It is only in the past three centuries in western culture that mental illness has received any degree of sympathy. Remarkable practitioners including Pinel in France, around the time of the French Revolution, led to a humanistic revision of the way the mentally ill were managed in society. The deviance of the madman was traditionally perceived as due to evil powers bewitching and possessing, or to the influence of the moon (lunatics). In consequence, shackling and torture were often applied to mentally disturbed people in attempts to combat these alien influences. Asylums, when they were first constructed, were meant as places to which the madman could retreat to escape the purgatorial experience of social ostracism and persecution.
Recently, there has been a drift to the use of the prison system in the management of the mentally ill. ‘Society could be measured by the way [its] prisoners are treated,’ Michael Levy, Director of Centre for Health Research into Criminal Justice, quotes from Winston Churchill, while lamenting the standard of health services in prisons in Australia. In prison different rules apply. This is not the place where harm-minimisation strategies (condoms, needle exchange etc.) find favour. Prison is a dreadful place for someone who is mentally ill, yet those in prison have far higher rates of mental illness than those in the general population.
Indeed, mental illness and the criminal justice system are inextricably linked. The 2001 New South Wales Inmate Health Survey provides comprehensive and alarming figures on the extent of mental illness amongst the NSW prison population. Over half of all female and 41% of male prisoners had suffered a severe emotional or mental health problem at some stage in their life. Of this number, 25% of women and 34% of men had been admitted to a psychiatric hospital and 40% of all female prisoners and 21% of all male prisoners had made at least one suicide attempt at some stage in their lives. Such rates of mental illness are far higher than in the general population. Sane Australia, for example, found that the level of psychosis amongst the prison population is an astonishing 30 times greater than in the population as a whole.
There are several reasons for the high levels of mental illness found amongst prisoners. First, it is more common for those with a mental illness to commit crimes and be incarcerated for them. Approximately one in five of those with a serious mental illness come into contact with the criminal justice system at some stage in their lives. This can be because psychotic episodes that accompany certain mental illnesses can lead to offending behaviour. Secondly, the prison environs lead to the development of mental health problems. In New South Wales, for example, the Corrections Health Service has found, using the Beck Depression Inventory, that over 50% of the prison population have depression. Thirdly, the inadequate state of mental health services in Australia is such that prisons become holding grounds for the mentally ill. The Royal Australian and New Zealand College of Psychiatrists comments that some mentally ill people are detained in forensic facilities because of the shortage of mental health beds in the public health system in Australia. The Chair of the South Australian Parole Board stated that the government was using prisons ‘as a ‘sump’ for people who should be cared for by mental health services.’ In addition,, mental illness is sometimes mistaken for perversity or criminality: Cornelia Rau, who was suffering from an acute psychiatric disturbance, was detained for ten months in Queensland’s prison system and immigration detention without treatment or clear recognition of the nature of her problem.
When treatment for mental health is available within prisons, it is often carried out in segregated areas away from the rest of the prison, is poorly staffed and functions in a way that serves to further ‘punish’ those with a mental illness. Debbie Kilroy has described how:
The Crisis Support Unit (CSU) is intended to be for women who require support in terms of their mental health…The CSU is however not staffed by trained mental health workers — it is staffed by ordinary prison officers who have no training in caring for the mentally ill… [Patients] may end up being confined in cells for 23 hours a day, with no personal property of any kind and released only for showers and exercise, for one hour daily, usually in body belts and handcuffs.
Drug and/or alcohol dependency is also poorly dealt with in prisons. People with comorbid drug/alcohol dependency and a mental illness are already at a greater risk of offending behaviour. A 1998 study by the Victorian Institute of Forensic Mental Health found, for example, that 67% of those with schizophrenia and comorbid drug or alcohol dependency had committed an offence. When they find themselves in prison, they are unlikely to admit to their drug habit for fear of punishment. In consequence, they may receive no treatment.
