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Psychiatric Serrvices in Prisons: Deteriorating Realities of Trying to Provide Psychiatric Support to Inmates in Custody Cost-effectiveness evaluation of personal care services to prisoners is fraught with exceptional difficulty. Here are two extreme examples, by way of introduction. Visiting Psychiatrists An unpublished Royal College of Psychiatrists discussion document for a 1977 working party to consider the role of visiting psychotherapists in prisons concluded that "there is a great deal of work for psychiatrists in prisons. Many rehabilitative schemes would profit from psychiatric input. Acute crises like cell smashing, swallowing, selfmutilation & suicidal gestures could be better handled than they are by traditional methods of containment and dissuasion. Only very specialised psychotherapists might be able to work in isolation - - - a modern psychiatrist would want to be involved in the daily life conditions of his prisoner patients - - - many apparently less ill prisoners genuinely want help with conflicts and symptoms and could profit from modern treatment approaches". When in 1976 I joined the Prison Medical Service, as a sessional visiting National Health Service consultant psychiatrist from the worlds of mental handicap and child care, it was already apparent that there were difficulties in trying to provide a range of A local residential school for delinquent adolescents had been closed down recently. Those former Approved Schools had been transferred from Home Office management to county Social Services Departments, which found them embarrassingly expensive resources to run. Another similar Community School in Kent has ceased employing a sessional visiting psychiatrist so as to save the cost of a regular salary. Financial considerations have played an increasing role in psychiatric appointments to caring establishments during the 1970s and 80s. One anticipated an increasing use of penal institutions for young offenders. The Medical Officer at the nearby Borstal, a very experienced psychiatrist who had trained in psychoanalysis, had welcomed an additional appointment to join his two visiting psycho-therapists then in post. He occupied the three of us reasonably well in assisting him to help some of the more disturbed and inadequate young trainees, for a joint total of 10 half-day sessions each week, over and above the time he himself could spare for psychiatric work alongside his other duties. Although several penal institutions in southern Englarrd had a strong therapeutic orientation at that time, Rochester was always considered to be rather conservative, and during my decade several progressive therapeutic initiatives were frustrated. At the same time as hospital psychiatry was moving towards multi-professional team work, and nurses were being encouraged to relinquish uniform, the Borstal officers were newly put into uniform, and the attempt to offer inmate trainees individual personal officers was discontinued. Staff routine changes constrained the times during which patients might be seen, and the visiting doctors and hospital staff became increasingly isolated in the hospital wing. The Medical Officer, in one of his Annual Reports to the Prison Department, described his inability to influence a deteriorating situation, including the failure of the attachment of each of the 3 psychiatrists to individual wings, which it had been hoped might add a new dimension of reality to their work and provide a resource to staff. During my 10 years there was continual change at Rochester. The Borstal became a Youth Custody Centre with a Classifying Wing which did not involve the visiting psychiatrist despite offers to assist, but took up a great deal of medical officer and hospital staff time and energy in processing the boys through in a few days, so that they could be distributed elsewhere. A new women's prison was opened in the same campus, as an overflow facility for London's overcrowded Holloway Prison. Two visiting psychiatrists were involved, but one withdrew and subsequently retired, eventually leaving myself alone to cover both establishments. During my decade, there were 5 Governors, and 5 different Medical Officers responsible for psychiatric referrals. Vacancies arising when my psychiatrist colleagues retired were never filled, although in 1979 the then Medical Officer at the Borstal, also a psychiatrist, as was the first one I knew, took the view that one-third of the population had psychiatric problems. Over the years to follow there was an insidious but progressive decrease in referrals until eventually the Prison Medical Department assessed an approximately 10-fold reduction in estimated "requirements" for psychiatric services. From an initial situation, with a psychiatrically involved psychiatrist as medical officer assisted by 10 sessions a week visiting psychiatric input to the boys' establishment aIone, we eventually arrived during 1986 at a proposal that I should provide all that was needed in 1 session per week for the women's prison, and 1 session fortnightly to cover what had become a virtually non-existent "requirement" in the boys' Youth Custody Centre. However teachers, and a research psychologist there, considered that despite a somewhat changed population, the level of emotional and psychological disturbance remained high. My doubts as to the viability of the proposed arrangements for these two volatile institutions were considerable, the women's prison especially having numerous major problems which could be of legitimate concern to a psychiatrist. During the course of renegotiation of my contract with the London administration, my appointment was suddenly terminated without a replacement, so that several months ago there were still no longer any regular visiting sessions from the outside world of psychiatry at either establishment, nor even a psychiatrically trained medical officer. How can one make sense of this sequence of events? Referral criteria have remained undefined and have patently varied according to the inclination of individual doctors. Occasional opportunities to interview inmates routinely after reception during periods of medical staff shortage (a practice normally strongly discouraged) provided insight into arbitrary referral practices. Referrals from non-medical staff, or at the request of inmates themselves, invariably had to be vetted and endorsed, with written referrals by the Medical Officers, however new, temporary, inexperienced and harrassed these might sometimes be. Free access to the prison Wings and those officers in