CRIMINAL JUSTICE AND MENTAL HEALTH:

‘LONG ABSENT SOON FORGOTTEN’

Professor Charlie Brooker

Introduction

• Mental Health

• Debts

TheThe

CriminalCriminal

JusticeJustice

SystemSystem

PolicingPolicing

CourtsCourts

ProbationProbation

Prison ServicePrison Service

Prevalence of Mental Health Disorder

Prisoners Community-based

offenders

DEPARTMENT OF HEALTH POLICY

Education & Training

Research Clinical Initiatives

CSIP IMPLEMENTATION PROGRAMMECSIP IMPLEMENTATION PROGRAMME

CRIMINAL CRIMINAL JUSTICE AND JUSTICE AND

MENTAL HEALTH MENTAL HEALTH PROGRAMMEPROGRAMME

UNIVERSITY OF UNIVERSITY OF LINCOLNLINCOLN

FACTS ABOUT PRISON

•The population in custody as of 30th April 2007, was 80,955

Prisons 80,261

Police Cells 208

Secure Training Centres 256

Secure Children’s Homes 229

•The Total in Prison was made up as follows:

95% Men 5% Women

16% On Remand

•The number of sentenced prisoners increased by 6% over the past year

•Those with an indeterminate sentence increased by 31%

•The population aged 18-21 year old increased by 9%

•The largest number in any one prison is 1,482 - Wandsworth

Introduction Prisons

The Consequences of

Prison Overcrowding:

Increased Lock up Time (Despatches – North Sea

Camp)

Wrong People in the Wrong Level of

Security

Less monitoring of substance misuse

Increases in “Short Notice” Moves

Less Health Resources

Facts about Probation•The National Probation Service supervises 175,000 offenders

a year (200,000 a day) of whom 90% are men.

•Nationally 10% of women, but in Lincolnshire the figure is 16%, one quarter of whom are aged 16-20.

•The most common orders under which people are supervised a:

o Community Rehabilitation Order (59,000 commencements 2004)

o Community Punishment Order (55,000)

o Drug Rehabilitation requirements formerly DTTOs (8,000)

•Community Service 8 million hours of unpaid

work undertaken by offenders (2005/6)

Prevalence of Mental Disorder for Offenders on Probation Officer Caseloads

Very little useful information in this area

Dunning OASys assessment offenders are asked if they have current psychological / psychiatric problems diagnosed by a clinician

This is then coded but clearly giving very crude estimates

OASys dataset of sentenced offenders n=28, 467

Figure 1 % identified within in offence category having either psycholgical or psychiatric problems diagnosed

41 3830

24

40 4147

3136

01020304050

Offence category

Perc

en

tag

e

Prevalence of Mental Health Disorders

• 16% people in England have a mental health problem (Sainsbury Centre, 2006). This compares with 72% of male and 70% of female sentenced prisoners who suffer from 2+ mental health disorders (Prison Reform Trust, 2006)

• ONS survey examined rates of neurosis, psychosis, personality disorder, alcohol abuse and drug dependence, and found that 12-15% of sentenced prisoners screened positive in four out of these five areas (DoH, 2001)

• 1/100 people in England have a severe mental health condition e.g. schizophrenia/bipolar disorder (Sainsbury Centre, 2006)

• 7% of male and 14% of female sentenced prisoners have a psychotic disorder. This is 14 and 23 times the general population level (Prison Reform Trust, 2006)

• 40% of male and 63% female sentenced prisoners have a neurotic disorder – over three times the general population level (Prison Reform Trust, 2006)

• HM Chief Inspector of Prisons 2003-04 report showed that:

• “Many prisoners had mental health needs, some so acute that they were awaiting transfer to NHS acute psychiatric care. At Brixton, 30 of the 33 inpatient beds were occupied by mentally ill prisoners, five awaiting sectioning and transfer” (p44).

• Also, “There remains a lack of primary mental health provision in a number of establishments. There was also a general lack of any service that could begin to meet the needs of the many prisoners (both male and female) who might want to disclose histories of significant physical, emotional or sexual abuse and the relationship of that to subsequent offending behaviour” (p28).

Self-harm

• In 2005, 597/1000 (60%) women and 50/1000 (5%) men harmed themselves while in prison (Prison Reform Trust,

2006)

Number and Rate per 100,000 of Self Inflicted Deaths in Prison Establishments 1997 - 2005 and The Rate per 100,000

1997-2002 in the General Population

0

20

40

60

80

100

120

140

160

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Date

Nu

mb

er

/ Ra

te p

er

10

0,0

00

Number

Rate ofSuicideper100,000

GeneralPopulation rateper100,000

• Amanda: Amanda Downton, an inmate of Styal Women's Prison talks about self-harming while

she is having her wounds bandaged.

http://www.bbc.co.uk/mediaselector/check/player/nol/newsid_4730000/newsid_4732400?redirect=4732446.stm&news=1&nbram=1&bbram=1&nbwm=1&bbwm=1

Case Study A

•David is a 40 year old man with approximately 10 year history of contact with psychiatric services charged with rape and attempted murder, offence occurred some 13 years previously.

