Month: March 2014

On mentally disordered offenders: How we fail 90 000 people at once

I like working with offenders. I haven’t done it in a while, since I’ve spent the last three years training as a clinical psychologist, but I miss it enormously. It’s perhaps odd that I find anxiety harder to work with than things like personality disorder (though words like ‘easy’ and ‘hard’ are both crude and relative). Still, someone has to do it, and I’d far rather play to (what I see as) my strengths.

I have issues with the treatment of both offenders and those with mental health issues. On the whole, practitioners are dedicated and compassionate; be they social workers, nurses or support staff. I’m not so keen on psychiatry, though I have met and worked with some psychiatrists who are fantastic. I suppose it’s not psychiatrists per se I am wary of but the tendency to see mental health through a psychiatric lens. But that is probably a topic for another day.

In mental health, we are rightly very concerned with good and bad practice when working with offenders who are also in contact with psychiatric services. Of the 85 000 people in British prisons, an estimated 70% have mental health problems (MHP). Furthermore, 4000 people are held in the ‘special’ hospitals – Broadmoor, Ashworth and Rampton, and, in Scotland, Carstairs. These patients tend to be the ones thought of as ‘untreatable’ and are invariably seen as extremely dangerous – Peter Sutcliffe, David Copeland, Charles Bronson, Robert Maudsley, Ronald Kray, Ian Brady. Interestingly, 87% of the patients at such institutions are male.

There is little doubt that prison is bad for your mental health. The WHO pinpoints the greater risk of isolation, loss of privacy, aggression from others and the loss of control. Add on the stigma and the pressure to engage in illicit activities and the situation is certainly bleak.

And the effects? For a start, each year, 17 000 children are placed in care after their mothers have been remanded at Her Majesty’s Pleasure. Then there is the problem of life after prison. Prisons are very good places to find work, whatever that may be. Some are very good at giving you skills (literacy and numeracy being a case in point; though Chris Grayling has put an end to that) necessary for any hope of a life on the outside. The problem is that there is no support upon release. A release grant of £47.50 is given to all those going back into the community. But, let’s be realistic. £47.50 is not going to get you much. The average person (not the average offender, note), would perhaps buy some cigarettes and then go to the pub. That will leave you with little to buy food and find accommodation. Benefits exist, of course, but, as anyone who has ever dealt with them will know, the DWP is very good at stopping payments when you’re remanded and very bad at reinstating them upon release. It can take weeks. No Housing Benefit can mean nowhere to live. Without other allowances it can be virtually impossible to survive. It’s not uncommon for people to shoplift and then end up back in jail when all they were trying to do was feed themselves. Prison may be unpleasant, but at least you’re provided with the basics. In addition, even if you make it out of prison and get somewhere to live and something to eat, who’s going to employ you with a criminal record? Research shows, unsurprisingly, that those who have been imprisoned are more likely to reoffend. The likelihood increases with each extra spell spent behind bars. Now imagine the situation if you’re an ex-offender with MHP. The difficulties are magnified – 40% of prisoners with MHP are homeless; 60% have no work outside the prison. It can be hard to manage psychosis in prison. There are few specialist services and trying to get someone in the midst of a breakdown referred is never simple. There are targets in place: a person breaking down should be referred to an appropriate service immediately and transferred within fourteen days. What actually happens is that the person is referred and it can take months before a bed becomes available. They continue to deteriorate. In 2013, there were 70 suicides in custody; the highest figure in six years. There have been increases in recent years in the number of adolescents killing themselves. But the target for transfer is met through the back door – many services start counting the fourteen days form the date a bed becomes available, not the date the referral was made.

Another obstacle is funding. Because prisoners are moved around the country so much, a Londoner may find themselves in HMP Wakefield, in Yorkshire. So, who pays for the psychiatric care? The London Borough of Lambeth (for example) or the Wakefield Primary Care NHS Trust? Invariably, wrangling ensues. Contrast this with the prisoner who’s had a heart attack. In general, an ambulance will draw up within ten minutes and no one will dare question their financial liability.

Prisons are, unfortunately, not places steeped in morality. On average, there is an assault every other day at most prisons. Robbery and violence are commonplace; the atmosphere is brutalising, to say the least.

