Health Care Standards in Irish Prisons

In June 2004, the Irish Prison Service published a statement of Health Care Standards, covering the care of those detained in Irish prisons and places of detention. The core aims of the Standards are stated as being: “to provide prisoners with access to the same quality and range of instruments to which they would be eligible within the general community” and to give priority to the promotion of the health of prisoners.1

These aims accord with Article 12 of the International Convention on Economic, Social and Cultural Rights (ICESCR) which recognises “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”. Ireland has ratified the ICESCR, which under international law obliges the State to ensure that the rights enshrined in the Covenant are guaranteed for all persons in its territory.

The United Nations Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care outline the basic rights, freedoms and entitlement to care of people with a mental illness. 2 Key principles include:

• All persons have the right to the best available mental health care (Principle I)
• Every person shall have the right to be treated in the least restricted environment. (Principle 7(I))

Crucially, these standards are to apply equally to all, including  “persons serving sentences of imprisonment for criminal offences, or who are otherwise detained in the course of criminal proceedings or investigations against them”. (Principle 20(I))

A new study, Mental Illness in Irish Prisoners,3 carried out by a team led by Dr Harry Kennedy, and shortly to be published by the National Forensic Mental Health Service, serves to draw our attention yet again to the high incidence of mental illness among prisoners in Ireland and to the question of how well this country is adhering to its own as well as internationally agreed standards for the care of  prisoners with mental health problems.

Prevalence of Mental Illness in Irish Prisons
The new study is the first systematic and representative survey of mental health in the Irish prison population. Previous studies, though more limited, still served to highlight the high incidence of mental illness among prisoners by comparison to the population as a whole. For example, a study, in late 1992 and early 1993, of a sample of prisoners in Mountjoy Prison found that 14% of pre-trial prisoners and 9% of sentenced prisoners were clinically evaluated as having a mental illness.  When substance abuse was included as a psychiatric disorder, the incidence increased to 62% of pre-trial and 54% of sentenced prisoners.4

A 1996 study of female prisoners in Mountjoy Women\’s Prison again showed a very high incidence of mental ill health. One in two of the prisoners had received psychiatric treatment, and one in four had been an in-patient in a psychiatric hospital or in the Central Mental Hospital. One-third of the women reported that they had attempted suicide.5

A high incidence of mental illness among prisoners is, of course, not unique to Ireland. An analysis of the results of sixty-two surveys of prisoners in twelve countries found that almost 4% of the 22,790 prisoners covered in these surveys had a psychotic disorder, compared with an estimated prevalence for the general population of between 0.1% and 0.4%. Over 10% of prisoners suffered from major depression; 47% of male and 21% of female prisoners had an “antisocial personality disorder”.6

Kennedy Study: Findings
In the Kennedy study, a total of 1,582 prisoners were interviewed, 1,396 men and 186 women. The survey covered five separate representative samples that included 7% of all men newly committed to prison in 2003, 50% of all men in custody on remand in that year and 15% of all sentenced male prisoners. It also covered 9% of all women newly committed to prison in 2003 and 90% of all women in prison in that year.

The findings showed a very high incidence of mental illness in all the samples. Among male prisoners, 15% of those committed to prison in 2003, 25% of remand prisoners and 22% of sentenced prisoners had a mental illness of some kind. Among female prisoners, the rates were even higher: 37% of sentenced women and 23% of women committed to prison in  2003 had a psychiatric illness.

The study found an incidence of psychosis among Irish prisoners that was significantly higher than in comparable samples in other countries. Rates for psychosis among men varied between 7.6% among those on remand in 2003; 3.9% of those committed to prison in that year and 2% of sentenced prisoners. Among women, the incidence of psychosis was 5.4%.

The extent of mental illness among prisoners committed during 2003, highlights the high incidence existing  before custody, and therefore before the impact of being detained in an environment likely to increase the risk of illness.

With regard to alcohol and drug dependence, the findings of the Kennedy study are striking and alarming. In the different samples, between 61% and 79% of prisoners were experiencing dependence. Furthermore, most prisoners with a mental illness also had problems with drugs and alcohol.

