Prison mental health: vision and reality Prison mental health: vision and reality 1

Contents Introduction

1 Introduction It is now almost a decade since the government introduced the 4 Authors’ biographies principle of ‘equivalence’ into prison health care in England and Wales and set the stage for the NHS to take responsibility for 6 Louis Appleby Offender health: reform is gathering pace achieving it (DH, 2001).

10 Paula May and Calum Meiklejohn Prison mental health: representation and reality The principle of equivalence means that prisoners country following the publication of the National should receive the same quality of care for their Service Framework for Mental Health (DH, 1999). 16 Kimmett Edgar health as they would receive outside prison. It does Recognising mental health: balancing risk and care not mean that health care will be identical to that This publication aims to examine what has been outside but that services will aim to achieve the achieved in prison mental health over recent years 22 Ian Cummins same quality of care as the prisoner receives from a number of different personal perspectives The relationship between mental institution beds, elsewhere. and individual observations of working in England. prison population and crime rate It looks at the specific achievements of inreach The need for better mental health care in prisons teams and of efforts to divert offenders from has been evident for some time. Reports custody. It also looks more broadly at the rapid throughout the last two decades have shown that growth of the prison population during the same prisoners have dramatically higher rates of the period and the treatment of offenders with mental whole range of mental health problems compared health problems outside as well as inside prison. to the general population. Not only is prison itself a risk factor for emotional distress but the prison Louis Appleby sets out the principles that should population is comprised disproportionately of underpin offender mental health policy and practice people from disadvantaged backgrounds with a and examines how far we have travelled in the last history of trauma, loss and low resilience to distress decade towards those ends. He concludes that the (Durcan, 2008). health and criminal justice systems have developed improved responses to mental ill health among With high levels of mental ill health in prison, the offenders, for example through better screening on last decade has witnessed the creation of new reception to prison, drug treatment and suicide inreach teams in every establishment in England. prevention. But, he argues, ‘changing only one part These new teams were designed to be broadly of the offender health care pathway will merely equivalent to the community mental health teams expose other weak points in the system’ and with that operate outside and to incorporate within the development of inreach the shortcomings of them the outreach and crisis resolution functions prison primary care and diversion from custody of the specialist teams that were set up across the have been held in stark relief. Nonetheless, Appleby 2 Prison mental health: vision and reality Prison mental health: vision and reality 3

concludes that we do now have a broad consensus inform how they are managed by the health and mental illness and offending are inextricably improve the way offenders with mental health about what needs to be done to make the whole justice systems. Public understanding of mental ill linked and is not supported by the evidence of problems are supported, inside and outside system work better and a ‘momentum to bring it health is still very mixed and often quite different any clear link between rates of crime and rates prison, not through adding extra investment about’. Such windows of opportunity do not to reality, as a result of which ‘divisive images of of imprisonment. In its place, we need to onto an unreformed system but by looking at appear very often, and grasping it while it exists mental health problems lead to contradictory examine what it is mental health services should how it all works and reinvesting resources will be vital. solutions’. So we are at one and the same time offer people experiencing mental distress. And towards more effective interventions that are developing more compassionate and better this means we need ‘to do things differently’, in everyone’s interests. Paula May and Calum Meiklejohn write from resourced responses to mental ill health while also using the recommendations of the Bradley the perspective of working currently in a prison becoming ‘ever-more coercive’ towards people Report (2009) as a starting point. References mental health services. They describe the journey who are seen as a threat. the mental health service at HMP Bristol has taken All four contributions make it clear that while a Bradley K (2009) The Bradley Report: Lord over the past five years and what challenges lie Edgar argues that some groups are particularly great deal has been achieved to mitigate mental Bradley’s review of people with mental health ahead for prison mental health care. vulnerable to poor treatment within the criminal distress among the prison population over the problems or learning disabilities in the criminal justice system, such as women and people with past decade, fundamental changes are needed justice system, London: DH. The creation of prison inreach, they argue, saw the learning difficulties. Better management of the both to reduce the size of that population and Department of Health (1999) The National NHS ‘parachute in’ mental health provision to a recent convergence between mental health and the proportion of people within it who have Service Framework for Mental Health: Modern new and difficult environment. The service criminal justice, he argues, will be vital to ensure mental health problems. We need to develop standards and service models, London: DH. inevitably had to adapt to the reality of its that the two services do not compound the ‘whole system’ responses that acknowledge that environment, for example by separating disadvantage those groups experience. most prisoners are incarcerated for short periods Department of Health (2001) Changing the assessments and emergencies from planned work at a time: that almost all return to their outlook – a strategy for developing and with the team’s clients to avoid the former Ian Cummins, finally, examines what the communities and need care and support that modernising mental health services in prisons, becoming the team’s sole function. May and exponential growth of the prison population tells continues ‘through the gates’ and addresses the London: DH. Meiklejohn also conclude that one of the biggest us about our society and how an understanding of things that concern them most in life. Durcan G (2008) From the inside: experiences challenges facing inreach teams is not from within why it has happened it essential to any effort to of prison mental health care, London: the prison but in the attitude of mental health address it. He cites the widely held ‘Penrose Prisons will never be free of mental ill health. Centre for Mental Health. services outside to working with offenders. Again, hypothesis’ that the prison population has grown in No matter how well we divert people with it is how the whole system, not just individual parts response to the closure of the long stay ‘asylums’: mental health problems from custody, we still of it, works that determines how effective prison that there is a ‘static proportion of any population need to ensure that prison mental health care mental health services can be in supporting people that will need or be deemed to need some form of works for those who need it and supports them in their treatment and recovery. institutional control’. in their recovery journeys. After a decade of growth in public services, we face a new decade Kimmett Edgar examines the way in which attitudes He argues that there are, however, serious problems of contraction and retrenchment. Yet as the about mental illness and those experiencing distress with this approach. It assumes, for example, that contributions to this volume show, we can 4 Prison mental health: vision and reality Prison mental health: vision and reality 5

