The link between mental illness and Scotland’s prison population

Calls to reverse Scotland’s soaring prison population are a permanent fixture on the political calendar with pledges to tackle overcrowding and slow the revolving door culture at the gates of our jails ongoing.

But despite the rhetoric, the number of people incarcerated in Scotland continues to rise and the nation now locks up a higher proportion of its citizens than almost anywhere else in Europe.

A steady flow of commissions and inquiries have looked at the problem and flagged up the need to address factors that motivate most people to commit crime – for example, these have included addiction and poverty.

The link between mental illness and the prison population has long been talked about, with studies stating the majority of inmates in Scotland have at least one mental health problem.

The issue has come to the fore again in recent weeks following the publication of two significant reports, both exploring the issue of female offending and the country’s now infamous sole women-only jail, Cornton Vale.

The Commission on Women Offenders, led by former Lord Advocate Dame Elish Angiolini QC, published a report in April on women in the criminal justice system which recommended that Cornton Vale be demolished to make way for specialist units.

It said the prison should be replaced with a smaller specialist jail for long-term and high-risk inmates, as well as regional units to hold shortterm and remand prisoners.

Dame Angiolini said the majority of females who offended did so while suffering from “addiction, trauma or mental health problems”. She added the “significant cost to society” of locking up women suffering from addiction or mental health problems could no longer be ignored.

Just weeks ago it was revealed a teenage inmate, who had a history of self-harm, committed suicide in her cell at the prison. Nineteen-year-old Sarah Mitchell was jailed for setting fire to her flat in Dumfries, which she had to be rescued from.

Her mother, Joyce, said her daughter was locked up instead of being offered support to help her face her problems.

Brigadier Hugh Monro, the Chief Inspector of Prisons in Scotland, last month published his third inspection of the jail, near Stirling.

He called for inmates suffering from complex mental health issues to be moved into specialist care facilities. He described visiting the jail’s Ross House, which houses prisoners who are kept separate from others because of their “behaviour or state of mind”, as a “harrowing experience”.

Monro also said the condition of “silent cells”, where prisoners were being held temporarily, were “disgracefully poor”. He said: “I saw one prisoner lying on a mattress on a concrete plinth and there was no window to provide ventilation or light. On moral and health grounds, these cells are unacceptable.”

But the link between mental health and offending are not consigned to the female prison population, and expand across the board to adult male and youth offenders.

More than 70 per cent of the overall prison population is said to suffer mental health problems.

Scotland’s predicament is not unique – indeed across England and Wales 72 per cent of male and 70 per cent of female prisoners are said to suffer from two or more mental health disorders. Nine out of 10 of the prison population south of the border reportedly have at least one diagnosable mental health problem, such as depression, anxiety, drug or alcohol misuse or personality disorder.

Carolyn Roberts, head of policy and campaigns at SAMH (Scottish Association for Mental Health), said: “The best figures we have for Scotland come from a 2008 thematic inspection of mental health in prisons. It found that a very large proportion of prisoners have some form of mental health problem. Of these, a relatively small proportion had severe and enduring mental health problems, but this was still 4.5 times the level of mental health issues in the general public. The most common problems identified were schizophrenia and bipolar disorder.

“Research suggests that 80 per cent of prisoners in Cornton Vale have mental health problems, and a European study has also found that Scottish women face such huge problems that they regard a jail term as ‘a refuge’, with some women choosing jail to escape abusive partners, debt problems or drug addiction.

“We need to improve diversion away from prisons for people who need care and treatment: short sentences and spending long periods of time on remand are expensive and do nothing to reduce reoffending.

“We want to see increased use of measures like Community Payback Orders (CPOs), which provide a managed way of diverting people away from prison. But of the 7,318 CPOs issued between February and December 2011, only 47 included a Mental Health Treatment Requirements, which could help people to get the care they need. That’s less than 1 per cent.”

Juliet Lyon, director of the Prison Reform Trust, insists the evidence shows that for many inmates, it is treatment they require.

She said: “It’s hard to think of a more damaging environment for people with mental health needs or a learning disability than a bleak, noisy, sparsely-staffed jail.

