The Challenges Faced By A Prison Psychiatrist

17/08/2017 17:13
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There has been a plethora of recent media attention about mentally unwell people in prison (stoked, sadly, by some tragic suicides). Tempers have been flaring with a lot of anger from the dark depths of the internet.

I can understand the anger; it's a reasonable response to seeing the vulnerable suffer and be discriminated against. Psychiatric patients who have been charged with a crime are arguably doubly vulnerable and doubly condemned. As a society, we need to look out for them and not just judge them. Anger is not enough, though. Anger rarely achieves solutions. We need to understand the issues and talk about them. I'd like to share some of the difficulties I face (as do my colleagues) as a prison psychiatrist.

I am a Consultant Forensic Psychiatrist. Part of my job is working as a psychiatrist within a major prison, under an NHS contract. I oversee the care of the most psychiatrically unwell; those that have been transferred to our Healthcare Unit (like a psychiatric ward inside a prison). I also carry out medico-legal assessments in other prisons, YOIs and immigration centres. I've seen some very troubling case. I've helped some prisoners get better. For those that I can't treat (because they are too unwell, or are refusing treatment), I make referrals to secure psychiatric units so they can be transferred under the Mental Health Act to receive the care they need.

Mental health treatment in prison is an area of contention. It is very familiar territory for me.

A recent BBC article suggested that all mentally ill people should be treated in hospital and not in prison. I agree with this sentiment (even though it would probably put me out of a job). But there are significant challenges and problems with making this a reality. Here are some difficulties, born from my personal experiences that mental health workers in prison on the front line, face on a daily basis.

Workload / throughput of prisoners

It's not exactly a secret; the NHS is overstretched and under-resourced. This, unsurprisingly, is reflected (and even amplified) in prison care. There are long waiting lists for my psychiatry clinics. Dozens of new prisoners arrive every week. They spookily disappear just as quickly; either suddenly transferred to other prisons without any notice (presumably by some mystical ever-powerful God of prison) or released at court hearings. This means our ability to observe their progress is severely disabled (for example charting their response to a new medication).

No background information

In my experience, sometimes prisoners arrive with no background information whatsoever; their old medical notes seemingly swallowed up into the ether. With no background knowledge, it is hard to make an accurate snapshot diagnosis with our limited power of observations; we might see our patients once every couple of weeks, and don't have the benefit of assessing their mental state daily, as my colleagues in psychiatric hospitals have. On a day-to-day basis, our eyes on the ground are prison officers, untrained in mental health issues, not trained nurses.

Mental illness is not always obvious, clear or linear

Some symptoms are subtle. Some people are insightless and can be paranoid, so they isolate themselves and deny or hid or minimise their symptoms. They can easily get lost (or even intentionally hide) in the vastness of prison. I have had many refuse to attend the appointments I have offered them, and even refuse to speak to me in their cells.

Some symptoms and illnesses are temporary, changeable or short-lived

Drug-induced psychosis is a perfect specimen of this slippery hard-to-treat creature. Drugs are often freely available in prison. I once saw a delusional woman, who was convinced that she was pregnant and carrying the devil's child. Worryingly, she talked about getting a knife and cutting out the unborn foetus within her. In this case it transpired that she was suffering from a temporary drug-induced psychosis after smoking Spice (as opposed to a more permanent, trenchant psychosis). With such a sudden inexplicable change in mental state, I suspected this diagnosis. We transferred her to the Healthcare Unit, and within days she had completely and reversed back to her normal self (after the Spice had left her system). The change was unbelievably dramatic. I almost felt like I myself had to question my own reality.

If variety is the spice of life, then Spice is the flavour of death in prison

This horrible, nasty substance can cause extreme agitation and temporary psychosis. These cases need to be monitored but shouldn't (and realistically couldn't) be treated in a hospital setting.

Some prisoners fake / exaggerate symptoms

This might come as a revelation but there are some criminals in prison. I have personally assessed numerous prisoners who have tried to fake mental illness in order to be shipped out to 'Easy Street" (their skewed, and very mistaken perception of a psychiatric hospital). This muddies the waters and makes it harder to pick out the genuinely unwell and vulnerable.

Mental illness isn't always black and white

Like a beautiful rainbow of insanity, mental illness is a spectrum. On one end is the floridly psychotic prisoner, clearly agitated and tormented by hallucinations and delusions. They obviously should be transferred to hospital - no argument there. I would like to think that even the most bitter, cynical, right-wing, Daily Mail reader would agree with that.

On the other end, there might be a fully compos mentis career criminal who might have only a mild depression, which is completely unrelated to their offending or previous violence. I think they should be offered a level of psychiatric support within prison and I do this kind of work regularly. However, they should remain in prison and not go to hospital. Again- this judgement call is fairly obviously.

The trouble is, the vast majority of psychiatrically disturbed prisoners lie somewhere in between these two extremes. Throw into the mix - the natural fluctuation of some mental illness, difficulty observing prisoners within the vast belly of the beast of the prison wings (with prison officers, not nurses, as our eyes), a small (though significant) proportion of salubrious fakers and also illicit drugs - it is often not as easy as you may think to decipher who is genuinely ill and who to prioritise transferring to a psychiatric unit.

The process of assessing prisoners (to make the decision to refer somebody to hospital) has enough hurdles. But that's the easy part. Next, I have to make the referral for hospital admission.

