Mentally Disordered Offenders: Standard 4 At Prison
This is one of a series of papers setting out the desired standards (i.e. the necessary skills and arrangements), which should be present when working with mentally disordered offenders. The ‘standards’ will apply to different points of intervention in the criminal justice process where there is an interface between the criminal justice system and that of health and social care1. The aim of this series is to identify the skills, resources, and strategic and operational arrangements necessary to achieve effective and appropriate outcomes for mentally disordered offenders and those agencies working with them. It is not the purpose of the papers to explore how these skills and arrangements should be developed or established. Rather, its purpose is to state what should be in place and the standards can be used by agencies and areas as a checklist against which their services and the skills of their practitioners can be measured. Each standard will:
describe the relevant ‘point of intervention’ and the possible outcomes; identify the key practitioners, agencies and organisations; identify the desired and relevant skills required by practitioners to achieve an effective outcome; identify the necessary resources; identify the appropriate strategic arrangements; identify the appropriate policies and operational protocols.
For the purpose of this series, a mentally disordered offender is defined as : “Those who come into contact with the criminal justice system because they have committed, or are suspected of committing, a criminal offence and: who may be acutely or chronically mentally ill; those with neurosis, behavioural and/or personality disorders; those with learning difficulties; some who, as a function of alcohol and/or substance misuse, have a mental health problem; and, any who are suspected of falling into one or other of these groups. It also includes those in whom a degree of mental disturbance is recognised, even though that may not be severe enough to bring it within the criteria laid down by the Mental Health Act 1983, and those offenders who, even though they do not fall easily within this definition – for example, some sex offenders and some abnormally aggressive offenders – may benefit from psychological treatments.”
Standard 1 ‘Initial Contact with the Police’; Standard 2 ‘At the Police Station; Standard 3 ‘At the Court’. All three are available online at http://www.nacromentalhealth.org.uk. Further ‘standards’ will include those that apply to the community
AIMS To ensure that the prisoner’s health and social care needs are met whilst in custody2. To achieve effective resettlement and rehabilitation on release from prison – in particular in addressing the prisoner’s mental health needs and other complex needs - as well as ensuring personal and public safety. IN PRISON Changes to prison health care outlined in The Future Organisation of Prison Health Care3 (Department of Health, 1999) and Changing the Outlook 4(Department of Health 2001) mean that prisoners are entitled to health provision – including mental health provision – equal to that available in the community. They should be able to access both primary, secondary and tertiary care to the same standard. The Department of Health’s Offender Mental Health Care Pathway5 (Department of Health, 2005) is a best practice template for dealing with mentally disordered offenders including mentally disordered prisoners and should be used to develop both practice and strategies for effective care. All new prisoners received by a prison - either on remand or under sentence – are subject to a health screening and are seen by a health care officer or nurse and a doctor on arrival at the prison. Any concerns about a person’s mental health at the reception stage or subsequently may require further assessment which may be facilitated by the Prison In-Reach of Mental Health Team. A number of prisons operate a ‘First Night in Custody’ scheme to meet the needs of vulnerable or potentially vulnerable prisoners, as the first week in prison is the time when the risk of suicide and self-harm can be greatest. In addition, Insider peer support schemes provide information and reassurance to new prisoners. Some prisons have developed relevant services to meet the needs of mentally disordered and vulnerable prisoners including day care services