Authors’ biographies

Louis Appleby Paula May Ian Cummins

Louis Appleby has recently been appointed as Paula May qualified from Hereford and Worcester The delivery of health to the criminal justice services Ian Cummins is a senior lecturer in social work in Department of Health National Clinical Director College of Nursing in 1995. She has worked across is developing and nurses working in criminal justice the School of Social Work, Psychology and Public for Health and Criminal Justice and is Professor a wide range of areas including inpatient services, services require a forum to represent them. The RCN Health at the University of Salford. He has of Psychiatry at the University of Manchester. The high secure forensic settings, PTSD (post-traumatic forum is proactive in representing issues raised by worked as a probation officer and approved aim of his new post is to reduce mental illness in stress disorder) units and also with the third sector. members and advocating nursing issues to wider social worker. His research interests are in the prisons and improve collaboration between mental stakeholders involved in policy and practice issues. areas of forensic mental health services with an health services and the criminal justice system. In Paula managed the court assessment and referral emphasis on policing and mental illness. He has his previous role as National Director for Mental service Avon and Wiltshire in Mental Health Kimmett Edgar carried out research with police forces exploring Health in England he played a central role in plans Partnership NHS Trust from 2007 to 2009 whilst it ways to improve the mental health awareness of to reform mental health services, bringing in a was involved in the national pilot around court Dr Kimmett Edgar, Head of Research at the Prison officers. He has published several journal articles range of new services including home treatment, reports with offender health and Her Majesty’s Reform Trust, has been a prisons researcher since based on this work. Ian is also a member of early intervention and assertive outreach teams, Courts Service (HMCS). the 1980s, having previously worked as a Research NACRO’s National Mental Health Reference and mental health legislation. He led numerous Officer at the Oxford Centre for Criminological group. He regularly presents at NACRO and initiatives including to reduce suicides and improve More recently she has undertaken specific pieces of Research. He has published books on prison other conferences. the physical environment of mental health wards. work reviewing the mental health service in Horfield violence and on restorative justice in prison. He has prison in her current role as development manager. written Home Office reports on racist incidents in Since 1996 he has been Professor of Psychiatry at prison and mandatory drug testing. At the Prison the University of Manchester and since 1991 a Calum Meiklejohn Reform Trust, his publications cover mental health, consultant psychiatrist in Manchester. He was women on remand, and prison councils. awarded a CBE for services to medicine in the Calum has been a registered mental nurse since 2006 New Year Honours. 1985, and has worked as a clinician and manager in Kimmett Edgar is a member of the Northern Ireland secure mental health services for most of his Ministerial Forum on Safer Custody, the HMPS continuous career in the NHS. Grendon Research Advisory Group, and the steering group for Back on Track, a project using restorative Since 1998 he has been actively working in prison justice with excluded school students. He is Quaker mental health. Calum completed his original MSc Representative to the UN Commission on Crime research in a remand prison, looking at the attitudes Prevention and Criminal Justice, and a former chair and beliefs of prison staff towards mentally ill of the Alternatives to Violence Project. He sits on prisoners. Since 2005 he has been involved in the Executive Board of the Restorative Justice developing mental health services in prisons Consortium. and courts in the south west of England.

Calum is Chair of the RCN Nursing in Criminal Justice Services Forum. As an experienced clinician and manager in the delivery of mental health to the Criminal Justice Liaison Services, he is well qualified to represent RCN members on the national level. 6 Prison mental health: vision and reality Prison mental health: vision and reality 7

Offender health: reform is gathering pace

Louis Appleby female prisoners had a personality disorder. A Governments from the 1990s onwards have included as one of five high-risk groups within National ClinicalClinical DirectorDirector forfor Health Health and and Criminal Justice decade later, in 2008, a Ministry of Justice survey attempted to tackle these challenges and there the population. The Safer Custody initiative, a CriminalDepartment Justice of Health gave similar figures. It also found that 69 per cent have been significant changes in the way that partnership between the National Offender DepartmentProfessor of Psychiatryof Health of prisoners had used illicit drugs in the year before mental health care is delivered, most notably: Management Service and DH, aims to improve ProfessorUniversity ofof PsychiatryManchester custody, and that 31 per cent had used heroin. safety and the management of suicide risk in In the four weeks before custody 36 per cent had • the introduction of criminal justice liaison prisons. The number of self-inflicted deaths fell been drinking heavily. and diversion services from over 90 deaths per year in 2002-4 to 60 • health screening on reception: all new offenders per year in 2008-9 The relationship between the mental health of entering prison, either on remand or sentenced, • treatment of drug dependence: from 2006-7, offenders and their risk of offending and have an initial health assessment to ensure that a new integrated mode of assessment and At the heart of offender health care lies an re-offending is, however, more complex than any immediate health needs are identified on treatment has led to a step change in clinical indisputable fact: people with acute severe these figures imply. For many, mental disorder is the first night. A comprehensive health management of drug misuse throughout the mental illness should not be in prison. No associated with poor social circumstances and a assessment should be completed within a week adult prison estate. In 2008-09, 64,767 matter how much better prisons become at lack of social supports. Those with ‘lower level’ of admission into custody prisoners received an intervention – 45,135 providing for mental ill health in the broader individual needs may also have chaotic lifestyles. • mental health inreach – mental health treatment received detoxification and 19,632 received a sense – and they have greatly improved in They are frequently unemployed or homeless. within prisons: most prisons now have access to maintenance prescription for opiate dependence recent years – they are not the right place, They may have been poorly educated or victims mental health inreach teams. People with an • support for older prisoners: an older prisoners’ clinically or ethically, for psychosis. Our best of abuse. It is their combination of problems that identified mental health problem are referred for action group has been established to improve figures on mental disorder in prison are still keeps their prospects poor and their risk of specialist assessment, treatment and, if needed, the well-being of older and disabled offenders, those that came out of the 1997 psychiatric offending high. referral to inpatient care and training has been delivered to prison staff morbidity survey in England and Wales • transfer to hospital: improvements have • information systems: rollout of the national (Singleton et al, 1998). It found functional Unpicking the web of relationships between mental occurred in the process and speed by which, clinical IT system for prisons SystmOne gives psychosis in seven per cent of male sentenced health, social adversity and addictions presents under S47 and S48 of the Mental Health Act clinicians round-the-clock access to prisoners’ prisoners, 10 per cent of males on remand and policy makers, the NHS and criminal justice 1983, severely mentally ill prisoners are medical records. In January 2010, 87 prisons had 14 per cent of female prisoners – these figures agencies with a number of challenges: identifying transferred to hospital accommodation. In 2008, adopted the system. The aim is that it will be are several times higher than the equivalent people with mental health problems early in the 75 per cent more prisoners, with mental illness universal by the end of 2010. findings for the general population. criminal justice pathway and providing alternatives too severe for prison, were transferred to to custodial sentences ensuring that people with hospital than in 2000 – up to 937 from 537. It was against this backdrop that Lord Bradley was The same study reported that more than 90 per severe mental illness receive appropriate care In the quarter ending March 2010, 25 prisoners commissioned to consider the experience of people cent of prisoners had a mental health problem of providing an equivalent level of mental health care were waiting in excess of 12 weeks for transfer, with mental health problems or learning disabilities some kind and that more than 70 per cent of both for prisoners compared to services available in the a lower figure than in previous years in the criminal justice system, to examine how the male and female sentenced prisoners had at least community contributing to inter-agency action to • suicide prevention: in 2002, the Department of various agencies currently work and how they two mental disorders. Sixty-four per cent of reduce re-offending. Health (DH) launched its National Suicide should work in the future. Several reports had sentenced male prisoners and 50 per cent of Prevention Strategy for England; prisoners were covered this territory before and the Bradley Report 8 Prison mental health: vision and reality Prison mental health: vision and reality 9

