Mental health in detention: “We must keep a light shining in dark places”
Catherine Paulet is a psychiatrist at Hôpitaux Universitaires de Marseille. She is also a member of the UN Subcommittee on the Prevention of Torture, providing expertise from more than 30 years working with people deprived of liberty. On World Mental Health Day, we invited Ms Paulet to share her insights with us.
In your experience, what is the impact of detention on the mental health of people deprived of liberty?
Around 11 million people around the world are incarcerated and most prison systems are overcrowded. This has negative consequences for the physical and mental health of prisoners, their safety and their prospects for rehabilitation. However, the simple fact of incarceration alone is enough to plunge people into distress and illness. This does not in any way erase the reasons, sometimes serious, that led them to prison in the first place, nor does it minimise the suffering of their victims. But the impact is real and demonstrated by the fact the suicide rate is 10 times higher in the penal population than in the general population.
In addition, the prevalence of psychiatric pathologies and addictions is much higher in the penal population. For example, a quarter of American prisoners and half of French prisoners have a psychiatric history on entry into detention. And we know that detention aggravates pre-existing fragilities and can lead to episodes of psychiatric decompensation, when their mental health deteriorates significantly. Various studies show that one in ten prisoners is hospitalised for psychiatric decompensation at some point during their detention.
Are there specific groups that are at greater risk of suffering from mental health problems in detention?
Yes, of course, and this constitutes a wide variety of situations that need to be identified and taken into consideration by detaining authorities, including: people with pre-existing psychiatric conditions; people suffering from addictions; people with mental and/or physical disabilities; people in situations of vulnerability because of their sexual orientation or gender identity (LGBTIQ persons) or because of their age or condition, such as pregnant women, mothers with their children, elderly people and children.
Some aspects of the detention regime can also impact people severely and lead to major reactive, depressive or delusional disorders. Two groups I would highlight include prisoners in strict and prolonged isolation regimes with little or no contact with others, and prisoners serving life or very long sentences with no hope of completing their sentences.
What is the current state of mental health care in detention?
The situation is mixed. The health of detainees is not always on the agenda of States, especially their mental health. Nevertheless, the idea that detainees are citizens with basic rights, including the right to health, is gaining ground around the world, especially the right to access care of a quality equivalent to that provided to the general population.
In my opinion, this is the result of tireless advocacy by NGOs, civil society, national and international monitoring bodies and international consensus recommendations. I am thinking, in particular, of the Mandela Rules for the treatment of prisoners that have been adopted unanimously by States.
On the ground, there is a growing awareness among governments and the public that rehabilitation of prisoners and the prevention of recidivism also depend on an improved state of health among detainees. And so there is now a greater involvement of health ministries in the provision of health care for detainees. Although, in some regions of the world, the lack of financial resources and health personnel can undermine the efforts of States.
I have to admit that, overall, mental health remains a poor relation. One of the reasons for this is the continuing stigmatisation of psychiatric disorders and discrimination against those who suffer from them. Few States have a specific and consistent mental health care system for prisoners.
Have you documented good practices in places of detention?
When governments, parliaments and civil society are committed to implementing progressive policies, and providing the resources to support them, the results are there. This requires the definition of a mental health policy in prisons, in line with the policy defined for the general population. It also requires public awareness initiatives, training for staff working in prisons, having a sufficient number of personnel in prisons, opening prisons to the outside world and ensuring regular monitoring.
Mental health training for prison staff, especially those who work directly with prisoners, is an important example of good practice. It is especially essential where there are few or no health care staff present. Training helps to overcome preconceived ideas, to acquire basic data on the main symptoms and causes of mental health or psychiatric problems, and to feel less afraid and more at ease in different situations. In addition, learning de-escalation techniques in violent situations and approaches for suicide prevention provides staff with useful and practical skills.
How can places of detention make mental health a priority?
The criteria for maintaining a peaceful atmosphere within places of detention, and therefore having a positive effect on the mental health of the prisoners, including those with known psychiatric pathologies, are quite well known. They include:
- Ensuring that custodial sanctions, while necessarily punitive in nature, above all have a restorative focus
- Having smaller facilities and local management so prisoners are known to the detaining authorities
- Involving prisoners in assessing and improving the conditions of detention
- Providing training and work opportunities for all prisoners, including people with disabilities and those with limited skills.
Other important steps that detaining authorities can take include supporting and facilitating the entry of civil society organisations, integrating the principle of ‘peer helpers’, and handling requests and complaints as an individual requirement and for a collective benefit.
Monitoring places of detention can be a complex and intense task, both physically and mentally. Can you share with us your experience of conducting monitoring visits?
I have had the good fortune to contribute to the mandates of the Committee for the Prevention of Torture for more than 20 years and to the UN Subcommittee on Prevention of Torture for the last nine years. My focus today is on prisons, but our field visits cover a wide range of facilities, from police stations and prisons to psychiatric hospitals and social care homes, migrant centres and other more ‘confidential’ places.
Monitoring places of detention cannot be improvised; it must follow a rigorous and systematic methodology. Monitoring the premises, procedures and registers, along with conducting interviews with persons deprived of liberty, management and staff, is all guided by the principle to ‘do no harm’. It is also important to maintain neutrality. This does not exclude empathy or benevolence, but it is important to be ‘wary of emotions’.
That said, monitoring visits can be physically trying (the overcrowded cells, the dirt, the rats, the cockroaches) and psychologically trying (the distress, the resignation and the rage that sometimes fills those we meet). These men, these women, these children agree to speak us and, when we leave them, we sometimes fear they will face reprisals. But their humanity and their courage in speaking out, not for themselves but for others in detention, compels us to act.
I am optimistic but not naive. The implementation of universal, high-level standards, that are respectful of the fundamental rights of people in general, and those in detention in particular, can come up against populism, corruption, impunity, cultural or religious relativism, autocratic regimes, and war.
The challenges are great but the stakes are even greater. And we start with small victories. As Ghandi said: "Whatever you do will be a small thing, but it is essential that you do it.” I believe our presence is essential to keep the light shining in closed and dark places.