and ‘Listener’ schemes. Listener schemes are supported by the Samaritans who train up volunteers – most usually prisoners – to provide confidential emotional support to other prisoners. Additionally, prisoners can access the Samaritans directly through dedicated phones which provide access 24 hours a day, 365 days a year. Alternatively, prisoners may ask prison staff to arrange a visit by a Samaritan. If a prisoner is identified as being at risk of suicide or self-harm then incident reporting is crucial for risk management and prevention. An Assessment, Care in Custody and Teamwork (ACCT) form will be opened that details the risk posed and the extra care and checks that are needed to ensure the prisoner’s safety. It also
It should be recognised that prison should not be used for people with mental health needs – in particular for those with severe mental illness 3 HM Prison Service & NHS Executive (1999) The Future Organisation of Prison Health Care: Report by the Joint Prison Service and NHS Executive Working Group London: Department of Health 4 Department of Health, HM Prison Service & The National Assembly for Wales (2001) Changing the Outlook: A Strategy for Developing and Modernising Mental Health Services in Prison London: Department of Health 5 Department of Health & National Institute for Mental Health in England (2005) Offender Mental Health Care Pathway London: Department of Health
includes review periods. (The ACCT form is replacing the ‘F2052SH’ file and its roll out across prisons should be fully effective by the end of March 2007.) Because mentally disordered prisoners are likely to have complex needs including substance and alcohol use then close liaison with prison drug workers and the Counselling, Advice, Referral, Assessment and Through-care (CARAT) programme may be necessary. It should be noted that prisons are not a ‘place of treatment’ for the purpose of the Mental Health Act 1983 and, therefore, mentally disordered prisoners cannot be treated without their consent except under the auspices of common law. However, the provision of treatment under common law is not desirable and should only be used as a last resort. TRANSFER FROM PRISON People who are remanded into prison custody and who are the assessed as being mentally disordered can, where appropriate, be transferred to a psychiatric hospital. Under section 48 of the MHA the prison senior medical officer has the responsibility to suggest that a prisoner be transferred but the decision is taken by the Home Secretary, who must have recommendations from two psychiatrists. The Department of Health and the National Offender Management Service have published guidance which aims to assist in the transfer of such prisoners6. Convicted prisoners who are subsequently assessed as mentally disordered can, where appropriate, be transferred to a psychiatric hospital under section 47 of the MHA. The transfer to hospital of mentally disordered prisoners under sentence involves the same professionals and individuals as transfers of remand prisoners (prison senior medical officer, two psychiatrists and the Home Secretary) and follows the same procedures. A number of pilots are taking place to effect such transfers within a period of 14 days. ON RELEASE FROM PRISON Mentally disordered prisoners are entitled to the same arrangements as mentally disordered persons being discharged from hospital. As at other stages of the criminal justice system, the prison process allows an opportunity for intervention and linking an individual with, or back into, services in the community. The process is facilitated by the Prison In-Reach or Mental Health Team, which liaises with the appropriate community-based services. If the prison does not have an In-Reach or Mental Health Team this role may be taken on by the visiting psychiatrist, Criminal Justice Mental Health Liaison schemes, the prisoner’s Care Coordinator in the community or the prison staff – most usually health care staff or probation officers. In some areas the Crisis Resolution Team has been extended to undertake assessments of prisoners. Some prisons have resettlement officers who will be involved in this process. All practitioners likely to be involved in the person’s care and treatment in the community should ensure that a care package is drawn up in conjunction with the individual and his or her carers and family prior to release.
