April 09,2021
The prevalence of mental health conditions in prison populations is much higher than in the general community; however, access to mental health services is significantly lower. Such a relationship holds constant across the globe. In England and Wales, efforts have been made to understand the prevalence of mental health conditions amongst offenders, the types of currently available treatments, the shortfall, and the possible path forward. While the relationship between the treatment of mental health disorders and reoffending is unclear, there is an opportunity for us to use the criminal justice system not purely as a means to punish but as an aid in recovery. This has been termed 'equivalence'; that is, offenders incarcerated in prisons are entitled to the same mental health treatment as anybody else in the population.
Various ideologies exist in treating offenders and criminals; some tend to one extreme of severe punishment, whereas others believe in rehabilitation and recovery. And while there is no 'absolute' blanket ideology that will apply to offenders of all backgrounds, genders, ages, and criminal histories, it's important to consider the majority who have committed relatively 'minor' offences. Can our lack of focus on mental health rehabilitation put us at risk of perpetuating a vicious cycle of reoffending behaviour and prevent us from helping the same individuals contribute positively to society in the longer term?
We must first consider why the prevalence of mental health disorders in prison systems are so high. Everything from environmental factors and substance abuse to disruptions in neurological functioning may lead to risky behaviour. While none of these schools of thoughts is 'incorrect', we cannot consider them in isolation as the 'causes' of criminal behaviour. However, mental health conditions in prisons across England and Wales co-occur with a high prevalence of childhood physical or sexual trauma, PTSD, substance abuse, and the manifestation of psychosis [1]. We can also look at the conditions of prisons and prison culture. Naturally, they are not environments that have been constructed to deliver care and can often be anti-therapeutic in themselves. Therefore, the experience and pain of imprisonment can often exacerbate and trigger mental health issues in prisoners who did not enter with a diagnosis. In this context, suicide is a major concern.
The provision of mental health treatment for offenders generally poses many challenges in mainstream community settings. People serve probation orders and face stigma amongst mental healthcare professionals themselves, many of whom equate offending with risk. Often the call is to refer such individuals to forensic services. Mental healthcare in the general population is already in a state where the demand significantly outweighs the supply, so one may wonder why we should focus time and resources on individuals in the criminal justice system. While you are in prison, however, a mental health referral could be triggered in several ways and is usually catered to by an 'in-reach team’. Prison Officers may notice behavioural patterns in inmates, prisoners could proactively ask for interventions from their primary care staff, and self-harm, suicide attempts, or violent instigation can also prompt intervention. If an offender undergoes mental health treatment in prison, many rooms are designed to balance the inmate and the mental health professional's safety. The rooms are usually equipped with a 'panic button' in case there are any emergencies.
Another primary concern with pushing the need for access forward is the lack of education and resources for prison-based programs that already exist.
There are several ongoing debates about the culture of control and punishment instead of recovery and therapy and what it would mean for prison staff to deal with offenders in a 'trauma-informed way' (acknowledging the trauma someone has experienced and interacting with compassion on a day-to-day basis).
This would require the recruitment and training of a prison's operational staff and those who interact with inmates daily. In England and Wales, while it is necessary for prison officers to have formal training in mental health awareness, they generally report too many daily stressors and a lack of support [2]. Also, resources available to conduct formal therapy are scarce (in-reach teams in England are often small) and are usually available to prisoners only when they are extremely unwell. The levels of distress leading to self-harm or suicide in prison are high, so it's important to acknowledge the workforce's insufficiency across the criminal justice system.
Advocates of rehabilitation may ask for equivalence in access to mental health care regardless of whether you're an offender in prison or an individual in the community serving a probation order. The argument here is that this access to appropriate services can help offenders with recovery and promote better mental and physical health, which would lead to a reduction in risky behaviour, violence, self-harm, and possibly their reoffending. However, when we assess the prevalence of mental health conditions in prison systems, we see that 'equivalence' is perhaps not what we are truly seeking. There is not only a high prevalence of mental health issues but more than 1 in 10 cases where the individual has 4-5 co-existing mental disorders [3]. If you look to general society, the likelihood of such co-existence is minimal, if at all. And this begs the question, are we seeking equivalence of care? Or should we try to understand the specific situation and gaps in prison systems and create relevant models to address these individuals in the community appropriately?
Let's now re-look at the spectrum of punishment and rehabilitation. Whenever a crime, any crime, is committed, most people tend to the former end of the spectrum and believe that the individual should be punished for their offence and locked up due to the pain and grief they have caused. We also consider society's safety in general, so people who are likely to inflict harm on others are kept away from communities. However, we must look to the nature of the crime and understand the punishment not only in terms of tenure of imprisonment but to the background of the individual, the possibilities of rehabilitation and recovery, and access to physical and mental health care. Perhaps, for the vast majority who commit significantly minor offences, we can create systems and models that encourage and build understanding and compassion, hopefully ending the vicious cycle in the criminal justice system rather than perpetuating it.