(2009) did not attempt to re-invent a familiar and the criminal justice system where effective offending or are at risk of offending. Community Commissioning, workforce reform, evidence, wheel. It listed the changes that most people in the liaison and diversion services are in place, to collect mental health teams have always practised in outcome measurement – these are the foundations field knew to be necessary and set them in a new evidence on which models of diversion are most offender health, although at times this went on which better care is built. Offender health also context – the modern NHS driven by successful, and to describe how diversion fits with unacknowledged. In future, as we work across has two crucial current assets that should overcome commissioning, multi-agency working, and care other NHS and local authority services. All health previous agency boundaries and health care moves the tight budgets that will be a fact of NHS life in pathways based on patient experience. and criminal justice partners will be encouraged to towards care in the community, this will be more the next few years – a consensus about what is invest and evaluate. explicit. needed and, vitally, a momentum to bring it about. The Bradley Report put forward wide-ranging recommendations about training, the development However, changing only one part of the offender Mental health staff will also have a role in ensuring References of liaison and diversion services, information health care pathway will merely expose other weak that prison and probation staff have the skills technology, public health, practice in courts and points in the system. That is the experience of needed to recognise and assess mental disorder Bradley K (2009) The Bradley Report: Lord Bradley’s police stations, sentencing and research. It prison inreach teams whose excellent work has and suicide risk. Good progress has been made in review of people with mental health problems or described models of good practice nationally and exposed the lack of satisfactory primary mental this area with over 17,000 prison officers receiving learning disabilities in the criminal justice system, internationally and called on the NHS, National health care in many prisons. Without good primary mental health training between 2006 and 2009. London: DH. Offender Management Service (NOMS), the police, care, or a form of specialist mental health service The recently published training framework will the judiciary and the third sector to respond. It focussing mainly on severe mental illness, inreach promote consistency in content but allow flexibility Singleton N, Meltzer H, Gatward R, Coid J, Deasy acknowledged that services would have to be teams receive referrals for people who could be for local adaptation. D, (1998) Psychiatric morbidity among prisoners, redesigned and reshaped from existing resources treated without specialist input or who need a London: Office for National Statistics. as the current system wastes money. behavioural programme to address longstanding Any strengthening of diversion or transfer, any difficulties in personality or emotional control. improvements to joint working between health and Liaison and diversion services are key to the Conversely, some people who do need specialist criminal justice, any new roles or new skills, rely on proposed transformation. Court diversion services treatment for mental illness are never detected and robust and well-informed commissioning. The were first introduced in the 1990s but initially go untreated. Just as good inreach requires Department of Health will soon be issuing generic evolved in an uncoordinated way leading to wide effective primary mental health care, good diversion offender health commissioning guidance that will in variations in size, type of services offered, highlights the need for skilled and accessible time be augmented by more specific advice about effectiveness and availability. There are currently community services. each stage of the care pathway. It is commissioners, around 130 diversion services. Some are well- who can calculate the costs of poor offender health developed, taking the form of multi-disciplinary In the end, mental health reforms are about in their localities, who can put arrangements in teams that provide mental health assessment to workforce roles and this one is no different. The place for care in the community on release from both police custody suites and courts. Others are mental health care of offenders is not the exclusive prison, who can turn research evidence and clinical limited, relying on a single dedicated individual responsibility of forensic psychiatrists, though their guidelines into better outcomes for patients – providing services to courts on set days. The task is leadership is vital. Many of the patients in our though the good commissioner will always consult now to show that there are savings for the NHS clinics and CPA meetings have a history of local clinicians to get this right. 10 Prison mental health: vision and reality Prison mental health: vision and reality 11

