Ms Deirdre Malone:

IPRT welcomes the invitation to make a submission on mental health and we commend the committee for its initiative in choosing to focus on the state of psychiatric services in Ireland’s prisons and detention centres. IPRT views gaps in mental health provision as one symptom of wider social exclusion and is intrinsically linked to criminal justice and penal policy. The committee can refer to the briefing provided for the detailed sources supporting our key points but during this oral hearing, we will highlight those which we consider most pertinent.

The level of mental ill-health difficulty in the Irish penal system is overwhelming in both its scale and complexity, and the challenges are growing daily. Walking through our prisons, that current reality is evident on every landing and every wing and ranges from the severely psychiatrically unwell to those experiencing anxiety and depression. This should come as no surprise. The experiences which precede incarceration are often marked by multiple vulnerabilities, including adversity, trauma, abuse, violence, addiction, and experiences of care, poverty and homelessness. The experience of prison itself such as overcrowding, enforced solitude, lack of privacy, lack of meaningful activity, violence, isolation, insecurity about future prospects and broken family relationships compounds those problems. It can actively exacerbate existing mental health issues, heighten vulnerability and increase the risk of self-harm and suicide. Why then does the State continue to warehouse those with the most complex needs in prisons that of themselves both cause and exacerbate existing mental illness?

A decade ago, 3% of the prison population had a severe, enduring and disabling mental illness such as schizophrenia. Since 2015, this has more than doubled to 7% to 8% of the prison population. A 2005 study on the prevalence of mental illness among prisoners in Ireland showed that for sentenced prisoners taking into account all mental illnesses, the rate for men was 27% and for women almost twice that level, at 60%. More recently, those working on the ground report to the IPRT that even higher overall levels of need are present and, within that, there are increasing complexities and multiple vulnerabilities. In addition, our prison population is rising. After a period of relative stability, more and more of those convicted have been sentenced to prison and our female prisons are consistently overcrowded. At the same time, both the Central Mental Hospital and the Irish Prison Service face difficulty recruiting sufficient staff to meet the overwhelming need.

In 2015 the European Committee for the Prevention of Torture, CPT, said: "Irish prisons continue to detain persons with psychiatric disorders too severe to be properly cared for in a prison setting." The committee recommended that Irish authorities enhance the availability of beds in psychiatric care facilities for acute mentally unwell prisoners. It particularly queried the level of psychiatric care provided at Castlerea Prison and the long waiting list for the CMH. Similar concerns were voiced in 2011, yet seven years later there is still a lengthy waiting list for the CMH, there is no psychiatrist at Castlerea Prison and we still have the lowest ratio of psychiatric beds in Europe. The CPT will return to Ireland next year to inspect our prisons. After this hearing has concluded and after the Oireachtas committee report is published, will the committee witness the same indefensible state of affairs they saw three years ago? I ask this committee to consider in the coming years what will have changed.

While the focus of this hearing is on psychiatric care, the terms of reference of this committee is to look at the future of mental health broadly in Ireland. A properly resourced mental healthcare profession in the community at the earliest point and especially for children will reduce the number of those coming into contact with adult criminal justice system. Researchers and clinicians agree that early mental health assessment is required in order to prevent escalation of need.

On 14 May,theIrish Examiner reported that almost 2,700 children are currently on the list for mental health appointments with 368 having waited over 12 months. This has been described as a service reaching crisis point. Failing to resource the child and adolescent mental health services, CAMHS, increases the number who end up in our penal system. In Oberstown in April of this year, there were concerns for 23 out of 50 young people in respect of their mental health, 13 had a history of self-harm and 32 had been misusing alcohol and-or drugs prior to detention.

Mental health care provision in the community is also especially relevant to continuity of care on release.While prison-based medical personnel make great efforts to create these links, they report there is effectively no adult psychology service available to which to refer in the community.

We note that the committee has been specifically tasked with examining the "significant challenges in the recruitment and retention of skilled personnel". The current ratio of senior psychologists to prisoners is in the region of 1:260 but should be in the region of approximately 1:150. A Vision for Change recommended that "[w]here mental health services are delivered in the context of prison, they should be person-centred, recovery-oriented and based on evolved and integrated plans.” It is simply not possible to deliver that level of service to all who need it in a situation where prisons cannot recruit a sufficient number of psychologists.

High support units provide expert support to prisoners who are in an acutely disturbed phase of mental illness as a short-term intervention within the prison. There are currently only two in operation but it has been recommended that one is required in all prisons.

The number of secure forensic beds for the mentally ill is currently the lowest in Europe at two per 100,000. As of April 2018, 26 prisoners were awaiting transfer to the Central Mental Hospital, CMH, from prison. There is no published data of how long each individual prisoner waits to be transferred but it appears that many lower on the waiting list for a transfer are unlikely to be transferred due to the lack of available spaces.

Twelve years ago, A Vision for Change recommended that the CMH “be replaced or remodelled to allow it to provide care and treatment in a modern, up to date humane setting" and to maximise capacity. With the opening of the new facility at Portrane, the psychologist-prisoner ratio of 2:100,000 is likely to only reduce to 3.5:100,000, which is still well below European average. The alarming growth in the prison population during the past six months makes this situation even more concerning.

The Report of the Commission of Investigation into the Death of Gary Douch was published in May 2014 and found at that time there was "reckless disregard for the health and safety" of prisoners and staff alike in a decision taken to transfer a prisoner who had been assessed as "acutely psychotic" to Mountjoy Prison. At that, I commented that "if there can be any positive legacy at all from this tragedy then it should be that concrete and effective changes will be swiftly introduced". That report contained 35 recommendations specifically in the area of mental healthcare and treatment in Irish prisons. Four years later, while an interdepartmental group was set up in 2012 it is unclear to what extent, if any, those responsible for implementation have taken action.

In April 2018, more than 500 prisoners in our prisons were on a restricted regime with the majority of those prisoners held on 21-hour lock up. This practice is detrimental to any prisoner's mental health. The European Committee for the Prevention of Torture, CPT, has recommended that the maximum period an individual spends in solitary confinement is 15 days and beyond that point the psychological damage may become irreversible. Similarly, suicides are over-represented among the prison population.

In brief, the human reality of the combination of failures to provide sufficient mental health services at an early point, coupled with the failure to provide sufficient spaces in our acute and psychiatric facilities along with tough-on-crime rhetoric, results in: mentally unwell women in the Dóchas Centre sharing cells; prison staff trying to cope with high numbers in unsuitable facilities; and Ireland contemplating a bleak future in which nothing has changed and nothing changes.

In our view there are many things that can be done to start to improve the situation, which we have set out in our briefing document. In short, before prison, we propose: more investment and use of prevention and early intervention supports; urgently addressing the current waiting list for children and young people could be urgently addressed; the development of diversion schemes in courts and police stations; and in respect of Central Mental Hospital to ensure sufficient spaces and provide sufficient deal to deal with those with severe mental illness. In prison, we propose: solitary confinement should be prohibited and access to justice for those in solitary confinement; implementation of the recommendations of the Report of the Commission of Investigation into the Death of Gary Douch; the provision of enough prison psychologists to reach an appropriate ratio; ensuring all prisons have a high support unit; ensuring single cell accommodation for every prisoner; and to make mental health training available for every prison staff member. After prison, we propose the making of links to the community, linking with psychology supports or to make them available if they do not exist.

We urge the committee to do everything that is within its power to make an impact on the ground for those who are currently suffering in our prisons and detention schools and those staff and professionals who are trying to cope with an untenable situation.