The rising number of mentally ill patients in prison with a lack of healthcare professionals is one of the major challenges in civilized society. It’s a fact that thousands of people with mental health problems get no treatment in prison. Most states have a philosophy of treating mental illnesses in jail rather than just prosecuting the inmates. Over half of all inmates have mental health problems in prison at least once in their life. People with severe acute mental illness should be sent to the mental health services first before they reach the prison. The prisoners with very serious mental disease should be immediately transferred to a psychiatric care unit. The health care professional should understand the specific needs of vulnerable inmates, including children, women and the elderly. “Jail admission offers a unique opportunity to assess and begin meeting the health needs of a population with high levels of physical and psychiatric morbidity; many of whom are rarely in touch with the National Health Service. Problems with drugs and alcohol can be addressed, blood-borne viral infections identified and treated, dental health improved, and mental health issues assessed and treatment began. Prisons are not hospitals, however, and unlike inmates with severe physical disability, many inmates with severe mental illnesses that include in-patient care from the National Health Service remain in prison “(Reed, J., 2003).
According to mental health act there are four types of mental disorders. “The four specific categories of mental disorders include mental illness; psychopathic disorders; and arrested or incomplete development of mind, which include most any kind of mental handicap or sub normality ranges from mental disability to severe mental disability. The definition is expansive and includes any other mental disorder or disability residually “(Laing, J. M., 1999). The Conservative Government introduced Diversion policy in 1990. This policy aims the mentally ill patients. This policy diverts the mentally ill inmates into a criminal justice system. In the case of a mentally ill person this approach considers detention as a last resort. The policy also stresses the need to improve prison conditions, such as overcrowding. This policy identifies that that at present there is no healing environment in prison for mentally ill patients.
Many mentally ill offenders reported that they at the time of crime they were at the influence of alcohol or drugs. Most often the mentally ill criminals are drug dependent. “Abuse of alcohol and illegal drugs is common among prisoners because addiction often leads people to crime to support their habit: intoxication may lead to crime; substance abuse itself may be a crime; and drugs in many jails are freely available. Although most of the prisons are adult men, they may also jail juveniles and women. Most authorities try hard to keep young people out of institutions, recognizing that many become school for criminals with three quarters or more of the young people reoffending after release. Women in jail are likely to be treated on a model that is therapeutic rather than pumitive-but often with little success. The same high rates of mental disorder, substance abuse, and HIV infection are seen among women, and there are additional problems of genitourinary infection and of what to do and pregnant or young children in jail. (Lock, S. et al., 2001)
With the help of many specific program and evidence based approaches can certainly reduce the number of mentally ill inmates and drug addicts in jail. “While it may be true that in prison women take fewer drugs than on the outside, it would be a mistake to think that prisons are entirely drug free environments. Indeed, almost half of the women in the home office study reported that they had used an illegal substance while in custody-27% heroin,21% cannabis and 17% tranquilizers- albeit less frequently than in the year prior to imprisonment. More worrying is the fact that prevalence of drug use among women in prison rose significantly between 1977 and 2001 with a particular use in the increase of heroine and crack cocaine. Home office researchers suggest that this may in part be a consequence of mandatory drug testing in prison which can encourage switching to harder drugs which are detectable in urine tests for shorter periods than cannabis.” (Joint Committee on Human Right, 2004)
If effective treatment is given to heroin addicts in jails after release many tested were negative for heroin. A properly conducted jail diversion program for mentally ill person can produce an impact on future life of the person and this in produce public safety. Usually certain mental health policy lack practical support and commonly goes neglected.
Mental health treatment in jail will certainly reduce the burden on the untrained prison staff and this in turn leads to unnecessary intervention and punishment in prison. Another important issue is that many prisoners refuse treatment for mental disease inside the prison. Sometimes major mental health diseases like psychosis may be present among the prisoners.
