The drugging of prisoners
Anthony Clare
There has beetteo.nsiderable publicity given recently to the fact that large numbers of individuals in British prisons are receiving psychiatric drugs. This growth in the use of what has been inelegantly termed 'the liquid cosh' has been discussed largely in, terms of I he failure of the prison system to do much more than control and contain. Attention has also been focused on the role of prisons as precipitants of serious psychiatric disturbances in people who at the time of their original incarceration were of sound mind. One ex-prisoner has pointed out, with much justification, that if you take able-bodied people and submit them to a regime in which they eat, sleep, urinate and defaecate in the same room, in which their mail can be withheld, their visits limited and their parole refused with little in the way of explanation, then it is hardly surprising that a sizeable number of such people break down under stress and require psychiatric
Ire atment.
But there is another side to this phenomenon which tends to be neglected in any analysis of psychiatric treatment within the prison system. Over the years, some say as a direct result of the so-called 'Open Door' policy within British psy chiatric hospitals, there has been a steady rise in the number of people with overt psychiatric ill-health and a previous history of psychiatric break-down, being committed to prison for minor offences. The reduction of beds which followed the declaration by Enoch Powell in 1961 that the mental hospital was to be phased out has highlighted the problem of the mentally abnormal offender. The incautious discharge of chronic patients from the mental hospital system has compounded, the problem further.
The growth of small psychiatric units within the new district general hospitals has made little difference, for such units are not well suited to cope with certain patients, particularly those with aggressive,, anti-social, immature or damaged personalities and those with drug dependence, alcoholism, epilepsy or other organic conditions.
Psychiatrists are now reluctant to accept mentally disordered offenders as inpatients and the number of patients from so-called forensic sources who are treated in English NHS facilities is accordingly small. Less than 3 per cent of all admissions arc referred by the courts or the police while only 0.65 per cent are admitted from prison, borstal or approved school. Those patients, and they are many, whose offences stem solely from their illness are in effect being denied treatment. The psychiatric units attached to the general hospitals take the more acute, less chronic patients while' the larger, understaffed mental hospitals are reluctant to accept patients needing intensive nursing care at a time when staffing cuts are being ruthlessly implemented.
Every bit as important in all of this, however, is the fact that attitudes at the present time to patient management are such that any form of involuntary treatment — the discussion of professional responsibility to society or the acceptance of the 'asylum role' — is seen as running counter to progressive concepts of treatment and rehabilitation. The wholesale unlocking of wards during the 'sixties, (the so-called 'Open Door' movement) was seen as a tremendous step forward and as the single most effective factor in altering the image of psychiatric care over the past fifty years. Like so many movements, however, it had consequences few of its enthusiastic supporters had foreseen. A crucial mistake is to divide psychiatric patients into the dangerous, i.e. those with anti-social propensities best treated in prison or the Special Hospital system, and the safe. There are, of course, both these.categories but there is in addition a third. This group contains people who at times, by virtue of their illness or a disturbance in personality, may be potentially dangerous or may indulge in crime of an often petty but repetitive nature; when such people come Into contact with the la'.', the latter, recognising that t hey are ill and/or are more suitably treated in hospital than in prison, looks to the psychiatric services for assistance. To be told, as judges and magistrates are being told, that the majority of psychiatric hospitals cannot provide a minimally secure setting, even on a short-term basis, leaves courts with the stark choice of imposing a longsentence to an orthodox prison as an alternative to a hospital order to a non-secure hospital. At the same time, the Special Hospitals, Broadmoor, Rampton and Moss Side, have had to take more and more referrals from the courts and have become grossly overcrowded, strained and, in the opinion of some, anti-therapeutic. Overcrowded wards and shortages of skilled staffs have led to a situation in which there is an undue reliance on psychiatric drugs as a form of treatment and behavioural control. Indeed, as one forensic observer has pointed Out, it is somewhat paradoxical that at a time when open-door psychiatry reflects a concern with individual liberty, more and more people are being incarcerated within prisons because of staff shortages. The prized freedom within the NHS psychiatric hospitals is illusory — many patients are being detailed elsewhere, namely in prison.
Several studies have estimated that between 5,000 and 10,000 men in prison require psychiatric assistance, The Butler Report estimated that approximately 2,000 might require some form of medium-secure hospital and recommended the setting-up of special hospital facilities within each region. Indeed, as far back as 1974, the Interim Report of the Butler Committee made an urgent recommendation along these lines and the DHSS sent out a circular underlining the critical nature of the situation. Three years later not a single unit has been built and there is little evidence that anyone has seriously faced the issue of how such units are going to avoid being turned into overcrowded, understaffed waste-bins for rejects from the orthodox psychiatric facilities — the fate, in other words, of the Special Hospitals at the present time.
Not all hospitals have unlocked aI1 their . wards. One forensic psychiatrist, Paul Bowden, in a study of psychiatric hospital facilities in one region, found that those hospitals which had retained at least one
locked ward for seriously disturbed patients took more patients referred from the courts and referred less to the Special Hospitals. However, it seems doubtful that the tide which flowed steadily through the 'sixties against locked wards can now be turned. In addition, the rise of hospital unions and of nursing militancy makes it unlikely that many hospitals will be willing to take patients demanding intensive nursing care. Indeed, there have been several incidents which confirm that hospital staff are becoming increasingly unwilling to accept bona fidc psychiatric patients, let alone those with dangerous and antisocial tendencies.
It is against this background that any discussion of an increase in the use of psychiatric drugs in British prisons should be seen. More and more psychiatric patients are finding their way into prison and they receive there, for the most part, little more than the most basic of psychiatric treatments. In addition, their arrival in the prison system only serves to further aggravate the problem of overcrowding which is now endemic within the prison world. There is no sign of any immediate change in such a situation and the current financial state makes it most unlikely that any new impetus will be provided for the building of the medium-secure units. Are the Butler recommendations therefore dead? They certainly do not seem in very good health. The best that might he hoped for is that one or two such units might be built within the next two years on an experimental basis. But for a significant alteration to the present deplorable situation, it is going to be necessary for another recommendation of he Butler Committee to be acted upon, namely that orthodox psychiatric hospitals should once more provide treatment and care for the majority of difficult, violent and mentally abnormal offenders judged by the courts to he in need of psychiatric treatment. To do this effectively would mean, however, that nursing cuts within the psychiatric service would have to be restored and those hospitals which have discarded their most rudimentary secure facilities would have to reinstate them.
Neither of these options seem likely at the present time. Accordingly, one is forced to conclude that accounts of drugged Prisoners, snake-pit prisons and widespread confusion between treatment and control are going to' increase as more and more psychiatrically ill people end up in prison. It is all a sad, sorry and unnecessary end to a decade which began with such high and, in retrospect, such unrealistic expectations.
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