Women who challenge - Nacro

Women who challenge:women offenders and mental health issuesby Sue Kesteven© Nacr o169 Clapham RoadLondon SW9 0PUTelephone 020 7582 6500Fax 020 7735 4666www.nacro.org.ukISBN 0 85069 190 7Nacro is a registered charity no. 226171The views expressed in this report may not necessarily reflect those of Nacro.April 2002Photos: front cover third from top reproduced by courtesty of The Prison Service. Photos posed by models

Executive summaryThe aim of this report is to examine theenduring concerns about women offenders inthe particular context of mental health issues.There are compelling reasons for these concernsand these include the fact that the level ofpsychiatric morbidity among women prisonersis very high. Mental health problems contributeto women’s offending and women’simprisonment can be extremely damaging bothto the women themselves and to their familiesand children.The report sets out to provide a comprehensiveoverview of the relevant issues so as to informthose who want to know more and to alertpolicy and decision-makers to what needs to bedone to tackle the challenges presented bywomen offenders with mental health problems.The report provides the background to theconcerns expressed through an examination ofthe scale and nature of the problem presentedby women offenders generally and those withmental health problems in particular.Women offenders are responsible only for asmall proportion of all crime. In 2000, theyconstituted just 19% of known offenders – thatis those who have been cautioned or foundguilty of committing an offence. Their offendingprofile is quite different to that of men. Theirpatterns of offending are different and theircriminal careers are shorter and less persistent.Only 88,900 female offenders were found guiltyor cautioned for indictable offences in 2000(considerably less than the peak of 101,100 in1992), according to statistics published by theHome Office under section 95 of the 1991Criminal Justice Act. Yet the female prisonpopulation has been growing at an alarming rateover recent years. In October 2001, it reachedan all time high of 4,040; an increase over theprevious year of a staggering 18%. The increasein the male prison population over the sameperiod was 5%.The high levels of psychiatric morbidity amongwomen prisoners found by the 1997 ONS surveyare also a major cause for concern. Fifty percent had a personality disorder, 66% had aneurotic disorder and functional psychosis wasfound in 14%. Substance misuse was also asignificant problem, with 38% reporting levels ofhazardous drinking prior to imprisonment and44% reporting some degree of drug dependence.These rates are all much higher than thosefound in the general household population andplace the concerns about women’s offending andmental health issues in context.Key themes are examined by the report. It foundthere are differences in the way that men andwomen are treated by the criminal justicesystem and that these had implications both interms of sentencing and psychiatric disposals,though the differences were by no means clearcut in terms of advantage or disadvantage toeither sex.Despite accepted policy that mentally disturbedoffenders should, wherever possible, receivecare and support from health and socialservices, not punishment through the criminaljustice system, many such offenders of bothsexes are ending up in prison. The situation isexacerbated by the fact that mental healthservices for prisoners, especially womenprisoners, are woefully inadequate. In particular,the report highlights concerns about theprescribing of psychotropic medication forwomen prisoners.The re p o rt reviews evidence showing that thee ffect of imprisonment on women is moredetrimental than it is on men and that there p e rcussions extend beyond the womenthemselves, causing long-term damage to theirc h i l d ren and families. One way in which theh a rm can be seen to manifest itself is in theway women prisoners offend against prisondiscipline at a far higher rate than maleprisoners. In 2000, the figures were 256o ffences per 100 female prisoners compared to159 offences per 100 male prisoners. Thisd i ff e rence is especially striking whenc o n s i d e red against the fact that, outside prison,women commit far fewer criminal offences thanmen.Reviewing the concerns about substance misuse,the report concludes that the prevalence of druguse within prisons and the bullying that isassociated with this cast doubt on the efficacyof the Prison Service’s strategy for tackling drugmisuse. Furthermore, lack of liaison withpage 4

