Memorandum submitted by Sainsbury Centre
for Mental Health
EXECUTIVE SUMMARY
— The effectiveness of prison should
be judged not only in terms of reoffending but through outcomes
such as improved health, housing and employment.— Prison
mental health care needs to be improved, especially for those
with complex problems, depression and anxiety.— Rehabilitation
needs to focus on what offenders want for their lives, not merely
on their offending behaviour.
— The arrival of IPP and increasing
numbers of hospital transfers are increasing the time prisoners
spend in custody: this is both costly and delays their resettlement.
— Diversion from custody, within or
outside the criminal justice system, can be cost-effective. Community-based
alternatives that command the confidence of sentencers need to
be developed.
— Women, children and young people
are especially damaged by the use of custody. Investment in improved
support in the community is vital for these groups.
— Anti-social behaviour orders are
being used too commonly with people with mental health problems
and is at risk of escalating their progress into the criminal
justice system.
— Early years work with young children
at risk of conduct disorder and emotional or behavioural problems
is highly cost-effective in reducing offending later in life.
1. Introduction
1.1 The Sainsbury Centre for Mental Health
works to improve the quality of life for people with mental health
problems by influencing policy and practice. We focus on
criminal justice and employment. The evidence we have provided
focuses on the experience of people with mental health problems
in the criminal justice system and how that system could provide
better value through more effective approaches to mental ill health
and offending.
1.2 The effectiveness of criminal justice services
are usually defined in terms of offending and reoffending. While
this is an important measure of success or failure, it should
not be the sole determinant of achievement. Effectiveness should
also be judged through other outcomes: in finding employment,
in having a stable home and in maintaining good health. This is
crucial to understanding what value services add to people's live
and to the communities they live in.
2. Mental health care in prison
2.1 Levels of mental ill health in prison
are very high. It is vital that prisoners are offered support
for mental health problems. Gaps in provision cause unnecessary
distress but also exacerbate the exclusion individuals face and
reduce their prospects of recovery before and after release.
2.2 Most English prisons now have mental health
inreach teams. These work with people with severe and enduring
mental health problems. Many have begun to improve the quality
of care prisoners receive but they face major barriers:
— Staffing levels are less than one-third
of those found in community mental health teams compared with
the level of need in prison (Sainsbury Centre, 2007b).
— Hurried receptions make screening
for mental distress difficult.
— Frequent movement of prisoners between
establishments damages continuity of care.
— A lack of follow-up by community
teams of released prisoners.
2.3 While inreach teams are beginning to
make a difference to those with more severe conditions, the larger
number of prisoners with depression, anxiety and other common
mental health problems receive little or no health care (Sainsbury
Centre, 2007b). There are also major gaps in provision for prisoners
with personality disorders and those with complex problems, eg
a "dual diagnosis" of substance use and mental health
problems.
2.4 Psychological therapies may help offenders
with a range of mental health problems, particularly depression
and anxiety. The Improving Access to Psychological Therapies (IAPT)
programme aims to provide better access to talking therapies for
people who require support from mental health services. There
has as yet been little discussion as to how IAPT could be made
available to offenders with mental health problems, particularly
those in prison.
3. Rehabilitation
3.1 The Sainsbury Centre has carried out
a review of Offending Behaviour Programmes (OBPs) in the UK. These
are delivered by psychologists and aim to change the way offenders
think in order to change their offending behaviour. We found a
mixed picture of effectiveness (Sainsbury Centre, forthcoming).
3.2 The major limitation of offender rehabilitation
is its focus on reducing maladaptive behaviours, eliminating distorted
beliefs, removing problematic desires and modifying emotions and
attitudes that promote offending behaviour. These are predominantly
negative goals; they ignore many other factors in the process
of rehabilitation such as a person's need for somewhere to live,
a job, family relationships that are pivotal in helping offenders
to pursue more socially acceptable goals and to seek alternative
ways of living that are meaningful and valuable.
3.3 Employment is widely considered to play
an important role in the rehabilitation of offenders. An overview
of 400 research studies concluded that employment-related prison
programmes were the single most effective intervention for juveniles
(Lipsey, 1995). However, even the best employment schemes in prison
may not help prisoners to find and maintain employment unless
they are supported by good aftercare services (Gillis, 2000).
3.4 Accommodation is also crucial: a resettlement
survey in 2001 found that 31% of prisoners with an address on
release got into paid work, compared to 9% of those who did not
have housing on release (Niven and Olagundoye, 2002).
3.5 Education programmes to address low
literacy and lack of other basic skills are also thought to improve
offenders' employability and reduce re-offending. Porporino and
Robinson (1992) found lower re-imprisonment rates for offenders
who had completed an adult basic education programme while in
prison.
