Mental health services at young offenders institutions. Are they any good? Mubarek report suggests not

At last there is recognition that mental health services at young offender institutions need a total rethink, but can young people with mental health problems be treated in such settings, asks Natalie Valios

They are bleak, isolating and frightening, and often lack properly trained staff: it is hard to think of a worse environment for a young person with mental health problems than a young offender institution.

Despite this, the criminal justice system continues to lock up a shockingly high number. Figures from the Office of National Statistics reveal that 90 per cent have a diagnosable mental disorder including substance misuse; 10 per cent have a severe psychotic illness – compared with 0.2 per cent of the general population.(1 )Two-thirds of all young prisoners experience anxiety and depression, many in response to the setting and circumstances in which they find themselves.

This issue has been brought sharply to the fore by the Mubarek report. Zahid Mubarek’s murderer, Robert Stewart, who has a deep-seated psychotic illness, is one of those 10 per cent. He was 13 when he had his first recorded offence – arson. After that he was rarely out of trouble with the law and it was clear he was extremely troubled; arson, in particular, is an indicator of mental health problems. But it seems he was allowed to drift into the criminal justice system. The Mubarek inquiry report asks a lot of questions about Stewart, but the one it fails to ask is: what was someone who was so seriously mentally disturbed – he was diagnosed with personality disorder after the murder – doing in a YOI in the first place?

Juliet Lyon, director of the Prison Reform Trust, is angry about this. “There were clear indications that he was seriously ill and yet nothing was done. That’s very hard to justify.”

At the time of Mubarek’s murder, the care of prisoners with mental health problems was unacceptably poor, says the report. “They were shuffled between the segregation unit if they misbehaved and the healthcare centre where they were dumped if they were difficult to manage.”

On the eight occasions when Stewart arrived at Feltham as a transferee or returnee he was only once recorded as having been seen by a healthcare worker. For Lyon there is a missing element to the report recommendations (see Mental Health proposals…from The Zahid Mubarek Inquiry): “It should be much stronger on using court diversion and transfer to take mentally ill young people out of the prison estate and into secure health care.

“Once they enter the criminal justice system few courts will have mental health diversion schemes open to them. Few youth offending teams have been able to fully involve the NHS in their work and psychiatric hospitals will continue to use diagnosis to screen out challenging patients. In the absence of more appropriate services, magistrates and judges will pass a custodial sentence at an early stage. Far too often prison gets used as a dumping ground for young people who have been failed by other public services when the real solution lies outside the prison walls.”

Lyon is by no means alone in her views. Roger Catchpole, consultant and trainer at YoungMinds believes it is a systemic problem. “Sometimes it feels almost random for a lot of kids as to whether they end up on a trajectory that takes them through the youth justice system or through the mental health system,” he says.

Catchpole was recently commissioned to analyse Feltham’s mental health service on the back of a national decision to commission mental health services through primary care trusts rather than through the prison service, which in itself is a huge step forward, he says. Although Catchpole’s presence wasn’t specifically related to Mubarek’s death “the presence of the event was hanging over people”, he says.

Predictably, one recommendation to emerge from his work was the need for better screening and assessment of mental health problems. Feltham now has a large specialist mental health service but the central question remains: how should we handle young people who are severely unwell but have committed serious offences? As Catchpole says, “Treatment versus punishment pervades the system.”

And he is not convinced that the two can be married. “There is a public demand for protection which is reasonable and understandable, but what could be helpful to a lot of kids in the criminal justice system are things that are quite supportive. But you provide these and the public view is that we are rewarding kids who have committed crimes. There are no easy answers. Staff have to work with that tension.”

So have things improved? Highly critical inspection reports have led to better practice on self-harm and suicide risk in YOIs, says Catchpole, but more needs to be done around lower scale mental health problems, such as depression and anxiety.

But this presupposes that young offenders with mental health problems will remain within the criminal justice system. Like many others, Catchpole wants to see far fewer children locked up: “But we are only going to get to that if we provide better support before they get into the system.”

This would mean raising awareness about the mental health of children generally and the links between that and offending behaviour. The risk factors for offending behaviour and mental health problems are very similar, for example, poverty, social exclusion, poor housing and family structure. “The real answer has to be trying to intervene with kids before they go into the criminal justice system,” says Catchpole.

Lyon agrees: “We should look at youth offending generally through a public health lens and have a health and prevention response to it.”

She would like to see special health care units – secure or medium secure – for young offenders with mental health problems, staffed by special multi-disciplinary teams to ensure the prison environment is a thing of the past. She envisages these units being self-managing so that young offenders take responsibility for their lives, by cooking and cleaning, for example, to ensure that they don’t become dependent on institutions.

“It is possible to work with some damaged people who have done serious crimes,” she says.

Back in the criminal justice system, Home Office figures from 30 June show there were 11,279 under-21s in the prison population. Of these, 2,682 were under 18. Up to 90 per cent will have mental health problems and 10 per cent a psychotic disorder. The murder of one prisoner by another is rare – six since 1990. Over the same period 200 young people aged 21 and under have killed themselves in prisons and YOIs. Until we move them out of these non-therapeutic settings that only compound their mental illness, this statistic will continue to spiral.

(1) ONS, Psychiatric morbidity among young offenders in England and Wales, The Stationery Office, 2000

Mental Health proposals…from The Zahid Mubarek Inquiry

  • A comprehensive review of the quality of care provided to prisoners with mental health problems and its effectiveness should be conducted once the changes introduced since Zahid’s murder have had a chance to work.
  • The first reception health screen questionnaire should be revised so as to trigger a referral to a mental health professional on the healthcare team even if the prisoner has only self-harmed in prison. A referral should also be triggered where the prisoner’s behaviour is such that the healthcare officer completing the questionnaire considers it desirable.
  • When prisoners are referred for a mental health assessment, the assessment should address the risk which they pose to staff and other inmates.

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