Women who challenge: women offenders and mental health issuescommunity services can result in scarceresources being wasted because of a lack ofthroughcare.The position of women detained within thesecure mental health system is alsoconsidered.The report examines strategies already inplace or beginning to emerge to tackle thechallenges presented by women offenderswith mental health problems. These includethe Home Office’s strategy in relation towomen offenders, the Department ofHealth’s Mental Health National ServiceFramework in relation to the provision ofmental health services generally and itsjoint strategy with the Prison Service inrelation to mental health services forprisoners in particular. The proposalscontained in the Government’s White Paper,Reforming the Mental Health Act, are alsoconsidered.The report finds that the strategiesconstitute positive steps with the potentialto impact favourably on women offenderswith mental health problems. It argues,however, that they fall short in a number ofrespects and that much more needs to bedone in terms of co-ordinating currentactivities and policies so as to ensure thatmaximum benefit is derived from them.The re p o rt ’s main recommendation in thiscontext is that the Women and EqualityUnit should assume a more proactive ro l ein co-ordinating and pulling together thevarious strands of policy which aff e c twomen in general and women offenders inp a rt i c u l a r.In the light of its review of a number of keythemes in relation to women offenders withmental health problems, the report makesmany wide-ranging proposals andrecommendations for improvements to theway in which the challenge presented bythis complex group is tackled.From these, those which are considered tobe the report’s key recommendations areset out opposite.Key recommendations• More needs to be done to reduce the number ofwomen being sent to prison.• Community alternatives should become thesentencing norm for women in place ofcustodial sentences.• Concerted action should be taken to promotethe immediate development of supportivecommunity programmes, the benefits of whichhave already been demonstrated.• There should be a requirement to assist withresettlement, regardless of the length ofsentence, since the adverse consequences ofshort-term imprisonment can be just as seriousas those of long-term imprisonment.• The function of prison mental health care shouldbe to provide efficient and effective primary carewith proper arrangements in place for theprompt referral and transfer of prisoners tosecondary health care settings if required.• Mainstream community mental health servicesshould provide a comprehensive range oftreatments and psychotherapeutic approacheswhich are accessible to women offenders.• The secure system for women shouldincorporate:– an environment in which womenoffender/patients can feel safe– different levels of security so that patientscan be transferred to less secure provisionas their condition improves– a comprehensive range of treatments– a constructive regime of educational andother activities.• There should be a co-ordinated and strategicapproach to tackling substance misuse whichaddresses the issue both inside and outsideprison.• Initiatives within the criminal justice system andthe provision of mental health services shouldbe planned with gender sensitivity in mind.• There should be an overarching strategy aimedat co-ordinating all the work relating to womenoffenders in general and those with mentalhealth problems in particular, which isunderpinned by joined-up thinking and workingat both a national and local level.page 5

CHAPTER 2Women who challenge: women offenders and mental health issuesWho are we talking about?The scale of the problemMental health issues cannot be considered inisolation, so we begin by looking at the widerperspective of how the criminal justice systemimpacts on women and what bearing this mayhave on their mental health.Our starting point is to get a picture of the scaleand nature of the problem presented by womenoffenders. So why women offenders generally,when our primary concern is female mentallydisturbed offenders? Notwithstanding that theyare not classed as such, many women offendersshare many of the characteristics of those whoare labelled as mentally disturbed. They areaffected by many of the same factors andcircumstances or have had similar adverse lifeexperiences that have contributed to theircurrent behaviour and state of need. It is,therefore, relevant to consider the group as awhole. Despite the media hype about theincrease in girl gangs, female violence andfemale criminality, it is still the case that womendo not commit much crime. Figures included inthe Home Office publication Statistics on Womenand the Criminal Justice System 1 , which arepublished under the requirements of section 95of the Criminal Justice Act 1991, provide a clearpicture of the scale and nature of