“Yet this is the reality for a large number of people in Scottish prisons today. The Inspectorate of Prisons for Scotland reported that more than two-thirds of prisoners are known to have mental health problems, and as many as 7 per cent may have psychotic illness – a rate seven times higher than in the general population. In our report on learning disabilities and difficulties in Scottish prisons, the Prison Reform Trust found that few procedures were in place in prisons specifically for identifying prisoners with learning disabilities and difficulties or meeting their needs.

“Many of these people would be better served receiving treatment and care in the community or in residential and, in some cases, in-patient or secure psychiatric accommodation, rather than languishing in prisons which are ill-equipped to meet their needs and almost bound to make their condition worse.”

But while there seems to be a growing acknowledgement that mental illness has a significant impact on crime, the situation is complicated by the difficulties there are in defining mental health problems, and how they contribute or not to a person’s offending.

Frances Simpson, chief executive of the charity Support in Mind Scotland, said: “The legislation surrounding the Mental Health Act and Criminal Justice Act are very clear about mental health disorders and they are very clear about the kinds of problems that fall into these categories. There are things like a psychotic illness, and that may be more recognisable to the public because they can identify some of the symptoms.

“But with something like personality disorder it is harder for it to become recognised as a mental illness. But we know from research that a significant number of prisoners will be diagnosed with personality disorders in prison and that illness can lead to very difficult behaviour for the prisoners themselves and the prison itself.

“The majority of prisoners with mental health issues, for example with depression, wouldn’t necessarily come under the legislation … but that does not mean the need for treatment is diminished.”

According to a research briefing by SAMH, there are still many problems in identifying mental illness amongst prisoners.

It said: “Reception and induction processes can provide the first opportunity to identify mental health needs. However, reception in prison can be chaotic and not well suited to identifying health needs despite the high risk of self-harm and suicide in the first few days in prison. During a sentence, the main ways of identifying mental health problems are through observation by prison staff, other workers, prisoners, and through self-referral.

“There are a number of gaps in the identification of mental health problems and needs. These include: problems with the transfer of information from courts and the community; difficulties for prisoners in disclosing issues; problems with processes and operational issues; and problems with staff being able to identify issues. These difficulties can mean that some prisoners with severe and enduring mental health problems may not access assessment and referral.”

Laurie Russell, chief executive of the Wise Group, a social enterprise body that works with offenders to help them reintegrate back into society, said: “I think the prisons will have information on some people, but not others. I suspect for a lot of the inmates they may have relatively mild mental health issues, but it is combined with issues going on in their life, whether that is about addiction or whatever pressures they have from family situations or whatever.

“I also suspect it is going to be quite difficult from a treatment point of view for the offender because I don’t think the resources are there for prisons to be able to do a detailed psychiatric analysis.

“Unfortunately, prisons have essentially become about keeping people under lock and key and providing them with routine, food and water and then letting them out the door at the end of their sentence. The amount of contact time with professionals, certainly for short-term prisoners, is probably pretty low.

“But the problem is also tied to public policy that has seen institutions that would have housed a number of people with mental health issues closing. Prisons have become a last resort for people, it is the only residential facility that is available in some cases.”

Professor Alec Spencer, a former prison governor and convenor of the Scottish Consortium of Crime and Criminal Justice, said there has been an awareness of the link between mental health and offending for some time.

He said: “I think we have been aware of mental health as a contributory factor for many years. I think going back to the 1960s we had a thing called the criminal lunatic department per prison, so it was always known there were people with severe mental health disorders in the criminal justice system.

“But I think after many years the major mental health institutions around the country have closed. The difficulty has been not so much with those who clearly have medical issues, but for those who have a bit of both, who have committed crime before people realise they have a mental health disorder too. The difficulty [for authorities] has always been to know where they should go.

“Are they criminals with mental health problems or are they people with mental health problems who have committed a crime?” He added: “We have a lot of people in prison short-term, a lot of people with a range of problems – mental health problems, people affected by trauma, drug and alcohol problems, a whole range of things that effect a person’s capacity to perform and survive in society. Prison seems to be the default position for a lot of these people, in a way what we are seeing is a host of problems that can’t be dealt with in the community ending up in prison.

