Prison mental health: is a gold standard achievable?

Prison mental health: is a gold standard achievable? Dr Andrew Forrester Consultant and Honorary Senior Lecturer in Forensic Psychiatry Clinical Director, Offender Health Research Network, University of Manchester

CONTENTS OF THE WORKSHOP: International prison population and human rights Current evidence for interventions across the pathway Translating this evidence into internationally applied models Discussion and Q&A Dr Andrew Forrester Friday March 3 rd, 2017 2

Almost 11 million people are held in prisons across the world Pre-trial detainees/remand prisoners Convicted and sentenced Some countries have no figures available (e.g. Eritrea, Somalia, North Korea) Some have incomplete figures available (e.g. China) Global prison population rate is 144/100,000 Rates vary considerably across the world Western Africa 52/100k; Southeran Africa 188/100k Western Europe 84/100k; Eastern Europe 236/100k Growth of over 20% since 2000 Growth of 18% in general population in that time, to almost 7.5 billion people Walmsley, R. (2016). World Prison Population, 11 th Edition. London: Institute for Criminal Policy Research. Dr Andrew Forrester Friday March 3 rd, 2017 3

WORLD PRISON POPULATION BY CONTINENT (CHANGES SINCE 2000): Europe : 192-21% Asia : 92 +29% +41% Americas : 387 Africa : 94 +15% Oceania : 140 +59% Global population 144/100k (+20%) Dr Andrew Forrester Friday March 3 rd, 2017 4

PRISON POPULATION GROWTH IN ENGLAND AND WALES: 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 Average Growth rate: 2.5% per year 3.4% per year 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 Ministry of Justice. (2016). Story of the prison population: 1993 2016, England and Wales. London: Ministry of Justice. Dr Andrew Forrester Friday March 3 rd, 2017 5

REASONS FOR THE INCREASE: Increased length of determinate sentences 1993: 16 months 2015: 19 months Longer periods in prison (including remand time) 1999 8.1 months 2015 9.9 months Changes in sentencing practice: More offences carrying longer sentences VATP (23% - 26%) Sex offences (10% - 17%) Drug offences (10% - 15%) Almost 4,000 still serving IPP sentences at June 2016 Abolished 2012 98% men Almost 3,000 serving Extended Determinate Sentences at June 2016 Increased 50% since 2015 7400 serving life sentences at June 2016 Increased 40% since 2002 53 Whole Life prisoners Dr Andrew Forrester Friday March 3 rd, 2017 6

HUMAN RIGHTS INSTRUMENTS (NAYLOR, 2016): Human rights instruments International Convention on Civil and Political Rights (ICPR) International conventions Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (CAT: 1987) Convention on the Rights of Persons with Disabilities (2006) Europe European Convention on Human Rights Non-treaty instruments UN Minimum Rules for the Treatment of Prisoners (2015) Dr Andrew Forrester Friday March 3 rd, 2017 7

HUMAN RIGHTS PROBLEMS THROUGHOUT THE WORLD: Syria (Amnesty, 2016) Since March 2011, over 17k people have died in custody appalling abuse and inhuman conditions crimes against humanity European Committee for the Prevention of Torture (CPT) (2015) Minimum standards of living space applied since 1990s Overcrowding frequently encountered Some conditions beggared belief and are an affront to a civilised society Human Rights Watch Prison Project Numerous countries (e.g. India, Nigeria, Peru, Venezuela) Excessive pre-trial detention detainees may in many instances be held for years before being judged not guilty of the crime with which they were charged Penal Reform International (2016) Over-use of solitary confinement Short term isolation used almost everywhere as punishment Many States using if for longer (USA, 80k people held in isolation) Human Rights Watch (hrw.org) Some countries decline to disclose the most basic facts about their prisons Keeping inmate number secret Prohibiting scrutiny Dr Andrew Forrester Friday March 3 rd, 2017 8

UN STANDARD MINIMUM RULES FOR THE TREATMENT OF PRISONERS : First adopted in Geneva in August 1955 Revised in December 2015 Landmark resolution A/RES/70/175 The Nelson Mandela Rules 27 years in prison Dr Andrew Forrester Friday March 3 rd, 2017 9

THE NELSON MANDELA RULES: Respect for inherent dignity and value Freedom from torture and cruel, inhuman, degrading treatment Accommodation, hygiene, clothing, bedding food Healthcare is a State responsibility The same standards of healthcare that are available in the community All prisons should have multi-disciplinary healthcare services Prompt access to medical attention Clinical decisions must not be over-rules by prison staff A clinician should see prisoners soon after reception All prisons shall ensure prompt access to medical attention in urgent cases Any signs of torture, or cruel, inhuman or degrading treatment or punishment should be reported Services should be regularly inspected Dr Andrew Forrester Friday March 3 rd, 2017 10

RULE 43: In no circumstances may restrictions or disciplinary sanctions amount to torture or other cruel, inhuman or degrading treatment or punishment. The following practices, in particular, shall be prohibited: Indefinite solitary confinement Prolonged solitary confinement Placement in a dark or constantly lit cell Corporal punishment Reduction of diet or drinking water Collective punishment Solitary confinement is defined as confinement for 22 hours or more per day without meaningful human contact. Dr Andrew Forrester Friday March 3 rd, 2017 11

