The prison trap

It’s Monday morning and Dr Conor O’Neill is in a busy district court on the east coast, waiting for one of his patients to be called. Young men are being remanded for public-order offences, uninsured drivers are being fined, and an assault case is sent forward to the circuit court.

Then a tall, thin man, unshaven and with a yellowish pallor, is led up from the cells. Adam – it’s not his real name: O’Neill stresses patient confidentiality – was charged with breach of the peace. He had been sleeping rough and was causing a nuisance by shouting at passers-by. “Most people say ‘sorry’ to the Garda, but this guy is unwell or a bit paranoid, so the conversation can become a bit heated,” says O’Neill.

As the judge hears submissions, Adam stands silently, his arms dangling. He wears a muddy anorak and his trousers are ripped above the ankles. His scuffed runners suggest someone used to walking the streets.

This was Adam’s first time in custody, and when O’Neill had seen him at his clinic in Cloverhill Prison a month earlier, the forensic psychiatrist had quickly recognised that Adam didn’t belong there.

His is far from an isolated case. All over the State, people are falling foul of the law because of behaviour arising from mental illness. And very often they end up in custody, either at the Central Mental Hospital, in Dundrum in south Dublin, which is Ireland’s only specialist forensic mental-health facility, or at mainstream prisons where, according to repeated inspection reports, their mental and physical health deteriorates.

On the east coast this has lessened thanks to O’Neill’s project, now in its eighth year, which is aimed at diverting people with mental illness from the criminal-justice system. “Before we set up this service, Dundrum was full of people in for stealing sandwiches,” he says.

O’Neill, a HSE employee, is a familiar face in the court, and the judge accedes to a care plan that has the tacit approval of the Garda. Adam gets bail, is discharged by the Irish Prison Service into a psychiatric hospital, and commits to refraining from substance abuse. “Usually in these cases the charges will be dropped or he will be bound to the peace.”

Later, in his office at Cloverhill Prison, O’Neill updates his records. Adam’s name can be struck off a whiteboard on which 16 other remand prisoners are listed today. If someone such as Adam has a serious mental illness and commits a minor crime they are diverted to other services. If they have a serious mental illness and commit a major crime they go to the Central Mental Hospital. If they have a minor mental illness and commit a major crime they stay in prison. That’s the aim, anyway.

O’Neill admits it doesn’t always work quite like that. The hospital always has a waiting list, and community services are overstretched. In the case of Adam, he says, “We had to persuade the local psychiatric services that he was in their area.”

There are turf wars, and sometimes care plans are shot down in court. There is a need to balance justice and treatment, complicated by individuals’ complex needs. About 90 per cent of Cloverhill admissions have been substance abusers, 65 per cent have a history of deliberate self-harm and 33 per cent have psychotic disorders.

O’Neill operates on relatively small resources. He used to work on a similar project in Australia; it “would have had up to 30 nurses operating in the courts in New South Wales. Here we are trying to do the same thing with six people.”

Since it was launched, in 2006, the service has assessed more than 4,000 prisoners and diverted more than 600 to mental-health services. “In what’s a really busy system, it’s terribly important that we don’t lose anyone.”

The project is unique to Cloverhill, however, and although the prison accounts for about 59 per cent of all remands, there is a question of what happens to the other 41 per cent.

Psychotic symptoms
Successive research by the Central Mental Hospital shows that people with a mental illness are greatly over-represented in the prison population. Almost 8 per cent of male remand prisoners have current or recent psychotic symptoms, which is 10 times the rate in the community.

If two people commit a minor offence, the one with a mental illness is much more likely to be incarcerated. Why? “Because to get bail all you need is an address, a sum of money or someone to vouch for you,” says O’Neill. “These are things people with mental illness don’t tend to have. They are often homeless, impoverished, and they have lost contact with their families.”

There are other factors. Lack of early intervention, the prevalence of drug abuse and inadequate community resources all contribute to the high rate of mental illness in prison. Even the closure of psychiatric hospitals may play its part, as the phenomenon known as Penrose’s Law suggests: it says a country’s prison population increases as its number of psychiatric beds decreases.