As for the money, it costs £40 000 to incarcerate a person for a year. It costs £170 000 to build a prison cell. In these times of economic hardship, £2bn is being spent on new prisons. And, each year, budgets are cut by around 3%. The first to go is the rehab work, the work that actually can turn lives around.

There are alternatives. This isn’t about being a woolly liberal. This is about common sense and humanity.

The Sainsbury Centre for Mental Health advises the government on mental health policy. Their strategy is ‘diversion’ and it is simply based on identifying those individuals at risk of entering the criminal justice system and intervening appropriately. That may involve parenting classes or community sentences. It’s surely better to give someone a community sentence rather than sending them to prison for four months for a minor offence. Realistically, they’ll be out in two but the fact of the remand will count against them for quite some time. And the research supports it: people ‘diverted’ from the prison system tend to re-offend less. On average, the saving is £20 000 per individual. And that’s just for adults; successfully ‘diverting’ a juvenile could potentially save a lot more money. Factor in the benefits to society and surely there is compelling evidence?

As ever, there is apparently a shortage of money. 150 of these ‘diversion’ units have been set up but we need more like 300. Will the Coalition government put more money towards it? Given past form, probably not.

Then there’s the example of HMP Dovegate, a therapeutic community (TC). Dovegate is a prison but operates in a different way. A therapeutic community works on the basis of individual control, autonomy and group cohesion. You are encouraged to take responsibility for what you have done and learn new ways of coping and interacting with others. Again, the research is promising. After as little as six months, self-esteem has increased and inroads have been made into previously disturbed though processes. With time, hostility reduces and self-awareness increases. Again, people who are placed in the TC tend to re-offend less than those placed in a mainstream prison.

This all sounds like a manifesto for spending billions on violent, dangerous people. It’s not. It’s a manifesto for realising that the system is failing many vulnerable people and that something has to change. So I end with two stories, both completely factual.

Petra was taken into care at the age of nine as her mother was abusive towards her. She was repeatedly raped by staff at the children’s home she lived in and began to self-harm. At sixteen she had a son but, diagnosed with borderline personality disorder, common in those who were raped in childhood, she was unable to cope. She was deemed ‘untreatable’ and left to her own devices. Her self-harm escalated. One day, she phoned the community mental health team and asked to be assessed as she felt she was deteriorating. They refused. She set fire to herself and, rather than being assessed for psychiatric care, she was charged with arson with intent to harm. She was imprisoned and, within 130 days, there were 90 incidents of self-harm involving burning, cutting, overdosing and ligatures. No action was taken to address her obviously deteriorating state. She eventually hanged herself, aged nineteen.

Petra had a twin sister whose experiences during childhood had been similar. Her sister was placed in a therapeutic community and is now a well-adjusted member of society. In her words, if Petra had been given the same chance, she would probably still be alive.

Ashley Smith had her first contact with psychiatric services aged thirteen. They decided she was too difficult to handle and sent her home. She was diagnosed, after assessment, as having ADHD and a learning disability, as well as a borderline personality disorder and narcissistic traits. By the age of fifteen, she was in prison and began to harm herself. The crime? Throwing apples at a postal worker. She was troublesome and she was punished for it; repeatedly tasered and put in isolation. Canadian law states that you cannot be put in seclusion for more than sixty days at a time. The prisons side-stepped this by transferring her to another prison after sixty days and having her secluded again. In twelve months, there were 150 incidents recorded. At the age of nineteen she too hanged herself. The only difference was that there were seven prison guards watching her. They had been instructed not to intervene if she tied a ligature as that would be ‘giving in to her manipulative behaviour’.

If that doesn’t indicate we need to rethink how we treat mentally ill offenders, what does?

This post is also due to appear at

On offenders, rehabilitation and the importance of books

It is one of the great mysteries of life that government policy is never rooted in anything as mundane as evidence. We have seen this in terms of drug policy and the advice given to expectant mothers over the amount of alcohol they should (or should not) take. It’s there in Gove’s disastrous education rhetoric and in Hunt’s much-criticised health reforms. The latest piece of dangerous twaddle relates to books, which are now apparently to be used as a carrot to convince prisoners to ‘be good’. Let’s think a bit about what we know of prisoners, shall we?

