On the evening of Thursday August 19 this year, a prisoner was locked in his cell in the segregation unit of Wormwood Scrubs prison in west London. This man had been sent to the seg to be held in solitary confinement as a punishment because he had threatened a cellmate. But that was three weeks earlier and, since then, he had settled down and been quite easy to manage. Everything was normal.
On the following morning, August 20, an officer called Dickie Hampson unlocked the door of the cell, and, without warning, the prisoner pounced on him and stabbed him in the back of the shoulder with a toothbrush which he had sharpened into a rigid blade.
Hampson was rushed to hospital where doctors found that the epaulette on his shirt had saved him from the worst of the wound.
Nobody could understand why this prisoner had suddenly turned violent. Immediately after the attack, a group of officers with a riot shield restrained him, handcuffed him and removed him to the "safe cell", designed to prevent self-harm, while they searched his possessions to make sure he had no other weapon concealed. That afternoon, the prisoner was calm again, remorseful and worried about Hampson's condition, and soon he was taken back to his normal cell.
The next morning, Saturday August 21, a second officer, John Leadley, unlocked the same prisoner to take him to the governor for an adjudication for the assault on Dickie Hampson. As Leadley approached him, the prisoner slipped another sharpened toothbrush out of his shirt sleeve - nobody ever found out where he had got it from - and clawed at Leadley's face: the spike cut down through his eyebrow and into his cheekbone, missing his eyeball by less than an inch.
With blood flowing from his face, Leadley too was taken to hospital. The prisoner was moved back to the safe cell. It was several days before the prisoner spoke to the senior officer on the seg, whom he trusted, and explained what had happened: soon after he was locked in his cell on that first night, he said, a black cat had slipped through his window and sat on the bed next to him. This cat had been following him for some time. Now, it handed him a card, the ace of spades, and then dropped down to the floor where it danced for him. There was music. The dance went on for hours, the prisoner watched, and then the cat turned to him to warn him that the next person who came into the cell would be his enemy: the prisoner must kill him. The cat had promised to stay with him to make sure he was all right. The prisoner had started sharpening the toothbrush.
This man was psychotic; he had already been diagnosed as paranoid schizophrenic. None of the officers who work at Wormwood Scrubs is trained in psychiatry. Yet routinely, they deal with mentally disordered men. When John Leadley was stabbed in the face, it was the fifth time he had been attacked in three months; every one of his attackers was suffering from a severe mental illness.
There is nothing unusual about Wormwood Scrubs. Every prison in the country now warehouses the mentally disordered: the numbers have been spiralling upwards since the closure of the old asylums. This has reached a point which beggars the imagination: figures from the Office of National Statistics (ONS) show that, if we diverted to treatment all those prisoners who are mentally disordered and/or addicted to alcohol or drugs, 90% of inmates would no longer be held in jail.
There are now 75,000 men and women behind bars in this country. The findings of the ONS suggest that nearly 50,200 of them have personality disorders; 6,175 are psychotic; and more than 35,000 of them have neurotic disorders. Several tens of thousands of them suffer a combination of disorders. More than 75% of them are intellectually impaired, with IQs below the national average. And these are not figures that the government denies.
The prisons minister, Paul Goggins, describes these ONS statistics as "our principal source of knowledge about the extent of mental ill health in the prison population". Most mentally disordered people do not end up in prison; but overwhelmingly most prisoners are mentally disordered.
And every one of our prisons suffers from the "treatment gap" - the gulf between the care that is needed for the mass of mentally disordered men or women within its walls and the care that is provided. After years of neglect, when there was no effective mental healthcare in prisons, the government is finally tackling the crisis, but resources are short, there are real limits to what can be achieved in a prison regime and, worst of all, as the health minister, Dr Stephen Ladyman, told the parliamentary mental health group this year: "It is generally accepted that mental health will deteriorate in prison."
