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.

Female offenders: The role of trauma and mental illness

My professional background (though not my personal, I hasten to add) is in offending and it remains an area which fascinates me. A lot of the research in the area is obviously dedicated to reducing offending, be that in terms of severity or frequency, and a significant amount tries to identify factors which increase the risk of offending, i.e. ‘risk factors’. Recently, an article was published in Psychology of Women Quarterly. The paper investigated the effect of trauma and mental illness in imprisoned women using a mixed methods design. As a general rule, research is divided into ‘quantitative’ (typically employing questionnaires or other measurable outcomes which can then be analysed statistically to ascertain whether there has been a change in whatever has been investigated) and ‘qualitative’, which often uses interviews or focus groups. Crudely, one involves numbers and the other involves words. Both have their pros and cons but it seems to me that quantitative research has more adherents and I sometimes worry that by focusing more on numbers we lose the richness of qualitative research, which can provide extremely in-depth data and which is equally valid, despite the lack of statistics.

This study is relatively unusual in that it combines qualitative and quantitative methods; thus using a ‘mixed methods design’. Up to 90% of women prisoners experience physical or sexual violence in the year preceding imprisonment and many have experienced chronic lifetime abuse. Those abused or neglected in childhood are more likely to offend and to be arrested as adults. For many women, delinquent behaviour can be directly linked to the traumatic event, e.g. running away, using drugs, etc. It’s well-known that trauma experiences are common in those who offend (but, crucially, not all those who experience trauma will go on to offend). Secondly, trauma and mental disorder, be it depression, psychosis or personality disorder, are strongly associated. This paper, then, looks at the effects of both trauma and mental illness (MI) in female inmates.

The authors found that 85% of their sample had a history of substance misuse disorders and that half had a history of post-traumatic stress disorder (PTSD). PTSD can only be diagnosed if you have experienced life-threatening violence or a natural disaster, so rape at knifepoint would warrant a diagnosis but chronic, non-violent sexual assault would usually not. In this case, half the women had had PTSD but even more would have experienced acutely traumatic events without developing PTSD. Half had also experienced a MI such as depression or psychosis, both of which are also associated with trauma experiences. Conclusion: major trauma is very common in female prisoners. Specifically in this sample, 86% had experience sexual violence, and 77% had experienced domestic violence. Only 2 of the sample (of a total of 115) had not been victimised in any way at any point in their lives.

This is all interesting enough, but it’s simply associations; it doesn’t tell you what causes what. Similarly, there’s an association between age and height, but without statistical analysis it’s impossible to see the direction of the relationship. Regression analyses are designed to do just this. They look at factors as predictors and outcomes to show you what the biggest predictor is. They also allow you to control for baseline factors. So for example you could look at the relationship between mental illness and gender (predictors) on reoffending (outcome) but since people who have a history of offending a lot are more likely to reoffend a lot you can might also adjust the analyses for baseline rates of offending to even the analysis out.

Unsurprisingly, women with substance problems were more likely to engage in sex work and driving under the influence of alcohol or drugs. Domestic violence was associated with property crime, drug offending, and commercial sex work and it looks as though these men acted as partners, drug dealers, partners in crime (as it were) and pimps. Witnessing violence was associated with property crimes, engaging in assaultive behaviours and use of weapons, sometimes in self-defence and sometimes in defence of others, such as parents or grandparents. Those who had experiences of caregiver violence were much more likely to run away during adolescence; 4 times as likely as those who were not maltreated. Whilst for some this will allow them to escape being at home, we also know that living on the street is associated with substance use and other offending behaviour, as well as placing the person at greater risk of violence.

This paper looked at a number of mental illnesses but not at anxiety or personality disorders. Up to 70% of inmates have a personality disorder (PD) and we know that trauma is implicated in the development of such disorders. The fact that it wasn’t included means that it’s possible that it s PD which is the underlying factor and not necessarily the trauma experience. Nevertheless, it seems that several life events significantly increase the risk of offending and incarceration, including abusive childhood experiences, violent relationships, criminal environments and self-medicating with substances. It also seems that life events such as running away from home following maltreatment are critical.

So pragmatically, what does this mean? Well, for a start, it seems that MI is common in prison, therefore there need to be more funds allocated to assessing and treating it. Secondly, if people have histories of abuse, neglect and maltreatment, how is prison going to care for them? Will it provide consistent care to try to rebuild people’s abilities to form positive relationships? Given that early experiences are so crucial to adult functioning, how can we identify maltreatment more effectively and intervene to reduce the impact? Finally, how will social care, education, housing and substance misuse services join together to create ‘packages’ of care and support for those at the greatest risk of MI and offending? We try to implement such care packages in the UK (it is of note that this study used an American sample) but we still have a significant female offender population and we know that many of the issues raised in the paper are pertinent on this side of the pond. It has long been known that women offenders have specific needs; it just seems that we’ve still not found a way to attend to those needs as well as we could.