•Initially presented reporting auditory and visual hallucinations and a complex delusional belief system. Shortly prior to his arrest local his CMHT were reviewing his diagnosis of paranoid schizophrenia.

•He was referred to an outside hospital who were unconvinced by his presentation and felt he had a complex personality disorder, including psychopathic traits.

•Now convicted and awaiting sentencing, future involvement with mental health service needs to reflect the change in the nature of the formulation of his issues.

Case Study B•Joe is a 23 year old single man of no fixed abode who was a patient of an assertive outreach team. He was charged with Trespass with Intent to commit a sexual offence.

•Prior to coming to Prison, he had several admissions to Psychiatric wards and lately most of the admissions were of short duration as he was deemed to have a Drug Induced Psychosis.

He was difficult to engage in the community and lived chaotically and missed appointments with clinical staff. His compliance with medication was erratic. During the imprisonment, he began to exhibit florid psychotic symptoms.

He was moved to Prison Healthcare In-Patients where he had no access to illicit drugs. It became clearer that he had a schizophrenic illness and now he has been accepted by a low secure rehabilitation ward. Being in Prison, helped to clarify his diagnosis and effective treatment.

Case Study C

• Steven is a 32 year old male known to community mental health services for 12 months following a suicide attempt. He is diagnosed with depression and managed on standard CPA.

• On coming into prison contact was made with his local CMHT to clarify contact and his medication regime. From initial assessment it appeared that a number of the factors influencing the course of his depression related to issues which happened during his childhood and his 10 year history of persistent back and arthritic joint pain.

• Although on a short sentence he will be assessed by the Psychological Therapies Service to assess the degree to which he may benefit from counselling input when he returns to the community and any recommendation from this will be made to his local CMHT.

Factors Associated with People Convicted of Crime

Social Exclusion – PrisonersMore likely to have been In Care

More likely to be Unemployed

More likely to have been regular Truant

More likely to have Family Member Convicted of a Crime

More likely to have been a Young Father

More likely to be HIV positive.

X13

X13

X10

X2.5

X6

x15

Have Basic Writing Skills

Reading skills below the age of an average 11year old child

Were using drugs before imprisonment

Suffer from at least 2 mental disorders

Have made at least one suicide attempt, Men:

Have made at least one suicide attempt, Women:

80%

50%

60-70%

70%

20%

37%

Social Exclusion Unit Report, 2002

50%

X20

70%

20%

Denial of Access to Service

Have no GP before coming into Prison

More likely to have been excluded from school

Have a drug problem

Of those with a drug problem have received any help from a formal drug agency.

33%

66%

20%

40%

The Impact of Imprisonment

Lose their House whilst in Prison

Lose their job

Face severe financial problems

Loose contact with their families

The NHS Service Response on Release from Prison is

far from whole hearted.

Continued...

Daily Suicide Battle: HMP Styal women's prison was criticised in a report last year

after the deaths of six inmates in 12 months. A BBC documentary has

highlighted the problems faced by staff in their attempts to keep inmates safe.

Justin Rowlatt reports.

http://www.bbc.co.uk/mediaselector/check/player/nol/newsid_4750000/newsid_4757300?redirect=4757360.stm&news=1&bbwm=1&bbram=1&nbram=1&nbwm=1

Prison Health Policy Developments

o The Provision of mental health care in prisons (1997)

Emphasises equivalence

o The National Service Framework (1999)

Sets Standards for mental health care in five areas

o The Future Organisation of

Prison Healthcare (1999) Health Needs Assessments Reception screening Provide Primary care Introduction of the CPA Development of In-Reach

How these relate to prisons set out in Changing the

Outlook (2001)

• NHS Plan (July 2000)

Stated that an additional 300 staff would be employed to work in prison mental health.

Also stated that “All people with severe mental illness will be in receipt of treatment, and no prisoner with serious mental illness will leave prison without a care plan and a care co-ordinator” (p124).

