Time to act on behalf of mentally disordered offenders
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39237.692975.94 (Published 07 June 2007) Cite this as: BMJ 2007;334:1222
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
A bin is a bin by any other name
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
Competing interests: No competing interests