femaleoffending. The statistics contained in thischapter come from this publication, exceptwhere otherwise indicated 2 . Data in relation tomale offending are included to provide acontext without which the significance of thedata on women would be liable to be lost.The role of women in criminal activity is still farexceeded by that of men; only 19% of knownoffenders (that is those who have beencautioned for, or found guilty of, committing anoffence) in 2000 were female. Of the totalnumber of offenders found guilty or cautionedin 2000, only 315,700 were women comparedwith 1,336,800 men. The majority of youngoffenders simply grow out of crime but girlsgrow out of crime more quickly than boys. Thepeak age of self-reported offending for girls is14, compared with 18 for boys, so that, once1 Home Office (2001d) Statistics on Women and the Criminal JusticeSystem London: Home Office2 Other statistics, such as those from the British Crime Survey, whichmight otherwise be preferable in providing an overall picture ofoffending, do not contain any gender breakdownover the age of 17, the number of maleoffenders exceeds the number of femaleoffenders by a rate of about three to one.This difference between men and women interms of the scale of the problem is clearlydemonstrated by a comparison of the figures forlifetime prevalence of offending. Figuresillustrating the criminal careers of those born in1953 show that only 8% of women had beenconvicted of an offence by age 40, comparedwith 34% of men, and only 1% of women hadreceived a custodial sentence by that age,compared with 7% of men. Likewise, a closerexamination of convicted offenders born in1953 shows that, in the case of women, 78% hadbeen convicted only once by the age of 40whereas, in the case of men, the proportionconvicted only once is much smaller at 55%.Women are also shown to be less persistentoffenders: 83% of female offenders have acriminal career lasting less than one yearcompared with 60% of male offenders.Pattern of offendingIt is not only in terms of the volume of crimecommitted that men and women differ but alsoin terms of the nature of the crimes committed.In 2000, 88,900 female offenders were foundguilty or cautioned for indictable offences,compared with 386,200 male offenders. The topthree categories of indictable offence were thesame for both male and female offenders but anexamination of the figures makes it clear thatthis should not be taken to be indicative of adegree of parity between male and femaleoffending – see table overleaf.The crimes most likely to be committed by girlsunder 16 include criminal damage, shoplifting,buying stolen goods and offences of minorviolence. With increasing age, the proportionsinvolved in theft and handling and fraud andforgery increase so that women form a largerproportion of those arrested for these offences(21% and 27% respectively) than for any otheroffence.It has been argued that criminal behaviour bywomen, and especially the predominance ofproperty crime, can be explained by economicfactors – women are generally poorer than menin capitalist societies and, particularly as singlepage 7

CHAPTER 2Table 1 Offenders found guilty or cautioned for indictable offences in 2000Offence Female offenders Male offendersNos. in 1000s % Nos. in 1000s %Theft and handling 53.5 60 142.1 37Drugs offences 9.3 10 76.5 20Violence against the person 8.2 9 47.1 12mothers, more likely to have to provide for theirchildren (see Heidensohn [1994] 3 for a review).This may indeed be a motivating factor whichmay be relevant in some cases but it cannot betaken to explain the motivation for female crimegenerally. It does not, for example, explain whythe peak age of female offending is 14 and mostfemale offenders have grown out of crime bythe time of their late teens.Findings from the 1998/99 Youth LifestylesSurvey 4 , in relation to self-reported offending bymale and female 12-30 year olds, identified druguse and frequent drinking as importantpredictors of offending and also illustrated thatfamilies, school and peer groups were keyinfluences on a young person’s likelihood ofoffending. One of the difficulties about makingjudgments, however, is that the data on crimedo not give the background circumstances tothe offence or the characteristics of the offender– which may sometimes go some way towardsexplaining why the crime occurred – so it isimportant to be cautious about makingassumptions that particular circumstancespredispose individuals to commit offences.Women in prisonThe most alarming issue in relation to femaleo ffending is the explosion in the female prisonpopulation. Between 1993 and 2000, the femaleprison population rose by over 115%, compare dwith a rise of 43% for men. By Febru a ry 2001, theoverall increase had