Ireland’s justice and mental health systems failing one of the country’s most vulnerable groups, says Mental Health Commission12 November 2021
Irish prisoners and people in the community who require forensic treatment for their mental illnesses are not being afforded the same access to and quality of mental health care as the general population, according to a new report we have released today.
Authored by the Inspector of Mental Health Services, Dr Susan Finnerty - with special support from Inspector of Prisons, Ms. Patricia Gilheaney - the report, entitled ‘Access to mental health services for people in the criminal justice system’ states that Ireland lags far behind other comparable countries with respect to providing a comprehensive forensic mental health service when a person with a mental illness encounters the criminal justice system.
The report also states that longstanding and persistent gaps in both the mental health and criminal justice systems in Ireland are leading to people who are mentally ill ending up in prison. Compounding the matter is that this vulnerable group of people can be subject to bullying, victimisation and often do not receive the treatment they require to recover from their illness.
“It is clear from our report that people who have had a mental illness, and who have offended because of their mental illness, are not afforded the same access to mental health services as those who have not,” said Dr Finnerty. “Since the early 1990s, there has been a vision of ‘equivalence of care’ for prison health, indicating that people in prison should receive the same standard and delivery of healthcare were they not in prison. However, this is not yet embedded, and many prisoners are receiving inappropriate or no treatment for their mental illness. Forensic mental health in-reach teams in prison provide an excellent service, but they are under-resourced and there are long delays in obtaining a bed in the Central Mental Hospital.
“The right to healthcare is not negated by the fact that a person commits an offence because they were mentally unwell. The findings in this report show that people with a mental illness are being criminalised and this suggests the need for systemic change in both the criminal justice and mental health systems.”
One of the major findings of the report was the lack of diversion services. The aim of diversion is to identify persons with mental illness who come into contact with the criminal justice system and, where appropriate, ensure they are treated in a psychiatric setting rather than continuing through the standard criminal justice process.
“People with major mental illness increasingly present to the courts with minor offending behaviour, rather than to psychiatric services,” explained Dr Finnerty.
“Many people who are mentally ill and who have committed minor offences can be appropriately and safely managed in general psychiatric healthcare settings. There is a lack of diversion for people who are mentally ill to local psychiatric services in Ireland and currently there are no pre-arrest diversion teams in place, unlike in other jurisdictions. This has resulted in people with mental illnesses coming before the courts for minor offences and ending up in the prison system. However, Irish courts should not be expected to act as a substitute for local mental health services in identifying mental illness and deciding on the most appropriate treatment. It is clear that resources must be put in place at pre-arrest, arrest and court liaison stages.”
The report finds that courts are helpless when it comes to finding a suitable placement for offenders who are mentally ill. There are no beds in the Central Mental Hospital – at the time of writing the report, there were 22 people on the waiting list, but it was noted that this figure can rise to 40 - and local mental health services are not resourced adequately to look after offenders who present with challenging behaviour.
“The only recourse is prison, where they will at least have benefit of an in-reach service,” said Dr Finnerty. “However, our report found that the life of a mentally ill prisoner is stark. There are long periods spent in isolation cells with no protection from the rules on seclusion as the decision to isolate a prisoner rests with the prison governor. We also found that mentally ill prisoners are bullied and victimised in the general prison areas, including having their medication taken from them, while they can often be forced to take illegal drugs. The report also noted that under criminal law legislation, prisoners cannot be forced to take medication, so prisoners who are seriously mentally ill remain untreated and become even more unwell. Added to this is the fact that prison officers are ill-equipped to deal with the complex needs of prisoners with mental illnesses, while mental health treatment programmes and resources are severely lacking.”
The Chief Executive of the Mental Health Commission, John Farrelly, said: “It is clear that prisons are unsuitable locations for those with mental disorders and the negative effects of incarceration on a person with mental illness are profound. Many of these prisoners are accommodated on an extremely restricted daily regime. These restrictions amount to inhuman and degrading treatment. The treatment of prisoners who are mentally ill must be addressed as a matter of extreme urgency.
“It also must be noted that the report finds that the majority of crimes committed by the mentally ill are minor and non-violent. Only a very small number of individuals with serious mental illness carry out serious offences.”
The report also looked in detail at the Central Mental Hospital. There are currently 102 beds in the hospital, which will soon increase to 160 beds when the new service opens in Portrane.
“A decision was made in Ireland to concentrate all forensic services on one site in a relatively remote area,” said Dr Finnerty. The policy in Ireland had been for a ‘hub and spoke’ model but there are no spokes: there are no regional low-secure units, no forensic mental health community teams, while there exists just two psychiatric intensive care units (PICUs). The very poor resourcing of the forensic mental health teams in Cork and Limerick prisons is quite astounding, for example, especially as there is no coherent plan for the development of these services, even in view of the new women’s prison planned for Limerick.
“So, it is clear that while people who are mentally ill are accumulating in prison waiting for a bed in the Central Mental Hospital, there are insufficient rehabilitation, low-secure and community facilities at the other end for people to move onto when their high and medium-secure needs have been met. The successful rehabilitation of people through forensic inpatient services relies ultimately on there being places in the community and community support available for them to return to. For example, at the time of the report 54 patients have been in the Central Mental Hospital for more than five years, the majority of whom are likely to continue to require care and treatment and could move on to less secure facilities in a therapeutically safe and secure hospital setting but this is not possible as these less secure facilities do not exist. This increases consequences for human rights, recovery, socialisation, and sexual expression.
The report’s authors state that forensic mental health services should be underpinned by an ethos of recovery, focus, and rehabilitation. As such, people need to be able to move from higher levels of security through lower levels of security and back into their communities in a timely way and when it is indicated. People’s transitions between secure services and discharges to the community are being delayed. As they wait, they are not being held in the least restrictive conditions necessary to manage their risk. This is - at the very least, according to the report - an infringement on their human rights. There are concerns that an extensive period of forensic inpatient care can be detrimental in that it seriously restricts patients’ autonomy, their quality of life, and their perspectives for future independent living. People need to be supported by clear pathways into and out of forensic mental health services, the report states.
“What this report clearly outlines is that we are failing people with mental illness who come into contact with the criminal justice system,” said Mr Farrelly. “While Ireland’s new forensic hospital sets the correct tone for the future, we are still failing people who are mentally ill at all parts of the process, including diversion, courts, prison and probation.
“We need a human rights-based culture and system to divert individuals at their earliest possible point of contact with the justice system with teams of specialist mental health-trained staff located at police custody suites or courts in order to assess and refer people on to more appropriate mental health services outside of the justice system. Our justice and health systems are failing one of the most vulnerable groups in our society. I would urge all relevant parties to read this report in full and both note and act on its recommendations. Widespread systemic change is urgently required to prevent more people from suffering into the future.”
Both Dr Finnerty and Ms. Gilheaney expressed their gratitude to all those who helped them put the report together, particularly forensic mental health care service users and their families and carers.
You can read our full statement here.
The report is available to download here.