• A third of prisoners has been in the care system
• Half ran away from home as children
• Poverty is highly correlated with offending
• A third truanted from school on a regular basis
• Between a third and half were excluded from school
• Up to 70% have no qualifications when they leave school
• Up to a quarter attended a school for people with special educational needs
• 65% have poor numeracy levels (below the standard expected of an 11 year-old)
• Half have poor literacy
• 80% have poor writing skills

Incidentally, these figures are all taken from a report published by the Cabinet Office. So we have a group of people who are severely disadvantaged and who, unsurprisingly, tend not to be in secure employment, if any. They tend to have drug and alcohol problems (remember the social and emotional effects of an unstable childhood and traumatic experiences. If you’re not sure what they are, use your imagination, and then look again at the list above. The consequences are often bad).

We often talk in forensic services (those for offenders with mental disorders) about whether prisons are there to protect the public, to punish or to rehabilitate. Governments tend to like the first two; people who actually work in the system tend to favour the latter, with a healthy regard for the former. We see that there are reasons for offending behaviour; not excuses, but reasons. For lots of people life is tough and if you haven’t experienced it, it can be hard to understand why someone won’t just sort themselves out, get a job and a flat and be a good citizen. But it’s not always that easy. Some people do manage it and I take my hat off to them. But when you work with offenders you are likely to be dealing with people who have already been excluded from their families and schools and marginalised by society. No matter how liberal you think you are it’s quite possible you won’t want your children to be friends with the truant who began smoking and drinking when they were young and that you’ll try to encourage them to have more ‘suitable’ friends. What we end up with is two quite distinct social groups, with a significant disparity between them.

No matter what your political leanings, my suspicion is that almost everyone wants offenders to stop offending. A lot of time and effort and research goes into working out what helps. There are lots of offender training and treatment programmes in use but I won’t re-hash it here. Put simply, with appropriate input, even the most dangerous, high-risk offenders can demonstrate a reduction in violent and offending behaviour. Some will re-offend, but there’s no magic wand and none of us would claim there is. But do you know what does help? Being able to read. Literacy opens doors. If you can read and write, you are more likely to be able to get onto a training course. With qualifications you can get a job. With a job, you can enter another part of society. Yes, the stigma persists. Ex-offenders might not be top of your list of people to have to dinner, but don’t for one moment think that a criminal record stops you from wanting to change your life. The role of government and the public sector, therefore, is to facilitate that change. As a result, there has historically been a significant focus on providing prisoners with opportunities to learn, do to Access courses and NVQs and GCSEs and degrees. And lots of people come out of prison with qualifications and, crucially, with literacy levels which will enable them to get qualifications from mainstream providers. What’s more, the research backs all this up.

Chris Grayling, in his infinite wisdom, has decided that he doesn’t like this and that prisoners can’t be sent parcels of books or magazines. They still have access to prison libraries (which are unfortunately often under-funded and dependent on charitable donations) but can’t be sent them by those charities or their families. If prisoners are very, very good, they can get a little more money for privileges and are welcome to spend them on books. Most prisoners get £10-15 a week to spend on privileges. Once you’ve paid for toiletries and cigarettes, how much do you have left for books? Do you know how much books cost? Eight pounds for an average paperback. It’s not as though prisoners can nip to Oxfam to pick up a stack of improving literature, is it?

It’s not just books, of course. The prohibition relates to all parcels. No Christmas cards or gifts from your kids, so bang goes your relationship with them (never underestimate how important it is for a child to send their parent a card at Christmas). No stationery (so God help you when you want to practice your writing). No packages of clothing; not even underwear. Instead you go to the prison shop, run by a private company, to get whatever you need. Even if you took out all my costs of food and travel and curtailed my social life, I could not buy everything I need for a week for £15. Grayling thinks this will encourage rehabilitation. Like many of his colleagues in the Cabinet, he’s a dangerous fool. Humiliating people is anathema to rehabilitation, and make no mistake; this policy, dear reader, is nothing but sheer, vindictive humiliation.

On the impact of cuts in MH services and the myth of ‘parity of esteem’

This piece was originally written for publication in the press and is due to be published towards the end of the month. I have taken the liberty of reposting it here.