reached 145%, compared to47% for men 5 . In October 2001, the female prisonpopulation was 4,040, a staggering increase of18% over the previous year, compared with ani n c rease in the male population of 5% 6 . Thedramatic increase led the Director General of thePrison Service to urge sentencers to think againabout community alternatives before sentencingwomen to custody 7 .The increase is not accounted for by acorresponding increase in serious offending, asfigures showing the number of female offendersfound guilty or cautioned for indictable offencessince 1990 do not indicate an inexorable rise inserious female crime. Instead they fluctuate,showing a peak in 1992 followed by a fall in1996 back down to 1990 levels. The increaseappears to be due primarily to changes insentencing by the courts as a result of toughersentencing guidelines and legislative changeswhich have led, for example, to harsherpenalties and thus longer custodial sentencesfor drugs offences. This appears to have had asignificant effect on the overall size of thefemale prison population, as we shall see next,though other factors may also have had a part toplay, such as the championing by recent HomeSecretaries of the argument that ‘prison works’.Chart 1 Female offenders found guilty orcautioned for indictable offences1051009590858075ssSource: Home Office (2001) Statistics on Women and the CriminalJustice System London: Home Office3 Heidensohn F (1994) ‘Gender and crime’ in Maguire M, Morgan R andReiner R (eds) The Oxford Handbook of Criminology Oxford:Clarendon Press4 Campbell S and Harrington V (2000) Youth Crime: Findings from the1998/99 Youth Lifestyles Survey Research Findings No.126 London:Home Office5 Nacro (2001) Women Beyond Bars London: Nacro6 Home Office (2001b) Prison Population Brief, England and Wales:October 2001 London: Home Office7 Reported in the media on 26 November 2001sssspage 8

Women who challenge: women offenders and mental health issuesWomen remain a tiny proportion of the totalprison population even though that proportionhas increased from 3.5% in 1993 to 5.2% in2000. In June 2000, 20% of the female prisonpopulation were on remand. The most commonoffence for which women are received intocustody is theft and handling at 42% in 2000, inkeeping with the fact that this offence accounts,as shown above, for the larger part of femaleoffending. The figure compares with 23% ofmale receptions for the same offence. However,because sentences for such offences are usuallyshort, the proportion of the female sentencedpopulation held for them drops to 20%. Incontrast, as a result of longer sentence lengths,37% of the female sentenced population arebeing held for drugs offences even though suchoffences account for only 20% of receptions intocustody. There is also a difference, though notas large, between the proportion of receptionsfor violent offences – which also carry longsentences – at 13%, and the overall percentageof the female sentenced population held forsuch offences (16%). By far the majority ofwomen prisoners have not committed a violentoffence and do not pose a danger to the publicin this regard.There is also a difference between male andfemale prison populations in terms of theirethnic composition, which demonstrates thatminority ethnic women are represented inprison at an even more disproportionate levelthan minority ethnic men in the male prisonpopulation. Minority ethnic groups made up 25%of the female prison population, 19% beingblack. In the case of male prisoners, 19% werefrom minority ethnic groups and 12% wereblack. The difference in the proportion ofminority ethnic prisoners in the male andfemale populations is to a large extentaccounted for by the larger percentage offoreign nationals in the female prisonpopulation (15% of foreign national femalesagainst 8% of foreign national males), most ofwhom are held for drugs offences (usuallyacting as drug couriers). The overwhelmingproportion of black sentenced women (68% in2000) are held for drugs offences and, evenwhen foreign nationals are excluded from thisfigure, the remaining proportion servingsentences for drugs offences is still very muchhigher (50%) than that for white women (25%) oreven for black men (19%). Unfortunately, thereare no data to explain the context in which theseoffences were committed, so it is not possible todraw any significant conclusions from thesefigures.If we look at the socio-demographiccharacteristics of women prisoners 8 , we findthat, before being imprisoned, 40% of womenprisoners were cohabiting and 33% were single.The level of educational attainment was lowerthan that of the general population, with 47%having no educational qualifications and GCSEbeing the highest level of qualification obtainedfor 