The problem of mental illness in the criminal justice system is, of course, wider than is revealed by the incidence of mental illness among prisoners. This larger group would include people who come into contact with the Gardai as a result of an alleged infringement of the law or because of their disturbed behaviour; people who appear before the courts and who have a mental illness which may or may not be brought to the attention of the court, and people who receive a court conviction but are given a sentence other than imprisonment. There are no available statistics to  indicate the number of people who come into these categories, but the incidence of mental illness among prisoners suggests that it must be significant.

Why Such a High Incidence?
The factors underlying the high incidence of mentally illness among prisoners are complex. However, it is clear that the features that so often characterise the backgrounds of prisoners – social deprivation, high unemployment, substance abuse, low educational attainment and lack of skills, family breakdown and parental absence – are all in themselves factors which give rise to increased risk of mental illness. The Kennedy study includes some information on the background of the prisoners interviewed and this confirms the findings of previous Irish studies, in showing that a disproportionate number came from Dublin; a significant number had, in childhood, spent time in care or in juvenile detention centres; most had been unemployed at the time of their imprisonment, and many had experienced homelessness or living in insecure accommodation.

The Kennedy study also draws attention to two issues which  frequently have been cited as factors in the high incidence of mental illness among prisoners – namely, the inadequacy of mental health services as a whole and the failure to devise ways of ensuring that offenders with a mental disorder can be diverted away from the criminal justice system and into care and treatment.

Shortcomings in Mental Health Services
Since the 1950s, advances in the effectiveness of psychiatric medications have allowed greater possibilities for treating people with mental disorders on an outpatient basis, decreasing the need for hospitalisation. The result, world-wide, has been a systematic shift of emphasis from providing psychiatric care in large, residential psychiatric hospitals to community-based treatments.

The guiding principle that appropriate treatment should be offered in the least restrictive environment, is widely accepted in theory. The reality in many countries, however, is that the range and level of provision of alternatives to institutional care have been far from adequate.

Several Irish reports, including the Annual Reports of the Inspector of Mental Hospitals, have drawn attention to the inadequacies of Irish mental health services. A report in 2003 by Amnesty International (Irish Section) drafted in consultation with many stakeholders in the medical profession, service providers and the NGO community, concluded:

While many strides have been made in Ireland in improving mental health care services, development to date has been piecemeal and reactive, with the result that, in both in-patient care and the community, they remain inadequate in many respects, and inconsistent in their application throughout the country.7

The most recent examination of the Irish mental health services is that of the Expert Group on the Mental Health Services, whose Report, A Vision for Change, was published in January 2006.8 The Report shows serious inadequacies in the mental health services for all the main population categories – children and adolescents, the general population, those with severe and chronic mental illness, older people.

A Vision for Change highlights, in particular, that the comprehensive services provided by multi-disciplinary teams, which  are widely agreed to be essential if the various and complex needs of people with mental illness are to be met, are often not available. There is, for example, an inadequate provision of psychological, counselling and social support services. There is also insufficient provision of services at community level – services that would be \’accessible\’ not just in terms of geographic proximity but in terms of acceptability. Both outpatient services and community-based acute services are inadequate. Patients themselves – as well as their families – are not sufficiently enabled to be involved in the development and implementation of plans for their care and recovery.

Speaking of the needs of people with “severe and enduring” mental illness, the Expert Group states that they are perhaps the “most vulnerable in the mental health service” and that the ultimate test of the overall quality of mental health services is the quality of care provided for these people (p. 104). The Group says that the programme of ward closures which has resulted in a dramatic  decrease in the numbers of people in psychiatric hospitals (from 19,801 in 1963 to 3,556 in December 2004) has not been followed by the provision of adequate community-based mental health services and of the other care services needed to the address the significant problems which people in this situation may have in living their daily lives. Many experience repeated admissions to acute hospital care, “despite the clear evidence of the failure of a predominantly medication-based, bed-based service to meet their needs”. The Expert  Group comments:

The lack of appropriate services for this group of service users has had major consequences for mental health services and for the individuals themselves. In addition to the distress of illness, they are at high risk of ending up homeless, becoming involved in petty crime, being inappropriately imprisoned, or being in a state of social isolation and dereliction. (p. 105, emphasis added)

