BY ANASTASIA REPOULIOU
We previously examined the issue of mental health in prisons around the world, showing how big of an issue it is, what the main causes of the disproportionately high rate of mental health disorders in prisons are, evaluating the challenges faced by institutions trying to resolve such issues, and articulating the goals of the efforts to combat mental health issues in the prison environment. Now, we will look at specific issues countries around the world dealing with mental health in prisons face, as well as specific approaches that have been tried.
The WHO established Health in Prisons Programme (HIPP) in 1995 to support member states in improving public health by addressing health and health care in prisons, by providing technical advice on the development of prison health systems and on issues related to communicable diseases (especially HIV/AIDS, hepatitis, and tuberculosis), illicit drug use (including substitution therapy and harm reduction) and mental health. HIPP aims include: establishing integrated work between public health systems, international nongovernmental organizations and prison health systems, reducing reoffending by contributing to rehabilitation, and encouraging prison health services to reach standards equivalent to those in the wider community.
The Pompidou Group, in cooperation with the Council of Europe, published a collection of papers following an international conference on mental health and addiction in prisons in Bucharest. A European study on health problems arising in prison outlined substance abuse, mental health problems, and communicable diseases as the main issues with regard to mental health in prisons in Europe. Dr. Hans Wolff, head of Geneva University Hospitals Unit of Penitentiary Medicine, describes the Geneva model in which effective drug policy therapies such as Opioid Substitution Treatment (OST) or Needle and Syringe Exchange Programs (NSP) are used as successful and cost-effective means of rehabilitation.
In Belgium, according to Dr. Sven Todts, medical director of Prison Health Care Service, there is an increasing lack of capacity, tackled through expanding the system of electronic surveillance, renting prisons from the Dutch government, and finally building new prisons. Belgium also implements the system of psychiatric wards and “social defence units” in which mentally diseased offenders remain before getting transferred to a treatment facility, and receiving treatments based on the necessary intensity of care and the degree of danger the prisoner posed to society. So the treatments range from help within the community, on an ambulatory basis, in psychiatric care centres, or in regional general psychiatric hospitals, to treatment in dedicated forensic psychiatric units of regional psychiatric hospitals.
In Romania, where according to Dr. Mihai Corciova, psychotherapist, the main mental health issues faced by prisoners have to do with drug abuse, there exist services for drug users systematised on three levels:
- Basic medico-psychosocial care with the purpose of reducing the harm/risks of drug use, including information, condom distribution, counselling, and voluntary testing for HIV and Hepatitis B and C
- Out-patient services, additionally providing substitution treatments (methadone, buprenorphine), abstinence maintenance treatment, detoxification, and occupational therapy
- Therapeutic communities, aiming to facilitate rehabilitation and social reinsertion of ex-drug users, including training of human resources
Dr. Sanja Stojadinovic, psychologist, Belgrade, outlines the established Special Prison Hospital in Serbia, an institution specialised for legally enforced treatment of offenders with drug, alcohol, and mental health problems. Psychosocial treatment of drug users in the Special Prison Hospital involves structured group work (motivational enhancement, relapse prevention, pre-release), counselling and psychotherapy (cognitive-behavioral), and a drug-free unit. By introducing risk assessment tools, the Serbian judicial system will be able to treat criminogenic needs of offenders in order to decrease the rates of reoffending.
Professor Peter Sinapius, International Institute for Subjective Experience and Research (ISER)/ MSH Medical School Hamburg (University of Applied Sciences) describes a program of art therapy in prisons, an attempt to make the prison environment comply with the German penal law requiring that life in prison should be as similar to the general conditions of life as possible. The art projects include a workshop called Open Walls, in which the prisoners produce sculptures.
It seems that in Europe, and probably other continents as well, the important steps to be taken by member states are: accepting that prisons are not good places to treat those with serious mental health problems, assessing the vulnerability of newly admitted prisoners through reception policies, training staff and promoting mental health and wellbeing as a central prison policy.
The African Prisons Project (APP) reported severe overcrowding leading to frequent outbreaks of communicable diseases such as tuberculosis, scabies, and HIV and treatable conditions such as diarrhea and TB becoming fatal. The broad societal misconceptions and legal inadequacies surrounding mental illness as well as the general lack of access to healthcare in prisons mean that inmates suffering from mental illnesses often receive no treatment. The APP has set the goals of providing health education, clinical services, and support and improving health and sanitation-based infrastructure, and has proposed solutions like the biogas toilets model which reduces the threat of disease and environmental distraction in prison and the environmentally sustainable sanitation facilities at Namalu Prison, Karamoja region in Uganda.
APP’s efforts to improve health, including mental health in prisons, stem from their belief that “every human being has a tremendous inherent dignity and value” which suggests that protecting individuals from disease and providing adequate treatment should be independent of their background and history. Even if treatment is not available and an early release not feasible, APP maintains that every person ought to receive compassion and pain relief and be made comfortable, because of their right to dignity and respect. Ways to solve these issues are equipping, developing, and empowering medical professionals, maintaining a clean and well-equipped environment, and allowing inmates to play a role in attending to and caring for their peers who are sick or dying.
To realize these solutions, APP suggests three levels of specific goals: In the short term, health education, clinical services, and support, promoting healthy bodies and minds through activities. In the medium term, improving sanitation, developing model clinics using shipping containers stocked with medical supplies, and refurbishing heath facilities. In the long term, sharing skills, knowledge, and training with staff and inmates in terms of training in specialist areas such as palliative care and mental health, establishing links between prisons and independent health organizations, facilitating research by academics in health in prisons in Africa, improving and strengthening the relationship with the Ugandan Prison Service (UPS) and support the building of its capacity to ensure health and sanitation for prisoners and staff, providing nutritional support for vulnerable groups, health promotion campaigns distributing mosquito nets, increased TB and HIV screening and treatment, screening and treatment of malaria, and ultimately upholding the dignity of people in prison.
Finally, we should talk about Ethiopia, where the International Committee of the Red Cross (ICRC) reports how health professionals learn to manage mental health issues in prisons. The goals of the program was to enhance the participants’ skills detecting, treating, and managing mental health problems among detainees, in accordance with recommendations issued by the WHO. Ato Mebrate Teklemariam, deputy director-general of the federal prison administration, talked about the efforts of the program to protect “the right of prisoners, like any members of society, to mental health services.” The country is the first in the world to implement WHO’s Mental Health Gap Action Programme (mhGAP) in prisons.
“Healthcare.” African Prisons Project. African Prisons Project 2004-2013. Web. 19 March 2016. <http://www.africanprisons.org/our-work/healthcare/>.
“Mental Health and Addiction in Prisons.” International Conference on Mental Health and Addiction in Prisons. Council of Europe and Pompidou group, Bucharest: 27-28 Feb. 2013. Web. 19 March 2016. <https://www.coe.int/T/DG3/Pompidou/Source/Activities/Prisons/2014/MentalHealth-2013-dlv.pdf>.
Ayalew, Zewdu. “Ethiopia: Health professionals learn to manage mental health issues in prisons.” International Committee of the Red Cross. International Committee of the Red Cross, 27 Oct. 2014. Web. 19 March 2016. <https://www.icrc.org/en/document/ethiopia-health-professionals-learn-manage-mental-health-issues-prisons#.VLaoKSvF98E>.