Chapter 9
Special Settings: The Criminal Justice System

Richard Byng¹ and Judith Forrest²

¹ Primary Care Group, Institute of Health Services Research, Plymouth University Peninsula School of Medicine and Dentistry, University of Plymouth, Plymouth, UK

² Derbyshire Healthcare NHS Foundation Trust, UK

OVERVIEW

Within prison settings, the prevalence of mental health problems approaches 90%, and of these, 40–50% have anxiety and/or depression; the remainder have a variety of substance misuse and personality disorders, with a small minority having severe mental illness.
Demonstrating respect, care and concern; avoiding the label of ‘mental health’; and taking a flexible, problem-solving approach can ensure therapeutic engagement.
Management options for offenders in the community will be the same as for any other person, although it might be more problematic to persuade them either to take medication, or to attend psychological therapy sessions.
Because of high levels of comorbidity and, particularly, the likelihood of substance misuse in this population, there is need for a wide range of interventions to be available across teams and sectors to enable continuity of care both in prison and beyond.

Case study: Patrick

Patrick had been arrested again – the police had caught him dealing drugs in the pub car park – he knew that his father would shout, his mother would cry and his grandparents wouldn’t be told. This is what always happened. He was so angry that George never seemed to get caught, and this was his second arrest in a month. He thought that this time it might mean jail.

He also knew it was ridiculous. Yes, he had been using more and more cannabis to try and stay calm, but he didn’t need to be so blatant as to do his dealing in the car park. Part of him realised that in a way he wanted to get caught as he didn’t know any other way of asking for help. He knew that his mind ‘wasn’t right’, but wouldn’t have known how to explain it or express it. He didn’t see himself as ‘mental’ and was certainly not as bad as the ‘junkies and crack heads’ he despised. His father was an alcoholic and he had often witnessed violence to his mother and taken a few beatings himself. As a teenager he had ‘gone tough’, trusting no one and building a group of lads around him who would do his bidding. But gradually, as he starting using street drugs, mainly amphetamines, diazepam and cannabis, there was a breakdown in previously good relationships with his grandmother, older brother and a couple of close friends. Now, walking through town, he felt like everybody saw him as a loser, and if they gave him a look or said anything out of turn, he could easily get into fights. Knowing this would end up with him in a police cell, he had stopped going into town and started keeping himself to himself, buying and selling enough cannabis to reduce his anxiety.

One day, by chance, when his doctor’s surgery had asked him to come in to discuss his asthma, he met a GP who seemed ‘alright’ and when she asked him how he was feeling he found himself talking openly for the first time in many years. He described feeling useless, not being able to sleep and more recently losing weight and then answered questions about his poor appetite, interrupted sleep, low energy and palpitations. He was a bit surprised when the doctor said he had both anxiety and depression, and was very wary of admitting he was unwell and even more resistant to taking medication.

This case exemplifies many of the characteristics of those in contact with the criminal justice system who have mental health problems. They often come from socially excluded backgrounds, have ongoing social problems and have a range of symptoms across a number of diagnostic categories, in this case substance misuse as well as anxiety and depression. Patrick’s anxiety includes both fight and flight responses, and he has been using street drugs as self-medication. He does not recognise himself as having a mental illness, or know where he might get help. His self-worth is very low and his trust in everyone, including the health service, has been minimal for many years. At 18, Patrick is probably too young for a diagnosis of personality disorder, which his troubled relationships might suggest, but later it may become a more obvious or defining problem. He would share this difficulty with many offenders.

This chapter will outline how, when dealing with individuals like Patrick, either in primary care or within a justice setting, there are particular issues that need to be considered in assessment, treatment and the design of services. Each of these will be taken in turn and background contextual issues are briefly outlined below.

Background

Practitioners are often unaware that individuals have contact with the criminal justice system. Offenders may be divided into three groups: those with long prison sentences; short-stay prisoners, including those on remand, who have not been convicted and may be released at any time; and those with community sentences or contact with courts and police. In October 2013 the total prison population in England was over 84 000. While many of these individuals have long sentences, in the year ending March 2013, 57% of convictions were for sentences of 6 months or less, of whom 58.5% were likely to reoffend within 12 months of release. Twenty-six percent of offenders received a non-custodial sentence.

Box 9.1 Mental health and social problems of offenders

Within prison settings, the prevalence of mental health problems approaches 90% and of these perhaps 40–50% have anxiety and/or depression; the remainder have a variety of substance misuse and personality disorders, with a small minority having severe mental illness. Those with anxiety and depression often also have symptoms diagnostic of one or more other ‘disorder’: post-traumatic stress disorder (PTSD); obsessive-compulsive disorder (OCD); antisocial, narcissistic or borderline personality disorder; and substance misuse, in particular alcohol, heroin and amphetamines. In women, self-harm as a part of borderline personality disorder is particularly common. Furthermore, many have symptoms but are sub-threshold making the total symptom load very high.