Department of Health (2006) Procedure for the transfer of prisoners to and from hospital under sections 47 and 48 of the Mental Health Act 1983
If the person is subject to ongoing supervision by the probation service then that is likely to be the agency with responsibility for co-ordinating this plan. Other important agencies are likely to include health, social services, housing, drug and alcohol services, and employment or training providers. Many prisoners are not registered with a GP and the resettlement process should include registration as one of its aims. WHO IS INVOLVED Prison officers play the key role in caring for mentally disordered prisoners. This will include health care officers and officers located on wings and landings and in other locations. The Department of Health and HM Prison Service have launched a self-directed workbook, ‘Mental Health Awareness in Custodial Settings’. This is targeted at all staff who come into contact with offenders in custodial settings who present with behaviour that may be the result of mental health difficulties. Within the Health Care Centre and other relevant settings many prisons employ nursing staff who can provide both care and treatment and advice. Doctors and other clinical staff will also be employed who are able to assess a person’s mental health needs, prescribe treatment or therapy and refer them to other appropriate services. Prisons are moving towards a primary care model of health and, therefore, many prison doctors will now be GPs. Visiting psychiatrists and other mental health professionals will also assess and advise on a prisoner’s treatment. The Prison In-Reach or Mental Health Team will have a key role in assessing prisoners, facilitating further referrals and assessments, advising prison staff, and linking mentally disordered prisoners with secondary and tertiary services and community-based services. Prison-based probation officers play a key role in the process of resettlement and rehabilitation and identifying appropriate resources. They will also be involved in identifying people with mental health problems, assisting with holistic assessments including risk assessments, delivering some appropriate offender management programmes, and making referrals. Similarly, resettlement staff will play a key role in assisting with assessment of need, identifying appropriate resources and services, and making referrals on behalf of mentally disordered prisoners. CARAT workers and other drug workers under the Drugs Intervention Programme and alcohol workers will play a key role in identifying prisoners with mental health problems, especially where a mentally disordered prisoner may have a dual diagnosis, ie, a mental disorder and a substance or alcohol misuse problem. Such workers will also assist in providing an assessment of need, identifying treatment options, and making referrals to appropriate services and resources. Other prisoners and, in particular ‘Listeners’, are very likely to raise concerns about an individual prisoner’s mental health and/or vulnerability, including where there is a risk of suicide or self-harm.
Other prison-based staff including work officers and education staff are likely to be key in identifying people with mental health problems or at risk of suicide or self-harm and making appropriate referrals to prison and health care staff. WHAT IS NEEDED Individual Skills For health care staff, prison doctors, nursing staff and other clinical staff these would include:
knowledge of the specific needs of the prison population understanding of mental health issues including learning disability - especially for staff carrying out health screening at reception understanding of issues to do with capacity, informed consent, and confidentiality knowledge of how to obtain a mental health assessment for a prisoner risk assessment and risk management skills including knowledge of the ACCT process knowledge of local services and how to access them eg, community mental health teams, drug/alcohol teams, crisis teams etc including voluntary sector provision and specific services for Black and Minority Ethnic service users and women knowledge of the procedure7 for transferring a mentally disordered prisoner from prison to hospital working knowledge of how to access and make appropriate referrals to the Prison In-Reach or Prison Mental Health Team
For prison officers these would include:
mental health awareness training including learning disability, self-harm and suicide prevention (especially for reception and segregation unit staff) First aid training eg. how to resuscitate, ligature removal, recovery position etc. risk assessment and risk management skills including knowledge of the ACCT process and cell sharing risk assessments working knowledge of how to access and make appropriate referrals to the Prison In-Reach or Prison Mental Health Team knowledge of relevant services available in the prison eg. Listeners schemes, Samaritans, voluntary organisations knowledge of recommendations in relation to suicide prevention strategies
For members of the Prison In-Reach or Mental Health Team these would include:
knowledge of psychological interventions eg.cognitive behavioural therapy, brief solution focused therapy, general counselling skills risk assessment skills including risk of suicide and self-harm knowledge of the ACCT process knowledge of the Mental Health Act 1983 and Codes of Practice knowledge of local mental health services and how to access them knowledge of appropriate local voluntary sector providers including specific services for Black and Minority Ethnic service users and women knowledge of, and good liaison with, other support services including substance misuse services, accommodation providers, employment and education providers, advice services knowledge of the Offender Mental Health Care Pathway (Department of Health, 2005) knowledge of the Care Programme Approach (CPA)
For probation staff these would include:
mental health awareness training including learning disability, self-harm and suicide prevention risk assessment skills including risk of suicide and self-harm knowledge of the ACCT process knowledge of the Mental Health Act 1983 and Codes of Practice knowledge of local mental health services and how to access them knowledge of appropriate local voluntary sector providers including specific services for Black and Minority Ethnic service users and women knowledge of, and good liaison with, community-based services including substance misuse services, accommodation providers, employment and education providers, advice services knowledge of the Offender Mental Health Care Pathway
For CARAT workers, other drug and alcohol workers, resettlement workers these would include:
mental health awareness training including learning disability First aid training eg. how to resuscitate, ligature removal, recovery position etc.
