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Minisymposium

Mental health in prisons: great difculties but are there opportunities?

A. Fraser a, A. Gatherer b , * , P. Hayton ca WHO Collaborating Centre and Scottish Prison Service, Edinburgh, UK b WHO Health in Prisons Project and former DPH, Oxford, UK c WHO Collaborating Centre for Health in Prisons, Department of Health and Settings in Health Promotion Unit, University of Central Lancashire, UK

a r t i c l e i n f o

Article history:Accepted 21 April 2009Available online 5 June 2009

Keywords:PrisonsMental disabilityMental health

s u m m a r y

Prisons carry a great burden of mental disability from major conditions (despite diversion schemes) tolesser forms. This article gives facts and gures which justify the call for urgent action. In the light of theWHO Trencin Statement on prisons and mental health and other reports, it lists the key aspects of anemerging new agenda for mental health and prisons.

2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Introduction

An experienced prison governor was quoted a few years ago assaying that

the failure to tackle widespread mental illness among prisoners isstoring up huge social and public health problems for the future. 1

In a lecture in which he talked about court diversion, dualdiagnosis and the huge unmet need of lower level mental healthproblems, he stated:

Add to this the additional unmet need amongst black and minorityethnic prisoners, the complexities of foreign national prisoners,older prisoners and the huge number with learning disabilities, wehave not only a recipe for despair but also for an increased likeli-hood of re-offending and the creation of more victims if the prob-lems are not addressed.

Since then, considerable effort has been undertaken to outlinethe problem clearly and to determine which remedies should betaken. 2 However, the feeling persists that the mental healthproblem in prisons is still under-recognised, not high enough onthe public health agenda, and a constant daily nightmare for prisonsystems everywhere.

For some years, there has been a clear policy to divert the mostobviously mentally ill away from prisons to more adequate

specialist facilities, with some success. In the UK, a range of servicelinks between the judicial and the public health systems has led tovarious arrangements for looking after the severely mentally ill,although the prisons still shoulder much of the responsibility forsecure mental health care. 3 Numerous men, women and childrensuffering from a wide range of mental health conditions are still inthe criminal justice system. Within the sometimes overwhelmingburden of need for care within prisons today lies the on-goingproblem of people with addictions to drugs and alcohol and withvery low mental health resilience, low self-belief and little possi-bility of recovery without skilled help.

There is increasing recognition that prisons carry a considerableload in these lesser forms of mental illness; conditions suchas depression, anxiety and stress-related conditions affect themajority of prisoners. 4,5 The impact of imprisonment on the mentalhealth of all prisoners should be better understood.

It is the authors belief that a new agenda for mental health andprisons is beginning to emerge. Through better understanding of the size and complexity of the challenge, collaboration betweenexpert groups, the World Health Organization (WHO) and researchbodies such as the Sainsbury Centre for Mental Health concen-trating much of its effortson the criminal justice system, it is clearerwhat needs to be done. However, this still represents a considerableand important challenge for prison authorities. 2,6

The desired outcome will not be possible if other aspects of mental health care are not developed. The notion of trans-institutionalization remains unproven; the theory that the closureof long-stay mental institutions without adequate development of community services is a key reason for the dramatic increase inprison populations in some developed countries such as the USAand UK. Whether true or not, there is little doubt that national

* Corresponding author.E-mail address: Alexgatherer@aol.com (A. Gatherer).

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0033-3506/$ see front matter 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

doi:10.1016/j.puhe.2009.04.005

Public Health 123 (2009) 410414

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strategies for mental health care must include a prison strategy sothat a range of caring facilities are available, allowing those in needto be looked after in places where their needs can best be met.

Some basic facts on prisons and mental health

Of the two million prisoners in Europe, at least 400,000 sufferfrom a signicant mental disorder. Overcrowding, bullying,marginalization, stigma and discrimination have a negative inu-ence on mental health. 2 There is also considerable co-morbidity,with the overall percentage of prisoners who suffer from a mentalhealth problem and/or drug dependency estimated to be 6065%.Indeed, the prevalence of drug use among prisoners is high; formale prisoners, the prevalence rates range between 10% and 48%. Ingeneral terms, the lifetime prevalence of psychiatric co-morbidityamong drug users in prison is two to three times higher than in thegeneral population.