For those leaving prison, homelessness or unstable accommodation is common (37%), unemployment is found in the majority, and about 50% have children, though male offenders are rarely the responsible adult. These social problems are both their main concerns and motivators. For female offenders, care for their children is often a paramount concern and safeguarding issues are complex for practitioners. Emotional and physical trauma, as well as abandonment, are common antecedents of most mental health problems for those in prison, sometimes dominating their narrative, and likely to be key causes for the range of symptoms each individual experiences.

Care received varies by setting: general practice and primary care prison services are the mainstays of care for physical health and also for mental health care, mainly in the form of antidepressant prescriptions and fit-notes. Specialist mental health care is provided by in-reach teams in most penal institutions. Substance misuse treatment, which is funded mainly via the Home Office and often provided by a third-sector organisation rather than the NHS, is available to large numbers both in prison and those on community sentences. A small but growing number of prisons have their own Improving Access to Psychological Therapies (IAPT) services, and there is anecdotal evidence to suggest that most community IAPT services are ill equipped to deal with offenders such as Patrick, with comorbid substance misuse and symptoms of anxiety, depression and personality disorder.

Assessment and formulation

While distrust and stigma might seem insurmountable problems to initial access, research with offenders in prison and evidence from services set up in selected areas show that in the right situation, offenders are often willing to engage with practitioners, services and treatment. There is compelling evidence to suggest that demonstrating respect, care and concern; reducing talk of mental health or diagnosis; and taking a flexible, problem-solving approach can ensure therapeutic engagement. Box-ticking and heavily protocol-based care with inflexible attitudes are less likely to be successful.

We suggest that formulations need to be based on a jointly agreed psychosocial assessment. An individual’s background, including trauma, abandonment and other childhood and adolescent problems is important as is family history. An assessment of mental health symptoms is important to demonstrate whether individuals achieve the criteria for anxiety and depression, but in this group, screening for other problems such as substance and/or alcohol misuse, OCD, PTSD and personality disorder is crucial. We also find that some individuals may barely fulfil the criteria for anxiety and depression but have a range of other problems so that the total symptom load is very great. Many men express emotional turmoil as anger, so it is always key to discover whether this is masking other symptoms, such as underlying fear or feelings of inadequacy. It may be difficult to tease out whether offence-related violence is, at root, an expression of distress.

Comorbidity can manifest in a number of ways. Sometimes there are two clear diagnoses that need to be treated in conjunction but with separate interventions (e.g., depression and OCD). More commonly, diagnoses are interrelated in terms of symptoms, meaning and aetiology, and the formulation needs to reflect this. Classification of individuals primarily according to disorder in order to decide a treatment plan may not be the best strategy, and would not reflect collaborative effort between practitioner and client. Furthermore, diagnosis is likely to change over time. Anxiety and PTSD can often be revealed when substance use is reduced, or anxiety might return when depressive symptoms decrease and individuals become more active. In addition, individuals may feel more anxious in the community than in prison, or vice versa: both prison and community may be depressogenic and anxiogenic.

Developing a person-centred collaborative formulation should be based around an individual’s personal goals, their strengths and preferred treatment options. Significant social problems such as unemployment, housing and relationship issues are likely to be much higher priority than admitting to having mental health difficulties. Rather than focusing on potentially stigmatising diagnoses it is important to explore the connection between the individual symptoms (thinking, emotions and behaviours) and specific social problems in order to determine whether and how treatment can help a client achieve goals. Assessment of an individual’s strengths requires purposeful questioning. We are constantly surprised at how resourceful patients have been at maintaining their own mental health and any treatment needs to link with existing and potential self-care strategies. Figure 9.1 depicts the elements of a psychosocial formulation diagrammatically and emphasises the social.

c9-fig-0001 — **Figure 9.1** A psychosocial formulation.

Source: *Psychiatry in Primary Care*. Patricia R. Casey and Richard Byng. New York, NY: Cambridge University Press, 2011. Reproduced with permission of Cambridge University Press.

Lastly, the assessment should consider which services are engaged, or should be engaged, with the individual, who may already have trusting relationships with other practitioners. A joint formulation involving all appropriate services seems likely to have most therapeutic effect.

Case study: Patrick (cont’d)

Patrick’s GP suggested that he might benefit from an antidepressant, and offered to refer him to the local IAPT service. He wasn’t keen on either idea, and didn’t collect the prescription. Then he got into another fight, and ended up on remand in the local prison.