37%. The profile of women prisoners andtheir family responsibilities are examined inmore detail in Chapter 3 when the impact ofimprisonment on women and the evidencerelating to their mental health is considered.Psychiatric morbidity amongwomen prisonersClearly there is a link between mental disorderand offending. This is self evident from dataabout the number of people with mental healthproblems identified at all key stages of thecriminal justice system. Care needs to be takento avoid assuming a causal relationship wherethe link may be no more than a simpleassociation between the two. Nevertheless, thehard truth is that prisons house significantnumbers of people with mental health problems.There have been relatively few surveys ofpsychiatric morbidity in prison populations andsome are now quite dated. Equally, methodologyused in different surveys varies so care must betaken when comparing the findings. Forexample, in a survey of 334 mentally disturbedmen remanded at Winchester Prison, Coid(1988) 9 found that the offences they hadcommitted were frequently minor in nature,such as shoplifting for food or stealing milkfrom doorsteps, and stemmed from their needfor food or shelter due to a lack of necessarycare and support. In 136 of these cases, prisondoctors concluded that, at the time of theirarrest, the offenders were incapable of caringadequately for themselves in the community. A8 O’Brien M, Mortimer L, Singleton N & Meltzer H (2001) Psychiatricmorbidity among women prisoners in England and Wales London:Office for National Statistics9 Coid J (1988) ‘Mentally abnormal prisoners on remand: rejected oraccepted by the NHS’ British Medical Journal 296: 1779-82page 9

CHAPTER 2study by Dell et al (1993) 10 of female remandprisoners at Holloway prison looked at 196cases of mentally disturbed prisoners, identifiedby prison psychiatrists at reception and dividedinto two groups: psychotic and non-psychotic.Again the majority had been remanded forminor offences, such as theft or criminaldamage, with the offences of the psychoticgroup tending to be less serious than those ofthe non-psychotic group.Some studies and surveys, which have looked atthe prevalence of psychiatric morbidity in theprison population, have found high levels inboth male and female populations. A survey of across-sectional sample of the female prisonpopulation, reported in 1994 11 , found that theprevalence of psychosis in male and femaleprisoners was similar at around 2%. In othercategories of mental disorder, the level ofprevalence was higher in women than men, withboth personality disorder and neurotic disorderat 18% and 10% respectively, and substanceabuse at 26% and 12% respectively.In 1997, a very comprehensive survey ofpsychiatric morbidity among prisoners inEngland and Wales 12 was carried out by theOffice for National Statistics on behalf of theDepartment of Health. One of the most strikingfindings of the survey was the contrast betweenmale and female prisoners in relation to theirreceipt of treatment for mental health problems.As the following chart shows, the findingssuggest that the level of psychiatric morbidityin the women was already significantly higherthan that in the men before entering prison,with the proportion of female prisoners whohad been receiving help (40%), double that ofthe male prisoners (20%). The differences inadmission to mental hospital were alsoparticularly striking, ranging from 22% of femaleremand to 8% of male sentenced prisoners, whohad ever previously been admitted to a mentalhospital or ward.Substance misuseThe high prevalence of substance misuse amongwomen prisoners is illustrated by a surveyconducted in 1996 for the Chief Inspector ofPrisons 13 . This found that 40% reported heavydrug use or addiction, of which over half usedheroin. A quarter of the women who reported%Chart 2 Receipt of help or treatment formental or emotional problemsby prisoner type and sex454035302520151050MaleremandMalesentencedIn year before entering prisonEver admitted to mental hospital or wardFemaleremandFemalesentencedIn the past year/since entering prisonSource: Office for National Statistics (1998) Psychiatric MorbidityAmong Women Prisoners in England and Wales London: Office forNational Statisticsaddiction were continuing to take drugs while inprison and intended to continue on release.The ONS surv e y 1 4 also found high levels of dru gdependence in prisoners, especially femaleremand prisoners, based on their re p o rts ofdependence prior to imprisonment, whichranged from 41% of female sentenced and 43% ofmale sentenced prisoners to 54% of femaleremand and 51% of male remand prisoners.Women prisoners were considerably more likelythan men to have been dependent on opiates,either alone or with other