Dr Brendan Kelly, a consultant psychiatrist at Mater Misericordiae University Hospital, in Dublin, who has studied the trend in Ireland, says: “The obvious hypothesis is that persons released from psychiatric hospitals somehow end up in prison, but that’s not at all clear.

“Is there a subgroup of patients who have ended up in prisons” as a result of hospital closures, he asks. “The answer is probably yes, but it is a small subgroup and it needs to be addressed. The correct solution is not to reopen custodial-style institutions, because they resulted in casual violations of human rights”.

No one is campaigning for the asylums to be reopened, but there is a fear that abuses have transferred from one setting to another. A series of reports into Irish prisons have highlighted inhumane and degrading practices, raising particular concern about the overuse of isolation cells in dealing with disturbed prisoners.

Last year, in his annual report, the Inspector of Prisons, Judge Michael Reilly, concluded that the management of prisoners with mental illness remained a “significant problem”, and a review group operating under the Department of Justice recently admitted that “imprisonment can aggravate mental health problems, heighten vulnerability and increase the risk of self-harm and suicide”.

There have been some improvements. A few years ago, when prisoners arrived at Mountjoy, they were brought straight up to the landings and put into shared cells. Now they spend their first night in a committal unit, where they see a nurse and, if necessary, a doctor. They are allowed a phone call and given details of the Samaritans listener service, a counselling network run by fellow inmates.

“We are much more proactive in identifying risk. Officers will approach us and say, ‘X is not well.’ That is probably the single most important development: the changing culture,” says Enda Kelly, Mountjoy’s nurse manager, walking along the brightly lit corridor of the committal unit.

Prisoners who are mentally ill now have a clear pathway through Mountjoy. If mental illness or a suicide risk are diagnosed on admission, they can be transferred to the high-support unit, which was opened in December 2010. This includes a communal area furnished with chairs, a foosball table and a magazine rack. Televisions are encased in plastic, and ligature points have been removed from all cells.

Padded cells
It's not exactly a cheery environment, but it's better than being locked up in a special observation cell, more commonly known as an isolation or padded cell, which was once the standard accommodation for a prisoner with mental illness.

“These were locked cells, where people suffering from a mental disorder were cut off from the rest of the prison. This was countertherapeutic and made their mental health deteriorate even further,” says Dr Damian Mohan, who runs the high-support unit.

The unit, which won a World Health Organisation award for innovation, reduced Mountjoy’s use of special observation cells by 60 per cent in its first year. Isolation cells are still needed for the most serious cases, but most of those at Mountjoy have been decommissioned. At the other end of the treatment spectrum, prisoners who are improving can step down to a low-support unit next door.

But Mohan stresses this is only a small part of the jigsaw. “Mental healthcare is much more than meeting a doctor . . . It’s to do with environmental risk, managing overcrowding and in-cell sanitation.”

The introduction of methadone treatment, TVs and kettles in cells, and ending the prescription of benzodiazepines from prison were “hugely important”. The proliferation of “benzos” had “created a culture of bullying” as inmates fought over access to the mood-altering medication.

Returning to the front gate at Mountjoy, Mohan walks through the yard where the old prison gallows are preserved in a two-storey barn. “If you were mentally ill in the 1800s this is where you might have ended up. Now you’d go for treatment. That is a dramatic shift in culture, and Mountjoy captures some of that change.”

The social-justice campaigner Fr Peter McVerry says the improvements in facilities at Mountjoy over the past five years means it is becoming “the model prison of the future”. But he is concerned that other prisons are on a downwards curve, citing Wheatfield as one institution where overcrowding and lack of investment in facilities have created an intimidating and oppressive atmosphere.

Fergal Black, director of care and rehabilitation at the Irish Prison Service, says there are plans to develop two more high-support units, at Midlands Prison, in Portlaoise, and at Wheatfield. But, as with the Cloverhill diversion project, “there is an issue of scale. You are talking about highly qualified experts [in forensic psychiatry]. You would not set one up in every prison.” But, he said, “I would like to think in 12 months we will witness these improvements coming through the system.”

Health professionals warn of a false economy in skimping on services today. If prisoners with mental illness return to society without their underlying conditions being addressed they will only go on to reoffend. And for young offenders early intervention is key.