Prison mental health: representation and reality

Paula May The rationale was that mental health practitioners through planned changes to the service provision, health care could be picked up initially via screening Development Manager AWP should conduct an early assessment of an offender, the team grew significantly. at the local courts. The care pathway between the Criminal Justice Liaison Service, divert the offender to a mental health service if courts in Bristol and HMP Bristol is particularly Avon and Wiltshire Partnership NHS Trust needed, and where appropriate, ensure that The Community Mental Health Teams (CMHT) cohesive as HMP Bristol is the local remand prison information is shared across the offender health model at HMP Bristol now consists of: serving the courts in Avon and Wiltshire. This Calum Meiklejohn care pathway. • one band 7 team leader makes the service model clear and contained. Service Manager • one band 7 independent nurse prescriber Avon and Wiltshire Partnership NHS Trust Another challenge was to ensure that the services • two band 6 practitioners Review of Community Mental Health Teams were ‘mainstream services’ and not forensic mental • two band 5 practitioners (HMP) Bristol health services. Traditionally, prison mental health • one consultant psychiatrist services were provided by local forensic services. • counsellors A clinical review of the prison mental health service The majority of the mental health need in prisons • one full time administrator. was undertaken in March 2010. The outcomes and is primary and secondary. Developments of mental recommendations of the clinical review clearly In 2003 mental health services to prisons were health services to prisons and courts have been in In addition to the community service provided in identified the challenges and the journey that has generally inreach where local mental health primary and secondary service provision, with an prison wings, the team also supplied the prison been undertaken at HMP Bristol. Key publications trusts or service providers supplied mental emphasis on ensuring that mainstream services with an inpatient facility. were reviewed including the Bradley Report (DH, health practitioners to prisons (usually remand accept appropriate responsibility, especially in 2009), Improving health, supporting justice (DH, locals) to identify prisoners who were eligible CPA cases. The initial model in operation at HMP Bristol 2009) and From the inside; experiences of prison for a Care Programme Approach (CPA) involved sorting mentally ill prisoners into groups mental health care (SCMH, 2008) (Meiklejohn et al, 2004). In 2006 Primary Care HMP Bristol Service Model based on their need for or likely benefit from Trusts (PCT) began commissioning mental immediate mental health treatment on arrival Key points to the review are: health services which heralded a new The community mental health team at HMP Bristol (triaging). All referrals were discussed at a team approach to developing a comprehensive started as an inreach team in 2003, and operated meeting. Following triage, prisoners were allocated 1) The lack of cohesion between inpatients and mental health service in local remand prisons. outside the prison walls. The inreach team became to a team member’s caseload, and reviewed the community part of the team based within the prison in 2007. The rationale for according to their treatment and care requirements. Commissioning this change was to develop joint partnerships with The underlying philosophy is based on the CMHT Historically, the inpatient unit at HMP Bristol was other services such as ‘counselling, assessment, model which envisages the prison wings as the run by the prison with a mixture of health care Key changes to the local mental health offender referral, advice and through care’ (CARAT), community and the inpatient unit as a mental officers and nursing staff employed by the prison. care pathway have been achieved through offender management unit (OMU), primary care health inpatient acute facility. In this model, the A review of the health care officer role at HMP negotiations with local PCT commissioners. A key and safer custody. The prison team consisted of a CMHT is the hub which joins all of these services Bristol in April 2009 concluded that prisons should document is the Offender Health Care Pathway (DH team leader and two mental health practitioners. together. The intent was to combine inpatient and no longer employ health care staff in the inpatient and NIMHE, 2005). This policy document was used community care, with the wing (community) team department. All clinical work was to be undertaken to help develop a new scheme for the local courts In 2008/2009, the prison mental health team was and the inpatient team working together. by the mental health trust employees. The prison around Her Majesty’s Prison Service (HMP) Bristol – transferred to Avon and Wiltshire Mental Health The service was based on an integrated care would continue to provide a discipline presence at Court Assessment and Referral Service (CARS). Partnership NHS Trust. During this process and pathway model where individuals needing mental all times in the inpatient unit, as it was still deemed 12 Prison mental health: vision and reality Prison mental health: vision and reality 13

a residential unit of the prison and cares for some It was clearly identified that Avon and Wiltshire To address the above it was recommended that the both within the prison and the general community. very challenging and at times, disturbed and violent Mental Health Partnership NHS Trust (AWP) had CMHT model should include a practitioner who is The operational workings between the mental individuals. The inpatient unit accommodates a significant difficulty retaining registered mental allocated the role of duty worker on a daily basis. health team and Offender Management Unit large number of lodgers who are predominantly nurses (RMN) in the inpatient unit. One reason was The practitioner will respond to requests for (OMU) were not clearly defined at this point. A awaiting places on the safer custody unit. The 20 that there are very few RMN specific roles within assessments and implement these assessments as process for public protection and MAPPA systems inpatient cells are included on the certified nominal the unit. A majority of the roles for the RMNs are they come in, negating the need for a triage will be implemented in conjunction with the accommodation role for the prison. As long as this task orientated within the prison regime and function to run separately. They would also act as a offender management partnership agencies. remains, the admitting rights lie with the prison medication specific with little scope for the single point of co-ordinating contact for all queries governor. development of the environment or therapeutic and referrals that come in on that day. The duty Health care governance services. For some prisoners within the prison worker would clear their caseload for the day to 2) A need to define the function and purpose system there is a need for containment and allow the other practitioners within the team clear The definition of integrated governance is unclear of the prison inpatient unit observation, or sanctuary, away from the main time and space to plan their work. The duty worker and further clarity is needed by AWP and its wings, for a given period of time. The inpatient unit system means that a dedicated crisis service is built partners within prison management. AWP met with Historically the inpatient unit would have become to date provides this function for prisoners. What into the service model. the prison ombudsman and the primary care trust overloaded with mentally ill prisoners waiting for we will be doing in the coming months is to define to encourage discussion about systems to reduce transfer to medium secure units or specialist whether prisoners who require sanctuary should be The use of CPA post incident reporting and encourage multi hospitals. The 14-day prison transfer pilot in 2009 provided through an inpatient service by a mental organisation learning within the prison. AWP defined clear targets for the identification and health trust. There is ambiguity regarding practitioners’ views of welcome the recommendations set out by the Care transfer of prisoners with acute mental illness. This what constitutes primary and secondary care in the Quality Commission (CQC) and Her Majesty’s has reduced the need for prison mental health beds Wing work in crisis complex prison population. Practitioners were at Inspectorate of Prisons (HMIP) in the paper as prisoners with acute symptoms requiring hospital times unclear about the realistic working of the Commissioning health care in prisons 2008/2009 treatment are transferred to a hospital bed within It was identified that mental health teams are CPA process and their responsibilities in managing (2010) that PCTs must provide a lead in developing 14 days. In Bristol, we have transferred prisoners to constantly responding to emergencies, including, complex caseloads. Many cases do not meet the clinical governance in the prisons that they have psychiatric intensive care unit beds where perceived mental health emergencies out on the thresholds for CPA within the prison systems and commissioning responsibility for. Another recent appropriate. The 14-day target is within the new wings. This created the atmosphere of a fire- often only need brief solution-focussed interactions. development is the requirement for health care prison health performance and quality indicators fighting type service, rather than a planned or Further guidance is needed from the trust CPA providers to register their services with the (CQC). (PHPQI) which each prison’s performance is audited systemised service. One of the most contentious leads to enable the team to work through these The CQC has standards that mental health against annually. The Department of Health is issues within the staff base was the process of challenges and reach clear guidelines. providers are rightly expected to meet. The authors producing a new national policy on 14-day transfer. working ‘out on the wings’. There appeared to be a are not clear what this means for providers of Inpatients is not a mental health facility and a lack of systemised structures in which to operate. Public protection and Multi-Agency mental health services to prisons, especially challenge for a mental health provider is to provide Confidentiality is an issue if a room is not available Public Protection Arrangements (MAPPA) inpatient facilities. the evidence to support this. In the coming months for an assessment to take place. Further guidance we will be reviewing all admissions to the prison from the trust health and safety teams is required A more systemised process is needed to facilitate inpatient unit against an acute mental health/PICU to enable practitioners to construct safe and clear liaison of MAPPA and public protection issues, admission criteria. practicable ways of working within this complex environment. 14 Prison mental health: vision and reality Prison mental health: vision and reality 15