drugs, the rates being41% of female remand and 23% of femalesentenced prisoners, compared with 26% of maleremand and 18% of male sentenced prisoners.An issue to consider in this context is thefinding by the Home Office Policing andReducing Crime Unit 15 that sex markets can play10 Dell S, Robertson G, James K and Grounds A (1993) ‘Remands andpsychiatric assessments in Holloway Prison I: the psychotic population;II: the non-psychotic population’ British Journal of Psychiatry 163: 634-4411 Maden A, Swinton M and Gunn J (1994) ‘A criminological andpsychiatric survey of women serving a prison sentence’ British Journalof Criminology 34 (2): 172-9112 Singleton N, Meltzer H, Gatward R, Coid J and Deasy D (1998)Psychiatric Morbidity Among Prisoners in England and Wales London:The Stationery Office13 HM Chief Inspector of Prisons (1997) Women in Prison: A ThematicReview London: Home Office14 Singleton N et al (1998) op cit15 May T, Edmunds M and Hough M (1999) Street business: the linksbetween sex and drugs markets. Police Research Series Paper 118London: Home Officepage 10

Women who challenge: women offenders and mental health issues%Chart 3 Substance misuse by prisoner typeand sex70605040302010Table 2Prevalence of personality disorder inthe prison populationType of Male Male Female 16personality remand sentenceddisorder % % %Any personality disorder 78 64 50Anti-social 63 49 31Paranoid 29 20 16Borderline 23 14 200FemaleremandDrug dependencyFemalesentencedOpiate dependencyMaleremandMalesentencedHazardous drinkingSource: Office for National Statistics (1998) Psychiatric MorbidityAmong Women Prisoners in England and Wales London: Office forNational StatisticsSource: Office for National Statistics (2001) Psychiatric MorbidityAmong Women Prisoners in England and Wales London: Office forNational Statisticsa significant role in the development of drugsmarkets and vice versa, one of the results beingan intensification of the threats posed tovulnerable individuals by drug markets. Thismay be a relevant factor in relation to drugdependency in some women offenders.In addition to high levels of drug misuse, theONS survey also found evidence of a significantp roblem with alcohol misuse, with 38% ofwomen prisoners re p o rting patterns of alcoholconsumption at hazardous levels prior toimprisonment. This is, nevertheless, significantlylower than the levels in the male prisonerpopulation which are 58% for male remand and63% for male sentenced prisoners. The levels ofsubstance misuse are illustrated in Chart 3 andthe issue is considered further in Chapter 3.Personality disorderPart of the diagnostic criteria for anti-socialpersonality disorder is that the individualshould have exhibited anti-social behaviourbefore the age of 15 years, which persists intoadulthood. It is, therefore, unsurprising thathigh prevalence rates for this disorder shouldbe found in offender populations. What is lessobvious is that other types of personalitydisorder should also have high prevalence rates,as shown by the following figures for the mostcommon types:Some features, such as disregard for the safetyand well-being of other people, or their feelingsor property, are common to a number ofcategories of personality disorder and do makeoffending behaviour more likely. Closerexamination of the characteristics of those withpersonality disorder 17 reveals that prevalencerates decrease with age so that, whereas only14% of 16 to 20 year olds (when offending ismore common) show no signs of personalitydisorder, that proportion increases to 50%among those aged 45 and over. Marital statusalso appears to be significant with 45% ofmarried women prisoners showing no evidenceof personality disorder compared to 24% of thegroup as a whole. This difference was alsoreflected among male prisoners with 32% ofmarried male remand prisoners showing noevidence of personality disorder compared to20% overall, and 43% of married male sentencedprisoners revealing no evidence compared to27% overall.PsychosisWhile the prevalence of personality disorder infemale prisoners is lower than that in their malecounterparts, the same does not apply when itcomes to functional psychosis. The prevalenceof functional psychosis found in womenprisoners was 14%, considerably higher than thelevel in the general population, which is around1%, and also considerably higher than thatfound in earlier surveys, such as that referredto above which found a level of 2% 18 . As16 Prevalence of personality disorder was measured using structuredclinical interview and the female sample is not broken down intoremand and sentenced prisoners.17 O’Brien M et al (2001) op cit18 Maden A et al (1994) op citpage 11