The mental health problems of prisoners may be linked with the past bitter experience in life such as violence or sexual abuse. The mental health problems may be recent in origin. Other form of mental health disease includes mania, depression, substance misuse and minor mental disorders. The female inmates have high incidence of mental health problems when compared with males. The symptoms include persistent sadness, loss of interest, decreased appetite agitation, uncontrollable anger, loss of sleep or excessive sleep etc. Many prisoners had attempted suicide more than once. Delusions, illusions and hallucinations indicate psychotic disorders. Many prisoners have a feeling of worthlessness. They have a decreased ability to concentrate. Many of them have increased sexual activities. Many of the female prisoners have a history of sexual abuse or physical abuse. “Some prisoners have mental health problems that are privately cared for satisfactorily by primary health care services, and prisons need to ensure that these are addressed services in line with community practice. Prisons urgently need to improve programs to provide those with a concurrent condition, taking into account once again a woman’s particular needs and problems in jail. This care needs to be continued upon release, where the needs of the individual may change with increased opportunities for the use of drugs and alcohol”. (Moller, L. et al., 2007)
Some of the prisoners were homeless or many were unemployed. The parents were lost in their early life or parents separated. Unemployment or illegal income is other major cause of mental problems in young prisoners. In case of very young prisoners the parents were alcoholic or drug addicts. Many prisoners were under the influence of drugs when they committed the crime. Hashish, cocaine, crack, heroin, opiates or marijuana was the common drugs they use.
“Substitution treatment ST has established itself as a generally recognized type of treatment for opioid dependence worldwide. Although the number of countries offering ST in prison has begun to grow slowly over the last few years, its use in the custody setting remains controversial. ST in jail is mostly used as detoxification. Maintenance treatment is available in only a limited number of international prisons. Prison-based ST and especially prison-based methadone maintenance treatment – PMMT can reduce drug use and injection in penal institutions. Moreover, PMMT provision can reduce injecting risk behaviors as well as drugs charges and re-admission rates. However, for PMMT to retain patients in treatment and reduce illegal drug use and criminal behavior a sufficiently high dose of methadone e.g., >60 mg and the treatment duration.
Duration of the entire imprisonment period seems crucial “(Stallwitz, A. & Stover, H. 2007)
Binge drinking is common habit among many prisoners. Violent offenses were committed by many mentally ill patients and this may include homicide, robbery or drug trafficking. Some mentally ill patient used weapons such as firearm or knife for the offense. When compared with short term sentences the prisoners with long term sentences were having more mental problems. The offenders who were sentenced to life or death had more difficult mental health problem. The prisoners with mental health problem usually violate rules and fight among them self. There are incidences of verbal or physical assault with the staff who correct them.
The incidence of alcohol use is more in married prisoners while the use of drugs was common in single prisoners. The main reason for the use of drugs by the prisoners is that they used it as an escape from social pressures. The authorities have to implement separate action plan for elderly prisoners. “Outside prison, the development of specialist services for older offenders could be considered. In the UK, a number of authors have considered the development of supra regional medium – security units, which may be able to focus their treatment regimens more appropriately to older offenders and provide a safer setting. In particular, the admission of older individuals with dementia to normal medium and low security units would be problematic as the medical and allied healthcare staff would have had little training and experience in dealing with such patients”. (Jacoby. R. et al., 2008)
To avoid the incidence of HIV in prisoners the world health organization recommends distribution of condoms in prison. While during drug treatment the injecting equipments are cleaned to avoid transmission of diseases. In some jails the risk of infectious disease, HIV infection and hepatitis C is very high. The increased incidence of HIV infection has raised much criticism from the people and there is need to improve the diagnosis and treatment facilities in jails. There is lot of difficulties in eliminating the sexual activities and injection of drug in jails. The incidence of sex in prison may be consensual or forced. Homosexuality among the men is having a high risk for incidence of HIV.
There is should be a national network of mental health professionals for the service in jails. The authorities should appoint some disability specialist for the prisoners once they are released from jail. “Last year £20.8m – £300 per inmate – was spent on in-reach teams which were set up to treat people with the most serious mental health problems such as psychoses and bipolar disorder. But rates of psychoses are 16 times higher among prisoners than the general population and 70 per cent of prisoners have two or more mental disorders.” (Lakhani, N., 2008) There is risk of suicide when giving drugs to mentally ill patients. There should be special care plan for prisoners awaiting trial. A prison heath policy needs to be developed which include the prisoner’s activities, the provision for their education and employment opportunity. The policy should enhance a healthy relation between the prisoners and the staff.
Some Important Guidelines
The health care service provided to the prisoners should be equal to that given to society. The fundamental human right should be protected. The inmates need good shelter and basic sanitation facilities must be provided.
The Main Issues
- Mental health care – The top priority for the inmates should be health care. The prisoners need medicines of good quality, and opportunities to prevent infectious diseases. Psychiatric assessment should be given to every inmate at least twice a year. The mentally ill patient is treated by a psychiatrist and not by a general physician.