Summary References The journey over the last five years of developing There is no defined model for the provision of prison mental health has been made up of three Bradley K (2009) The Bradley Report: Lord Bradley’s prison mental health services. Our work to date distinct phases: the development of inreach teams review of people with mental health problems or has proved to us that working in prison mental where mental health parachuted into prisons; PCT learning disabilities in the criminal justice system, health teams is very challenging, particularly commissioning mental health services; and a whole London: DH. because it is often isolated from mainstream health. systems approach to prison mental health. We are Care Quality Commission and Her Majesty’s Although prisons are unique environments, the now in the third phase where the aspirations and Inspectorate of Prisons (2010) Commissioning answers to many challenges lie within the collective ideals are equally matched to the reality health care in prisons 2008/2009, London: CQA mainstream services. It is important that wider of providing health care within the prison and HMIP. mental health services be involved in the environment. A lack of understanding and development of our work. motivation from some of our NHS Mental Health Department of Health (2009) Improving health, Trust colleagues regarding mental health care in supporting justice, London: DH. To attempt to manage the issues raised in this the prison environment remains a challenge. Department of Health and National Institute of paper, service providers must have robust Mental Health in England (2005) Offender mental integrated governance structures in place. All health care pathway, London: DH. stakeholders within the prison need to work in Durcan G (2008) From the inside: experiences of partnership, following a clearly defined mental prison mental health care, London: Centre for health care pathway. To enable cohesive care Mental Health. pathways it is advisable to have diversion schemes in local courts, as set out in the Bradley Report. Meiklejohn C, Hodges K, and Capon D (2004) This will allow for the early identification of mental Inreach work with prisoners, Mental Health health care needs and the referral of individuals to Nursing, 24 (6), 8-10. the appropriate services as they progress along the criminal justice pathway. 16 Prison mental health: vision and reality Prison mental health: vision and reality 17

Recognising mental health: balancing risk and care

Kimmett Edgar The Department of Health (DH) survey, Attitudes to judgemental definition as this are more exclusion, public, and applying custody until professionals are Head of Research Mental Illness (TNS-BMRB, 2010) shows how coercion, and discrimination. convinced they are safe to release. Prison Reform Trust mental illness is linked, in public perceptions, with stigma and risk on one hand, and tolerance and Standard 1 of The National Service Framework Current arrangements do not provide a healthy compassion on the other. The survey measured for Mental Health states: balance between therapeutic interests and public fear of mental illness. Fewer than six in ten people protection, or even suggest what a healthy balance agreed with the statement that, “people with “health and social services should… combat would look like. Public institutions, such as health services mental illness are far less of a danger than most discrimination against individuals and groups and criminal justice agencies, often find it people suppose”. with mental health problems, and promote • The number of people received into prison difficult to honour the individuality of people. their social inclusion” (Department of Health, under sentence in 2008 to serve twelve months A person’s mental health can change There was a significant increase from 29 per cent in 1999: page 14). or less was over 65,000iii. considerably over time, yet an offender can 2003 to 36 per cent in 2010 of those who believed • Around 70 per cent of women entering custody be stuck with the label ‘mentally disordered’ that mental illness indicated “someone prone to The campaign, Time to Change, established by require clinical detoxificationiv. throughout their contact with the criminal violence”. So while most agree that mentally ill the charities Mind and Rethink, has targeted • Revolving Doors Agency has estimated that justice system. A person’s capacity for people are not as dangerous as people suppose, stereotypes of mental illness, because stigma leads 60,000 people who have mental health responsibility – the extent to which someone over a third of the public equates mental illness to discrimination; discrimination is linked to social problems enter prison every yearv. is able to make decisions in the knowledge with “someone prone to violence”. exclusion; and isolation exacerbates certain of right and wrong – also varies. Courts mental health problems, thus setting up a For most people, time in prison is more likely to distinguish between those who are, and who A factsheet published online by the mental health destructive cycleii. aggravate than resolve any existing mental health are not legally responsible – with little room charity Mind cites evidence from Clark and Rowe problem. We also know that diversion away from for responding sensitively to someone whose that psychiatrists were more likely to diagnose The Bradley Report was commissioned to consider the criminal justice system and to mental health capacity is limitedi. someone as suffering from schizophrenia if the the extent to which offenders with mental health treatment works. Dr David James’ study of a court patient had a history of violence (Clark and Rowe, problems or learning disabilities could be diverted diversion process found that it achieved double There is a gap between government policies and 2006). This suggests that even the definitions of from prison to appropriate services. Over a year benefits: providing therapeutic outcomes for the structures, with their categories and distinct some mental health problems are influenced by the on from the Bradley Report, discussions about person’s mental health problems and reducing the pathways, and persons, whose lives transcend the stereotypes held by the public. For example, mental health and criminal justice are still polarised: rates of reoffending among those who were ‘boxes’ imposed by institutions. When that gap is personality disorder has been defined thus: one side highlights an individual’s mental health diverted away from criminal justice (James et al, bridged, it is by professionals exercising discretion problems; the other is focused on the dangers 2002). as they try to apply the policy to the person in “people with antisocial personality disorder posed by people with mental illness. front of them. exhibit traits of impulsivity, high negative Despite the evidence that people respond better to emotionality, low conscientiousness and Polarised images of mental health problems also mental health care in the community, despite the Public attitudes may influence professionals’ use associated behaviours including irresponsible lead to contradictory ‘solutions’: the former asking clear evidence that increased use of diversion away of discretion in at least two ways. First, the and exploitative behaviour, recklessness and for more resources for mental health treatment and from prison would be in the public interest, the professional is also a member of the public and deceitfulness...” (www.patient.co.uk). support; the latter requiring ever-more coercive over-use of prison for people with common mental susceptible to many of the same influences (e.g. management of people defined as a threat. illness continues unabated. The system is out of media). Second, government policies, which shape When presented with a description of a mental Therapeutic interests, meeting offenders’ needs for balance: it prioritises risk so that large numbers of the functions of health and justice, can also be health problem, the test should be: is this profile mental health care and/or support with learning vulnerable people are being defined – unnecessarily influenced by what the government believes to be likely to increase, or decrease empathy for this disabilities, compete with the risk averse interests in – as dangerous. It is also out of balance in that the concerns of the public at large. person? The policy implications of such a labelling them dangerous, excluding them from the there is a lack of care, therapy and support that 18 Prison mental health: vision and reality Prison mental health: vision and reality 19