This is not the first time that an official Irish report has explicitly cited the failures of mental health services as a reason for people with mental illness ending up in prison. In 2001, another committee, the Review Group charged with examining the Structure and Organisation of Prison Health Care Services, stated:
It is clear that for one reason or another, there is a significant and apparently growing number of persons who are not benefiting from the services available to a varying degree under the aegis of the health boards. The Prison Service believes strongly that this situation has led to a continuing increase in the number of persons with psychiatric problems who end up in prison9

What the Review Group and, now, the Expert Group have  highlighted is, in effect, the transfer of responsibility for people with mental illness from mental health services to the prison system.

The Need for Diversion
Another key reason that so high a percentage of people in prison have a mental illness is that the criminal justice system as a whole lacks adequate powers, mechanisms and resources to ensure that people with mental illness who come into the system can be diverted to mental health and other care services and away from prison. At the present time, Irish legislation regarding persons with a mental disorder who come before the courts makes provision only in relation to those pleading \’guilty but insane\’ or those found \’unfit to plead\’ – in other words only the relatively small percentage of defendants with a severe mental illness impacting directly on the question of their guilt in relation to the crime with which they have been charged.

If a defendant does not come within these narrowly defined categories, but the court has concerns that he or she may be suffering from a mental illness, it has no formal powers to arrange that the person should receive treatment. The 1995 White Paper on Mental Health noted that in the absence of a \’formal mechanism\’ a judge had three options – to postpone sentencing and remand the person on bail on the understanding that he or she seek a medical assessment and/or treatment; to remand the convicted person in prison with a recommendation that he or she receive psychiatric assessment; to annex to a sentence of imprisonment a recommendation that the person receive psychiatric treatment.10

The White Paper on Mental Health acknowledged the need for legislative change to provide formally for the assessment and treatment of accused or convicted persons suffering from a mental disorder. “Ireland is unusual among European countries in not providing in law for such treatment and assessment.”11

The call for new legislation was reiterated in 2001 in the Report of the Review Group on the Structure and Organisation of the Prison Health Care Services. The Criminal Law (Insanity) Bill, 2002 represents potential for progress in this area, since it provides somewhat wider options and greater safeguards in relation to people with serious mental illness who come into the criminal justice system. However, the fact remains that it does not address the situation of those defendants who have a mental disorder but not one of such severity that they would come within the scope of the narrowly-defined situations with which the Bill  it is intended to deal. The right of such people to receive care and treatment, rather than punishment, is still not addressed.

In a reply to a Dail question, the Minister for Justice, Equality and Law Reform acknowledged the limited scope of the Bill when he stated: “the Bill is not designed to alter the sentencing powers of courts to include treatment orders, so that persons who are mentally ill, but who are not found to be criminally insane, who are charged with or convicted of a criminal offence, could be sent to an appropriate local hospital instead of being committed to prison.”12

A number of commentators on the Bill have argued that its provisions should be widened to provide courts with a range of options for dealing with defendants who have less severe mental illnesses. Examples of such options might be to enable the court remand a person on bail so that they could  receive psychiatric assessment on an outpatient basis, or provide the court with the power to place defendants under an order to attend an outpatient psychiatric treatment centre.

In any case, even the narrowly focused Criminal Law (Insanity) Bill has not yet been passed – nearly four years after its publication.

Psychiatric Services in Prisons
The study by the Kennedy team identifies three major ways in which the present mental health care services in prisons fall short of desirable standards:
1.    There is an incomplete provision of treatment modalities in prisons, for example, psychology, occupational therapy, counsellors, etc. A multidisciplinary approach is not widely available in prison.

2.    Patients requiring inpatient hospital treatment are transferred to a special security hospital (Central Mental Hospital) regardless of their security needs. In its 2001 report, the Review Group on Prison Health Services pointed out that, in fact, there was no legal requirement that inpatient care for prisoners be provided only in the Central Mental Hospital.  However, it noted that, partly due to the unwillingness of local health services to provide inpatient services for prisoners, “a practice has developed over the last 20-30 years where.. prisoners requiring psychiatric care are not treated locally but are transferred to the Central Mental Hospital with significant attendant inconvenience and disruption.” (p. 39) The Review Group pointed out that this policy contrasts with that which pertains when a prisoner needs surgical or medical inpatient hospital care.  In addition, the Group drew attention to the fact that there is a long waiting list for entry to the Central Mental Hospital, with the result that many of the prisoners who are recommended for transfer to inpatient psychiatric care never receive it.

