#MHForAll Webinar: Mental health in prisons & institutions
Chair
Prof. Dinesh Bhugra, Professor of Mental Health and Cultural Diversity at the Institute of Psychiatry, Psychology and Neuroscience at King's College London.
Panellists
Senop Tschakarjan, Deputy Head of the MHPSS unit, ICRC
Mathew Mutiso, Nanga Support Network
Howard Ryland, Health Professionals for Global Health
Robert Van Voren, Chief Executive of Human Rights in Mental Health-FGIP
Prof. Dinesh Bhugra
Welcome to all our panellists, who have been working on this issue in various countries.
Why should we be interested in the mental health of prisoners? A society is known by the way it looks after its vulnerable, including those in prisons. There is considerable data on this issue - 66% of the population in US prisons has psychiatric disorders, and it is undoubtedly the case in other areas of the globe. One of the big challenges is how do we, as mental health professionals and members of society, advocate for this?
Howard Ryland
I work in a prison in the UK as part of the secondary mental health team, known as the inreach team. We work in an interdisciplinary way, with a variety of mental health workers and prison workers. I see severe mental illness in prisons, sometimes the first time they are offered support is in prisons. We use psychoeducation, signpost to support, help with sleep hygiene or relaxation techniques, and liaise with psychologist colleagues, and considering whether hospital transfer is necessary are some of things we do.
There is a very high rate of mental health illness in prisons. 1 in 30 prisoners has a psychotic illness, such as schizophrenia, 1 in 10 has major depression, which is much higher than in the general population. Add to this that prison can be a very stressful environment; deprivation of liberty, uncertainty about legal situations, reduced support from loved ones, victimization or bullying all have a big impact. Many also come from a disruptive social situation prior to coming to prison, with limited access to support, and a high proportion are lacking GP registration before entering. There is also an issue with continuity of care with prison transfers.
Prof. Dinesh Bhugra
Moving to LMICs, how does the situation compare with what you do, Mathew?
Mathew Mutiso
My work in prisons started in 2018. I was in prison for about 3 weeks, which changed my thinking about care. There were similar characteristics to what Howard mentioned, most came from difficult backgrounds, high rates of dropping out of education, there were issues of drugs, abandonment, etc. In addition the prison I was in had about 3000 inmates, despite being supposed to house about 1500; so something was very wrong. The common thing you find in many prisoners is adverse childhood experiences. There is an important connection between crime and mental health.
In my work I invite psychologists into prisons and we run therapy sessions. There has to be an analytic approach to this, and we started 10 week programmes with officers on stressors of their work etc. We’ve been doing this since 2018, although COVID-19 has disrupted this work. There are other deprivating factors, such as issues of nutrition, beddings, vectors in the prisons etc. which act as stressors.
Prof. Dinesh Bhugra
What are the implications of the pandemic from those who are confined? Who can’t necessarily keep themselves isolated or take care of their health? Particularly when the level of occupancy is so high. And what has your experience been in terms of prisons over the last few decades?
Robert Van Voren
There has been a shift in attitudes and development, sometimes in the right direction, but sometimes then shifting back. In St Petersburg, Kresty prison was one of the largest prisons in Europe. It was significantly over capacity, with guards with kalashnikovs and dogs. It was a horrendous situation with prisoners in terrible conditions. In winter it was very cold, and in summer very hot. For 7 years we tried to turn the psychiatric department into something more therapeutic. It worked at the start, at the beginning of the Putin period, but now the prison has been closed and moved to a new building, with 6 floors that are below the ground. Prisoners have been reduced to little cogs in the system.
The Kaliningrad oblast, between Poland and Lithuania, has a war camp with a prison hospital and psychiatric department. It was probably one of the worst things I’ve seen in my life. Georgia has seen a lot of progress in the right direction. We have also been working in Ukraine, particularly since the 2014 Maidan revolution.
Generally security is at the heart of the prison system, not creating a therapeutic environment. There is a complete lack of understanding for the high rate of mental health problems among prisoners.
Prof. Dinesh Bhugra
What do you observe globally in your work?
Senop Tschakarjan
The ICRC’s entry door is always in a conflict area, initiating from protecting political detainees, particularly what is written in International Humanitarian Law. The ICRC powers a very holistic approach. Basic infrastructure, such as food and hygiene, is always part of the response. And mental health is much further down the agenda.
There is greater credibility if these issues are integrated and not separated. In our settings, we often see that there are no human resources to have educated staff that can be placed and take care of the more complex cases. There is also a myth that psychologists are seen as potential spies, or with some kind of dual loyalty, who are also reporting for forensic reasons.
Prof. Dinesh Bhugra
What is the situation with vaccination and COVID-19 in Nairobi? And what about the pressures that prisoners and staff may be under?
