For the UK Prison Issue we wanted to look at mental illness in jail, and were pointed towards the Centre for Mental Health, where Andy Bell works. The Centre is an independent charity that seeks a fairer chance in life for people with mental health problems. Its research aims to change policy, promote innovation and improve practice in mental health services. Andy is currently chair of the Mental Health Policy Group and is also a trustee of YoungMinds, the children and young people's mental health charity. Along with his colleague Graham Durcan, an expert in criminal justice at the Centre for Mental Health, Andy provided us with an up-to-date portrait of research into mental health issues in England's prisons.
There are currently about 85,000 peo- ple in prison in England and Wales. For the vast majority, a mental health problem is just one of a number of chal- lenges they face while they're inside, and for many it's an issue they've had to deal with throughout their lives.
The statistics only tell part of the story, but they are stark. About half of prisoners have a common mental health problem such as depression or anxiety. One in ten has a psychosis such as schizophrenia. Psychosis is ten times as common among prisoners as in the population outside. At least half of prisoners also have problems with alcohol or drugs, and a similar proportion have a so-called "personality disorder". Women in prison and children in youth custody both have even higher levels of mental ill health than men.
These high rates of distress may partly relate to the experience of being impris- oned, which can be particularly damaging for women, who are at much greater risk than male prisoners of having their children taken into care while they're in custody. And women prisoners are more likely to be detained far from home than men, putting them and their children at higher risk of the psychological distress caused by separation.
But there is growing evidence that peo- ple who end up in our prisons very often have mental health problems that began early in life and got worse throughout childhood and adolescence. We know, for example, that children who have behav- ioural problems at a young age are 20 times more likely to go to prison than those who don't. We know that children who end up in the care of local authorities are more vulnerable to mental health problems and later imprisonment. And there is increasing evidence of the links between head injuries in childhood and subsequent crime and antisocial behaviour.
Trauma during childhood is particularly common among people who end up in prison. Large numbers report experiences of neglect, abuse and maltreatment.
Experiences of abuse and sexual exploi- tation are particularly prevalent among women and girls who become involved in gang activity and those who offend. Bereavement and loss during childhood are also widely reported experiences among people in custody.
Mental health problems among prison- ers do not happen in isolation. We know that homelessness and unemployment are common among offenders: two-thirds were out of work before entering prison and half had housing problems. Two-thirds of prisoners have numeracy levels below that expected of an 11-year-old child, and half have similarly poor literacy.
John, aged 42, was serving a four-year sentence. He could not recollect the exact number of times he had been to prison, only that in most years since turning 18 he had spent at least a few months inside. As a child John had spells in care and when he was 14 years old he stopped attending school. He was introduced to drugs by an uncle when he was about 11, and several members of his family had drug and alcohol addictions. Throughout his teenage years John was committing offences, mainly minor theft, and he was first imprisoned aged 18.
John had not had a permanent home in more than five years. He lived mostly in squats, slept on friends' floors and sofas and spent short periods sleeping on the streets. He felt that he had mental health problems but had never received help for them. He found it difficult to cope with life outside because he had never worked, and it was only in prison that he had experienced having a routine.
All prisons in England and Wales now have mental health services in place, known as "inreach" teams. Since they were intro- duced across the prison estate ten years ago, inreach teams have tried to offer the equivalent to the mental health services that are available in the community. They work in challenging circumstances with people who have complex needs. Many struggle to meet the needs of the large number of prisoners who have mental health problems. People often get moved around from prison to prison, disrupting any care they were getting, while those on short sentences have little time inside to receive any therapeutic help before they are released back to the same circumstances they came from.
For prisoners of all ages, being released can be as difficult and traumatic as get- ting imprisoned. Few have jobs to go to and many have nowhere to live and little money. Some prisons now have "Through the Gates" schemes that offer mentoring, advice and support both before and after release. A few offer practical help to peo- ple to get a job, working with employers like National Grid and Timpson's to train prisoners in the skills they need to work for them when they are released. But for many, especially those who are imprisoned far from home, support with mental health ends when they leave.
Aaron was 17 and in his third spell at a young offenders' institute. He had seen Child and Adolescent Mental Health Services (CAMHS) on and off since he was ten. During his previous spell in custody he had seen the mental health team and been referred to both CAMHS and substance misuse services upon release. The substance misuse service could not see him for two weeks, and when he arrived at the CAMHS clinic he found that his appointment had been cancelled. Aaron felt let down and did not attend any further appointments with either service.
Despite the difficulties, changes are happen- ing to tackle these problems. Police stations and courts in many parts of England now have access to Liaison and Diversion ser- vices. Their job is to identify people with mental health problems or with learning disabilities and to assess their needs. They advise the police or courts on how to deal ￼￼￼with the person's needs and they link them in to local services. These are scheduled to be extended to cover the whole country by 2017. Through them, it should be possible to divert more people with mental health problems from custody, providing them with the support they need to change their lives without going to prison.
Katie was arrested and charged with GBH with Intent at the age of 16. Following her arrest, a Liaison and Diversion work- er conducted a mental health assessment, and spoke to Katie's mother about her behaviour. The family had been under con- siderable stress due to family illness and bereavements, and Katie was feeling very "angry with the world", becoming very argumentative at home and with peers, and she was beginning to self-harm. She had also lost two friends on separate occasions, fol- lowing car accidents, and her older brother had recently left the family home.
The worker set up individual counselling sessions to help Katie address her feelings and provide her with better coping strate- gies. She attended six sessions, where she explored her emotions and made positive changes to her social patterns and peer groups. Her attitude and actions were more under control, and family relationships im- proved. She learned how to talk rather than fight when she was upset or angry. Katie's school later provided weekly counselling sessions for her and she progressed well in her studies. She began a work placement at a school exclusion centre, got a weekend job and regularly babysat for family members.
For Liaison and Diversion to work, it will be vital that mental health services across the country offer help and support to people who have got into trouble with the police and courts. Too many currently get rejected by services because they don't attend ap- pointments regularly or their needs are too complex. With mental health services under financial pressure, this will be very chal- lenging in many areas, but without it too many people who could safely be supported outside will go to prison.
Even with the best community services available, though, people who need to go to prison will still have high levels of men- tal ill health. We need to see every prison become more "psychologically informed", with environments and routines that seek to improve rather than damage mental health, with staff who are trained and supported to deal with mental health issues, and with good-quality mental health care for all who need it. And help with health, employment and accommodation should be the norm for all offenders, both for those who are on com- munity sentences and those who are in prison.
It is also vital that we put a much greater focus on preventing mental health prob- lems and intervening quickly, particularly in childhood, to help people who are at risk of later offending to have a better chance in life. Evidence suggests that sup- porting the parents of young children with behavioural problems through group train- ing programmes can be highly effective. Families with the greatest risks can be sup- ported through more intensive programmes like Family Nurse Partnerships. And schools can help support children's mental health through classroom activities, anti-bullying schemes and offering help when children or their parents ask for it.
For too many young people, mental ill health is part of a long and painful journey to crime and custody. But with the right interventions, offered at the right times in the right ways, it needn't be this way. We can do much more to support people in the criminal justice system to enjoy better mental health, and to help people at risk much earlier and more effectively.
For more information about mental health in the criminal justice system, and the research work of Centre for Mental Health, visit centreformentalhealth.org.uk or follow @CentreforMH on Twitter.