people need in the community in order to improve re-offending by high-risk sex offenders: a learning disability can be held accountable for morally accountable and capable of personal their mental health and stop offending. criminal actions without discriminating against responsibility, then we may demand that such “at their heart, circles are about including, them if the support is in place to ensure that they responsibility be exercised in tackling the What is not so obvious is that the opposite set of rather than excluding: they provide a real and are not disadvantaged due to their disability. psychological, social and economic legacy of responses can be equally degrading. The meaningful community for a group that has victimisation and thereby changing the therapeutic model too often presumes that the previously been only stigmatised and Services that work with women offenders add to conditions in which offending has emerged as patient should not be trusted to make decisions. marginalised.” (Wilson, 2006). the knowledge about balancing public protection an adaptive solution” (Rumgay, 2004: page 15) The premise is that mental health care’s purpose is with support. Interventions that work best to ‘do things for’ the vulnerable person. When People with learning disabilities are disadvantaged acknowledge and address the prior victimisation This principle, balancing sensitivity to the diversion means that the person’s liberty is at the by the criminal justice system. The Prison Reform which women offenders have experienced: vulnerabilities of offenders with their obligations discretion of professionals in mental health care, Trust’s programme, No One Knows, revealed that not to re-offend, also seems to work with some of the patient may find that they are no better off from arrest through to resettlement, criminal justice “it is clear that the majority of women in prison the most dangerous offenders in the prison system. than prisoners serving indeterminate sentences. processes often neglect their particular needs and have experienced some form of abuse, and that That Grendon’s therapeutic regime reduces the risk The offender is passed from one coercive and discriminate against them (Talbot, 2008: page 75). a history of abuse is one factor amongst others of reoffending is well-established: stigmatising system to another. No One Knows showed that prison is an contributing to the risk of offending and of a inappropriate place for the vast majority of people range of associated problems, including drug “therapeutic communities within the prison Attempts to implement the Bradley Report reforms with learning disabilities. Many offenders with and alcohol problems, mental health problems offer intensive group psychotherapy and social will be strengthened if they can balance (and learning disabilities would be able to manage on and self harm” (Home Office and Prison therapy. This core therapy is complemented by moderate) these two interests. Fortunately, there community orders if they could receive special Service, 2003). activities such as art therapy, psychodrama and are some models that demonstrate that it’s support. cognitive behavioural groups. There is a strong possible. The risk of re-offending is closely tied to the emphasis on multidisciplinary working and each Are learning disabled offenders being denied the woman’s experience of being victimised by others. team consists of forensic psychologist, prison Circles of support and accountabilityvi work with opportunity to take up community orders – and Addressing the prior victimisation is not intended to officers, probation officer and psychodynamic high-risk sex offenders on release from prison. receiving custodial sentences – because their let an offender off the hook. Rather, it creates a psychotherapist. The focus of much of the work A circle is made up of volunteers who meet the disability makes it difficult for them to keep to the mutual obligation, between the offender and the is upon disordered relationships, which often offender before his release, and then provide conditions? No One Knows cited cases in which a state, to work on the consequences of that abuse arise from intolerable and uncontainable informal support during his resettlement. The learning disabled offender was recalled to prison for her behaviour. In short, helping her to resolve feelings, and the outcome of violence or other purpose of the group is to provide both help and for breaking his curfew, though no one had the damage caused by being abused is very likely to offending. Through exploring the past and monitoring. The support can include advice about checked to confirm that he could tell time. A prevent further offending. present, clients can begin to make sense of their housing, employment, finances, and other former offender said that no one had explained to cycles of being abused and abusing and through concerns. Accountability refers to an explicit him that a failure to pay a court fine was Rumgay (2004) has concluded that women forming reparative relationships with staff over a agreement that the circle will maintain imprisonable and he was not aware that he could offenders seem to be unusually receptive to these period of years the energy for violence can be communication with probation services and police be sent to prison for that offence. Schemes for approaches, which recognise their prior ameliorated” (NIMHE, 2003: page 19) and inform the authorities of concerns they might people with learning disabilities, like the charity victimisation, yet expect them to make amends, in have about the core member’s behaviour. KeyRing provide, enabling community support, can some way, for the harm they have caused others: There is a substantial risk in encouraging health offset many of the disadvantages imposed on them providers to make themselves aware of the The circles provide encouraging signs of reducing by the criminal justice system. Offenders who have “if we are bound to hold the victimised offender potential danger a patient might pose to the 20 Prison mental health: vision and reality Prison mental health: vision and reality 21