On reception there he had a health screening with one of the nurses, who picked up on his anxiety and low mood, and extracted the information from him about what his GP had said. Patrick was discussed at the weekly multi-agency meeting, and it was agreed that he should be referred to the IAPT service in the prison; to the Drug and Alcohol Service for help with his substance use; and that he might be suitable for the ‘managing emotions’ group as a first step in coping with his personality issues.

The following week, Patrick met a CBT therapist who helped him feel that his worries and depression were entirely understandable and shared by many other people. When she explained how well medication and psychological therapy complemented each other, he agreed to try taking the citalopram as a 6-week experiment, as well as working one-to-one with the therapist.

At their next session, Patrick and Jane, his therapist, worked together to make a list of his problems and goals. He felt low about having let his family down, and anxious about what would happen to him. He couldn’t sleep at night because of all the worries going round in his head, and he felt completely hopeless that things might somehow improve. Jane helped him learn how to control his breathing and relax his muscles, then visualise a place he loved and felt safe. Patrick couldn’t see how any of this would help him, but agreed to practise every day ‘as if’ he believed it – the first of what would become weekly challenges.

His next challenge was to reduce his rumination and worry time. Together, he and Jane listed all the ways that he could keep busy, like radio, TV, reading, drawing, phoning or writing letters to family, and cleaning his pad (cell). Over the week, he kept a tally of the number of times he did any of the things on his list, which helped raise his mood.

Patrick was surprised to find that with practice, the mindful breathing and relaxation actually helped, and his sleep gradually improved. In trying to comfort his family, he found relations with his Mum and Gran improved.

He began to set himself targets, like talking to one new person every day, to reduce his anxiety. This had the incidental benefit of helping occupy his time during association periods and he was soon playing pool, and going to the wing cv room, too. As his anxiety and low mood improved, Patrick’s irritability reduced, and staff began to trust him to behave well, so he was asked to ‘buddy up’ with new prisoners on the wing – a real boost to his self-esteem.

Management

Management options for offenders in the community will be the same as for any other person, although it might be more problematic to persuade them either to take medication or to attend psychological therapy sessions. Chaotic lifestyles do not lend themselves to regular commitments, and anecdotal evidence from the few wellbeing and therapy treatment programmes offered by probation services shows that client engagement is an ongoing challenge.

For offenders undergoing custodial sentences, there is a greater probability that they will attend for treatment (if only to get out of their cell for an hour, and to feel that someone is actively listening to and understanding them).

Medication prescribing needs to be approached thoughtfully, because prescription drugs may be used as currency in prison, bartered for tobacco and other commodities; or ingested in quantity in search of an illicit ‘high’. Some people may attempt to overdose in order to have a trip out to hospital, whilst others will use it to self-harm. Prison nursing staff will carefully evaluate whether an individual should have ‘IP’ (in possession) medication. In the community suicide risk is particularly important – the most critical risk is the prescription of benzodiazepines or methadone, which in combination with alcohol and street-bought prescription drugs continues to contribute to suicide risk nationally.

All prisons will have a primary health team, usually including mental health trained nurses, but often the emphasis is on providing physical healthcare and prison mental health in-reach for severe mental illness. Some offer group work, for example for stress, anger or low mood (avoiding the stigma of ‘mental health’ labels).

There is little evidence to suggest that particular psychotherapeutic modalities are more effective than others in this group with such high levels of comorbidity. There is, however, a rationale for employing therapy that is able to address relationship issues (e.g., cognitive analytic therapy, mentalisation-based therapy). Anecdotal evidence suggests integrated services, where the interventions are shared in order to provide seamless care, are most successful. This is the case whether only one provider is involved at all levels, or in the extreme, where three different Trusts are commissioned to provide primary mental health, psychological therapies and in-reach, but agree to share work together. Still another organisation will provide substance misuse services.

The complex problems of the prison population and the limitations of the regime make working with this group particularly demanding. A common intervention offered by CBT for depression is behavioural activation, encouraging the individual to use activity to raise mood and encourage a sense of efficacy and wellbeing. If a prisoner is on basic regime, he may be locked up in his cell for 23 hours per day, and allowed only books (not encouraging for many with low levels of literacy) and a radio. This makes helping a client find purposeful activity a challenge. Similarly, recommendations to engage in outdoor physical pursuits will usually prove fruitless.

Therapists have to be imaginative in finding solutions – later in treatment, patients will often find their own ways round these constraints, but in the early stages, it may seem to them insurmountable.