daily contact with the inmates was not permitted, although there were many senior prison staff who thought this might be beneficial. (Myra Hindley made me coffee, but I was not allowed to talk to her because she had not been 'referred'.) The physical facilities in the prison sick bay were cramped, shared and unsuitable, so that one's attempt at psychotherapy in a new, modern and ostensibly purpose-built prison had to be conducted at various times in borrowed cells, a patients' dining room, and the one medical room which had to serve for the medical officer's sick parades and for visiting physicians and surgeons. My invited attendance at the Governor's weekly senior staff meetings, which the Medical Officer often could not spare time to attend, was deemed an inappropriate and inadmissable use of sessional time, and was disallowed by an uncomprehending medical directorate in London. Latterly, even occasional personal meetings with the medical officer responsible for all referrals became impossible because of the constraints upon his own time at the prison. So the conditions of work themselves have militated against the successful practice of modern psychiatry in fundamental ways. Money was invariably brought in to explain difficulties and the final total disintegration of psychiatric support from outside specialists at these two establishments occurred after a
reorganisation in which, so far as I understand, the medical budget was transferred to the individual Prison Governors with an urgent requirement to find financial savings. Reduced referral rates and problems of patient access and availability had resulted in difficulties in completely filling notional sessions with individual office interviews with patients, but scope for
alternative deployment of psychiatric expertise was discouraged. The medical directorate did its counting and concluded that "there is little need of a psychiatric input from a visiting consultant", despite the high levels of disturbance, tension and prescription of psychotropic medication which is familiar in women's prisons and to which this one was no exception. The Regional Medical Officer confirmed recently that I have not been replaced at either establishment and that "the number of consultant sessions used is related to - - - perceived need in any establishment and experience of those available". Such crude indices of numbers of inmates seen and numbers of minutes spent interviewing them beg the question of who should be the people to do the perceiving, determine psychiatric support needs and assess how these should be met. There have been no job descriptions until now for the visiting psychiatrists and no sophisticated evaluation of the possible benefits which might arise from a more flexible and enlightened attitude towards their task and potential contribution. A research proposal to try to evaluate psychiatric .treatment in the first year of the women's prison was supported locally but turned down by Headquarters in London. Valid cost-benefit studies in so difficult an area would necessitate the participation of psychiatrists themselves and psychologists too. Compared with health service and socIal service developments, some of the arrangements in the prison system are seen by outside health care professionals as archaic and excessively compartmentalised. Opportunities for good communication between prison professional staff are significantly limited and the organisation of the various responsible departments within the Home Office is bewildering and impenetrable. The visiting psychiatrists themselves, of whatever experience and seniority outside, may have little influence on the organisation of psychiatric work inside penal institutions. There is an immense gulf between prevailing situations and attitudes in the health and penal services and the experiment of joint appointments some years ago did not succeed. Many colleagues have found my tabulated summary of the situation for Kent psychiatrists in National Health Service settings contrasted with the penal in titutions enlightening and helpful (Appendix 1). Even though the Prison Medical Service has been actively recruiting trained psychiatrists as full-time Medical Officers for a number of penal establishments, psychiatrists generally regret that merging of the two separate national medical services has not been preferred as a first option in radical reorganisation of prison psychiatry. Communication between psychiatrists and the Medical Directorate at Headquarters in London might become easier if there were a designated adviser on Prison Psychiatry, who would have had wide and recent experience of psychiatry in and out of prisons, and might have responsibilities to liaise with individual part-time prison psychiatrists, encourage appropriate training of psychiatric trainees, with funds to provide facilities for continuing study and research, and generally help to ensure that sessional availability is utilised to the greatest possible advantage of the establishments in order to help as many as posssible of the numerous disturbed and distressed inmates, who may not have certifiable or treatable mental illness but nonetheless deserve the support which psychiatrists can offer. Plainly, such ideals have substantial financial implications which would need to be faced before there can be any possibility that such deteriorating realities as have been encountered at Rochester could be reversed. It is ironical that although the longer paper upon which this presentation was based has been well received by colleagues within and outside the prison service, there has been no opportunity to discuss these thoughts with mixed professional groups locally in the establishments, nor at one of the occasional Prison Medical Conferences. The Prison Medical Journal editor, whilst agreeing with many of my points, was unable to publish my paper. The Deputy Governor of the women's prison hoped my presentation at Amsterdam would be well received, and regretted that it had not been possible to have any discussion of my paper during the months before my APPENDIX 1 For a meeting during 1986 to discuss future requirements, I provided abbreviated notes in tabular form summarising some important differences between the situation for consultant psychiatrists in Kent NHS hospitals & in the Rochester penal establishments
