Nick Clegg has launched the Department of Health’s latest action plan for mental health services, Closing the Gap: priorities for essential change in mental health. While the report was overshadowed by the Lord Rennard sexual harassment affair and the ensuing crisis among the Liberal Democrats, it represents an encouraging turning point in the policy discourse on mental health, sounding a robust call for change. But it stops short of a full-blown investigation of how serious mental health problems manifest among a too-overlooked group: the UK’s prison population.
In England and Wales in 2013, there were 199 deaths in prison. The prison population is ageing, so the number of deaths in prison is likely to rise. But on the whole, offenders have much greater healthcare needs than the general population. For example, there are higher levels of alcohol and substance misuse in this group, as well as higher levels of mental illness. This is reflected in the 2013 deaths figure, which includes seventy deaths that were self-inflicted. These incidents are not spread across the prison estate; for example, there were five male prisons that each recorded three self-inflicted deaths.
As the RCN guide for staff working in the criminal justice system notes, many offenders enter prison in poor physical and mental health because they have had limited access to health care services within their own community. As well as pre-existing health needs, offenders are also at risk of health problems created as a consequence of imprisonment.
The identified risk factors for suicide such as substance misuse, a history of mental illness and unemployment are much more prevalent in offenders than the wider population. These factors and the difficulties they cause are demonstrated very clearly in a 2010 study of psychiatric disorders among male prisoners who had attempted suicide.
The authors interviewed 60 prisoners who had made near-lethal attempts on their own lives, and compared their experiences with those of a control group of 60 other prisoners. The most common methods used were hanging or ligatures (40), followed by serious incidents of cutting (12). Institutions such as prisons or psychiatric units try to design out or reduce the opportunities for self-harm and injury. But it is clearly not possible to do this completely: 59 of the incidents took place in the prisoner’s own cell.
The study demonstrated that prisoners who had no educational qualifications, who had been in prison previously, who had been imprisoned for less than 30 days, or who had been in their current prison for less than 30 days were much more likely to attempt suicide than other prisoners.
The research also emphasises one of the problems with trying to tackle this issue: in a population where self-harm, suicide attempts and mental health problems are relatively common, identifying those most likely to take their own lives can be difficult. Nevertheless, the finding that only 24 (40%) of the cases were identified as being “at-risk” for suicide at the time of their attempt indicates that there is scope for improving detection of those at risk of suicide, perhaps with a structured suicide screening tool. The study suggests that such an instrument should include questions regarding prisoners’ history of psychiatric contact, previous self-harming and suicidal behaviour (especially if this occurred while in prison), and current psychiatric disorders.
Rehabilitating the system
The mental health needs of offenders and others who come into contact with the criminal justice system have been long neglected. But recently there have been a number of attempts to push this matter higher up the policy agenda. For example, after the tragic 2008 suicide of the son of a Women’s Institute member in HMP Manchester, the National Federation of Women’s Institute began its Care not Custody campaign, passing the following resolution:
In view of the adverse effect on families of the imprisonment of people with severe mental health problems, this resolution urges HM Government to provide treatment and therapy in a more appropriate and secure residential environment.
Wider concerns about the treatment of people with mental health problems in the criminal justice system were the subject of the 2009 Bradley report, which concluded that there are now more people with mental health problems in prison than ever before, and that “while public protection remains the priority … custody can exacerbate mental ill health, heighten vulnerability and increase the risk of self-harm and suicide”.
There are reasons to be hopeful, among them the apparent decline in female prison suicides. This is largely attributable to the response to the 2007 Corston Report on women’s experiences and welfare in prison. The inquiry was established following an increase in the suicide rate amongst women prisoners, including six suicides in 12 months at HMP Styal, and its recommendations from that report have been effective in reducing the number of these awful events.
The state has a clear moral and legal duty to do all that it can to ensure the safety of those in custody, whatever the reason for their imprisonment. The Trencin Statement on the treatment of prisoners emphasised that in accordance with the UN’s basic principles for the treatment of inmates, “Prisoners shall have access to the health services available in the country without discrimination on the grounds of their legal situation”. This involves mental health care, and there is no excuse for not providing it; as the Corston Inquiry shows, it is possible to take institutional steps to prevent these awful events.
As has been discussed previously on the Conversation, the use of imprisonment in the UK has increased significantly over the past 20 years. Prisons will never be therapeutic environments, as their focus will always be principally on security and any notions of rehabilitation are pushed to margins by crises such as overcrowding.
Above all, the circumstances under which people enter prison demand urgent reform. As the study quoted above shows, many suicidal prisoners are serving short sentences; all the research shows that short sentences serve no real purpose, and do more harm than good. This is not an argument for longer sentences, but rather for community-based alternatives that tackle the causes of offending – be they alcohol, drug misuse or a lack of training or skills. Until society tackles its own addiction to imprisonment, prison staff will still struggle to safeguard their most vulnerable prisoners.