CELL IN A SUPERMAX PRISON: Dr Andrew Forrester Friday March 3 rd, 2017 12

THE EFFECTS OF SOLITARY CONFINEMENT: Various names: Administrative segregation Care and separation Special housing Irreversible psychological effects in just over 2 weeks Anxiety Depression Anger Cognitive disturbance (concentration, memory, thought processes) Perceptual distortions Disorientation in time and place Paranoia and psychosis Self-harm Shalev, S. (2008). A Sourcebook on Solitary Confinement. London: LSE. Smith, P. (2006). The effects of solitary confinement on prison inmates: a brief history and review of the literature. Crime and Justice, 34 (1), 441 528. Dr Andrew Forrester Friday March 3 rd, 2017 13

THE COMMITTEE FOR THE PREVENTION OF TORTURE: Set up to build on Article 3 of the ECHR Ratified by all 47 member States of the Council of Europe Visits to places of detention Prisons, juvenile detention centres, police stations, holding centres for immigration detainees, psychiatric hospitals Unlimited access to places of detention Visits by delegates periodically, and ad hoc The State must be notified first Able to move around without restriction Interview detained people Detailed report to the State Findings and recommendations Form an ongoing dialogue with the States concerned http://www.cpt.coe.int/en/about.htm Dr Andrew Forrester Friday March 3 rd, 2017 14

WORLD PSYCHIATRIC ASSOCIATION TASK FORCE ON PRISON MENTAL HEALTH: Joint chairs: Dr Andrew Forrester, UK Dr Mary Piper, UK Writing and Consultation group: Professor Rakesh Chadda, India Dr Tim Exworthy, UK Professor Michael Farrell, Australia Professor Seena Fazel, UK Dr Seb Henagulph, Bermuda Professor Nahla Nagy, Egypt Dr Edward Petch, Australia Mr John Podmore, UK Dr Dene Robertson, UK Professor Jenny Shaw, UK Dr Jeffrey Waldman, Canada Dr Andrew Forrester Friday March 3 rd, 2017 15

WPA TASK FORCE ON PRISON MENTAL HEALTH: Remit: Reporting to the President of the WPA Prioritising the needs of marginalised groups Prepare a public health policy for prisons, with a focus on mental health To enable a WPA position statement To allow the WPA to negotiate with governments Prepare a curriculum For medical students For psychiatrists in training For operational prison staff Dr Andrew Forrester Friday March 3 rd, 2017 16

WPA TASK FORCE ON PRISON MENTAL HEALTH : Procedure: Virtual group Work taking place over the last 2 years Document research and preparation led by AF and MP Wider consultation group Comments and adjustments International perspectives Agree the final document Consensus meeting at the WPA Congress in Cape Town, 2017 Shape and agree the final document Dr Andrew Forrester Friday March 3 rd, 2017 17

DOCUMENT LAUNCH: World Psychiatric Association Prison Public Health Policy 9 key positions World Psychiatric Association Prison Public Health Curriculum Dr Andrew Forrester Friday March 3 rd, 2017 18

POSITION STATEMENT: The World Psychiatric Association (WPA) expects that all Governments are clear about the purpose of their prisons to ensure that all imprisonment is reasonable, proportionate, decent and humane. Health should not deteriorate or be exacerbated as a consequence of the custodial environment or its regime; The WPA supports mental health professionals in their work in prisons - this applies particularly in the event of any untoward or inappropriate discrimination, or any prevention of the ability to practise ethically based medicine, or of the need to speak out about any significant shortcomings; The WPA expects that people in prison who are socially, physically and mentally disadvantaged should have access to rehabilitation services, enabling them to lead purposeful and economically viable lives free from further criminal activity on release; Dr Andrew Forrester Friday March 3 rd, 2017 19

The WPA advocates that people in prison throughout the world should, at all times, have timely access to the same range, volume, and standard of mental health care services that are available to people in the general community; The WPA regards the accurate assessment and treatment of ill-health amongst people in prison as obligatory, as is the promotion of health and wellbeing; The WPA recognizes the high levels of mental health, physical health and substance misuse morbidity with which people in prison present. Given these high morbidity levels, reception health screening should be universally provided, and effective mental health assessment and treatment readily available; Dr Andrew Forrester Friday March 3 rd, 2017 20

The WPA understands that health and justice roles have the potential to conflict, and healthcare provision and practitioners should ideally function independently of the criminal justice system and be supported through the country s healthcare system; The WPA holds the clear view that health care providers should never be involved in punishment, inhuman or degrading treatment, or torture; The WPA considers that to enable prison healthcare systems to function optimally, processes should be in place to ensure independent monitoring of prison and health standards, with a robust complaints system. Dr Andrew Forrester Friday March 3 rd, 2017 21

RIGHT TO HEALTH Right to health: World Health Organization, 2015: The highest attainable standard of health as a fundamental right of every human being Includes access to timely, acceptable, and affordable healthcare of appropriate quality But about 100 million people are pushed below the poverty line every year because of health care expenditure Vulnerable and marginalised groups bear an undue proportion of health problems Universal coverage is a means to promote the right to health http://www.who.int/mediacentre/factsheets/fs323/en/ Exworthy, T., Samele, C., Urquía, N., & Forrester, A. (2012). Asserting prisoners' right to health: Progressing beyond equivalence. Psychiatric Services, 63(3), 270-275. Dr Andrew Forrester Friday March 3 rd, 2017 22

Current evidence for effective interventions in prison healthcare Jenny Shaw Translating this evidence into effective practice internationally Sandy Simpson Dr Andrew Forrester Friday March 3 rd, 2017 23

Thank You