A new project helps keep people suffering from serious mental illness out of jail, explains CONOR O'NEILL
IT IS winter. Mr X, a 60-year-old man is standing under a statue on O’Connell Street. He is dishevelled, bearded and talking about the Devil. Passersby laugh and he shouts back at them, using abusive language. The Garda is called. He refuses to move on, calling them “agents of the Devil”.
He is arrested and refuses to give his name and address. He is charged with breach of the peace and spends the night in the cells. In court next day he shouts at the judge. He is homeless. No relative is present in court and he has no money to pay a bail bond. Bail is refused.
He is remanded to Cloverhill Prison and seen by a nurse on reception. He is placed on a separate wing for vulnerable prisoners containing mainly other mentally ill individuals.
Mr X is seen by the Prison Inreach and Court Liaison Service (PICLS) and a detailed history is taken. He is actively psychotic and requires treatment in hospital.
Gardaí report that he sleeps on the street and has been assaulted recently. He has no history of violent offending. His family report that he has not been in contact in several months. They have been concerned for his safety. He has had previous admissions with his local psychiatric service who agree to provide an admission bed and follow-up care. Inreach Homeless Services arrange a hostel place.
Mr X appears in court. The charge is minor. He does not require treatment in a high-secure facility. A report outlines the treatment plan in the event of his being granted bail. This involves his admission to hospital and re-engagement with local services. The judge grants bail and PICLS staff bring Mr X to hospital where he is admitted and followed up by the community outreach team following discharge.
This is a hypothetical case, but typical of those that reach the attention of the PICLS.
Almost 8 per cent of male remand prisoners in Ireland have current or recent psychotic symptoms, 10 times the community rate. Most of those with major mental illness remanded to custody are charged with non-violent, often relatively trivial, public order offences, which would ordinarily qualify for bail.
People with mental illness face greater obstacles to receiving bail, such as inability to provide an address (due to homelessness), pay a bail bond (due to poverty), have a family member to vouch for them (due to social disconnection) or failure to give a coherent account of their actions (due to symptoms such as thought disorder).
Courts should not be expected to act as proxies for mental health services in identifying mental illness or be expected to arrange treatment. Judges have the option of ordering transfer to the Central Mental Hospital under “fitness to be tried” legislation. When this occurs in the absence of medical examination, minor offenders can be inappropriately placed in high-secure facilities.
Persons charged with serious offences or posing a significant risk require the high-secure setting of the Central Mental Hospital. Those charged with minor offences generally require treatment as an inpatient or an outpatient in a community setting. Gardaí have the option to bring people directly to hospital under section 12 of the Mental Health Act.
A prison inreach and court liaison service (PICLS) has been developed at Cloverhill Prison, which takes the majority of remand prisoners nationally, to identify persons with major mental illness and arrange treatment care plans in appropriate settings. While some countries have specific legislation regarding diversion to community services, diversion is possible under existing law, such as the bail Acts. This approach, known as “therapeutic jurisprudence” is now widely used in Irish courts.
It is delivered from the HSE’s National Forensic Mental Health Service at the Central Mental Hospital and attends Cloverhill Remand Prison daily. The service works closely with Irish Prison Service medical and nursing staff to screen and identify new remands with major illness. PICLS staff then carries out a detailed assessment, The majority of assessments by the service in 2008 took place within two days of committal.
A report is prepared for the court describing treatment plans in the event of custodial and non-custodial disposal. This increases the range of options available to the courts. Nursing staff help bring the person directly to hospital when required, although most patients are managed in outpatient settings. The service has facilitated diversion of over 300 persons with major mental illness since 2006.
Diversion should not be misinterpreted as a “get out of jail free” card. In general, where the person is transferred to local services, this is subject to conditions (as with non-mentally ill offenders receiving bail). This provides for a balance between rights and responsibilities.
The Prison Inreach and Court Liaison Service aims to bring together agencies which assist people with major mental illness. This involves close co-operation with families, GPs, homeless services, probation and welfare services, addiction services, prison staff, judges, gardaí and others. The service is able to operate because of the assistance and co-operation of these and community mental health services throughout the country.
Psychotic conditions such as schizophrenia are the most severe mental illnesses. Sufferers may experience distressing symptoms including hallucinations (for example, hearing voices), delusions (false beliefs, often paranoid and frightening), and difficulty in thinking clearly. They may be unable to recognise when they are severely unwell. These symptoms generally respond well to treatment and most people with such illnesses are not actively psychotic at any given time.
Untreated, such symptoms can make it difficult to maintain contact with friends and family, hold down a job, pay rent or remember appointments. Many end up homeless, in shelters or on the streets. People with schizophrenia have a considerably shorter life expectancy than the general population. Many die by suicide. Many more accumulate in prisons, which have a defined function in society. Treatment of severe mental illness is not one of these functions.
Dr Conor O’Neill is a consultant forensic psychiatrist at the Central Mental Hospital, Dundrum, and leads the Prison Inreach and Court Liaison Service at Cloverhill Prison. The Prison Inreach and Court Liaison Service won the awards for Best Hospital Project and Best Overall Project “An Duais Mhór” at the recent Irish Healthcare Awards