3.     Acutely disturbed patients with mental illness in prison are often confined to isolation cells (\’strip\’/\’pad\’). The Kennedy report notes that beyond being an immediate response to a crisis situation, there is no therapeutic benefit from confining a person who is acutely disturbed: rather, there is a danger of harm if the containment is prolonged “for more than the shortest of durations”. The Irish Penal Reform Trust has  drawn attention to the use of isolation in Irish prisons13 as has Amnesty International (Irish Section). In 2002, the Council of Europe Committee for the Prevention of Torture and Inhuman or Degrading Treatment, following its examination of conditions in Irish prisons, stated:

In general, material conditions in (isolation) cells, including sanitary arrangements, were very poor. Persons in need of in-patient psychiatric treatment remained in padded cells for days and, on occasion, for longer periods. In the CPT\’s opinion, such treatment could well be characterised as inhuman and degrading.14

Kennedy Recommendations
Kennedy and his co-authors put forward a series of specific recommendations in relation to prison mental health services. These are:

• Mental health services should be reorganised with the adoption of a multidisciplinary approach for its delivery. This should include:
  • prison mental health nurses (with training in psychiatry) dedicated to mental healthcare of the prison population.
  • better screening procedures undertaken by persons trained in the assessment of mental illness and suicide risk.
  • better access to allied health services including occupational therapy, psychology and counselling.
• The practice of confining prisoners in isolation for mental health reasons should be ended. In the absence of suitable alternatives, provision should be made for appropriate local low secure units and reorganisation of the Central Mental Hospital to accommodate approximately 300 transfers from prison to inpatient psychiatric care.
• There is an urgent need for the implementation of mental health legislation that would facilitate the diversion of mentally disordered individuals from the criminal justice system to treatment in community psychiatric services. Existing (civil) mental health legislation and case law could be used more consistently.
• There is an urgent need for more secure psychiatric beds on a national level. The lack of provision of low secure units and under provision of community hostel beds in many (areas) should be addressed. (p. 113)

Recommendations of  A Vision for Change
Given the findings and recommendations of the Kennedy Report, and indeed of  previous studies, including the Review Group on the Prison Health Services, what is the approach being proposed by A Vision for Change, the Report of the Expert Group on Mental Health Policy? At the time of publication in January 2006, the Government stated that it had accepted the Report as providing a comprehensive policy framework for the development of mental health services over the next seven to ten years.

In light of the guiding principle  that prisoners with mental illness should have equivalence of treatment to that available to the general population, the recommendations on forensic health services in A Vision for Change need to be viewed in the context of the broader recommendations of the Report regarding a new model for mental health services for the population as a whole. The proposed new structure will consist of outpatient clinics, community mental health centres, day hospitals, crisis houses (used for crisis intervention and for acute respite purposes, both of which are envisaged as of being of brief duration), and acute inpatient units (based in general hospitals). The Report says that ‘difficult to manage behaviours’ (DMBs) can pose the most serious challenge to services and represent a serious risk to the service user and others. It is proposed to deal with acute DMBs by including a close observation unit of six beds in each fifty-bed acute psychiatric unit. Those with enduring illness DMB will be treated in thirty-bed intensive care rehabilitation units that will be located in each of the four Health Service Executive regions. It is stressed that the movement and transfer arrangements between the acute unit, close observation, intensive care rehabilitation units and  community-based facilities must be smooth and flow easily. (p. 101) It is clear from this proposed structure, and other broad recommendation of the Report, that the Expert Group  envisages that the main focus of policy in the future should be on optimum use of outpatient services and that where inpatient care is required this should be provided in small-scale units, with specialised services to meet particular needs, and that it should be used for the shortest duration possible.