When I’m not writing, I work in mental health. Mental health has always been the poor relation to physical health but it is clear that the disparity between the two is increasing exponentially. Although the public sector as a whole has had to tighten its belt since the economic crash that we, the public, didn’t cause, the NHS has been particularly vilified and, courtesy of the Health and Social Care Act, effectively privatised. Our budgets have been slashed and our workforces depleted. Although there have been some cuts in physical health, the fact remains that no government which aims to be re-elected is going to restrict the care given to people with cancer or heart disease. In the great hierarchy of illness, these people are top of the tree. In contrast, the people I work with, who are amongst the most vulnerable in society, are seen by successive governments as unworthy and ignored.

Since 2005, 30 000 people have lost social care support. 2000 mental health beds – 10% of the total – have been lost in the last two years. I have worked in wards which are running at 120% capacity, so God help you if you require an emergency admission, because it’s quite likely that you’ll be shunted off to a hospital several hundred miles from your home and your family. People with mental health problems are often already stigmatised and may lack social support. To ferry them across the country, effectively cutting off contact with their family and the professionals who know them is an outrage. Imagine the same happening in physical health. Imagine being told that your sibling, who had had a stroke, was being sent 250 miles away because there were no beds any nearer. You wouldn’t stand for it. I wouldn’t stand for it. But we make those in mental health services stand for it and because they are often unable to advocate for themselves it is allowed to continue.

Services aimed at young people have also seen swingeing cuts. Recent figures indicate that staffing levels in these services are only half the recommended level; as a result hundreds of under-18s are being treated in adult psychiatric units. Psychiatric wards can be confusing, frightening places even for adults. They are entirely inappropriate for children. Such an event should take place only in an extreme situation; for it to occur routinely is reprehensible.

In January Nick Clegg declared that there was too much ‘ignorance, prejudice and discrimination’ directed at people with mental health problems. He said that it was imperative that services were valued equally. As I write, it is being reported that mental health services have been asked to cut their spending by 20% more than physical health services, despite the fact that mental health services deal with 28% of the NHS disease burden whilst existing on 13% of the budget. Our services are crumbling; our clinicians are burning out. Lives are being put at risk and as things stand, we are hurtling towards a mental health crisis of gigantic proportions.

On therapuetic evangelism and why we should employ professional skepticism

Occasionally, when I am at a loose end, I think of three-letter acronyms and try to think of a model of therapy which might use that acronym. Amusingly (for a psychologist-type, anyway), more often than not, you come up with something that does indeed refer to a therapy which exists in the psychological literature. Despite stating over here  that there are three basic models of therapy, over the years, psychology has evolved and we are now in the situation where we have therapeutic models coming out of our ears. For the unitiated, here is a brief rundown of the main models we have at our disposal:

Acceptance and commitment therapy, Attachment-based psychotherapy, Behaviour therapy, Compassion-focused therapy, Cognitive analytic therapy, Cognitive behaviour therapy, Dialectical behaviour therapy, Emotion-focused therapy, Eye Movement Desensitisation and Reprocessing, Functional analytic psychotherapy, Intensive short-term dynamic psychotherapy, Interpersonal therapy, Mindfulness-based cognitive therapy, Mindfulness-based stress reduction, Mentalization-based treatment, Narrative therapy, Person-centred therapy, Positive psychology, Rational emotive behaviour therapy, Rational living therapy, Schema Focused Therapy, Solution focused brief therapy, Transference focused psychotherapy, Wilderness therapy.

And those are just the ones I am familiar with and which didn’t seem too left field. I haven’t included adapted models such as CBTi (for insomnia) or CBTp (for psychosis). It is, it would be fair to say, mind-boggling.

Lots of psychologists just rub along doing whatever seems to work for our patients. Whatever the clinical guidelines may say, one person with depression is rarely the same as another person with depression because they exist in a different family, with different experiences and goals, so the overwhelming majority of clinicians adapt their approach to fit the person.