The results are deeply worrying. It is not simply that mentally disordered prisoners may be violent to staff or other inmates. Indeed, they are far more likely to be violent to themselves. On average: every week in prisons in England and Wales, two prisoners take their lives and two or three others are resuscitated after trying; and every day, around 40 prisoners cut or gouge themselves in their cells. Beyond this, the fact is that we are herding disordered men, women and children into our prisons, storing them there for months and years, and then processing them back into the community with every prospect that their disorder has not been addressed and so they will offend again. They suffer. Those around them in prison suffer. Everybody suffers.
Every afternoon at Wormwood Scrubs, the white prison vans queue up outside the gate, ferrying men back from the courts - the young and surly, the old and confused, the crackhead who was caught shoplifting yet again, the homeless man who set fire to an empty building, the man who thumped a stranger because he looked at him in a funny way, the old Rasta who screams at himself in the park. The reception officers process them and give them a bedroll, a nurse takes them through a health questionnaire: "Have you ever received treatment from a psychiatrist outside prison? Have you ever received medication for any mental health problems? Have you tried to harm yourself?"
Once, several tens of thousands of mentally disordered men and women were held behind the high walls of the old asylums, but they failed and, in the late 1980s, they were all closed down. Now, those who would have been their patients rely on a network of community care which is notoriously overstretched and, if they fall through its gaps, they are scooped up by police and sent back behind high walls. Those walls protect a crooked structure.
There are now 139 prisons. There are already plans to build five more. By the end of the decade, the Home Office plans to incarcerate at least 80,000 men and women. If the ONS is right, around 56,000 of them will suffer from at least two types of mental disorder. Yet we have only just over 4,000 secure psychiatric beds, which are already full, and no plans to increase them.
The whole structure is crooked, because it is built on a crooked foundation - the emotionally satisfying but deeply ineffective idea that if we hurt these people enough, they will obey the law. Hospitals are built with bricks of care, prisons with the plans of politicians.
The old Rastafarian who screams in the park was arrested for trying to steal a handbag and for exposing himself in a public place. He is soon processed and taken down to A wing. Nobody realises he has lied about his psychiatric history, nor that he has been arrested, charged and now remanded in custody under a false name. Lots of new prisoners conceal their psychiatric history: they don't want the stigma, they are afraid it will count against them, or they have forgotten. On the wing, the old Rasta is soon marking himself out as an oddball, muttering to himself, eating next to nothing, refusing to wash himself or to clean his cell. It gets so bad that one day the officers force him to take a shower: nobody can stand the smell any more.
By chance, a visiting nurse recognises him from the hospital where she works and remembers his real name. The prison doctors contact the hospital's community mental health team for his notes and persuade the old man to take some medication while they wait for them to arrive. Three weeks later, the notes reach Wormwood Scrubs, detailing his long history of schizophrenia, but by that time, he has been taken back to court where he is given bail or a non-custodial sentence - nobody bothers to tell the prison - and he is back on the streets again.
The number of mentally disordered men and women in our prisons has increased seven-fold since the asylums were closed. We have talked to staff at every level of the Prison Service who are alarmed and depressed to find themselves warehousing the sick. The former director general, Martin Narey, now in charge of probation as well as prisons, has publicly described the strain as "overwhelming". A senior manager told us it was "a bloody awful problem".
The cutting edge of the government's response has been to create Inreach teams, to deliver care-in-the-community on prison wings. In Wormwood Scrubs, the team consists of one consultant psychiatrist, one social worker and one community psychiatric nurse. They care for a prison holding 1,167 men at any one time, with 3,900 coming and going over an average year - 90% of whom they reckon to be mentally disordered. The simple reality is that the Scrubs team spend so much time assessing new patients that they rarely have time to deliver a care plan.
There is also a new day care centre which borrows money from the education budget to run courses in relaxation, art and acupuncture, but staff are so short that sessions sometimes have to be cancelled. An unpaid counsellor comes in once a week, but there is no psychotherapy at all. There are signs that the centre has helped some of the low-end patients, but the service is limited and helpless to deal with the most severely ill who need beds in outside hospitals, which are extremely hard to find.
In a special report on nursing in prisons, the Department of Health acknowledged that, while staff may do their best, there is a level of care which "prison healthcare does not and can not provide".