April 2006 – PCTs become responsible for commissioning all Prison Healthcare

• NSF Five Years On (2004)

Outlines progress that has been made on each of the 7 standards

Provides examples of positive practiceStates that over 300 in-reach staff have been

employed in prisons during the 5 yearsStates that the number of prison suicides has

not fallen. However, prisons now have suicide prevention strategies and STORM (suicide risk management) training is now being piloted in prisons

TheThe

CriminalCriminal

JusticeJustice

SystemSystem

PolicingPolicing

CourtsCourts

ProbationProbation

Prison ServicePrison Service

Prevalence of Mental Health Disorder

Prisoners Community-based

offenders

DEPARTMENT OF HEALTH POLICY

Education & Training

Research Clinical Initiatives

CSIP IMPLEMENTATION PROGRAMMECSIP IMPLEMENTATION PROGRAMME

CRIMINAL CRIMINAL JUSTICE AND JUSTICE AND

MENTAL HEALTH MENTAL HEALTH PROGRAMMEPROGRAMME

UNIVERSITY OF UNIVERSITY OF LINCOLNLINCOLN

THE NHS OFENDER MENTAL HEALTH DEVELOPMENT AGENDA

Prison mental health in-reach

We have a unique perspective on this area having conducted 2 National Surveys in 2004 and 2007

The aim was to have 300 in-reach staff in post by April 2004 all focusing on prisoners with a serious mental illness

Mirroring mainstream NHS CMHTs

Average number of staff in post in 2004 and 2007

0

1

2

3

4

5

6

wte 2004

2007

Adequate triage by Prim Care by prison type

0

20

40

60

80

100

120

% o

f pris

ons

no

yes

Mean number of referrals per year for teams in 2007

228.36

367.67

446.13

0

100

200

300

400

500

2004 2005 2006

number of referrals

The comparison of the quality of liaison with NHS and social services by prison type

0

1

2

3

4

5

6

7

8

9

scal

e fr

om

1 t

o 1

0

liaison with NHS

liaison with social services

THE NHS OFENDER MENTAL HEALTH DEVELOPMENT AGENDA

The Challenge of Acute Transfers from Prison

• ‘The issue of the transfer of prisoners into the NHS is an issue brought up time and time again by in-reach staff’ (Forres 2005).

• “my experience was that when we did have inmates who had gross psychotic disturbance and I’m talking about a psychosis rather than a non-psychotic patient, it was very difficult to get a forensic psychiatrist to see them, very difficult to get an appropriate bed for them. We had to wait weeks and weeks, spend hours and hours and hours making phone calls, very, very difficult. The resources were not there to back us up” (Davies et al 2004).

• Recent Audit by the DH in 2006 had a response of 87.5% (N=119) of prisons across England and Wales

• Results indicate that at any one time across the Prison Estate there are 282 prisoners awaiting initial psychiatric assessment by an in-house / visiting psychiatrist who routinely works in the prison.

• There were some prisons with large numbers of people waiting, for example six prisons had more than twelve people waiting for an initial assessment.

WAITING TIMES FOR ACUTE TRANSFER IN THE PRISON ESTATE

Prison Category

Number of people

awaiting first psychiatric assessment

Number of people awaiting

second psychiatric assessment

Number of people awaiting transfer

after second psychiatric

assessment and transfer is agreed

Female Estate 29 10 5

High Secure Estate

26 17 21

Local prison 71 47 40

Open prison 0 0 0

YOI/Juvenile 58 23 20

Trainer 76 14 13

Cat B 7 7 16

Cat C 7 1 0

Local and YOI 3 0 2

Cat B and C 4 1 3

Cat C and YOI 1 0 0

Cat D 0 0 0

Total 282 120 120

Number for whom after secondassessment transfer not recommended

No. of Prisoners

No. of prisons

Combined Total

1 17 17

2 8 16

3 3 9

6 1 6

10 1 10

11 1 11

16 1 16

20 1 20

Total 119 105

Why is this group not deemed suitable?

• ‘not appropriate due to clinical profile’ ,

• ‘personality disorder not deemed treatable’

• ‘re-referral to appropriate security level’

• ‘awaiting decision to accept’

These findings confirm that there are relatively large numbers of prisoners across the Prison Estate for whom transfer under the Mental Health Act 1983 is not deemed appropriate but that remain within the prison estate requiring specialist management and care i.e. those with borderline personality disorder who prolifically self harm.

THE NHS OFENDER MENTAL HEALTH DEVELOPMENT AGENDA (cont)

Integrated Drug treatment Services

• Historically, drug services in prison under-resourced, delivered out-of-date clinical series especially maintenance prescribing, and poor links between the range of agencies involved such as CARATs, primary care and in-reach.

• New DH money provided in 2006/7 to:

£ Provide more intensive CARATs support

£ Greater maintenance prescription

£ Strengthening of links to community agencies

• The new money available in only 17 prisons of ‘enhanced psycho-social services’ and ‘enhanced clinical services’ in

28 prisons – 48/138

prisons in total

• However, new detailed

guidance issued by

the DH in December 2006 on

the clinical management of substance misuse

The NHS Offender Mental Development Agenda (cont)

Court Diversion

1992, the Reed review stated that:“There should be nationwide provision of properly

resourced court assessment and diversion schemes and the further development of bail information schemes ... The longer term future of many schemes is not yet assured but experience increasingly suggests that where diversion schemes become established these ... can make effective disposal easier.”

