Progress in the
Penal System (PIPS)

13: Mental healthcare Spotlight 1

Standard 13:

People with serious mental health issues are diverted from the prison system and receive the appropriate treatment and supports in a timely manner.

Rationale:

International research demonstrates the prevalence of mental health issues among the prison population. [334] According to the World Health Organization (WHO), prevalence studies from many countries show that 10–15% of the prison population suffer from severe and enduring mental illnesses, including schizophrenia, bipolar disorder and autism disorders. [335]

Poor prison conditions such as overcrowding, solitary confinement, violence and lack of meaningful activity can all have negative effects on mental health. [336] The WHO and the International Committee of the Red Cross state that “detection, prevention and proper treatment of mental disorders, together with the promotion of good mental health, should be both a part of the public health goals within prison, and central to good prison management”. [337]

More than a decade ago, the Health Service Executive published a national mental health policy, A Vision for Change. [338] A number of recommendations in the national policy related to the prison population, including that:

every person with serious mental health problems coming into contact with the forensic system should be accorded the right of mental health care in the non- forensic mental health services unless there are cogent and legal reasons why this should not be done. Where mental health services are delivered in the context of prison, they should be person-centred, recovery-oriented and based on evolved and integrated care plans. [339]

Current context:

Mental health in Irish prisons is in need of urgent action, with particular emphasis on severe mental illness. Ireland has one of the lowest per capita psychiatric forensic beds in Europe, at two per 100,000. [340] A new National Forensic Mental Health Hospital is currently being constructed in Portrane, Co. Dublin intended to replace the only designated centre, the Central Mental Hospital, in 2020. This new facility is to provide 130 adult forensic beds. [341] The opening of the new centre, with the aim of increasing forensic capacity, will increase provision to 3.5 per 100,000. [342] This increase in provision is unlikely to meet demand. The Netherlands has a rate of 14 per 100,000. [343] Other countries have between 5 and 14 per 100,000. [344]

On a monthly basis in 2018 there were consistently 20–30 prisoners with a severe mental illness awaiting transfer to the Central Mental Hospital (CMH). [345] According to the Director General of the Irish Prison Service, in May 2018 323 out of 4,000 prisoners in custody were deemed to be suffering from severe mental illness. [346]

Currently all prisoners in Ireland are assessed on admission. [347] Where clinically indicated, a prisoner is referred to a forensic psychiatrist who may make specific recommendations to the Governor. [348] A diversion system is in place: the Prison In-Reach and Court Liaison Service (PICLS) acting in liaison with clinicians from the Central Mental Hospital. This system is available to all Dublin prisons, and Portlaoise and Midlands Prisons. [349] However, no such diversion service exists in Cork, Limerick or Castlerea Prisons.

According to the Director General, “approval was granted by the HSE in 2016 to provide consultant- led mental health services to Limerick, Cork and Castlerea prisons, which was a most welcome development. However, it has not been possible for the HSE to recruit consultant forensic psychiatrists for those three prisons.” [350] In-reach psychiatry services have been discontinued in Castlerea Prison, which means prisoners with serious mental illnesses in Castlerea must travel to Dublin for assessment. [351]

International human rights bodies have documented a number of concerns. For example, in 2015 the CPT observed that “Irish prisons continued to detain persons with psychiatric disorders too severe to be properly cared for in a prison setting.” [352] The CPT made a key recommendation: [353]

The CPT recommends that the Irish Authorities reflect further on the steps required to enhance the availability of beds in psychiatric care facilities for acute mentally-ill prisoners. Further, it recommends that the staffing at HSUs [High Support Units] be reviewed in order to include the appropriate expertise...

The CPT will return to visit Ireland in 2019 and will expect the State to demonstrate improvement on these matters.

In 2017, the United Nations Committee against Torture [354] made a recommendation to the Irish State on mental health in Irish prisons:

Take urgent measures to […] hire additional medical personnel, including psychiatric personnel and psychologists, and enable the referral of inmates requiring specialized medical care to outside medical facilities without delays.

The Irish Prison Service has expanded the Prison Psychology Services in 2017/2018 with the recruitment of more psychology staff since the end of 2016. [355] Figures provided by the Irish Prison Service in its Annual Report 2017 show the Prison Psychology Service provided 759 individual interventions and 182 group-based interventions over that year. [356]

Indicators for Standard:

Indicators for Standard 13

Indicator S13.1: Number of prisoners awaiting transfer to the Central Mental Hospital (CMH)

CMH Waiting List 2017 [357] Average number of prisoners with a severe mental illness awaiting transfer to the CMH Lengths of time prisoners are waiting to be transferred to the CMH
January 21 Not available
February 20 Not available
March 20 Not available
April 18 Not available
May 22 Not available
June 25 Not available
July 17 Not available
August 19 Not available
September 18 Not available
October 21 Not available
November 21 Not available
December 23 Not available
CMH Waiting List 2018
January 17 Not available
February 24 Not available
March 25 Not available
April 22 Not available
May 29 Not available