Mathew Mutiso
We started a drive to provide prisoners with basic welfare and sanitary items, and work with the correctional officers to create team building officers to help stabilise their mental health against the immense pressures of COVID-19.
As a country COVID-19 has had very serious effects across the population, from children to parents to teenagers. There has been a high prevalence of teenage pregnancy which has further compounded these mental health issues, due to the stigma and trauma involved. That brings another element of psychosocial distress to the population. There is a cold feeling towards the vaccination, with lots of uncertainty and political issues surrounding all this.
Holistically speaking, there is a dire need for discussions on mental health. Since we began the coalition in September there have been hundreds of organisations involved. Each brings something different, working with mothers, teenagers, LGBTQI+ population, and others, all working at a community level. All organisations come onboard with members, with maybe thousands of people.
People want solutions. People want investments. There has been a complete neglect of mental health, but as we speak, right now as a country we now have an urgency to mobilise resources as we move forward towards recovery.
Prof. Dinesh Bhugra
What about in your work, Robert? And what should we be doing as a global community?
Robert Van Voren
It’s hard to say to what extent things have been slowed down in the long term by COVID-19, as the facilities are closed. There have been efforts to provide PPE to the prisoners, but there are many challenges.
I am much more concerned about social care homes in former Soviet republics. These hardly provide any care at all. In Ukraine there are around 300,000-400,000 people in them, and 90% to 95% will be in there for life. The system is a meat grinder. These people know something is happening, but they get no information from the outside world.
Prof. Dinesh Bhugra
In terms of the adverse childhood experiences mentioned earlier, it seems like there is an ongoing trauma for those trapped in there.
Robert Van Voren
Yes, and it’s a trauma for the whole network around them too. It is trying to reverse a fundamentally corrupt system. We are trying to use the COVID-19 situation to advocate among the population that prisoners have a kind of “double lockdown”, encouraging them to open their eyes to what is going on as they themselves are now in lockdown.
Prof. Dinesh Bhugra
What are the lessons for the UK?
Howard Ryland
COVID-19 has been a hugely challenging situation for the prison system in many ways. There has been an increase in necessary restrictions, which has had a significant impact on people’s day to day lives. Vocational and education opportunities, for example have not been accessed in the same way. The key thing now will be how we move forward from that, and how we reinstate these activities and opportunities and ensure that the prison environment fosters rehabilitation. These things are vital for mental health.
Prof. Dinesh Bhugra
In areas of conflict there are additional stressors. In terms of the pandemic how do you see us coming out of this? At what point do people in those situations get the vaccines, if at all? And what are the challenges for ICRC?
Senop Tschakarjan
I think the priority becomes a big question. If COVID-19 is around, that usually dominates everything and other topics become secondary. There is perhaps a connection in the additional stigma and discrimination against those who have COVID-19, such as health staff, which has been very challenging. We do a lot of work with frontline staff with managing this, so that they can keep working.
In the UK almost half the health workforce was not able to be available, in that they had COVID-19 or were isolating. COVID-19 makes scarce resources more scarce. There are also issues with child soldiers, or young adolescents, who have a high probability of becoming delinquent or doing something that means they end up in prison. We do a lot of work to reduce potential harm.
Prof. Dinesh Bhugra
One thing that really worries me is the high rates of COVID-19 in prisoners. Across the globe countries send people to prisons and forget about them, often for minor offences or none at all. For example in the social care homes that Robert was referring to. So as you said, the question of stigma exists against mental illness, and also against prisoners. This is a kind of double jeopardy. And there is a stigma of what it is like to suffer from COVID-19.
In Nairobi, what are the processes if a prisoner develops COVID-19?
Mathew Mutiso
One point about our prison is that it is a very secretive and demonised thing. It is seen as more of a place for punishment than for healing. Many prisoners are completely innocent. Some only have allegations against them. One of the core factors is that the prison system itself does not have psychologists, only social workers. They tend to work as welfare officers, or counsellors. But there has been a huge element of strain and pressure. We don’t know when the prisoners are going to get the vaccine, if it at all, and this is a problem that needs to be addressed.
These prisons need to be more of healing centres, and less places for punishment.
Prof. Dinesh Bhugra
In terms of rehabilitation and probation, how should we be moving forward? Do you know any examples of good practice?
Howard Ryland
This question of diversion and alternatives is important. The Bradley Reportemphasised the importance of diverting people from the criminal justice system to mental health services where appropriate. There are now cases of liaison services working in police stations and courts, providing a real opportunity to offer mental health support and avoid the kind of situation in prisons that can exacerbate existing mental health difficulties.
Prof. Dinesh Bhugra
What do you think is the way forward?
Senop Tschakarjan
A lot of communication. We need a whole mindset change, so that we all come to the conclusion that these people deserve care, and a level of care similar to the community.
Robert Van Voren
In many countries the prison system creates criminals. The prison system sees these people as bad. A complete change in attitude within the system and within society is needed.