APPENDIX 2 At a meeting of the College Working Party, I attributed some dissatisfaction with the visiting psychotherapist posts to the lack of a specified Job Description. Representatives of the Prison Medical Service promised draft guidelines, but these proved impossible to prepare "because the function of the visiting psychotherapist was so individualised to the person & establishment". Members of the working party, however, raised anxieties about the nomenclature & definition of the role, lack of specified standards, questions of confidentiality, clinical responsibility, management, education & training. A sub group of psychiatrists held several meetings & prepared draft documents, which however were not finalised in a form which was agreed by all parties as suitable for the College to issue as a policy paper and the matter was eventually shelved. Some points from those draft discussion papers are still germane for review of the problems a decade later. "- - - - - because the Prison Medical Service is independent of the NHS, practices differ & psychiatrists may feel professionally isolated in penal establishments. Duties are entirely delegated by the Medical Officer & control considerations, not directly involving psychiatrists, have primacy, in contrast with the multi-professional team approach in psychiatric hospital work. Prisons are conservative, & reluctant to risk innovations which might lead to exaggerated attacks if things go wrong. Visiting psychiatrists may be felt to be a threat to prison colleagues or to more remote administration, so that procedures taken for granted in psychiatric hospital work may be impossible in 'some prisons. Prisons staff have complex unadmitted punitive attitudes, representing society's legitimate retributive needs, & visiting psychiatrists can be seen as likely to undermine this largely unadmitted function of prisons, & therefore may meet hostility & suspicion amongst people they would like to work with. Anything which appears to be a loophole for manipulation or a weakening in the background strength of security arrangements, is felt as a threat, & many psychiatric procedures can be seen as exploitable in this way. Psychopathic personalities tend to let down those who have tried to help them in ways which are felt as a betrayal of trust & effort. This, combined with their known recidivism, makes those who have worked for long in prisons extremely sceptical about any treatment procedure. If one wants to work with prisoners who are not obviously mentally ill, one has to contend with tnis scepticism amongst one's prison colleagues. The social structure of a prison hospital is very different from cell blocks & wo+kshops & careful use of sessional time is needed for getting to understand the situations & There is a great deal of work for psychiatrists in prisons. Many rehabilitative schemes would profit from psychiatric input. Acute crises, like cell smashing, swallowing objects, self mutilation, suicidal gestures, could be better handled than by traditional methods of containment & dissuasion. Only some very specialised psychotherapists might be able possibly to work in isolation & with no more than a simple everyday relationship with prison staff. It is very unlikely that a modern psychiatrist will be content with such a role, whether he be an analytic psychotherapist, behaviourist or a
general psychiatrist. He will want to be involved in the kinds of conditions that his prisoner patients live in, the
sort of rehabilitative schemes that they have access to, their visits, work, leisure & study opportunities, number of hours in their cells alone or in company, & in the kind of Apart from the increasing number of mentally abnormal offenders, many apparently less ill prisoners genuinely want help with conflicts & symptoms & could profit from modern treatment approaches. It is to be hoped that psychiatrists, full time & visiting part-time, will find an increasing role within the prison team, & not be dissuaded by the problems of working in a special & unfamiliar environment. " * * * * * * Various papers have been brought to the attention of members of
Forensic Psychiatry Section Executive Committe of the Royal College of Psychiatrists. The former Chairman, Dr. Paul Bowden, argues that the dual allegiance to state & patient of the Prison Medical Officer inevitably results in activities which favour the state rather than the patient. The uniquely client-oriented Hippocratic code does not allow for the possibility of balancing apparently divergent interests. It is unethical not to warn an individual if the doctor is not acting in all respects as his personal physician. Yet one Senior Prison Medical Officer has suggested that "treatment & control are merely two sides of Doctors have increasingly become arbiters of the welfare state. By diagnosing need & rejecting or selecting for individual services they apply strictures or benefits which are made available to individuals by society. What treatments are available at anyone time will be related to a complex system of priorities, with inequitable distribution of care compounded by the way in which facilities and practitioners select patients who suit themselves. The prison medical service has concentrated more on public health aspects at the expense of development of personal services of a type which have flourished outside penal institutions. In 1972 for an average prison population over 38,000, there were less than 60 psychiatrists attending only 24 out of the 111 prison establishments. In relation to mentally disordered offenders it has been argued that many A residential conference at Cumberland Lodge in May 1985 brought together participants from various related fields concerned with custodial psychiatry in hosP1tal & penal establishments to consider the practice of psychiatry in the Prison Service. In discussion, participants thought that doctors in prison should be seen to make inroads into problems of conditions in prisons & special hospitals, & should therefore have a more active role in management & prison committees (the Prison Medical Officers present were much in favour of active management). There was anxiety about medical involvement in punishment & concern whether long term segregation may harm prisoners. More research was needed with greater medical involvement in research policy. Reception examinations were considered to be often cursory, inadequate & poorly documented (they are the basis for initial psychiatric referral). Training courses in psychiatry are needed for prison doctors. The few remaining joint consultants are in an invidious position as specialists with no position in prison or hospital hierarchy. * * * * * * In its response to the Committee of Inquiry, the Royal College of Psychiatrists (July 1985) urged the necessity for References
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