Recommendation: That mental health services and alcohol and drug rehabilitation services in prisons operate separately from prison authorities. This will allow prisoners who continue to use drugs whilst in prison to access services that address the full extent of their mental health needs.
Mental illness and the police
Legislation and inadequate provision of mental health crisis management teams in many states mean that police officers are often left to respond to individuals whose mental illness has reached a crisis. One Australian study found that 50% of referrals to psychiatric hospitals come from police who have in custody a disturbed individual. Among other aspects of inappropriateness, this is a heavy drain on police resources, which should properly be devoted to maintaining law and order. Officers often find that they are dealing with the same people over and over again. One mentally ill woman who was admitted by police for involuntary mental health treatment described how:
I panicked and struggled when the police put on rubber gloves and dragged me outside to a paddy-wagon. And so I was handcuffed. Because I was struggling, the handcuffs immediately tightened…I wasn’t told where I was going and I somehow assumed, given my general state of fear and the rough handing, that I was being carted of somewhere to be murdered.
There are several ways of preventing inappropriate contact between people with mental illness and the law. First, early intervention programs for those newly diagnosed with a severe mental illness are recommended by the Australian Institute of Criminology. These programmes aim to prevent anti-social personality traits from developing and to reduce possible violence associated with some mental illnesses. Multicultural Mental Health Australia advocates such programmes for newly arrived immigrants and refugees with a mental illness because this group is over-represented in the population of prisoners with a mental illness.
Recommendation 1: That community based early intervention programs be funded by State governments in order to address the over-representation of newly arrived immigrants and refugees in the prison system; and that mentally ill people in crisis should have their first contact with a mental health crisis team, not a police officer.
Recommendation 2: That State governments provide additional funding for mental health crisis teams.
Mental illness and living conditions
The living conditions of Australians with severe mental illness often serve to compound their problems – contributing toward offending behaviours that bring them into contact with the law. Following hospital care for severe psychotic episodes, many patients are released into the community to live in low-grade hostels and boarding houses. Accommodation managers are generally ill-equipped to care for those with complex psychiatric conditions. Cheap hostel accommodation tends to be located in poor, high-crime areas and other tenants often have criminal backgrounds or problems with drug and alcohol dependency. This situation is a ‘disaster’, according to the Victorian Institute of Forensic Mental Health. More structured support programs for those discharged from psychiatric hospitals are urgently needed so that individuals are not released into situations that heighten the risks of offending.
Recommendation: That professionals employed in health and housing sectors need to work in close collaboration to ensure people with mental health problems have appropriate housing following discharge from hospital.
Mental illness and incarceration
Because incarceration can trigger or exacerbate mental health problems, it should be recommended only when a significant danger is posed to society. Alternatives to the detention of refugees are also urgently needed. A study in 2001 found that 85% of detainees in Villawood Detention Centre demonstrated symptoms of chronic depression and 65% expressed ‘pronounced suicidal ideation’.
Recommendation 1: That incarceration is recommended only as a last resort. There should be more use of diversionary programs for young and first-time offenders.
Recommendation 2: That mandatory detention of refugees is ended, and that limits be placed on the length of detention allowable, so that no one is detained indefinitely. Those whose refugee status is not proven and who cannot be repatriated should not be detained.
In sum, the connections between mental illness and the criminal justice system are too close. This need not be the case. Preventing those with mental illness ending up in prisons should be a high priority. Policies that promote early intervention and enhance mental health crisis teams and other community-based supports would be a constructive start. Within the ‘criminal justice’ system (where the mentally ill frequently receive little justice), there needs to be a fundamental shift in the management of mental health problems. Michael Levy suggests that prisons should become a place of opportunity in which government services work to improve the health of those incarcerated with a mental illness, especially when that illness is a risk factor for offending behaviour. Treating people with mental illnesses as lunatics in the past was wrong. Treating them as criminals is no better. It is time they were treated just like those with a physical illness – as patients.