Young offenders are more likely to become adult offenders of thefutureif they donotreceive early interventionandcare.Young peopleare 18 times more likely to commit suicide in prison than in thecommunity, and they have an even greaterprevalence of poor mentalhealth than adults, with 95% having at least one mental healthproblem and 80% having more than one mental health problem.

Imprisoned women are far more likely to have had traumaticexperiences in early childhood than imprisoned men; these eventsinclude early sexual, mental and physical abuse. Half of thesewomen will have experienced domestic violence, one-third sexualassault and one in 10 will have attempted suicide before beingimprisoned. Eight out of 10 women in prisons will suffer fromdiagnosable mental health problems, and two-thirds will be drugdependent or use alcohol to dangerous excess. 7

International research in Europeon mental health and prisons hasproduced very similar results. 8 Approximately 4% of maleand femaleprisonershave psychotic illnesses, and10% of menand12% of womenhave major depression. Forty-two percent of women and 65% of menhave a personality disorder. No fewer than 89% of all prisoners have

depressive symptoms and 74% have stress-related somatic symp-toms. Approximately 612% of prisoners should actually be trans-ferred out of prisons to specialist psychiatric facilities, and 3050%require some assistance from mental healthcare services.

It is likely that diversion approaches will gradually becomemore effective and that specialist psychiatric in-reach services willbecome more widely available to prisons in all countries. However,it is clear that radical change and considerable development will beessential if the current unsatisfactory position is to be rectied.

The WHO statement on prisons and mental health: the Trencin Statement

The above statistics led the WHO Health in Prisons Project 9 to

focus on these issues within Europe. After two conferences andexpert group meetings, a consensus statement on prisons andmental health was issued with a strong call for action. 2 In itsopening sentences, it indicates clearly that something must bedone:

Without urgent and comprehensive action, prisons will movecloser to becoming twenty-rst century asylums for the mentallyill, full of those who most require treatment and care but who areheld in unsuitable places with limited help and treatment available.

The Trencin Statement puts forward the case for prison systems,and wider public health systems, to take prisons and mental healthmuch more seriously. It advocates that while recognizing the

concentration of people with severe and enduring mental illness in

prisons, the treatment of acute or major mental illness is inappro-priate for prisons.

The ethos of prison is wrong. Resources, facilities and clinical skillsare usually inadequate, the institutions are not geared to thera- peutic environments. People with very high needs fail to thrive.Responding to the needs of people with severeand enduring mentalillness who are acutely unwell is a complex matter it is expensive

for whichever system responds to their needs. 10

The development of suitable systems that meet these needsrequires collaboration between health, judicial and legislativeinterests, and merits resources. It is often bound up with mentalhealth legislation of the country and closely allied with humanrights and entitlements. However, the Trencin Statements asser-tion is unavoidable as a challenge to public health systems, giventhe experience and knowledge available from Member Stateswithin the WHO European region.

The Trencin Statement goes on to state:

As a great majority of prisoners will at some point return to thecommunity, it is in the best interests of society that a prisonershealth needs are met, that the prisoner is adequately prepared for

re-settlement and that the causes of re-offending are addressed. Prisoners, regardless of whether or not they are patients with

mental health problems, need to be ready to face and, wherepossible, thrive in the world outside on completion of theirsentence.

The emerging agenda for mental health and prisons

The Trencin Statement gives some shape to the new agenda formental health and prisons. Prisons have to cope with mental illnessof every severity, but, in addition, prisons accept the need to reducefurther harm to mental well-being from the experience of prisonwhile reducing the risk to the public through crime or acts made

more likely by mental disorders. It stresses the need for increasedsupport to prison staff as well as continuing training in the subject.It highlights the importance of in-prison services having closerelationships with services provided in the community. It seesmental health care in prison as part of an overall mental healthcarestrategy, and part of a wider public health service.

The Trencin Statement also suggests that mental health andresilience can be protected and even promoted despite the inevi-table constraints from the imperative of security. Mental healthpromotion, unlikely as it sounds, is possible in prisons and is anessential component towards rehabilitation.