CHAPTER 2indicated above, it is difficult to draw inferencesfrom differences in the survey findings becauseof differences in methodology. For example, thesurvey by Maden et al was of sentencedprisoners, whereas the ONS survey includedboth sentenced and remand prisoners. However,it is important to note that the level is alsosignificantly higher than that found in maleprisoners, which was 7% for male sentenced and10% for male remand prisoners.C e rtain features of illnesses such ass c h i z o p h renia-like delusions or hallucinations,which may take the form of hearing voices, cana ffect an individual’s judgment and lead tobehaviour which results in criminal damage orpublic order offences. Dell et al 1 9 note criminaldamage as the most common offence among thepsychotic group. The ONS survey found that thel a rgest pro p o rtions of women assessed as havingfunctional psychosis were among those held forcrimes of violence (20%), ro b b e ry (19%) and‘ o t h e r’ offences (18%), while among those heldfor burg l a ry and drug offences, the pro p o rt i o n sw e re much smaller at 4% in each case.Neurotic disordersNeurotic symptoms are the symptoms of mentaldisorder most likely to be found in the generalpopulation, so it is instructive to see how theprevalence rates for women prisoners comparewith those for women in the householdpopulation. In overall terms, the difference isstartling, with 66% of women prisoners assessedas suffering from a neurotic disorder, such asdepression, anxiety or phobia, compared to 16%of women in the household population 20 .Looking at individual symptoms, such as sleepproblems where the rates vary from 28% ofwomen in the general population to 62% ofsentenced women and 81% of women remandprisoners, some difference may beunderstandable in terms of the relativediscomfort of prison living conditions withshared cells or dormitory accommodation,higher levels of noise and so on. The prevalenceof other symptoms such as worry anddepression may also be relevant factors whichcontribute to difficulties in sleeping, especiallyconsidering that symptoms of depression werefound in 54% of the female prisoners, comparedto 11% of women in the household population.The rates of neurotic disorder generally aresubstantially higher for female prisoners than formale prisoners, as the following figures show:Chart 4 Prevalence of neurotic disorder byprisoner type and sex% 80604020059%Maleremand40%MalesentencedNo clear association was shown between neuro t i cd i s o rders and particular types of off e n c e .Other mental disordersO’Brien et al (2001) 21 also found that about 6% ofwomen prisoners were suffering from posttraumaticstress and that they were about twiceas likely to be suffering from this as maleprisoners. The same proportion of womenprisoners was found to suffer from anorexia,while the proportion with bulimia was 14%.As the above examination of prevalence ratesshows, the levels of psychiatric morbidity inboth male and female prisoners are worryinglyhigh. Nevertheless, certain key differencesbetween them can be identified. Womenprisoners are more likely than men:• to have received help or treatment for amental health problem• to have been admitted to a mental hospital orward• to be suffering from functional psychosis• to be suffering from a neurotic disorder• to be dependent on opiates.76%FemaleremandWomen prisoners are less likely than men:• to be suffering from personality disorder• to report drinking at hazardous levels.FemalesentencedSource: Office for National Statistics (1998) Psychiatric MorbidityAmong Women Prisoners in England and Wales London: Office forNational Statistics63%19 Dell S et al (1993) op cit20 Meltzer H, Gill B, Petticrew M and Hinds K (1995) OPCS Surveys ofPsychiatric Morbidity in Great Britain Report 1: The Prevalence ofPsychiatric Morbidity Among Adults Living in Private HouseholdsLondon: HMSO21 O’Brien et al (2001) op citpage 12

Women who challenge: women offenders and mental health issuesFemale mentally disturbed offendersThe primary focus of this report is mentalhealth issues in relation to female offenders. Asmall but significant part of the femaleoffending population comprises thoseoffender/patients detained in the high securityand other psychiatric hospitals under theMental Health Act 1983 (MHA) 22 . In order to bedetained under the MHA, the offender/patientmust be diagnosed as suffering from one of thecategories of mental disorder specified in theAct. These are:• mental illness• arrested or incomplete development of mind(mental impairment or severe mentalimpairment)• psychopathic disorder• any other disorder or disability of mind.Home Office statistics relating to those subjectto a restriction order under Part III of the MHA 23indicate that the total population of restrictedpatients 24 detained at the end of 2000 