“When I was a prison governor, I and other colleagues had cases over the years where we identified people who had major mental health problems, but were sent to prison and they presented problems for prison management and we often had to put in lots of resources. The courts can be reluctant to use the excuse of mental health to avoid dealing with people.

“There is inadequate resources so sometimes a person will not get a proper assessment by a psychiatrist in time for a court to decide what impact a mental health problem had on their behaviour.

“At the moment the services are not as holistic as they should be and are not always dealing with people as people.”

Prof Spencer, a former director at the Scottish Prison Service (SPS), said he hopes the recent transfer of responsibility for prisoner healthcare from the prison service to the NHS will improve matters.

He said: “One of the things, and I actually started off this process in 2002 and am pleased it has finally happened, is the migration of prison medical care to the NHS so that any offender who comes into prison will be able to access what we hope is appropriate care.

“The new arrangements came into effect in November last year and prior to that prisons were responsible for providing healthcare. It was actually an oversight when the NHS was set up in the 1940s that they forgot to put prisons in amongst the various groups of society who would be included in the service. It wasn’t that they deliberately excluded prisons, but as a consequence prisons then had to provide their own healthcare. Obviously this was done through government funding so some people thought it didn’t make any difference and it didn’t matter. But the only problem that created was that actually they were separate systems and they didn’t talk to each other.

“So you had a separate prison medical service and separate health service and it was only a few months ago that era I suppose was corrected and the NHS became responsible for people in prison. The previous arrangement meant it was harder to access psychological services and get the people into state hospitals because the NHS could see that as an increased burden for them.

“In some ways for many years we had this arbitrary wall between the two systems and it made it harder to get the good integration of health services. In the past it was always a bit of a lottery whether somebody who seemed to have mental health problems got an assessment prior to going to court – I think Elish Angiolini has been pushing for more liaison between the health service and the court service. That would be a positive step, sheriffs should know as much as possible about a suspect before they sentence them.”

The Scottish Government last year started its initiative the Whole System Approach, which it claims will link authorities including prosecutors, social workers, health staff and a large number of other support services.

Simpson said early intervention is crucial to ensuring people with mental health problems get the appropriate treatment.

She said: “Going forward, intervention is absolutely crucial. A parent might say to us that the first they knew about their child being unwell was after they were arrested for something. They are pitched into this world where actually the criminal justice system can bring support that the person needs. It is very sad that it can take that, so early intervention, increasing awareness in primary care and ensuring support and treatment is there in the first place might help people avoid getting into that pattern of behaviour that leads to criminal activity.”

She added: “All mental health services and organisations have evidence from people about how difficult it is to be mentally unwell, even in the community, but in prison there are added pressures regarding restriction and being removed from family.

“In terms of provisions, I think we are seeing improvement and reports have shown there have been advances with things like staff awareness and staff training and the ability to spot symptoms. But there is still problems over discrimination and people tell us they are reluctant to come out and say that they need help.”

Prof Spencer added: “There are some positive examples of good service across the country. For example, Tayside Police have a scheme where a nurse is on duty at police cells so they can assist in any diagnosis. If a suspect is suffering from a problem they can alert the police early on. One of the problems currently is there is often no documents outlining a suspect’s mental health situation before a sheriff decides to send them to prison or not. Getting medical analysis at the earliest opportunity is one of the obvious ways of improving the situation.”

Scottish Government statistics on prisoner numbers make for grim reading. The average population has risen steadily over the last decade, from just over 6,000 inmates 10 years ago – to a new record high of more than 8,300 earlier this year.

Russell insists much more can be done to prevent people entering the criminal justice system.

He said: “Prison numbers are still going up, despite the fact crime is going down. Prison numbers are way too high and I think most people believe that.

“We have to make changes and find alternatives for people who commit relatively minor crime. We have to remember that although most offenders will commit minor crime, the issues around their life can be complex – it’s about their health, potentially it is about addiction, over 79 per cent of people in young offenders’ [institutions] were in care.

“We know a lot about the majority of people who end up in custody, yet we don’t prevent them becoming the people in our penal institutions. There is an awful lot we can do to prevent people going down that revolving door route, and it needs to happen soon.”