The production by the WHO Health in Prisons Project of a consensus statement on mental health promotion in prisons in1998 was, in many senses, ahead of its time. In the new agenda, the

promotion of mental health and well-being should be central toa prisons healthcare policy. Some of the 1998 reports recom-mendations have been recalled by Blaauw and van Marle. 8

Onecomplicating factor has tobe remembered;doctorsand nursesdo not determine when a prisoner with a mental health problemleavesprison. For theminoritywhocommit serious crimesand whosesentences are reviewed, health evidence is placed alongside otherconsiderations of a criminological, social, psychological and resourcenature in determining future risk and prospects for release andsubsequent support. For the vast majority, however, who are servingshort sentences foroften minor crimes, release dates are a function of punishment tariffs setearlierandareveryunlikelyto take into accountthe likely course of mental illness or deteriorating general healthsubsequent to serving a prison sentence.The transitionof release from

prison often means that prisoners are lost to community-based

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mental health services, even if they have the capacity to absorb theworkload. 3,6,10 Therefore, in addition to the effects of imprisonment,supervision of mental health care is likely to take a further step back.Throughcare is perhaps the greatest challenge to the development of mental health services in Western countries. 6

It can be seen therefore that the new agenda for mental healthand prisons broadens out from the historical position of concen-trating on the recognition and treatment of people with severe andenduring mental illness, towards accepting that the majority of prisoners have mental health problems of every degree of severity.The mental health agenda does not stop there. It is necessary toprevent illness or the worsening of illness amongst prisoners oncoming into prison. A further extension of this approach would bethe protection amongst prisoners of any existing sense of mentalhealth and well-being. In fact, is it possible to imagine prison asa place to aspire for the promotion of mental health as a positivestate, as set out in the WHOs principles of the attainment of thehighest possible standard of health and well-being?

It is broadly agreed that severe and enduring mental illness is,for the most part, not preventable. However, it is possible to deviseways of lessening the risk of deterioration of mental illness of thistype through close support, high-quality care and creating anenvironment in which that person, to an extent, can thrive. 10 Themass of other types of mental illness is preventable, or, at least,possible to prevent from deterioration. It is possible for a prisonsystem to exert substantial positive inuence on levels of mentalwell-being across the prisonpopulation. This could extend, even, toprison as a community, with a positive effect on staff; visitors,especially the families of prisoners; and the wider community towhich prisoners will return. This approach and agenda is not onlydesirable, but important, possible and strategically achievablewithout necessarily incurring great expense. A basic level of mentalhealth understanding and skilled health professional care isnecessary, especially for those who are most severely affected withillness. However, the entire environment of prison is a matter forthe whole institution and service, and can fundamentally change

the prospects of individuals and large groups within prison for thebetter. 10

Understanding prison as a setting for mental health andillness

First, which factors in prisons contribute to poor mental healthamong prisoners? These were listed by WHO and ICRC 11 to include:

overcrowding; various forms of violence; enforced solitude; lack of privacy; lack of meaningful activity; isolation from social networks; insecurity about the future; and inadequate health services, especially mental health services.

A more recent study 12 reported on the views of prisoners in oneregion of England about the impact of imprisonment, and theaspects of the prison environment and day-to-day life that mostaffected them. The reported factors were, not surprisingly, similarto those listed above but added some useful detail:

. bullying by other inmates; concerns about family; having no onethey can trust to talk to; having little meaningful activity, themonotony of the regime; substance misuse; incompatibility with

cell mates; poor diet; limited access to physical activity; unresolved

past life traumas and difculty in accessing services, particularlyhealth care and counselling.

Against these factors which have a poor effect on prisonerswell-being, research in different types of prison regimes anddifferent countries revealed a consistent pattern of expressed needsamong prisoners. 8 The top ve were as follows:

1. self-advancement and self-improvement through reliable andtangible assistance. Personal development and respect fromother people seem to be of great importance to prisoners;

2. to be loved, appreciated and cared for; supportive relationshipswhich provide emotional support and empathy;

3. activity and distraction; the need to maximize the opportunityto be occupied and to ll time;

4. need for safety and for environmental stability and predict-ability, although this seemed to vary with local circumstances;and

5. the need for privacy or autonomy are usually of lessimportance.

With these factors in mind, WHO has been keen to recommend

the steps necessary to raise the prospects for people with poormental well-being and mental illness in prisons. A checklist, rstissued in 1999 and repeated in the chapter by Blaauw and vanMarle 8 in the WHO Prison Health Guide, ts in well with the newagenda as it relates to all stages of imprisonment. A prisoners rstexperience on coming into prison can be crucial to the rest of his/her stay. The physical and social environments in which they live,and the quality of interaction with staff, are key to consistent andpositive relationships. Relative freedom from boredom andengagement in activity is a further theme, whilst the respect forindividuals and their basic human rights completes the checklistprole.