I became a psychiatrist because I wanted to help the mentally unwell. I did not become a psychiatrist because I wanted to chase-up emails, make dozens of phone-calls and generally work through mazes of complex referral processes. Unfortunately, there is often a long and frustrating wait between sending the referral and getting a reply or acknowledgement. Frequently, I get no acknowledgement, and need to relentlessly and assiduously keep following this up.

About a year ago, I assessed a man in prison with chronic schizophrenia. Unfortunately, he became very unwell, very quickly; he refused his medication as he was paranoid and convinced that the tablets were being tampered with. He rambled to himself all day, flooded his cell and was clearly hearing voices. He was aggressive when approached (paranoid delusions, not malice). He was placed on a 'three-man unlock'; i.e. he was deemed to be dangerous to leave without three prison guards escorting him. Predictably, this eventuated in him being locked in his cell 24 hours a day for most days; there was always a shortage of prison guards.

After I made a referral I spent several weeks waiting; for the referral to be accepted, for him to be assessed, and before the transfer to hospital was arranged. To be fair, I think there were genuine reasons for this delay; some polite disagreement about his catchment area, as well the appropriate and necessary level of security (both which determined which psych unit he would go to). During this time, the poor man was left festering alone in his cell, untreated. At his worst, he had covered his wall in faeces and literally pulled his own hair out. As time went on, I felt like doing the same (pulling my hair out that is).

Why does it take so long for referrals to be processed?

Frustratingly, most NHS Trusts don't have a central referral hub so it is a challenge to even figure out where to send referrals in the first place. A large proportion of the ones that I send out get batted back. There are so many different teams (e.g. covering close geographical areas or particular psychiatry specialisms) and also so many factors that determine whether or not any given prisoner will be accepted by a service; place of birth; place of current residence; place of GP registration and place of arrest. These can all be used as potential reasons to 'bounce back' a referral; this usually elongates the process by a couple of more weeks. Some prisoners, unsurprisingly, have chaotic lives and might be homeless or may not have registered with a GP for quite some time. These issues makes it all the more complicated to navigate through the thorny referral process and are often used as reasons to reject a referral. I am sure there are good reasons for this; stretched, underfunded services (see earlier gripe). Nevertheless, I find it frustrating, when I just want to source treatment for somebody who really needs it.

Why is it so difficult to find beds in secured units?

The number of beds in medium secure units has increased significantly over the last couple of decades, yet waiting lists remain long in many areas. Why is this? This is a complicated subject, with many factors at play. The typical type of patient for these units is very complex and has serious mental illness and potential risks. An admission may typically last a few years and patients needing containment for decades are not unheard of. Medium Secure Units are expensive; costing upwards of £200,000 per patient, per year. These specialist units have to work on the assumption that many of their patients are potentially dangerous and violent (almost by definition, to qualify for a place there). Therefore, they need additional security measures; for example seclusion rooms, airlocks units, specially adapted furniture, big fences and extra staff. High secure hospitals (like Broadmoor) are even more expensive, and there has been a drive to reduce their intake and move patients over to lower levels of security. Government cuts to a wide range of services (non-forensic psych units, community mental health services, drug and alcohol rehab, etc) has gradually pushed a group of vulnerable individuals with mental illness away from mainstream services and towards lower socio-economic status (known as 'social drift') and sometimes towards crime (often, low-level offending in the context of being unwell, confused and not fully in control of their actions, and sometimes preyed on by nefarious criminals).

So what's the solution?
What's the solution for all issues related to healthcare?
More funding.

Although mental ill-health accounts for around 28% of the total burden of disease, it gets just around 13% of the NHS's budget. Despite this being public knowledge for a number of years, research indicates that only half of the mental health trusts have received a real-terms increase in their budgets in recent years (further details in this Guardian article).

If we had better facilities in the community, less mentally ill prisoners would find themselves trapped within the criminal justice system. If we had better facilities within prisons (to treat the unwell, as well as more, better trained staff), we could treat more effectively in-house, and cut down on the numbers that need those precious limited hospital beds. If we had more beds in secure hospitals, we can cut down waiting lists and, thereby decrease the time lag to get people assessed and out to hospital. If we had more general (non-secure, non-forensic) psychiatric beds, forensic services wouldn't get clogged up. Hopefully, this would also stop the bottleneck of referrals.

I firmly believe that criminals should be punished but also rehabilitated. However, those with severe mental illness shouldn't be assumed to be the same as criminals (though I acknowledge there is an overlap and a whole intricate grey area). The unwell deserve to be treated with dignity and need to be treated with our full arsenal of mental health therapies (be that medication or psychotherapy, etc). In many cases, this can only effectively be done in a hospital environment.

Severely psychiatrically unwell prisoners are people who, very likely, have been failed by services over and over again. They are very likely to have had horrific experiences (abuse seems to come as standard for the women, and even the men that I have assessed in prison). Sure, some of them have made poor choices and may have wronged others, and that can't be ignored. Nevertheless, for those who are too unwell to look out for themselves, we, as an apparently mature, developed society should step in and shoulder some of the responsibilities. It is not always simple; there are complications and barriers, but there are no excuses for floridly unwell psychotic prisoners to be trapped inside cells for weeks and months awaiting treatment.

If we don't look out for them and speak up for them, who will?