substantive way over the past few decades and finally, Is it right to continually support the burgeoning independent sector who, seeing Nero watching Rome burn, are in pilfering the treasure? As Holloway (2005) points out we have totally deconstructed the backbone of psychiatric practice-rehabilitation services, which are largely non existent in most areas. A factor leading to increased referral into independent sector forensic services. I have reviewed services the length and breadth of England and undertaken individual patient reviews only to find many people who would have been on rehabilitation wards languishing in the independent sector far from home. More worrying the fact that no one seems to want them home as clinicians breath a sigh of relief and 'wash their hands' and commissioners appear resigned to matters. I once worked in a large institution where true there were abuses, but largely the targets set by our forefathers were achieved. Care in a safeish environment, with fresh air and decent food and a social life. All at arms length from society at large. It sounds like it might just catch on; or has it, as Priebe et al suggest, done so already? References Priebe, S. Badesconyi, A, Fioritti, A. Hansson, L. Kilian, R. Torres- Gonzales, F. Turner, T. and Wiersma D. (2004) Reinstitutionalsation in mental health care: comparison of data on service provision from six European countries; www.bmj.bmjjournals.com/cgi/content/full/bmj;330/7483/123. Stein LI, Test MA (1980) Alternatives to mental Hospital Treatment. Archives of General Psychiatry 37: 392-7 Holloway, F., (2005) The Forgotten Need for Rehabilitation in Contemporary Mental Health Services-A position statement from the Executive Committee of the Faculty of Rehabilitation and Social psychiatry, Royal College of Psychiatrists, Royal College of Psychiatrists, London. Competing interests: None declared |
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