Forensic mental health  services
A Vision for Change recommends that forensic mental health services should be “expanded and reconfigured”. It proposes that in addition to the existing five multi-disciplinary consultant-led teams based in the Central Mental Hospital, there should be four multi-disciplinary community-based forensic mental health teams, one based in each Health Service Executive area.

The reorganised system should incorporate diversion schemes, so as to minimise the number of people with mental illness coming into the criminal justice system. The Report refers in particular to the need for the forensic health service to develop strong links with An Garda Siochana, as an agency likely to come into contact with people who have mental health difficulties. In this context, it is recommended that, in each Garda Division, a senior Garda should be trained to act as a “liaison mental health officer”. The Report also draws attention to the need for  legislative change to enable court-based diversion programmes.

A Vision for Change says that all forensic mental health teams should provide services for people with co-morbid substance misuse and mental disorder. It recommends the establishment of a specialised residential unit for intellectually disabled persons who come into the criminal justice system and who have mental health problems. Likewise, it recommends a small residential unit for children and young people  who are in detention centres and, in addition, specialised community-based mental health services  for young people who come into conflict with the law but are not detained.

Prison mental health services
The Report emphasises that mental health services in prison should be “person centred” and , “recovery oriented” and based on integrated care plans. Mental health services need to be “interwoven” with social work, educational, psychological and addiction services, if the complex social and health disadvantages experienced by so many prisoners are to be addressed.

The Report states as an key principle:

Every person with serious mental health problems coming into contact with the forensic system should be accorded the right of mental care in the non-forensic mental health services unless there are cogent and legal reasons why this should not be done.

Clearly, an area where this principle will be particularly tested is in the provision of inpatient care. There is widespread agreement that increased capacity to meet the inpatient care needs of prisoners is required. The waiting lists for admission to the Central Mental Hospital are indicative of the current shortfall. If additional inpatient services are to be provided in keeping with the principle advocated by the Expert Group, then how will the long-standing policy of not requiring local mental health services to provide for the inpatient needs of prisoners be reversed?

A Vision for Change recommends that the Central Mental Hospital be “upgraded and improved”, which is welcome. It also recommends that the capacity of the CMH should be increased (p. 140). It is not immediately clear the extent of the increase in capacity that is intended. If it is significant, then it needs to be asked whether this will not inevitably lead to the Central Mental Hospital continuing to be the sole provider of inpatient services for prisoners, with local mental health services continuing to  exempt themselves from providing any inpatient care for prisoners, no matter how low a security risk they might pose.

Such a situation would clearly be in contradiction of the overall thrust of the Report’s recommendations and of the principle that mental health care should be provided in the ‘least restrictive environment’.

Solitary confinement and padded cells
The Expert Group acknowledges  use of  what it calls “special cell confinement”, particularly in Cloverhill Prison. It says that this arises because  of the “physical
and human resource limitations at the CMH (Central Mental Hospital):” which mean that “many seriously ill prisoners cannot be immediately transferred there for treatment”.  (p. 138)

However, it is disappointing that the Report\’s recommendations in respect of forensic mental health services do not make specific  reference to ending the use of isolation cells for dealing with acute or crisis episodes experienced by prisoners with mental health problems.  (pp.142-143)

Post-Release Services: Avoiding \’ The Revolving Door\’
All too often, prisoners who have a mental disorder are released with little or no discharge planning.15 No agency has the duty to link them to needed treatment, housing and other services.

The consequence of a failure to ensure continuity of care is illustrated in the story, reported to us by an agency working with homeless people, of one young man who had spent time in prison and while there was treated for psychiatric illness. No arrangements for post-release psychiatric care were put in place; when the  young man came out of prison his medical card had expired, with the result that he was not able to  go to a GP to get a renewal of his prescription. There quickly followed a downward spiralling of his situation and a mere few months after his release from prison he was found dead.

