RE-SOCIALIZING MENTAL HEALTH OFFENDERS

Introduction

Mental disorders occur at high rates in all countries of the world.  An estimated 450 million people worldwide suffer from mental or behavioural disorders. These disorders are especially prevalent in prison populations. The disproportionately high rate of mental disorders in prisons is related to several factors: the widespread misconception that all people with mental disorders are a danger to the public; the general intolerance of many societies to difficult or disturbing behaviour; the failure to promote treatment, care and rehabilitation, and, above all, the lack of, or poor access to, mental health services in many countries.  Many of these disorders may be present before admission to prison, and may be further exacerbated by the stress of imprisonment. However, mental disorders may also develop during imprisonment itself as a consequence of prevailing conditions and also possibly due to torture or other human rights violations.

Prisons are bad for mental health: There are factors in many prisons that have negative effects on mental health, including:  overcrowding, various forms of violence, enforced solitude or conversely, lack of privacy, lack of meaningful activity, isolation from social networks, insecurity about future prospects (work, relationships, etc),  and inadequate health services, especially mental health services, in prisons. The increased risk of suicide in prisons (often related to depression) is, unfortunately, one common manifestation of the cumulative effects of these factors. 

Prisons are sometimes used as dumping grounds for people with mental disorders: In some countries, people with severe mental disorders are inappropriately locked up in prisons simply because of the lack of mental health services. People with substance abuse disorders or people who, at least in part due to a mental disorder, have committed minor offences are often sent to prison rather than treated for their disorder. These disorders therefore continue to go unnoticed, undiagnosed and untreated. 

People with mental disorders are exposed to stigma and discrimination: Within most societies, people with mental disorders face marginalisation, stigma and discrimination in the social, economic and health spheres, due to widespread misconceptions related to mental disorders. This stigma and discrimination usually persists in prison, with the person often facing still further marginalisation and isolation due to imprisonment.

Effective treatment is possible but too often the available resources are wasted: There are many effective treatments for mental disorders, but often the limited available resources are wasted in ineffective, expensive interventions and services that only reach a small proportion of those in need.  The building of separate psychiatric prison hospitals in particular is not cost-effective, because they are very expensive to run, they have a limited capacity, are associated with low release rates, and they often leave the individual with a severe and persistent stigma. Many operate outside of the health departments responsible for controlling the quality of health interventions.  Furthermore, there is no evidence that these expensive hospitals improve treatment outcomes.  Rather, these hospitals can put prisoners at risk of human rights violations

The Significance of Re-Socializing Mental Health Offenders in Prisons

With regards to the prisoners the process of addressing mental health needs will improve the health and quality of life of both prisoners with mental disorders and of the prison population as a whole. By promoting a greater understanding of the problems faced by those with mental disorders, stigma and discrimination can be reduced. Ultimately, addressing the needs of people with mental disorders improves the probability that upon leaving prison they will be able to adjust to community life, which may, in turn, reduce the likelihood that they will return to prison  

Meanwhile on the other hand, for prison personnel, prison settings are often difficult and demanding working environments for all levels of staff. The presence of prisoners with unrecognised and untreated mental disorders can further complicate and negatively affect the prison environment, and place even greater demands upon the staff.  A prison that is responsive to, and promotes the mental health of prisoners, is more likely to be a workplace that promotes the overall morale and mental health of prison staff and should therefore be one of the central objectives of good prison management..

For communities, prison health cannot be addressed in isolation from the health of the general population since there is a constant inter-change between the prison and the broader community, be it through the guards, the administration, the health professionals and the constant admission and release of prisoners. Prison health must therefore be seen as a part of public health. Addressing the mental health needs of prisoners can decrease incidents of re-offending, reduce the number of people who return to prison, help divert people with mental disorders away from prison into treatment and rehabilitation and ultimately reduce the high costs of prisons.

Measures adopted to assist the ex-mental health offenders

The detection, prevention and proper treatment of mental disorders, together with the promotion of good mental health, should be both a part of the public health goals within prison, and central to good prison management. Even in countries with limited resources, steps can be taken that will improve the mental health of prisoners and prison staff, and these steps can be adapted to the cultural, social, political and economic context within that country.

Divert people with mental disorders towards the mental health system: Prisons are the wrong place for many people in need of mental health treatment, since the criminal justice system emphasizes deterrence and punishment rather than treatment and care.  Legislation can be introduced which allows for the transfer of prisoners to general hospital psychiatric facilities at all stages of the criminal proceedings (arrest, prosecution, trial, imprisonment). For people with mental disorders who have been charged with committing minor offences, the introduction of mechanisms to divert them towards mental health services before they reach prison will help to ensure that they receive the treatment they need and also contribute to reducing the prison population. The imprisonment of people with mental disorders due to lack of public mental health service alternatives should be strictly prohibited by law.

