Mentally-ill reoffenders: As common as we think?
Mental illness makes many people feel uncomfortable and the resulting discrimination runs deep, despite the plethora of laws and right-on noise.
Public reaction can be strong, especially when mentally ill ex-offenders are released back into the community.
This is hardly surprising given the frenzied media attention that often accompanies high profile murders cases involving mental illness and their cumulative influence on the public psyche. It is also highly misleading.
Reoffending rates among the mentally ill are low compared to ex-prisoners and the prospect of becoming a victim remote. Fewer than one in ten re-offend within two years of discharge. Although this is somewhat problematic to compare, as those released from forensic services include closer supervision of those discharged from hospital in the community than for ex-prisoners, it is worth considering the figures.
It is hard to gauge what effect this backdrop of prejudice has on patients re-entering society on top of their daily struggle to manage conditions, including bi-polar disorder, schizophrenia and personality disorders.
Freedom brings its own challenges for ex-patients who spend an average of five years in a medium secure unit before being released for offences that range from armed robbery to murder.
They often face an uphill struggle on release including the day-to-day challenge of managing their condition, resisting the temptations of returning to their old life, public stigma, isolation and unemployment.
I typically handle a caseload of around 15 patients. The numbers are kept manageable to provide the necessary support and monitoring these patients require. My clients would have all originally received a hospital order or ‘section’ rather than judicial sentence because of their mental condition and remain subject to its strict conditions after release.
This includes knowing where they live and that they remain in regular contact with a community support team that includes a psychiatrist, mental health nurse, social worker and sometimes a psychologist.
A conditionally discharged patient can live in a hostel for two years before moving onto independent accommodation. My role is to monitor and assess their progress as well as ensure they meet the conditions of their release.
The advantage of a hospital order is that someone can be immediately recalled to a secure unit if deemed a risk to themselves or others. It negates the need for a mental health act assessment which can take several days to arrange and ensures the patient remains in the unit until a panel of experts decide otherwise. This is a last resort and my efforts remain focused on helping ex-offenders manage their condition on a day-to-day basis and hopefully move towards finding employment.
Life on the outside can be a tough pill to swallow with ex-offenders often surviving on benefits in basic accommodation. The chances of finding employment are stacked against them through a combination of prejudice, previous convictions and lack of employable skills.
The practicalities of my job include home visits to keep an eye on someone’s condition, ensuring they take their medication, screening them for alcohol and drug use where appropriate and helping out with issues like housing and benefit payments.
I conduct random drug tests if I suspect that someone is using. This is especially true for drugs like crack cocaine which only stay in the system for 24 hours.
Cannabis is another popular drug which can lead to psychosis. We also have an on-going problem with ‘legal highs’ many of which don’t show up in conventional testing.
The insights gained by a home visit compared to meeting in a clinical setting like a surgery are invaluable and often present tell-tale signs if someone is wrong.
An untidy living space, curtains drawn during daylight hours, a lack of foodstuffs and poor personal hygiene are all physical indications that something might be amiss.
A patient’s mental state can change for a number of reasons: some more obvious than others.
I’ve walked into flats littered with bottles after drinks binges as well as drug paraphernalia including crack pipes and foil. I have patients who miss appointments, go AWOL or don’t take medication which helps stabilise their condition.
These are extremes but adapting to the outside world as well as managing a mental illness can be testing and my clients have access to my work mobile.
A recent example was someone worried about the increased frequency of voices in her head. I was round there the same day to provide support and assess her mental state.
I think it’s important to treat people as you’d expect to be treated yourself irrespective of their mental health. A large part of that is listening to what people have to say rather than automatically linking their experience with their condition. It’s easier said then done because we make presuppositions and assumptions about situations and individuals we are familiar with.
It’s imperative we recognise that none of us experience events in exactly the same way because we all view the world through our personal lens of experiences and beliefs. Our perception of reality isn’t reality itself. It’s just our take on it and that understanding has to be extended to people with mental illness.
It certainly highlights the need to look beyond a patient’s immediate condition and see how their social and economic environment has shaped and possibly contributed to their condition. If we don’t, we are simply treating the effect without looking for the cause and that is just putting a band-aid on the problem.
An interesting example was a patient living with schizophrenia who was paranoid about being singled out by the police. It would be easy to dismiss this claim purely because of his illness. On closer inspection, his fear was not without reason when I understood that as a young black man growing up in London during the height of the controversial SUS law he most probably was regularly stopped and searched for no good reason.
It’s too easy to label and fit people into a box because of their illness and discount their opinion and experience of what’s happening to them.
You have to be a people person to get on in this job and I’m genuinely interested in what makes people tick.
There are an increasing number of mentally ill offenders filling up secure wards and that, in turn, is putting pressure on mental health services to effectively rehabilitate and release them.
We’re an integral part of that care pathway because there is a lot of public and political fragility around the subject and successful reintegration is crucial both for patients and mental health services.
Commitment isn’t a halfway house. You are either committed to staying the course and helping people or you aren’t.
We’ve seen the downside of that with the ill-fated Care in the Community programme in the 1980s and the dangers of not providing adequate community support to the displaced.
Make no mistake; rehabilitation is a time consuming and labour intensive business that can see patients move two steps forward and one step back. However, it is one we have to continue making if our commitment to rehabilitation and re-integration is genuine.
Ruth White is a community psychiatric nurse who works for Barnet, Enfield and Haringey Mental Health NHS Trust in north London.Tagged in: crime, mentall illness, police, reoffenders, society
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