- Mental health promotion – The mental health promotion can be best achieved by maintaining a positive environment inside the prison. Some recommendations for the health promotion of the prisoners have been issued by the United Nations. It involves recruiting specially trained mental health practitioners, while also increasing general awareness. The WHO says the countries should create positive legislation and integrate criminal and social health policies. The jails should be considered a part of the society. The united nations have laid down certain minimum standards for the basic principles on how the prisoners should be treated.
The prisoners should engage in activities which may give self improvement and autonomy. The activities need to provide the prisoners the emotional sustenance and empathy. The prisoners should have access to sports and games. The prisons should provide fitness facilities to all those who need it. Inmates need education, and they need opportunities to get qualifications.
After the release, if vocational training is provided, the prisoners can get some jobs. This in turn gives the prisoner a sense of self-confidence and security, which ultimately leads to an improvement in their mental health. The prisoners should participate in arts and cultural programs. The diet needs to be balanced. Dependency services will help the inmates escape drug dependency. The drug addicts should be properly rehabilitated. The health care professional can help the prisoner to cope with feeling of guilt and anger. The inmates are given parental counseling and education. The prisoners need a chance to understand their own offending or antisocial behaviour. Health care professionals will inspire the prisoner to take stock of their lives and help them make improvements. Once the prisoners are released they may be motivated to engage in socially useful activities in order to gain the company’s support.
Health care is very important to overall prisoner rehabilitation. “The level of health care should be based upon assessed need and be as equivalent as possible to that available in the community. Connection between inmates and staff should be facilitated wherever possible, and with the outside world. The current position is very unsatisfactory with regard to mental illness and prisons. It fails to meet the needs of vulnerable people, it fails to meet the standards of humane care called for by internationally agreed conditions of human rights, and it Is failing to make its rightful contribution to the WHO and the European Union’s emerging mental health plans. However, much can be done, even in countries with the most limited resources, to make substantial and long-lasting improvements and to contribute significantly to the mental health and well-being of all prisoners” (WHO, 2008)
“Prison is not the place for a seriously mentally ill criminal. By and large almost everyone agree with that proposition in principle but not in practice. In recent years a growing number of seriously mentally ill people have been sent to prison. Ultimately, most of them will be released to the community. It is also clear that substance abuse problems and mental disorders often go hand in hand, particularly among correctional population.” (Petersilia, J., 2003). There is increased incidence of mental disorders in jail because of the fact that many prisoners already have mental health problem before entering prison and also the environment in prison normally detrimental to protecting and maintaining the mental health of prisoners. If this continues the prisons will change into mental asylums in the near future. For the best interest of the society the prisoners should be treated in the jail other vice after the release they will become a burden to the public. The government will put in new programs to address overcrowding and prisoner discrimination.
- Jacoby, R. et al., 2008. Oxford textbook of old age psychiatry. Great Britain: Oxford University Press.
- Joint Committee on Human Right 2004. Third Report on Session 2004-05 Deaths in Custody Vol II: Oral and Written Evidence House of Lords Great Britain ; The Stationary Office .
- Laing, J. M., 1999. Care or Custody ? : Mentally Disordered Offences in the Criminal Justice System. Great Britain: Oxford University Press.
- Lakhani, N., 2008. Prisons unable to cope with rising levels of mentally ill inmates. The Independent On Sunday UK. [Online]
- Available at: http://www.independent.co.uk/news/uk/crime/prisons-unable-to-cope-with-rising-levels-of-mentally-ill-inmates-834038.html?r=RSS
- [accessed 28 Apr 2009]
- Lock, S. et al., 2001. The Oxford illustrated companion to medicine. 3rd Ed. Great Britain: Oxford University Press.
- Moller, L. et al., 2007. Health in Prisons: A WHO Guide to the Essentials in Prison Health. Europe: WHO Regional Office.
- Petersilia, J., 2003. When Prisoners come home: parole and prisoner re-entry. USA: Oxford University Press.
- Reed, J., 2003. Mental Health care in prisons. The British Journal of Psychiatry. 182. p. 287-288. [Online] Available at: http://bjp.rcpsych.org/cgi/content/full/182/4/287
- [accessed 29 Apr 2009]
- Stallwitz, A. & Stover, H. 2007. The impact of substitution treatment in prisons – A literature review. International journal of drug policy. 18 (6) p. 464-474 [Online] Available at: http://www.ohrn.nhs.uk/resource/library/record/index.aspx?PublicationID=1434 [accessed 28 Apr 2009]
- WHO, 2008. Towards best practices in developing prison mental health systems. World Health Organization. Conference on Prison and Health, Trencin, Slovakia. 18 Oct 2007. WHO Regional Office: Denmark.