4. The role of secure hospitals
4.1 The population of secure hospitals in
England is rising. While numbers in high secure hospitals such
as Broadmoor are falling, medium secure units are growing. In
July 2007, a record 3,723 people were being detained in "forensic"
mental health services (Rutherford and Duggan 2007).
4.2 An increasing proportion of people admitted
to forensic hospitals are transferred from prison. In 2006, 961
people were transferred to hospital directly from prison while
293 were admitted after being given hospital orders (Rutherford
and Duggan 2007).
4.3 Transfer times from prison to hospital
remain problematic. An average of 42 prisoners every quarter have
to wait for more than three months for transfer. While waiting
times have fallen in many parts of the country (to a government
guideline of 14 days), average waiting times in London remain
far higher (Rutherford and Duggan 2007).
4.4 Nine in 10 people transferred to medium-secure
services stay longer in detention than they would have done under
the terms of their original custodial sentence. This is because
there are inadequate step-down options available, and because
forensic mental health services are becoming increasingly risk-averse
and reluctant to discharge patients.
4.5 The cost of medium secure services is
£165,000 a year, compared with £40,000 for a year in
prison, but reoffending rates are (for a variety of reasons) far
lower. Decisions about the relative merits of prisons and secure
hospitals therefore need to take into account the needs and prospects
of the individual. Alternative forms of provision could also be
examined.
5. Imprisonment for Public Protection (IPP)
5.1 IPP is a sentence for offenders who
are deemed to be "dangerous". They are placed on sentences
with a minimum term, but of potentially indeterminate length.
Release is determined by the Parole Board, who assess risk reduction
following course completion and risk management planning.
5.2 Currently there are more than 4,000 IPP prisoners
in England and Wales. Only about 15 IPP prisoners have been released
to date, in part due to the shortage of treatment and behaviour
programmes available.
5.3 Mental illness is thought to be more
common among people on IPP than any other sentence type in prison.
This is thought to be in part because IPP is at times used instead
of mental health options such as hospital orders. There are also
concerns that the indeterminate nature of IPP, and the uncertainly
felt by prisoners about their sentence, has a negative impact
on their emotional health.
5.4 The number of IPP sentences has increased
while the number of hospital orders has fallen. It is possible
that the courts are identifying "dangerousness" (a prerequisite
of IPP) rather than obtaining a diagnosis for a mental illness
or personality disorder. As a consequence, many IPP prisoners
may require transfer to medium secure hospitals, putting pressure
on existing places.
6. Diversion
6.1 A major gap in provision for people
with mental health problems in the criminal justice system is
of criminal justice liaison and diversion (CJLD). This aims to
identify people in police stations and courts and to divert them
within or away from the criminal justice system to appropriate
health and social care. The absence of effective CJLD (NACRO,
2005) leads many people with severe mental health problems to
be imprisoned.
6.2 One of the key barriers to building better
systems of diversion is the fear that sanctioning alternatives
to imprisonment will put public safety in jeopardy. Research however
suggests that there is no added public safety risk from diversion
(Sainsbury Centre, 2008).
6.3 Research is beginning to show that diversion
is also cost-effective. In their first year schemes should expect
to spend more money than they save, but savings begin in years
two and three, where navigating people away from the revolving
criminal justice system door pays dividends.
6.4 Diversion will only work if a range
of different agencies work well together. This can be achieved
partly through creating protocols and service level agreements,
but it is also essential to ensure service users are equipped
to take advantage of the treatment and service packages that multi-agency
working allows.
6.5 "Diversion to what?" is the
stumbling block of CJLD across the world. Access to alternatives,
rather than legislation or political momentum, is the single most
important factor dictating the success or failure of diversion.
Investment is needed to create viable alternatives and prevent
the criminal justice system becoming the resting place for those
who have been forgotten elsewhere.
7. Community orders
7.1 Recent studies have indicated that about
one half of community-sentenced offenders have an emotional or
wellbeing problem that is directly related to their offending
behaviour (Seymour and Rutherford, 2008).
7.2 The Community Order is composed of a choice
of 12 different requirements. One of these is a Mental Health
Treatment Requirement (MHTR), available for offenders who have
an identified mental health problem that is not serious enough
to require the use of the Mental Health Act, where treatment is
readily available, and where the offender has given their consent.
7.3 While the MHTR could be a useful alternative
to custody for some offenders, less than 1% of Community Orders
include a MHTR. There has been a lack of awareness of, and confidence
in, the MHTR among sentencers. There is also a lack of availability
of treatment, and courts have found it difficult to obtain timely
psychiatric reports (Seymour and Rutherford, 2008).
8. Women
8.1 Last year's Corston Report (Home
Office, 2007) made a cogent case for radical changes to the women's
prison estate. It recommended greater use of community sentences
for women; reduced use of custody for remand; and the creation
of smaller, urban units for women to replace the current stock
of 17 women's prisons.