Provide prisoners with access to appropriate mental health treatment and care: Access to assessment, treatment, and (when necessary) referral of people with mental disorders, including substance abuse, should be an integral part of general health services available to all prisoners. The health services provided to prisoners should, as a minimum, be of an equivalent level to those in the community. This may be achieved by providing mental health training to prison health workers, establishing regular visits of a community mental health team to prisons, or enabling prisoners to access health services outside the prison setting.  Those requiring more specialist care for example, can be referred to specialist mental health providers where inpatient assessment and treatment can be provided. Primary health care providers in prisons should be provided with basic training in the recognition and basic management of common mental health disorders.  

Provide access to acute mental health care in psychiatric wards of general hospitals: When prisoners require acute care they should be temporarily transferred to psychiatric wards of general hospitals with appropriate security levels. In accordance with the principles of de-institutionalisation, special psychiatric prison hospitals are strongly discouraged.

Ensure the availability of psychosocial support and rationally prescribed psychotropic medication: Prisoners, through appropriately trained health care providers, should have the same access to psychotropic medication and psychosocial support for the treatment of mental disorders as people in the general community. 

Provide training to staff: Training on mental health issues should be provided to all people involved in prisons including prison administrators, prison guards and health workers. Training should enhance staff understanding of mental disorders, raise awareness on human rights, challenge stigmatizing attitudes and encourage mental health promotion for both staff and prisoners. An important element of training for all levels of prison staff should be the recognition and prevention of suicides.  In addition, prison health workers need to have more specialized skills in identifying and managing mental disorders.

Provide information/education to prisoners and their families on mental health issues: Prisoners and their families should receive information and education on the nature of mental disorders, with a view to reducing stigma and discrimination, preventing mental disorders and promoting mental health. Information can help prisoners and their families better understand their emotional responses to imprisonment and provide practical strategies on how to minimize the negative effects on their mental health and inform them as to when and how to seek help for a mental disorder.

Promote high standards in prison management: The mental health of all prisoners, including those with mental disorders, will be enhanced by appropriate prison management that promotes and protects human rights. Attention to areas such as sanitation, food, meaningful occupation, and physical activity, prevention of discrimination and violence, and promotion of social networks are essential. 

Ensure that the needs of prisoners are included in national mental health policies and plans: National mental health policies and/or plans should encompass the mental health needs of the prison population. Where policies and plans fail to do so, it may be necessary to advocate for their inclusion. Whenever a mental health policy or plan is being developed, prisons (staff and prisoners) should be included as stakeholders in the development process. 

Promote the adoption of mental health legislation that protects human rights: All prisoners, including those with mental disorders, have the right to be treated humanely and with respect for their inherent dignity as human beings.  Furthermore, conditions of confinement in prisons must conform to international human rights standards (see below). Mental health legislation can be a powerful tool to protect the rights of people with a mental disorder, including prisoners, yet in many countries mental health laws are out dated and fail to address the mental health needs of the prison population. The development of legal provisions that address these needs can help to promote the rights of prisoners, including the right to quality treatment and care, to refuse treatment, to appeal decisions of involuntary treatment, to confidentiality, to protection from discrimination and violence, and to protection from torture and other cruel, inhuman and degrading treatment (including abusive use of seclusion, restraints and medication, and non-consensual scientific or medical experimentation), among others. Legislation should provide prisoners with mental disorders with procedural protections within the criminal justice system equivalent to those granted other prisoners.  The protection, through legislation, of other basic rights of prisoners, such as acceptable living conditions, adequate food, and access to the open air, meaningful activity, and contact with the family is also important and can further contribute to the promotion of good mental health. Independent inspection mechanism such as mental health visiting boards can also be established through legislation, to inspect prisons as well as other mental health facilities in order to monitor conditions for people with mental disorders.

Encourage inter-sectorial collaboration: Many problems and issues can be solved by bringing relevant Ministries and other actors together to discuss the needs of prisoners with mental health disorders. Different stakeholders should meet to discuss mental health in prisons and to plan an inter-sectorial response. 

Programs implemented to re-socialise mental health offenders

Ex-Offender Reintegration Project

The programme seeks to reclaim and re-integrate all the ex-offenders. The need for the project emanates from the plight that the ex-offenders experience after their discharge from serving prison terms. These include joblessness, lack of employment opportunities (aggravated by their criminal record), employability, dysfunctional families, and marital disputes due lack of financial resources, and so on. The target group of this project will be mainly young people who are ex-offenders. They will be engaged in a leatherworks income generating project producing sandals and belts for sale throughout the province. Through this project the challenges facing the ex-offenders such as unemployment will be reduced whilst at the same time acquiring life time skills such and thus providing food on the table for their families.

The majority of the ex-offenders are unemployed due to lack job opportunities for them. They are stigmatized and labelled by their communities and in some instances by their family members as well. This project therefore seeks to reduce poverty and create job opportunities through income generating projects that will be provided. It will serve as a preventative measure for youth from engaging in criminal offences as they will receive empowerment on income generating programmes through this project. Further, the project will address the problem of recidivism in the area as it will provide the participants alternatives for survival than being involved in crime as a means of living.