The fate of too many offenders with a mental illness has been summed up by one commentator as follows:

Mentally ill patients with a criminal record are often placed in a lose-lose situation. While incarcerated, their condition tends to worsen. And upon release, they are often unable to access available community treatment because of providers\’ reluctance to serve themThe results are painfully clear: many defendants with mental illness churn through the criminal justice system again and again, going through a \’revolving door\’ from street to court to cell and back again without ever receiving the support and structure they need.16

The implementation of the comprehensive range of mental health services envisaged in A Vision for Change, and the improved liaison and more effective coordination between forensic and other mental health services called for in the Report, would in general increase the possibility that the post-release needs of mentally ill former prisoners would be met. None the less, it would have been useful if the Report had more explicitly explored this problem and made  specific recommendations  for addressing it.
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Conclusion
The findings of the first comprehensive study into the incidence of mental illness among Irish prisoners present a picture of worrying rates of mental illness and substance abuse. The study’s results obviously pose significant challenges to the Irish Prison Service which has overall responsibility for the management of our prisons. Arguably, they pose even greater challenges to other elements of the criminal justice system and to the mental health and general care services for the community as a whole. The study’s findings will reinforce the view of many that Irish society all too often pushes onto the prison system the task of dealing with people who have been repeatedly failed by other systems.

The recommendations put forward by both the Kennedy report and the Expert Group on the Mental Health Services show how mental health services in prisons can be improved and how the incidence of people with mental illness coming into prison in the first place could be reduced.

Irish society finds itself well-placed to radically transform mental health services, given its unprecedented levels of wealth. It has been offered A Vision for Change: does it have the will for change?

References:

1.    Irish Prison Service (2004) Health Care Standards, Dublin, p. 6. (http://www.irishprisons.ie/publicationsList.asp)
2.    United Nations Office of the High Commissioner for Human Rights, Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care, adopted by General Assembly Resolution 46/119 of 17 December 1991. The Principles are frequently referred to as the MI Principles.
3.    Harry Kennedy et al (forthcoming) Mental Illness in Irish Prisoners: Psychiatric Morbidity in Sentenced, Remanded and Newly Committed Prisoners, Dublin: National Forensic Mental Health Service.
4.    C. Smith et al (1996) “Mental Disorders Detected in an Irish Prison Sample”, Criminal Behaviour and Mental Health, 6, p. 180.
5.    P. Carmody and  M. McEvoy (1996) A Study of Irish Female Prisoners, Dublin: Stationery Office, pp. 14-15.
6.    S. Fazel and J. Danesh (2002) “Serious Mental Disorder in 23,000 Prisoners: a Systematic Review of 62 Surveys”, The Lancet, 359, p. 545.
7.    Amnesty International – Irish Section (2003) Mental Illness: The Neglected Quarter, Dublin: Amnesty International – Irish Section, p. 29.
8.     A Vision for Change: Report of the Expert Group on Mental Health Policy (2006) Dublin: Stationery Office.
9.    Report of the Group to Review the Structure and Organisation of Prison Health Care Services (2001), Dublin: Department of Justice, Equality and Law Reform, p. 39.
10.    Department of Health (1995) White Paper: A New Mental Health Act, Dublin: Stationery Office, par. 7.3 – 7.4, pp. 66-67.
11.    Ibid., par. 7.11, p. 69.
12.    Dail Debates, 13 May 2003.
13.    V. Bresnihan (2001) Out of Mind -Out of Sight: The Solitary Confinement of Mentally Ill Prisoners, Dublin: Irish Penal Reform Trust.
14. Council of Europe (2003) Report to the Irish Government on the Visit to Ireland Carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 20 to 28 May 2002, Strasbourg: Council of Europe, 18 September 2003 (CPT/Inf (2003)36[EN], par. 128.
15.    In his first Report, the Inspector of Prisons was critical of the way in which prisoners on completion of their sentences were released without adequate support or access to services (see First Annual Report of the Inspector of Prisons and Places of Detention for the Year 2002-2003 (2003), Dublin, pp. 52-55).
16.    D. Denckla and G. Berman (2001) Rethinking the Revolving Door: A Look at Mental Illness in the Courts, New York: Center for Court Innovation, p. 4.

Many thanks to Dr Harry Kennedy for making available to me the report, Mental Illness in Irish Prisoners: Psychiatric Morbidity in Sentenced, Remanded and Newly Committed Prisoners, which is soon to be published.