Treatment for the many who experience symptoms of post-traumatic stress can present difficulties: a common option would be exposure to the feared stimulus, but this is seldom an option. Therapists may therefore use imaginal, narrative or other exposure approaches to enable the client to reduce the emotional content of their intrusions (flashbacks or nightmares). Similarly, phobic reactions that might be treated using the exposure-response prevention approach might test the therapist’s ingenuity, although being given permission to go and disarrange a client’s cell can be both satisfying and successful!

Finally, it is worth considering certification related to work. This involves difficult decisions that can have important lifelong effects. Few offenders receive psychological therapy and most obtain mental health care from GPs who as well as prescribing, are often asked for ‘fit’ notes. The combination of anxiety, depression and substance misuse, along with the old favourite ‘nervous disability’ are often used as diagnoses. The first note issued to a 24-year-old offender could be an important 2-week opportunity to have a break from the stress of work, but is more likely to be issued to individuals who are not in work, and is likely to transform into 3-monthly notes and then following external assessment to ongoing Employment Support Allowance (ESA). GPs need to really consider whether ongoing certification is in the best interest of the individual.

Improving services

With such a complex patient population, there is a need for services to work together to provide integrated care across teams and disciplines. In prison, transitions between Steps 2 (mild to moderate anxiety and depression), 3 (symptoms not responsive to less intensive treatment, moderate to severe panic, OCD, etc.) and 4 (severe and enduring mental illness, or severe and complex anxiety/depression) must be straightforward and without delay. A variety of modalities is also important, so that CBT and person-centred counselling for depression are available alongside approaches to treating personality disorder (e.g., dialectical behaviour therapy (DBT) or schema therapy), and eye movement desensitisation and reprocessing (EMDR) for PTSD.

Another vital transition is for prisoners moving back into the community: research has shown that continuity of access is important, but equally so is continuity of information: there may be a tendency for NHS and CJS systems to guard confidentiality, sometimes to the detriment of the individual being ‘protected’. Flexible opening times and co-location with other services can increase the chances of engagement with services. Most important are the attitudes of the practitioners: a respectful, non-judging approach will do much to ensure the collaboration of service users, as will a determination to enable them to use their existing skills and strengths. All of these attributes are equally significant for those who are in the criminal justice system in the community.

Creating integration is complicated by having multiple commissioners for mental health care:

Local Area teams for general practice care;
National Commissioning Board, through specialised Local Area Teams for prison health;
Clinical Commissioning Groups (CCGs) for community mental health care including IAPT services.

Substance misuse is often separately commissioned, with Home Office funding, and third sector organisations supporting wellbeing are commissioned by local authorities. Increasingly, though, prison mental health, primary care and substance misuse services are being jointly commissioned and tenders awarded to consortia of providers to work together.

New ‘Liaison and Diversion’ services are designed to ensure that individuals are assessed by police and in the courts so that mental health problems and learning difficulties are detected early. For those with severe problems, diversion from criminal justice to healthcare should be immediate, but for the majority, individuals will continue within the criminal justice setting. The liaison and diversion teams provide short-term input, including assessment, signposting and referral.

Summary

Offenders are more likely to be socially excluded, to have experienced abuse or abandonment, to have multiple morbidities, than their peers resulting in a very high symptom burden. We have seen, however, that mental health care provision for those in the criminal justice system, whether on probation, on remand or in prison, is structurally deficient – both virtually absent and inappropriate. There is anecdotal evidence that recidivism rates are reduced where individuals have been offered treatment and support at vulnerable times. Research is needed to test different therapeutic modes and systems of care for individuals with anxiety and depression, coexisting disorders and social problems.

Anxiety and depression are experienced by many, in addition to symptoms of other conditions such as OCD, PTSD and/or personality disorder and substance misuse. Self-harm is a particular problem amongst women, adolescents and young men in the penal system. These conditions may be ameliorated or worsened by the individual’s situation in prison or in the community.

The importance of person-centred formulation cannot be overestimated: working collaboratively with the client to take all psychosocial and environmental factors into account will enable a treatment plan based on the needs of the whole person rather than a particular diagnosis. This will increase the individual’s commitment and engagement with the process.

Because of high levels of comorbidity and, particularly, the likelihood of substance misuse in this population, there is need for a wide range of interventions to be available across teams and sectors to enable continuity of care both in prison and beyond. Integration of the work of NHS, criminal justice and third sector providers will ensure that individuals will be given the best possible opportunity to progress successfully into the wider community.

This research was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula at the Royal Devon and Exeter NHS Foundation Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

Background

Assessment and formulation

Management

Improving services

Summary

Further reading