After care programs done by National Institute of Crime and Reintegration of mental health offenders (NICRO)

National Institute of Crime and Reintegration of mental health offenders (NICRO) has reworked its mental health offender reintegration programme, the oldest part of NICRO's work (which started in 1910). The aim of starting the new project, the "Tough Enough" programme, was to ensure that the institution do indeed have impact on the crime situation in South Africa, through ensuring that ex-mental health offenders take seriously their responsibility to be community builders, not destroyers of the social order. These programs are discussed below:

Phase One: Recruitment and Assessment Prisoners select themselves into the programme and are individually assessed by the facilitator (social worker). A maximum of twenty participants is allowed in the group. The success of the programme is dependent on the commitment of the participants. It is vital that the participants want to change their circumstances, thus, the principle of self-selection into the programme. Upon successful entry into the programme, the prisoner enters into a contract with NICRO which details the service and duration. The contract also ensures commitment from both and specifies the non-negotiable. The prisoner identifies three primary areas of his/her life that he/she wants to see changed at the end of the programme. These will be the primary focus of the intervention, but other issues or concerns will also be addressed during the programme.

Phase Two: Setting the Challenge

This is a group-based five day intensive phase which challenges the individual participants to objectively look at their lives (the past and present) and draft a path that they want to follow. The emphasis is on the future and how it should be different from the past. The participants take responsibility for their actions, especially the crimes they have committed, and make plans for restoration (Du Preez, 2003). Participants discuss the issues facing them, for example, their fears, anxieties, expectations upon release and experiences with imprisonment. They identify systems within their communities which can support them and their families and also develop strategies to access those systems. They commit themselves to certain actions and decisions which will impact positively on their reintegration. 

Phase Three: Facing the Challenge

Running over eight weeks (8 sessions), this phase is the beginning of the actual implementation of the decisions made in the previous phase. Participants handle issues either, in a big group or, smaller groups (with similar issues) as well as individually. Work with families or other support structures, and victims begin at this time, through either, Family Group Conferences or, Victim Mental health offender Mediation Participants are provided with support and encouraged to tackle challenges with a positive attitude. Participants develop 'projects' - their life plans - and gets a coach to support them. Resilience and perseverance by the participants in the implementation of their plans is crucial, as new or unexpected realities will be dawning for some of them. During this time, the facilitator actively engages the community and challenges them to commit towards the reintegration of the imprisoned participant.

Phase Four: Overcoming the Challenge

This is the most crucial stage, as all the results of the work done in the previous phases become important. The ex-prisoner comes back to the family, community, friends and other support structures. A lot of uncertainties around acceptance, promises and decisions made, might be experienced by the ex-prisoner and family. The life plan becomes the actual daily life, not just a project, for the ex-prisoner and the future becomes the present. This phase runs over a 6-9 month period. During this time the ex-prisoner acquires independence and strengthened relationships with the family and other relevant people. The community becomes an important support system for the ex-prisoner and his/her family. Wherever possible, a mentor is appointed for the ex-prisoner and/or the family.

 Phase Five: Staying Out

This phase is continuous for the ex-prisoner. The whole programme is about him/her staying out of prison and not re-offending. The previous stages determine the success of this stage. The ex-prisoner should be stable and making a positive contribution towards his/her family and the community. NICRO support, through facilitator, should be minimal or not necessary. Community and family support continues to provide for the sense of belonging and accountability by the ex-prisoner. The ex-prisoner accepts full responsibility for staying out. 

Phase Six: Tracking

An important feature of the programme is the ability to track and measure the impact and success of the programme. All the programme participants will be tracked at least twelve months after completion of the programme. 

Conclusion

As a result, it is evident that, there are adverse socio-economic conditions confronting the offenders after their release from prison are the main barriers to their successful rehabilitation and reintegration into society. Offenders released into society face numerous obstacles such as the need for employment, food, shelter, and the stigma of having been imprisoned. The community is reluctant to receive perpetrators back into society after their release from prison. Consequently, ex-offenders struggle to find employment because of this stigma, which often translates into family break-ups. They are then expected to invent new ways of making a living and surviving without any help from society; in consequence, they resort to crime, which in turn results in recidivism. Nevertheless, offenders participate in various rehabilitation programmes during their incarceration. However, the challenge is to sustain these rehabilitation efforts after their discharge from prison. Although various rehabilitation programs inside prison are offered by the Department of Correctional service it has become apparent that upon release these rehabilitation programs is not sustained.

References

Gcobani., N.,2014. Reintegrate Of ex-offenders on community: A case study of Whittlesea Township in Lukhanji Municipality. South Africa: University of Fort Hare

Stevens, R. & Cloete, M. G .T, .2004. Introduction to Criminology, Cape Town: Oxford University Press, Southern Africa.

World Health Report 2001: Mental Health: New Understanding, New Hope. Geneva, World Health Organization.