public, or in efforts to make prisons more • the over-representation of people from black References Rutherford M (2010) Blurring the boundaries: the therapeutic environments for mental health. Asking and minority ethnic (BME) groups in both mental convergence of mental health and criminal justice either department to take on the other’s functions health secure care and prisons suggests that Bradley K (2009) The Bradley Report: Lord Bradley’s policy, legislation, systems, and practice, London: adds to the pressures experienced by offenders. It further convergence could contribute to review of people with mental health problems or Centre for Mental Health. might be fair to require an offender to meet the institutional racism. learning disabilities in the criminal justice system, Centre for Mental Health (2002) Briefing 17: an requirements imposed by the courts, or to expect (Rutherford, 2010). London: DH. executive briefing on breaking the circles of fear, a mentally ill person to comply with the treatment Clark T and Rowe R (2006) Violence, stigma and London: SCMH. provided by mental health services. But holding the As Rutherford argues, convergence has potential psychiatric diagnosis: the effects of a history of same person accountable to both is likely to create benefits in both mental health and criminal justice. Talbot, J (2008) Prisoners’ voices: experiences of the violence on psychiatric diagnosis, Psychiatric criminal justice system by prisoners with learning unreasonable demands. The hybrid order, by which But to achieve these, it is vital that the joined up Bulletin, 30, pp.254-256. an offender can be sentenced to hospital for work is properly managed. disabilities and difficulties, London: Prison Reform mental health treatment and given a prison Department of Health (1999) The National Service Trust. sentence, is a clear example. Achieving a better balance will require a shift in Framework for Mental Health, London: DH. TNS-BMRB (2010) Public attitudes towards mental resources, through justice reinvestment. The Home Office and Her Majesty’s Prison Service health, London: DH. The institutional response to the twin demands of Revolving Doors Agency estimated in 2007 that five (2003) Abuse, interventions and women in prison: Wilson, D (2006) The prison trick, The Guardian, risk management and addressing therapeutic needs per cent of the budget for criminal justice could be a literature review, London: HM and HMPS. 17 June 2006. is joined up services of health and criminal justice, transferred to health to double the money primary James D, Farnham F, Moorey H, Lloyd H, Hill K, a process termed ‘convergence’. care trusts have to spend on mental health Blizard R, Barnes T (2002) Outcome of psychiatrist (Revolving Doors Agency, 2007: page 3). admission through the courts, Home Office RDS i “The criminal law is an unsophisticated instrument for Among the drawbacks of convergence are: Occasional Paper No 79, London: Home Office. determining blame. Apart from the specific defences of • prison ‘hospitals’ are a contradiction in terms, Finally, balancing the patients’ needs for mental insanity and diminished responsibility, there is no specified as the impact of imprisonment is anti- health support with reasonable precautions against Mind Factsheet: Public attitudes to mental distress, way in which defences are framed which make allowances online: www.mind.org.uk for the state of mind for a person who commits a criminal therapeutic their risk to others requires systematic service user act. It must therefore be acknowledged that the criminal • labelling the person as both an offender and engagement. A study of BME patients’ experiences National Institute for Mental Health in England law may operate unfairly in relation to people labelled as mentally ill will stigmatise them more of mental health care concluded with a call on (2003) Personality Disorder: no longer a diagnosis mentally disordered offenders.” Mind, cited in SCMH, • an increase in preventive detention is unjust, in service providers to listen more carefully to the of exclusion, London: NIMHE. Rutherford, page 39. ii Time to Change is England’s most ambitious programme to that prolonged custody is arbitrary; and it is perceptions of the service user: Prison Reform Trust (2009) Too little, too late, by K end the discrimination faced by people with mental health inefficient, in that the vast expenditure on Edgar and D Rickford, London: Prison Reform Trust. problems, and improve the nation’s wellbeing. indeterminate sentences and the Dangerous “service users and carers repeatedly ask to be www.time-to-change.org.uk Revolving Doors Agency (2007) Prisons: Britain’s iii People with Severe Personality Disorder treated ‘with respect and dignity’ and they Ministry of Justice (2009) Offender Management Caseload “Social Dustbins”, by J Corner, E Jones and R Programme (DSPD) programme are not justified demand better information about services with Statistics 2008, Table 6.1, page 51. Honeyman, London: Revolving Doors Agency. iv Prison Reform Trust (2009) Bromley Briefings, June 2009, by convincing evidence of their impact on less coercion, less reliance upon medication and page 43, London: Prison Reform Trust. re-offending other physical treatments and more choice. In Rumgay J (2004) When victims become offenders: v Revolving Doors Agency (2007) Prisons: Britain’s “Social • risk management and public protection this they concur with the views of many other in search of coherence in policy and practice, Dustbins”, by J Corner, E Jones and R Honeyman, London: dominate the treatment of mentally ill offenders, service users and carers who have commented London: The Fawcett Society. Revolving Doors Agency, page 1. vi www.circles-uk.org.uk as, for example, mental health needs are on their experience of mental health services. presumed to signal criminogenic factors They wish to be treated and respected as individuals.” (Centre for Mental Health, 2002: page 6). 22 Prison mental health: vision and reality Prison mental health: vision and reality 23

The relationship between mental institution beds, prison population and crime rate

Ian Cummins concludes that society responds to challenging or This incorporates the ideas that individuals live in a time as the rise in the prison population, as Penrose Senior Executive bizarre behaviour in one of two ways – either by community but have little interaction with other predicted. The clash of the two policies outlined School of Social Work, Psychology and the use of the criminal justice system or the mental citizens and major social interactions are with above – hospital closure and prison expansion – at Public Health health system. The system with the greater capacity professionals paid to visit them. first seems to provide evidence to support Penrose; University of Salford at the time takes on this role. they also create significant challenges for all those Other social outcomes such as physical health, working in these fields. As Lord Bradley (2009) has The problem raised by the use of the criminal which can be used as measures of citizenship or highlighted there is a need for all staff working in justice system as a response to mental illness is not social inclusion, are also very poor indicators. Kelly agencies in the criminal justice system to receive Lionel Penrose (1898-1972) made an enormous a new one. Howard (1780) noted that there were a (2005) uses the term ‘structural violence’, originally training in relation to mental health issues. contribution to the development of medical number of “idiots and lunatics” in prison. He also from liberation theology to highlight the impact of genetics, particularly in the study of Down’s argued that they did not receive appropriate care a range of factors including health, mental health Large and Nielessen (2009) undertook a review of Syndrome (Harris, 1974). In addition, he was and if they did they “...might be restored to their status and poverty that impact on the mentally ill. Penrose’s original hypothesis using data from 158 also concerned with the nature of the services senses and usefulness in life.” Stone (1982) argues countries. They suggest one of the main features of provided for the mentally ill and those with that this is a problem all urban societies have faced The response of successive governments since 1983 Penrose’s argument is that there is a unchanging learning disabilities. In this essay, I will explore in one form or another. In addition, he suggests to the developing crisis in the provision of mental proportion of any population that will need, or be his famous hypothesis regarding the use of that it is one that has never been solved. health services has been to focus on the legislative deemed to need, some form of institutional control. prison and psychiatric care in the light of and policy framework. They concluded that though there was a positive recent developments in both policy areas. The justification for the development of community correlation between prison and psychiatric populations based mental health services is based on moral and The policy of deinstitutionalisation is followed in low and middle income countries, there was no Penrose (1939 and 1943) put forward the clinical arguments. It is a combination of idealistic across the world (Hicking, 1994; Mizuno et al, such relationship in high income countries. intriguing hypothesis that there is a fluid and pragmatic approaches. The idealism can be 2005: Ravelli, 2006). The World Health relationship between the use of psychiatric seen in the human rights arguments that were put Organization (2001) highlights that long-term It is clear that in the UK, the prison population inpatient beds and the use of custodial sentences. forward. Community based services, it was argued, facilities are still the most common form of service has risen significantly over the past 25 years. The 1939 paper was based on the analysis of would be by definition more humane. Lamb and provision – 38 per cent of countries worldwide I remember working as a probation officer in the statistics from European countries and argues that Bachrach (2001) argue that this was based on a have no community-based mental health services, mid-1980s when there were great concerns that there was an inverse relationship between the moral argument with little evidence to support it. whereas there has been a shift in service provision the prison population would break the 45,000 provision of mental hospitals and the rate of serious Clearly, the supporters of community based mental in North America and Europe towards this policy. At barrier. Wacquant (2009) argues that prison policy crime in the countries studied – as one increases, health services did not argue that asylums should the same time, there has been a clear shift towards has replaced welfare services as a means of the other decreases. be replaced by jails. a more punitive prison policy. As Wacquant (2009) responding to the needs of marginalised individuals argues, throughout the industrialised world there and communities. Successive governments of The 1943 paper was a study of the rates of hospital Deinstitutionalisation, a progressive policy aimed has been a large prison building programme and differing political persuasions have been seemingly admission in different states in the USA and the at reducing the civic and social isolation of the investment in the criminal justice system. It should addicted to the expansion of the use of custody numbers in state prisons. Later in his work, he mentally ill, did not achieve its aims. Wolff (2005) be noted that this process has been overseen by despite its well-documented failings to achieve its argued that a measurable index of the state of and Moon (2000) argue that asylums have been governments, particularly in the UK and USA with a avowed aims. In addition, as Barr (2001) development of a country could be obtained by replaced by a fragmented and dislocated world of commitment to reducing both the role of the state demonstrates, the ‘zero tolerance’ approach widely dividing the total number of people in mental bedsits, housing projects, day centres or and public spending. Gunn (2000) and Kelly (2007) adopted in the privatising and policing of public hospitals and similar institutions by the number of increasingly, prisons and the criminal justice system. found that the reduction in the number of space results in more mentally ill people being people in prison. Penrose’s work in this area This shift has been termed ‘transinstitutionalisation’. psychiatric beds in the UK occurred at the same drawn into conflict with various public authorities. 24 Prison mental health: vision and reality Prison mental health: vision and reality 25