The NHS Offender Mental Development Agenda (cont)

Court DiversionNational survey undertaken in 2005 by NACRO with a 45% response (64/143)

25% of schemes had seen a decrease in staffing in the last year and one third operated with one member of staff.

50% of schemes had input from a psychiatrist or psychologist and 41% had problems obtaining psychiatrist’s reports.

72% had problems accessing beds.

The NHS Offender Mental Development Agenda (cont)

Other problems cited included:

o Inconsistent staffing

o Rejection of referral by the NHS

o Unwillingness of the courts to consider alternatives to custody (especially treatment in the community)

o No local medium secure beds

o Lack of interest by general psychiatrists.

The NHS Offender Mental Development Agenda (cont)

CAMHS Initiatives in the criminal justice / youth justice system

Current range of initiatives includes: Dedicated mental health practitioners working in youth offending teams (YOTs);

Small CAMHS teams offering support to YOT’s or the community;

Forensic CAMHS offering assessment and interventions to young people in secure settings (plus new commissioning framework);

National forensic CAMHS services including outreach / in-reach and patient services.

Some Examples of CAMHS Initiatives in the Criminal Justice

/ Youth Justice System

Dedicated mental health practitioners to YOS, (Leicester City YOS has 2 CAMHS practitioners).

Forensic CAMHS teams working in secure settings (Oxford, HMYOI Huntercombe Manor).

National forensic CAMHS Services (NSCAG services). Highly specialised Tier 4 CAMHS (Salford and Trafford).

Mental Health and Criminal JusticeEducation and Training• Basic Prison Officer Training has very little, if any, mental health training content. It only lasts 6 weeks in total.

• Basic 2 year probation officer training has 8 modules in the 2nd year one of which is mental health, substance misuse and crime.

• 156 occupational standards for basic 2 year probation to be a police officer – none relate to mental health.

• 80 prison in-reach teams working in prisons but no specific training for working in this environment.

NHS Initiatives in Mental and Criminal Justice

Evaluation of mental health awareness training for prison officers through CSIP (Brooker and Sirdifield, 2007).

Evaluation of the mental health promotion component of health trainers (Sirdifield, 2007)

Evaluation of dual diagnosis training in a pilot study in 5 London Prisons (Hughes et al, 2007).

Review of mental health service provision in prisons which concludes that the workforce has not been prepared for this task. (Durcan, 2007).

All of the above papers have been compiled in a

special edition of the Journal of Mental Health

Workforce Development.

Education and TrainingNHS Initiatives in Mental Health and Criminal Justice

The Challenges:

o PCTs only assumed commissioning responsibility in April 2006, and have no history of commissioning Education and Training in this sector.

o We are going to lose CSIP as the service improvement arm of the NHS.

o There has been no identification of the evidence base to inform training.

o A lack of alignment between NIMHE workforce programme and offender mental health ie mainstreaming.

o There is a lack of money for sustainable initiatives in Education and Training.

Criminal Justice and Mental Health

The research base: Systematic review of prisons and mental health in 2002 (Brooker et al) highlighted a serious deficiency in research and a wide raft of research priorities.

Since then the National Forensic R&D programme, which funded prison mental health research has disappeared.

In addition, generally, mental health research attracts a very small proportion of the overall NHS research resource.

Funding for UK research in 2004-5 by disease area and disability adjusted life year (DALY)

Funding – key finding How is the £74m overall funding used?

Fig 3 Annualised value

4

12

5

2

191

57

Understanding brain and mind inindividuals and society 57%

Domain specific research tounderstand brain and mind 1%

Causal processess leading tospecific states / conditions andillnesses 19%Prevention of ill health andpromotion of well being 2%

Assessment and diagnosis 5%

Therapeutic approaches andhealth/social care delivery 12%

Natural history and outcomesresearch 4%

Criminal Justice and Mental Health

Conclusion:

Offender Health is a new kid on the block at a time when healthcare funding is scarce.

Health commissioning experience is weak.

Untreated mental health disorder is likely to lead to higher levels of re-offending.

Service provision, education and training, and research are all seriously under resourced given the size of the problem.

New offender health strategy will be consulted upon Summer 2007.

Criminal Justice and Mental Health

The Lincoln Research Programme

will aim to establish:1. The size of the problem where it is not understood

2. Increases in the evidence base for interventions in CJ setting where disorder is complex

3. Funding for research that promotes integration of CJ mental health with mainstream mental health service provision.

4. Research that evaluates new training provision when this can be funded.