While data is not available on lengths of time individual prisoners are waiting to be transferred to the Central Mental Hospital, at the hearing of the Oireachtas Committee on the Future of Mental Health Care, the Clinical Director of the CMH stated:

“All of the people on the waiting list are urgent. All of them are severely mentally ill and should not be in prison. They have been on the waiting list for months and this is entirely unacceptable by any clinical standards”. [358]

Indicator S13.2: Lengths of time individual prisoners are being held in safety observation cells: [361] According to Irish Prison Service Census figures, [362] in April 2018 seven individuals were being held in Safety Observation Cells. In response to a parliamentary question, [363] the Minister for Justice and Equality said that information on the lengths of time individual prisoners were placed in safety observation cells was not collated, and that to collate this data would require a disproportionate and inordinate amount of staff time, which “could not be justified where there are other significant demands on resources”. [364] The Irish Prison Service committed to publishing lengths of time people were held in Safety Observation Cells in 2017 [365] , however this has not yet happened. Given that the placement of a prisoner in a Safety Observation Cell means isolating the individual and an additional restriction on their liberty, IPRT’s position is that such data should be collated and published to monitor trends and issues.

Indicator S13.3: Number of High Support Units across prisons nationwide: In 2015, the CPT visited High Support Units [366] in Castlerea, Midlands and Mountjoy Prisons and found they “were not properly resourced and did not address the needs of mentally ill prisoners; there was a complete lack of structured activities and no occupational or recreational therapy, only pharmacotherapy. Moreover, the prison officers in the units were not properly trained to work with prisoners suffering from serious mental disorders.” [367] Following the death of a prisoner by suicide in an Irish prison, an inquest jury recommended in 2016 that all prisons should have High Support Units and ongoing staff training on mental health. [368]

There are two High Support Units operational throughout the prison estate: Mountjoy Medical Unit, which currently caters for nine people and the D2 wing in Cloverhill Prison, which has been expanded to cater for 28 people. [369] The Irish Prison Service is in the process of recruiting an Activities Co-Ordinator for forensic input to provide a more supportive environment for prisoners in this unit. [370] However, this goes nowhere near meeting the recommendation to provide a High Support Unit in every prison.

Indicator S13.4: Ratio of one psychologist to 150 prisoners: A 2015 review of Prison Psychology Services [371] commissioned by the Irish Prison Service showed that the ratio of psychologists to prisoners is well below international best practice standards. In 2015, the ratio of psychologists was 1:233 in Ireland, compared to other jurisdictions such as Canada where the ratio is 1:78 and Scotland where is ratio is 1:123. [372] In 2018, the gap has widened to a ratio of 1:268. [373]

Progressive Practice:

A report by the Ministry of Justice in England states that “eligible prisoners should wait no longer than 14 days to be admitted to a secure hospital”. [359] The report described how “only 34% of prisoners were transferred within 14 days in 2016–2017”. [360] In Ireland, this data is not regularly published.

Forensic Care Capacity, The Netherlands

Forensic care capacity is reserved in mental health institutions where Dutch penal law allows governors, following medical advice, to transfer prisoners with specific psychiatric problems to mental health institutions. [374]

Penitentiary Psychiatric Centres, The Netherlands

Penitentiary Psychiatric Centres (PPCs) were established in the Netherlands as a result of the growing number of prisoners presenting with psychiatric issues. [375] Distinctive aspects of PPCs compared to the regular prison environment include: higher staff/prisoner ratio; the involvement of various types of healthcare professionals; and specific training for prison officers working with persons with mental disorders. [376]

There has been a mixed response to this initiative by the CPT, stating that “PPCs represent a more suitable environment for prisoners suffering from mental disorders than ordinary prisons”. [377] The same report highlighted that the delegation of the CPT “gained a favourable impression of the attitude of the frontline carers working daily in direct contact with the patients as well as training provided to them”. [378] However, a number of criticisms were also made in the report, including the length of lock-up times (17 hours a day) and limited access to therapeutic activities.

The CPT recommended that the Dutch authorities consider how the role of the Ministry of Health in the management and supervision of PPCs could be increased, “with a view to ensuring the provision of optimum care to the patients and the principle of equivalence of care in prison with that in the wider community”. [379]

Guidance for Prison Staff on Mental Health

In 2018 Penal Reform International published an informative guide for prison staff working with individuals with mental health issues. [380] This guide can help support the training of prison officers on mental health issues.

Actions required:

Action 13.1: The Irish Prison Service should regularly publish data on the number of prisoners with severe mental illness waiting to be transferred to an appropriate facility and the lengths of time waiting.
Action 13.2: A review must be carried out to assess current gaps in provision and provide additional options, ensuring there is a sufficient number of forensic mental health spaces ring-fenced for the prison population.
Action 13.3: Legislators should introduce legislation that supports the diversion of mentally ill individuals away from the criminal justice system.
Action 13.4: The Irish Prison Service must be provided with the necessary resources to support the mental health needs of prisoners in their care and to provide a continuum of care. This may include increased psychology and psychiatry staff to meet rising prison numbers; mental health training for prison staff; and supports and resources to run High Support Units effectively in prisons.

References:

IPRT Irish Penal Reform Trust

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