8.2 The vast majority of the 4,400 women prisoners
in England have a range of mental health problems. The Corston
Report's recommendations are supported by evidence gathered
by Sainsbury Centre (Rutherford, 2008) and others from women prisoners
with mental health problems:
— A short spell in prison can be sufficient
for a woman to lose her children and her home, especially if she
is imprisoned far from home.
— Screening remand prisoners for mental
health problems is unreliable.
— Many women prisoners have drug and
alcohol problems that cannot be properly addressed during their
imprisonment.
8.3 Instead of a short custodial sentence,
for many women a community order would be more beneficial, both
to the public and to them. Community sentences allow for a creative
package of requirements, including unpaid work in the community,
electronic curfews, drugs, alcohol and mental health treatment
and supervision by probation.
9. Young people
9.1 For most young people, incarceration
neither offers the best chance of reducing reconviction nor of
addressing mental health needs. Keeping young people with mental
health difficulties in custody is also expensive (costs range
from £50,800 to £164,750 per year per child) yet nearly
70% of young people are reconvicted on release.
9.2 The wish to avoid premature labelling, coupled
with the greater number of adolescents likely to have emerging
or unclear mental health difficulties, have made it easier for
early signs to be construed simply as bad behaviour requiring
punishment. From schools to police stations, there remains extremely
limited systematic and proactive activity to identify and divert
young people with mental health difficulties into more appropriate
packages of care (Khan, 2008).
9.3 Local systems should be developed to
identify young people with mental health vulnerabilities effectively
at the police custody stage, and to take necessary action to divert
them away from the youth justice system or to feed information
into the court process with the aim of diverting them into more
appropriate packages of care.
9.4 In Northamptonshire and Hereford, Youth
Offending Team (Yot) health practitioners work closely with community
psychiatric teams to identify young people with mental health
difficulties in police custody. The Yot practitioner assesses
the young person, liaises with the court to offer advice where
necessary and negotiates with local mental health providers to
facilitate a residential placement or the provision of a package
of mental health care (Khan, 2008).
10. Anti-social behaviour orders (ASBOs)
10.1 Despite government guidance that mental
health problems should be taken into consideration before an ASBO
is issued, one-third of ASBO recipients have mental health problems
and/or learning disabilities (BIBIC, 2007). Many do not get support
to help them keep to the conditions of their ASBO. This puts them
at risk, ultimately, of imprisonment if they breach their order.
10.2 We are concerned that the use of ASBOs among
people with mental health problems risks speeding up their journey
into the criminal justice system.
10.3 We believe that anyone being considered
for an ASBO should be screened for mental health problems and
for learning disabilities. Where possible those people should
be given appropriate alternatives, such as referral to community
mental health services (CAMHS for under-18s), specialist voluntary
sector agencies or Acceptable Behaviour Contracts (Sainsbury Centre,
2007a). Mental health problems, substance use and learning disabilities
should also be taken into account when a person breaches an ASBO.
11. Early years work
11.1 Longitudinal studies in the UK and
abroad indicate a high degree of persistence between adverse mental
states in childhood and those in adult life (Kim-Cohen et al
2003). The most common mental health problem in childhood is conduct
disorder, affecting nearly 6% of all children between the ages
of five and 16 in Great Britain (Green et al 2005). Conduct
disorder persists into adulthood in about 40% of cases. It is
also strongly predictive of a range of poor outcomes in adult
life, including criminal behaviour (Stewart-Brown 2004).
11.2 The social and economic costs of conduct
disorder are high. By age 28, the costs incurred by the public
sector for individuals with conduct disorder are about 10 times
higher than for those with no problems (Scott et al 2001).
Nearly two thirds of this cost is borne by the criminal justice
system. The lifetime costs of childhood conduct disorder (relative
to individuals with no conduct problems) may be in the order of
£250,000 per person, taking into account crime-related costs,
reduced earnings and poorer health (Friedli and Parsonage 2007).
11.3 Pre-school parenting programmes are
the main form of intervention aimed at addressing conduct disorder
and related emotional and behavioural problems in early childhood.
A recent review (Dretzke et al 2005) found that the costs
of intervention are relatively low, at around £6,000 per
child for a home-based individual programme and £1,350 per
child for a community-based group programme. Given the estimated
lifetime costs of conduct disorder, the effectiveness of a programme
in preventing or reducing the severity of childhood problems does
not need to be particularly high in order to make it worthwhile
economically.
11.4 The effectiveness of pre-school programmes
justifies investment on a significant scale. One US study found
that by age 27 the number of arrests among those who had participated
in a childhood programme were 50% lower than among a matched control
group. A study in Chicago found that every $1 invested in the
programme yielded cumulative benefits to society of $17 by the
time the participants reached 40 (Schweinhart et al, 2005).
February 2008
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