Increasingly, however, there seems to be a slight culture of evangelism around particular models. There has always been debate, of course; I have a bit of a soft spot for family therapy, but I wouldn’t consider myself exclusive to any model. But more and more, there seems to be an air of exclusivity amongst some clinicians. This is easily observable via social media, where CBT for psychosis seems to be the current topic of (interminable) debate. I don’t object to the discussion of these things on Twitter (although you have to admit that 140 characters is hardly the best medium for it) but what irks me is that the majority of those involved in such discussions seem to have no intention of changing their view and are simply content to hammer away at the same points over and over again. That’s not debate, and I would suggest that trying to persuade people who are as certain in their views as you are in yours is a bit of a waste of time.

But I don’t write this purely to grumble about Twitter debates. My concerns are a little bigger than that, and perhaps the best illustration is mindfulness. Mindfulness is very much in vogue at the moment and was the topic of a very good piece in the Guardian recently. Mindfulness derives from Buddhist meditation but its proponents are very keen to point out that it ‘doesn’t involve any religion’. Disclosure: I (attempt, often unsuccessfully) to meditate, but I do it firmly from the Buddhist point of view. I like some philosophy to back up my inner serenity. Mindfulness spurns the philosophy and adapts the practice and it is often used with depression and anxiety. I have attempted to use it with patients, with varying degrees of success.

I happen to own a well-known mindfulness book (I took part in some research purely to get this book) and recently I was flicking through it. I was stunned by the language, not because it was offensive or profane, but because it seemed like the sort of blurb you would find in the sacred book of some new-age cult. I shall not, for reasons of professionalism, identify the book or quote passages, but the general thrust was that a) you need mindfulness; b) mindfulness will, without a shadow of a doubt, change your life. And though I may be paraphrasing, I am not exaggerating. And I am worried that statements such as these are being made because there are people out there who will take them as Gospel.

Let me be clear: mindfulness, like any other therapy, will work for some people with some problems. It is not a magic wand. It is an unfortunate truth that in psychology, there is no magic wand. I cannot promise that I will help you to rid yourself of your difficulties and I make that apparent with every person who comes to see me. We can try something and see if it works. If it doesn’t, we’ll try something else. It is constant trial and error, combined with clinical experience. It’s not magical or mysterious; it’s simply having a go.

The problem is that virtually every therapy in that list was invented by someone. Someone, somewhere, developed it, tested its efficacy and wrote a book. They probably run training courses and charge for accreditation. They may well be earning a fortune from it. Obviously, they are hugely invested in that therapeutic model. I don’t think that’s great for science or for our patients. There has been much in the media (partly thanks to Ben Goldacre) about the corruption, falsification and suppression of clinical trial results and psychology is not immune from such things. If you have built an entire career from a therapeutic approach, you need it to work. You also need people to apply it and for it to remain credible. This means that you might promote it more than it deserves or that you might claim that its scope is wider than it really is. Lots of therapies might be of some use in some people with some problems; I challenge you to show me a therapy which works for all people with all problems. If that is too hard, show me one which works for all people with one problem. I doubt you’ll be able to. But some theoretical models are being funded more than they ought and are being pushed more than they ought and the result is that clinicians are being forced to work in ways which may not fit the patient, and that is no good for us or for our patients. I never promise anyone a cure, but the very least I want to do is offer them something which might have a decent chance of helping them. The only way to do that is to remain open-minded and to remain skeptical. There is no panacea for psychological distress. If you develop your own theory or model and the evidence suggests that it can work, that is all to the good. But you really owe it to your colleagues and your patients, not to mention to yourself, to consider that model critically, to accept its limitations and to admit it when something better comes along.

On trying to do therapy when your patient has no food or money

Last week, I called someone I was due to see that afternoon to remind them I was coming round (standard practice in learning disability, and good practice in general). ‘How are you?’, I asked. ‘A bit pissed off’, they said. ‘I’ve got no money and no food’. I couldn’t get much more information by phone, but assured them that I’d be over shortly and that we’d sort something out.  In the meantime, I had a chat with this person’s care co-ordinator (one of the benefits of working in an open-plan office with your colleagues) and we made a referral to Social Services because this person didn’t have a Social Worker. In fact, this person has little support, despite needing quite a lot, because when they moved area they didn’t know how to get that support moved with them. As a result, there is a constellation of difficulties: mental health, physical health, financial. I took the referral for a distinct mental health problem and am probably the professional they know the best. I seem to have become a demi-care co-ordinator, telling the actual care co-ordinator what the problems are. Which is fine – I’m happy to do it, but it makes me furious that I am the best option this person has, because it’s not my area of expertise. I don’t know about district nurses or benefits. But at previous appointments, this person has been worried by ATOS assessments. There is no way this person could work, but ATOS sent a letter with an appointment for an assessment. This person forgot to go and was terrified their benefits would be cut. I dealt with that, and it seems to be fine for the moment, but suddenly this person had no food.