Even at the lowest end of the scale of mental disorder, this leaves the neurotics with their phobias and anxieties and panic attacks hiding quietly in their cells, not eating and/or not sleeping and/or being punished for low-level disobedience. In the outside world, they might end up on the general ward of a local hospital; here, their disorders frequently pass unnoticed in the muddle of daily life. Sometimes, they are prescribed something to help them; sometimes it is stolen by other prisoners. The parliamentary mental health group has taken evidence on the victimisation of mentally disordered prisoners who report being robbed, bullied and indecently assaulted.
Others with neurotic disorders are screamingly obvious. A man was shipped into the Scrubs from Highbury magistrates court in north London a few months ago. Suffering from depression after the break-up of a relationship, he had slapped a police officer. Within four hours of arriving, he had cut his throat from ear to ear, including his jugular, and slit both wrists. All the prison could do was to send him into Hammersmith hospital to tend his wounds for four days and then beg the Home Office to allow them to transfer him to a local psychiatric ward to treat his anxiety. They refused: the courts had ordered that the man be held in custody awaiting trial and they deemed the security in the local hospital to be inadequate.
Some of the psychotics too can be withdrawn - "quietly mad" in the language of doctors - and likely to remain undiagnosed and untreated. To untrained prison officers, they may seem irritating, asking the same question over and over again, or simply weird, like the man who was frightened of water.
He would sit on one of the wings at the Scrubs staring at a splash of water on the floor, worrying that it was evaporating too quickly. It was two weeks before he clumped a member of staff, triggering a process that diagnosed his paranoid schizophrenia and eventually transferred him to an outside hospital. (His worry about water was that it was poison and he would die if he drank it.)
Once they are spotted, the psychotics can often be stabilised. There is a young schizophrenic in the Scrubs at the moment: his father lives abroad; his mother has been evicted from her home and is sleeping rough somewhere; he ended up living on the streets, cold, hungry, hallucinating and finally trying to steal a woman's handbag.
He is on remand awaiting trial and he is now stable and relatively secure in a single cell with a television. His main worry is that the court may take pity on him and put him out. The big problem with psychotics is that, if they refuse medication, the prison - unlike a hospital - has no right to treat them against their will.
One of the staff at the Scrubs told us about a psychotic man who refused to be treated. The prison wanted to transfer him to an outside hospital, but there was no bed. Without medication, the man's condition started to deteriorate. Soon, he took to standing on the sink in his cell, holding his arms out sideways and swallow-diving head first on to the concrete floor. His face was soon broken and bleeding, and staff were then able to use their limited power under common law to tranquillise him by force for long enough to stitch his wounds. Then the law required them to stand back and let him carry on swallow-diving. At one point, they got special permission from the Home Office to hold him in a padded cell in a straitjacket (something which officially is no longer done in UK prisons). Finally, an outside hospital bed was found for him.
The most disruptive are those with personality disorders. Technically, they are not suffering from a mental illness, but their behaviour is distorted by traumatic experience, usually in childhood: one out of every three men who is remanded into custody by our courts has been in care as a child; one in three women has been sexually abused; one in 10 men has been sexually abused. They may be withdrawn, mistrustful, aggressive, antisocial. At the top end of the scale, they may be grossly callous and cruel. In prison cells, they cut themselves, they bang their heads against the wall, they manipulate, they protest, they swallow pills like sweets. But, from the doctors' point of view, although they may be mentally disordered, they are not "ill" and are often dismissed as untreatable. The daily strain of the treatment gap, dealing with so much mental disorder without the resources or skills to match the challenge, produces some real tensions in the prison.
Read part two here
· To protect medical confidentiality, names and some identifying details of prisoners have been changed.
· Additional research by Roxanne Escobales
Mental disorder includes:
· Mental illness such as psychosis or severe depression, often occurring as an episode in an otherwise healthy person and liable to respond to treatment
· Personality disorder, such as antisocial or paranoid, occurring as a continuing pattern of abnormal behaviour, sometimes the result of childhood experiences, generally difficult to reverse
· Neurotic disorder, such as anxiety and phobias, occurring at a level likely to interfere with normal activity, generally amenable to treatment
· Learning disabilities, usually involving significantly impaired intellectual functioning
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