knowledge of the Mental Health Act 1983 and Codes of Practice knowledge of local and prison mental health services and how to access them knowledge of appropriate local voluntary sector providers including specific services for Black and Minority Ethnic service users and women knowledge of, and good liaison with, community-based services including substance misuse services, accommodation providers, employment and education providers, advice services
For Listeners these would include
mental health awareness training including learning disability risk assessment and risk management skills including knowledge of the ACCT process working knowledge of how to access and make a referral to the Prison InReach or Prison Mental Health Team
For prisoners these would include:
First aid training eg. how to resuscitate, ligature removal, recovery position etc. knowledge of relevant services available in the prison eg, Listener scheme, Samaritans, voluntary sector
For Primary Care Trust commissioners these would include:
understanding of the mental health needs of their local prison population
Prison In-Reach or Prison Mental Health Team with services of or access to a psychiatrist Listeners scheme including dedicated Listener suites or Insider scheme Therapeutic programmes (including behavioural therapies) and a counselling service Resettlement service Day centre including Occupational Therapy (OT) provision First Night in Custody scheme Suicide Prevention Coordinator Translation and interpretation services or use of Foreign National Listeners Administrator to liaise with Home Office and secure units to effect transfers to hospital under the Mental Health Act
Dual diagnosis worker or service Nursing staff with mental health training Mental health promotional materials Purposeful/therapeutic activity/programmes outside of cells eg. Activities boxes Criminal Justice Mental Health Liaison/Diversion scheme (based in the community) to prevent those with severe mental health issues going to prison and to liaise with prisoners nearing the end of their sentence.
Recruitment and retention strategy for healthcare staff including possibility of seconding staff from outside the prison Integration of prison mental health in-reach team and prison healthcare Regional and local resettlement strategy a local and/or regional Mentally Disordered Offenders Group to oversee current arrangements for mentally disordered offenders, including mentally disordered prisoners, and to develop new initiatives to meet the needs of this client group and the agencies working with them, including prisons a multi-agency training group to consider the training needs of all practitioners, including prison staff Prison Health Group with representation from the prison, the local PCT, mental health providers, local authority, and other relevant agencies and organisations a local suicide prevention strategy developed in conjunction with – and complementing - the prison’s own strategy Anti-bullying strategy Involvement of voluntary organisations in providing support and therapeutic activities eg. Rethink, Alcoholics Anonymous, Red Cross (camouflage makeup for people who self-harm) developed and advertised protocol for family and friends to alert the prison if they have concerns about a prisoner’s mental health or self harming.
Policies and Protocols
Risk assessment & risk management – a jointly agreed local protocol which includes the prison and identifies the risk of self-harm and suicide Assessments - a joint agreement between the prison and health for mental health assessments in prison.
Court Reports – a Service Level Agreement (SLA) between the court, the prison, mental service providers, and Strategic Health Authority (SHA) for obtaining psychiatric reports for the court. This should include: how the request is processed; what information might be required; what information; is possible; and, how the information is communicated to the court Operational Protocol – an operational protocol for the Prison In-Reach or Prison Mental Health Team including the referral process to the Team. This should include information on recording and monitoring the activity of the scheme Information Sharing – a joint written agreement between all relevant agencies, including the prison, on the sharing of confidential information8. It is also important to ensure that there is a working information sharing protocol between the prison officers and healthcare staff within the prison and between prison establishments. Recording and Monitoring – an agreed protocol to record the number of mental health assessments completed in the prison, the number of transfers between the prison and hospital, and the number of incidents of self-harm. Transfer to hospital – a joint agreement between health and the prison on transfer to hospital under the Mental Health Act 1983 Agreement between prison in-reach and Community Mental Health Teams about responsibility for the care of prisoners with mental health issues.
For guidance on confidentiality and data protection see ‘Information sharing – Challenges and opportunities: A guide to sharing confidential information regarding mentally disordered offenders’ Nacro (2004)