Discussion • what are the underpinning beliefs, on which, Bradley K (2009) The Bradley Report: Lord Bradley’s Mizuno M, Sakuma K, Ryu Y, Munakakta S, mental health services should be based? review of people with mental health problems or Takebayashi T, Murakami M, Falloon I R and It is possible to explore Penrose’s hypothesis as a • what is it that mental health services should learning disabilities in the criminal justice system, Kashima H (2005) The Sasagawa project: a model statistical argument about the use of two distinct seek to provide for those experiencing London: DH. for deinstitutionalisation in Japan, Keio Journal of institutional processes – prison custody and acute distress? Garland D (2001) The culture of control: crime and Medicine 54(2): pp95-101. psychiatric care – and the investigation of the social order in contemporary society, Chicago: Moon G (2000) Risk and protection: the discourse relationship between the two. I would argue that The answer is, in many ways, disarmingly University of Chicago Press. of confinement in contemporary mental health there are a number of dangers in this approach. It straightforward: an appropriate place to live, an Gunn J (2000) Future directions for treatment in policy, Health & Place Volume 6, Issue 3, equates, however unintentionally, crime and mental adequate income, employment and other activity, pp239-250. illness. In addition, it fails to explore the reasons respect, trust, help and support. These reflect civic forensic psychiatry, British Journal of Psychiatry, behind the changes in patterns of use of the two and human values of support and respect that 176 pp332-338. Penrose L S (1939) Mental disease and crime: institutions. As Garland (2001) suggests, the should be at the core of public services – whatever Harris H (1974) The development of Penrose’s ideas outline of a comparative study of European increase in the use of prison continues despite the their configuration. in genetics and psychiatry, British Journal of statistics, British Journal of Medical Psychology, general reduction in the crime rate. Therefore, it is Psychiatry, 125 pp529-536. 18, 1–15. part of a wider change in society and government The range of service initiatives that have been Hicking F W (1994) Community Psychiatry and Penrose L S (1943) A note on the statistical attitudes rather than simply a response to crime. developed to address the mental health needs of deinstitutionalization in Jamaica, Hospital and relationship between mental deficiency and crime The changes in the use of institutional psychiatric those in our prisons are to be welcomed. However, Community Psychiatry, 45(11) pp1122-1226. in the United States, American Journal of Mental care are the result of a combination of social these new ways of working should not obscure the Deficiency, 47: 462. Howard J (1780) The State of the Prisons in attitudes, improved medical and treatment fact that as a society we have become over-reliant Ravelli D (2006) Deinstitutionalisation of mental approaches, recognition of the cost of in-patient on the use of prisons. As a result of this and other England and Wales (2nd edition), Warrington: Cadell. health care in the Netherlands: towards an treatment and recognition that citizens should not policies discussed above, the distinction between integrative approach, International Journal of lose their civic and human rights because of mental some areas of the criminal justice system and Kelly B (2005) Structural violence and Integrative Care, Volume 6. ill-health. mental health services are increasingly blurred. schizophrenia. Social Science and Medicine, All too often, policy decisions in this area are 61 pp721-730. Ritchie J (Chair) (1994) The report of the inquiry The moral force of Penrose’s arguments can presented as if there is no alternative. The force into the care and treatment of Christopher Clunis, Kelly B (2007) Penrose’s Law in Ireland: an London: HMSO. perhaps be located in his Quaker beliefs. In a of Penrose’s initial papers today is the clear view ecological analysis of psychiatric inpatients and similar vein, in 1994 the Mental Health Foundation that we, as a society, have a choice to do things prisoners, Irish Medical Journal, 100, pp373-374. Stone L (1982) An exchange with Michel Foucault, published Finding a place. This was the result of a differently. I would argue that the message of the New York Review of Books: New York. Lamb H R and Bachrach L L (2001) Some general inquiry into the failings of mental health Bradley Report is that this is a choice that we perspectives on deinstitutionalization Psychiatric Wacqaunt L (2009) Punishing the poor: the neo- policy in the late 1980s/early 1990s that ultimately should exercise. Services, Volume 52 Number 8. liberal government of social insecurity, London: led to the Ritchie Inquiry. The messages of this Duke University Press. report are very relevant to this discussion. Instead References Large M and Nielssen O (2009) The Penrose Wolff N (2005) Community reintegration of of starting from an organisational or service Hypothesis in 2004, Psychology and Psychotherapy: prisoners with mental illness: a social investment structure perspective, the report adopts a values Barr H (2001) Policing madness: people with mental Theory, Research and Practice, 82 pp113-119. perspective, International Journal of Law and one. It ask the fundamental questions: illness and the NYPD in Quality of life and the Mental Health Foundation (1994) Creating Psychiatry, 28, pp43-58. new police brutality in New York City, New York: community care: report of the Mental Health NYU Press. Foundation Inquiry into community care for people with severe mental illness, London: The Mental Health Foundation. September 2010

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