Key to prison's mental health

The opening of a special high support unit in Mountjoy has revolutionised the delivery of mental health services in the prison and is serving as a model that will now be implemented across the Irish penal system

‘IT IS said that no one truly knows a nation until one has been inside its jails. A nation should not be judged by how it treats its highest citizens, but its lowest ones,” Nelson Mandela famously once said.

In the case of Ireland’s prisons and their healthcare services, the nation has long received harsh judgement.

Over the past 20 years the Council of Europe Committee for the Prevention of Torture and Degrading Treatment (CPT) has undertaken five preventative inspections of prison health services in Ireland and expressed concerns relating to mental health services for prisoners on each occasion. In its most recent report, the CPT was critical of the overuse of Safety Observation Cells (Soc), better known as padded cells, for management and punishment.

However a number of dedicated clinicians have been diligently trying to improve Irish prison mental healthcare services and reduce the use of Socs.

“Prisons have a high level of morbidity and mortality, high levels of psychosis, depression and suicide and over the years that has been a problem. The response of prisons has been to isolate people who are suffering from these disorders because of their increased risk and that is an understandable response. People would be isolated in isolation cells while waiting for transfer to the Central Mental Hospital (CMH). However, that was inhumane and for good reason we were criticised by the CBT,” says Dr Damian Mohan, consultant forensic psychiatrist at the CMH, and one of the key clinicians behind the establishment of the special high support unit (HSU) in Mountjoy.

It took considerable planning and effort to persuade the prison authorities of the need for a special unit for vulnerable and mentally disordered prisoners in Mountjoy, and there was opposition to putting so many high-risk prisoners in a unit together.

However the 10-cell high support unit was finally given the go-ahead in 2010.

“We were working with people whose primary concern was security so we had to show the prison staff that clinical interventions could assist in managing risks which took time. The HSU was designed very carefully to stratify risk,” Mohan says.

Prior to the unit becoming operational, joint training sessions were provided by national forensic mental health service staff and Irish Prison Service nursing staff for the Mountjoy prison officers.

Operational since December 2010, the unit now provides a dedicated area where mentally ill and vulnerable prisoners, who present with a risk of harm to themselves or others, can be separated from the general prison population and closely monitored in a safer environment. While very specifically not a hospital ward, the unit provides in-reach psychiatrist and psychiatric nursing services.

There is also a two-cell low support unit, which acts as a step-down facility, to help the prisoners’ transition back into the main prison.

While it follows the regime of the main prison in regards to meals and routine, the unit is more relaxed with increased interaction, as opposed to observation, between the prisoners and prison guards.

The creation of the unit means prisoners experiencing mental health difficulties can now be treated with dignity in a secure but supportive environment with the aim of addressing their issues and reintegrating them back into the general prison population when they feel better, or transferring them to the CMH if needs be, Mohan says.

The unit has a 100 per cent occupancy rate with two to three admissions a week, and vulnerable prisoners can be assessed and admitted rapidly, says Enda Kelly, Mountjoy healthcare nursing manager.

“The culture shift has been absolutely enormous. The prison officers can now pick up on the nuances of a prisoner who has started to isolate himself, someone who has become a little more overt or strange. They now feed that back to the clinical nurses and the doctors. It is a collaboration and that is so important,” says Kelly.

The Irish Times was invited to Mountjoy to inspect the unit. While still clearly part of a prison complex, it is spotless and painted in bright, cheery colours, though the recreation area is sparse for security reasons. Nine of the rooms are standard cells with in-cell sanitation while the remaining cell is an Soc/padded cell. Outside this cell is a large sign which clearly states that prisoners can only be placed inside by direct order of medical staff and under their supervision.

The establishment of the HSU resulted in a 59 per cent reduction of Soc use during its first year, which was one of its key aims.

“Most recently the Soc was used for an hour and 25 minutes for one prisoner who was removed as soon as he calmed down. It is now a prescribed intervention, a last resort for as short a time as possible to reduce risk,” explains Kelly.

The success of the unit is also highlighted by the fact that it has won a number of prestigious awards in the last year.

Internationally it won the World Health Organisation Health in Prison – Best Practice Award last October and nationally it won both the Excellence in Healthcare Management and the overall prize at the 2011 Irish Healthcare Awards, as well as the best community-based innovation in quality of service delivery at the 2012 Biomnis Healthcare Innovation Awards in May, while most recently it won a 2012 Taoiseach’s Public Service Excellence Award.

“There was a great deal of scepticism about the HSU initially but when we won our first award last year that gave us the recognition we needed and was a turning point to show everyone we were on the right track,” says Mohan.

Governor of Mountjoy Edward Whelan acknowledges the positive changes the unit has brought about in the prison, and says the environment is now calmer and more relaxed for both prisoners and staff.

Notably there has also been a dramatic reduction in suicides and attempted suicides in Mountjoy since its establishment.

“We are now driving the rollout of the HSU in all 14 prisons around the country, and even other jurisdictions are looking at it. We piloted it here so we are the showcase. Crucially we believed in it; if it wasn’t driven from the top it wouldn’t have worked.

All the prison staff believe in it,” says Whelan. He added that the establishment of the unit has been cost neutral and received no extra resources, highlighting what can be done with creative thinking and changes in work practices.

“With this unit we have in Mountjoy a better, more humane and safer prison and that is why it has attracted such interest. It only happened with the collaboration of all the parties involved and hopefully we are looking at getting a good response from the next CPT visit, Mohan says.

Entries are now being accepted for the 2012 Irish Healthcare Awards. The closing date is August 24th. For further information or to obtain an entry form please contact (01) 817 6330.