A study last year at St Patrick’s Institution found that 23 per cent of offenders aged from 16 to 20 were at risk of developing serious mental illness. “It’s an alarmingly high figure but not surprising,” says Dr Stephen Monks, a consultant psychiatrist at the institution, which has been earmarked for closure because of concerns about prisoner safety. “There are a whole range of different barriers to get people access to services.” He includes the reluctance of some adult services to take child and adolescent transfers.

Agencies working with disturbed and vulnerable young men express deep frustration about getting clients properly diagnosed. One care worker speaks of the “God complex of consultant psychiatrists”. Others complain that only the most severe cases receive treatment because of resource constraints in the mental-healthcare system.

The Peter McVerry Trust says a third of its clients have a diagnosed mental illness but more than half have very clear “mental health issues”. “Some of our clients would be bipolar or have schizophrenia, but a huge number don’t have a clear diagnosis,” says Noel Sherry, youth-services manager at Focus Ireland, the homeless charity. “There are so many people with glaring mental-health difficulties that are going undiagnosed.”

His colleague Conor Boksberger says there is a natural tension between balancing the need to address a mental illness with the necessity to provide justice. But “if the resources were there it would be an excellent opportunity to move people on, because the one thing about prison is that you have a captive audience”.

Expectation of justice
People working in the sector stress that mental illness does not excuse bad deeds. "Most people may have some irrationality as a result of mental illness, but they also have a lot of rationality," says Dr Brendan Kelly. "The majority of psychiatrists and citizens would agree there are occasions when individuals are so mentally ill they can't be held responsible for their actions. But, even in these cases, victims and families of victims have a legitimate expectation of justice."

The issue is complicated by the fact that mental illness is “not a binary state” and can evolve over a life. Kelly stresses, however, “the vast majority of mentally ill people are in no way more violent than other people. They are more likely to be the victims of crime than other people.”

Boksberger, who tries to help young offenders reintegrate after release from custody, says his experience of the prison service is that “they have very dedicated staff and a lot of officers go out of their way to help people with mental illness but lack of resources frustrates everyone.

“It’s not in the business of one government to take a hit for the next government. But if resources were pumped in now you would save a fortune in the long run.”

Monks agrees that among young offenders who have “very traumatic, very deprived and troubled upbringings, actually teasing out what mental illness is can be difficult. So in that context I think it’s important that you are not too categorical about what is and what is not.”

But Monks’s colleague Prof Harry Kennedy fears that concentrating on a “wide range of existential problems” and personality disorders “sometimes means we lose focus on very severe mental illness. If you do the maths on the number of people going to prison with schizophrenia or bipolar disorder every year, it is actually quite frightening. We reckon there are about 300 people with severe mental illness who come into prison every year.”

“A person with severe mental illness is much more likely than their well brothers and sisters to go to prison,” says Kennedy, who is the clinical director of the Central Mental Hospital. “No one in a court, no one in a Garda station, wants to discriminate against the mentally ill, but we have to recognise that there are forms of systemic discrimination.” He acknowledges that some progress has been made in the prison system, but this has been a double-edged sword in the absence of improved community mental-health services.

A few minutes later he is called away to a new referral. A man with severe manic depression has been charged with stealing a box of chocolates in a town in the midwest, and the judge has ordered that he be sent to the Central Mental Hospital for assessment. Kennedy points out that this is exactly the sort of case that should be dealt with locally, assuming services are available. Putting the man into custody and sending him to Dundrum will do nothing for his mental health. “It’s wrong that the criminal-justice system and the courts are used as a proxy for mental-health services,” Kennedy says.

Three months after Adam first appeared in court his case is up. “At the moment he is getting the help he needs,” his solicitor says. “He is taking medication, and he is happy to stay in hospital voluntarily.” The Simon Community is in discussion about step- down accommodation, and it is expected he will get probation and a fine. “People with mental illness don’t have a get-out-of-jail card,” O’Neill says. “They shouldn’t be treated as children or incompetent. They have responsibilities to other people.”

A positive outcome for Adam. Can that be said for so many others like him?

This series is supported by the Mary Raftery Journalism Fund

For more on this series, see mentalhealthontrial.com