Prison, therefore, rather than prison health services alone, canbe a setting for positive mental health, as well as the treatment of illness and protection against worsening of mental health prob-lems. A whole-prison approach, as outlined by Hayton, 13 is centralto what is required. Good mental health care has to includea supportive and promotional aspect; this cannot be left to healthstaff alone.

The context and dimensions of the challenge of mental healthin prison

Some important contextual aspects have been outlined recentlyby Fraser. 10 First, the burden of illness in general is substantial inprisons, and the health care needed is usually well in excess of many assessments. Health care alone is insufcient, especiallywhen the need is also to protect, preserve and treat mental illness

and promote mental health. Mental health in prison is a whole-prison concern. In many respects, it is not a matter of mentalhealth rather, a humane and decent regime that is properlyresourced and whose ethos is couched within a society thatunderstands the role of prisons and its potential for benet tocommunities. Therefore, explaining the work of prison to thepublic is a necessary element in the overall challenge.

Second, it is important to appreciate that mental health does notexist in isolation not at the individual level, and certainly not ingroups and across prisons. The majority of prisoners have complexproblems that are multi-layered and do not stop with labels such asmental illness and addiction. Problems with housing and home-lessness, family relationships, the total experience of poverty, basiclife skills and prospects for making a positive contribution to the

community on release operate as inuences and, often, severe

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brakes on progress in mental health and well-being. Mental healthin prison, therefore, has to be seen in the context of society, and thetotal experience of crime, punishment and poverty.

Third, as well as explaining its function to wider society, prisonalso has to set out its limitations:

Prison is not a place to receive people for whom society has noother answers. It is not a place to go if you are acutely mentally ill,

or if your offending is driven primarily by the state of your mind. It is not a place to go as a pre-paid public service that is easier, lessawkward and less visible to the public eye and public nances thanother, more appropriate, alternatives. 10

A feature of recent decades has been rising public expectationsof protection by state means, and falling tolerance of people whoexhibit antisocial or apparently abnormal behaviour. Prisons areunder considerable pressure to accept immediately and withoutconditions or selection anyone sent to them by the courts. It is nosurprise that many of those will have mental health problems.

Some key elements of a new agenda for mental health andprisons

Three majorreports have been pub lished about mental health ingeneral or mental health in prisons 2,14,15 with valuable recom-mendations from which guidelines and checklists can be devel-oped. They have several features in common and each believes thatthe time is right for action. Their recommendations seem to bebased on the following key elements:

a) Prisons are part of society. The complete isolation of prisons isnot possible nor acceptable in terms of human rights, publichealth or the job which prisons have to do. Prisoners retain alltheir rights intact except for personal freedom. Sooner or later,they return to society, and the modern-day prisons job is toensure that they are tter and better prepared for a crime-free

and productive life. Society has to understand and accept thiscentral fact.

b) The prison service is a public service. Although the least knownof allpublic services,the prisonservicehas been deliberatelysetupfor a set of purposes considered byall of us tobe essential. Inrecent times and in some countries, this simple fact hasencouraged close links between prisons and the public healthand educational systems, with the aim of ensuring equivalenceof teaching and treatment to what is available in the commu-nity. Despite the essential needfor security, servicesprovidedinprison should be as seamless as possible with those outside.

c) Appropriate placement should be the basic policy. It is surelyboth in the requirements and the spirit of human rights that allthose whose freedom is removed by due process of the lawshould be admitted to secure and safe premises able to meettheir needs. If those needs are for specialist psychiatric care,they should be admitted to places able to provide that care,whether in secure hospital or in prison.

d) Individual variability should be planned for, wherever possible.To most people, being imprisoned can be a shock. Any pre-sentence weakness can be worsened considerably by impris-onment. There has to be good personal assessment and accu-rate history-taking from the start, and good screening atregular intervals during the period of imprisonment.

e) Most serious health andsociomedical conditions need a whole-prison approach. It is often said that health is too important toleave to health staff alone. Although health staff have a vital

leadership and caring role, all staff have to be aware of the

nature of the problem and understand their part in providinga therapeutic environment.