So off I went to see them. This person and their partner had had their benefits cut. They had no money. Their phones had been cut because they couldn’t buy credit. They had no food and no benefits were due for five days. They already owed the local shop for food and the owner would give them no more credit. They had no friends nearby and no family who could help (not that they could contact them anyway). I offered to call their friends/family when I got back to the office to see what I could do, but there seemed to be little else I could offer. Then Social Services called and the person I was seeing asked me to talk to them. I explained the situation and tried to see what we could work out. They could apply for a crisis loan, but had to do so by telephone or online (as if that was an option). No social worker would be allocated until Monday and they apparently couldn’t help with money problems or filling out forms (as an aside, in one of my previous jobs, I was told that social workers couldn’t help with housing any more. How, exactly, does this help the people we work with, most of whom have money or housing worries and lots of whom can’t manage forms without support?). I got, I confess, a bit shirty with the social worker. I think social workers do a really hard job, and I would never want to be one, but I get so FRUSTRATED at the way the system seems to have been designed by some Kafkaesque entity which declares that the more help you need, the harder it must be made for you to be able to access it. In the end I agreed to make some calls when I got back to the office and we tried to do so some psychology (you know, my actual job). It was ridiculous, of course. If basic needs haven’t been met, what the hell is a bit of therapy going to do? Nothing. Not a jot. But it was our last session and we had to tie up some loose ends. So we tried. And I felt stupid trying. And all I could think was ‘if only I could give them a tenner’. But I couldn’t, for lots of reasons, which even now I find hard to justify to myself. And I hated myself for it.

So I left, promising they would get a phone call as soon as possible. I got to the office and phoned the Council Food Bank department. I requested a voucher and persuaded them to give extra food for another adult who happened to live at the same property (which they don’t usually do). I spoke to a delightful person who was very accommodating and who didn’t make me beg (though I was more than prepared to beg, shout or emotionally blackmail) and I then called my patient back and told them to get to the Town Hall before five to pick it up. Even so, all the food banks were closed (they only seem to open in the mornings) so they may have been unable to get food until the next day. The only option would have been the Salvation Army or similar, but, again, I don’t know enough about the services available to be much use.

This makes me furious. This person has a learning disability and a mental health problem. They are vulnerable. They find it hard to access services. They cannot fight without help. To them, the system seems impenetrable. If neither I nor my colleagues had been there when Social Services called, who would have dealt with it? Who would have called the Council? Would they have slowly starved over the next five days, a little like this gentleman, who died as a result of ATOS and their ghastly assessments?

In my line of work, we see people who need help in all sorts of areas. People with mental health problems are more likely to have a whole raft of other issues, such as poor physical health and social isolation. They are less likely to be able to work; more likely to be dependent on the decency of the State. Unfortunately, the State does not treat these people with much in the way of decency. The Bedroom Tax, the cuts in Housing Benefit, the scum at ATOS; all of these are making life Hell for vulnerable people. Half a million going to food banks! In Britain! It’s a a national disgrace. And somehow we’re expected to treat depression or panic attacks or help people with the voices they hear. How? If you’re cold and hungry, panic attacks become rather less of a problem in comparison.  But the dilemma is this: we can say such people are not ready for therapy and reject the referral, or we can accept it knowing that we can’t do much about the mental health element but that we can do something about the other stuff they’re having to manage. And, actually, that shouldn’t be the choice.  There needs to be a decent system of support that can help with housing and money and forms.  But until there is, people like me, who are a bit crap at that kind of stuff, actually, because we only have the faintest notion of what it’s all about, are the best option. And that is also a disgrace.