f) All parts of a modern effective mental health strategy should beavailable. This should include: comprehensive assessmentprocedures; a wide range of community services; diversionopportunities to a range of other facilities, including securespecialist hospital places; in-reach specialist teams; treatment

for addictions and conditions such as post-traumatic stressdisorder; all staff should have access to continuing training andalso to quick help; and all staff should have their own healthand mental health promoted.

g) Primum non nocere: by all services provided. Prisons shouldbe planned, run and given all the support necessary withproper stafng to ensure that their rst consideration is not tocause harm.

h) All national and local mental health strategies should havea clear prison component. Poor mental health care in prisonsmeans poor mental health care generally.

i) Hope. Thereis a new understanding thatoffersrealhope tothementally ill. 14 A successful mental health strategy will includethe importance of supporting, encouraging and initiating feel-ings of hope in those requiring help. Encouraging a realisticcondence that things can be better; that they can, in mostcases, recover and that they have a worthwhile future areimportant aspects of a humane caring service.

Mental health, prisons and public health: the future

It is now time forpublic healthto placemental healthat thetopof their agenda for research and action. A profession which believes inhealth for all as achievable and worth striving for, which has social justice as a core value, should do more for the manypeople in societywith mental health difculties. Those with mental disabilities need

understanding, a lessening of the stigma surrounding them, andaccess to the particular service which is best able to help them.However, everyone needs a much greater level of understanding;the society in which we live can do so much to harm mental health,and therefore has to become more caring and supportive.

There are steps to be taken by all of us. For politicians and policymakers committed to better health and better justice, there isa need to send out a message that good prisons can be good forpublic health; and that good prison practice that promotes mentalhealth makes the country safer because people in prison who haveproblems that are addressed are less likely to commit more crimeafter they leave.

For health services, the case of mental illness in prison isa reminder that the balance of care needs to shift towards the

support of people with complex problems. Prison is just one settingwhere health services are likely to nd people who are usually hardto reach, and who can gain so much from good services.

For policy makers in the prison system, the challenge willremain to appreciate the highlevel of mental disability which existsin prisons, and to provide, despite stretched resources, what is nowrecognized as being essential if a proper service is to be provided.Prison leaders need to be more engaged with the argument that thepotential for benet through good prison practice has benets forthe mental health of both the individual, and the overall running of the institution, as well as its staff and other prisoners.

The public and the justice system must understand that prisonshould not be a dumping ground for people with mental illness, asa rst step towards reducing the unnecessary, unjust and harmful

imprisonment of offenders with mental disabilities.15

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With the wider recognition that mental health, neglectedfor fartoo long, is crucial to the overall well-being of individuals, societiesand countries, and must be universally regarded in a new light, 14

the special needs of those in prisons and the contribution that goodprison mental health and general care can make to public health asa whole must be given the priority they deserve.

Ethical approval

None required.

Funding

None declared.

Competing interests

None declared.

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3. Edgar K, Rickford D. Too little too late: an independent review of unmet mentalhealth needs in prison . London: Prison Reform Trust; 2009. ISBN: 0946209 90 1.

4. WHO European Ofce. Health in prisons a WHO guide to the essentials in prison health. Copenhagen: WHO. Available at: http://www.euro.who.int/document/e90174.pdf ; 2007 (accessed 28 May 2009).

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363852d6-79d1-464c-9b65-857721c2a628.pdf ; 2007 (accessed 28 May 2009).6. Sainsbury Centre for Mental Health. On the outside (continuity of care for people

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9. WHO. Available at: http://www.euro.who.int/prisons ; 2009.10. Fraser A. In press.11. WHO/ICRC. Information sheet on prisons and mental health . Geneva: WHO.

Available at: http://www.euro.who/int/Document/MNH/WHO_ICRC_InfoSht_MNH_Prisons ; 2005 (accessed 28 May 2009).

12. Durcan G. From the inside; experiences of prison mental health care . London:Sainsbury Centre for Mental Health; 2008.

13. Hayton P. Protecting and promoting health in prisons: a settings approach.Health in prisons: a WHO guide to the essentials in prison health . Available at:http://www.euro.who.int/document/e90174.pdf; 2007 (accessed 28 May2009).

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