was2,937, an increase of 3% on the previous year,slightly less than the average annual increase inrecent years. This is a very small populationcompared with the prison population(approximately 68,000 by the end of October2001) and, given the high levels of psychiatricmorbidity we have already seen amongprisoners, perhaps surprisingly so. We shalllook at some of the reasons for this in Chapter3. The female element of this population (330)has remained at between 11% and 12% of thetotal since 1989. Of the 330 female restrictedpatients, 140 were detained in high securityhospitals and 190 in other psychiatric hospitals.The figures in Table 3 show the categories ofmental disorder under which those patients aredetained.Offender/patients can be admitted directly tohospital as a result of a court order or they canbe transferred from prison while on remand orunder sentence. The Home Office figuresshowing admission and detention according tolegal category and offence are not broken downby sex.Department of Health figures 25 do provide abreakdown of formal admissions by legal statusand sex, and also give information aboutTable 3 Restricted patients detained inhospital by type of mental disorderand sex (31 December 2000)Type of mental disorder Female MaleMental illness 185 1,803Mental illness with other disorders 38 117Psychopathic disorder 73 320Mental impairment 16 185Mental impairment withpsychopathic disorder 3 28Severe mental impairment — 13Not known 15 139Total 330 2,607Source: Home Office (2000) Statistics of mentally disorderedoffenders’ Home Office Statistical Bulletin 22/01unrestricted patients and civil admissions.These are set out in Table 4 on page 14. Theyshow that the overall numbers of patientsadmitted under Part III of the Act have beenfalling while, at the same time, the proportionsof those offender/patients of both sexes whoare subject to restriction orders have beenrising. These figures cannot be used for directcomparisons with Home Office figures due todifferences in data collection and accountingprocedures. They serve, nevertheless, toillustrate that the numbers of offender/patients,even including those who are not subject torestriction orders, are still very small comparedboth to the prison population and to thepopulation of patients detained under civilsections of the MHA. A factor which may have abearing on this is the limited resources withinthe secure system which restrict the number ofbeds available and we look further at this inChapter 3.A more detailed profile of the female patientsheld in high security hospital can be obtainedf rom re s e a rch commissioned by Women in22 They may also be placed there under other relevant legislation such asthe Criminal Procedure (Insanity and Unfitness to Plead) Act 199123 Home Office (2001c) ‘Statistics of mentally disordered offenders 2000’Home Office Statistical Bulletin 22/01, London: Home Office24 Restricted patients are those whose detention is subject to arestriction order which means that they can only be discharged fromhospital with the consent of the Secretary of State or a Mental HealthReview Tribunal25 Department of Health (2001b) ‘In-patients formally detained inhospitals under the Mental Health Act 1983 and other legislation,England: 1990-1991 to 2000-01’. Statistical Bulletin 2001/28 London:Department of Healthpage 13

CHAPTER 2Table 4 Patients admitted to NHS facilities (including high security hospitals) under MHA 1983 bylegal category and sex (1990/91 to 2000/01)Legal categor y 1990/91 1995/96 1996/97 1997/98 1998/99 1999/00 2000/01Part II (civil) patients 15,678 22,570 21,045 22,659 23,980 23,807 23,951Male 7,072 11,482 10,842 11,577 12,226 12,245 12,482Female 8,606 11,088 10,203 11,082 11,754 11,562 11,469Part III court and prison disposals 1,791 1,836 1,751 1,762 1,655 1,468 1,306Male 1,526 1,617 1,516 1,519 1,453 1,291 1,092Female 265 219 235 243 202 177 214Restricted patients 522 839 791 853 846 753 656Male* 457 761 711 755 758 673 57729.9% 47.1% 46.9% 49.7% 52.2% 52.1% 52.8%Female* 65 78 80 98 88 80 7924.5% 35.6% 34% 40.3% 43.6% 45.2% 37%Source: Department of Health (2001) In-patients formally detained in hospitals under the MHA 1983 and other legislation, England: 1990–91 to 2000–01Department of Health Statistical Bulletin 2001/28*percentages are of Part III male and female patientsS e c u re Hospitals (WISH) 2 6 . This includes detailsof those detained in high security hospitalswithout restriction orders or, under Part II of theM H A as civil patients, in addition to therestricted patients re f e rred to above. Even so,the population is still small. The re s e a rch wasbased on the data re c o rded in the SpecialHospitals Case Register for 1996 and shows atotal population at that time of 1,407 men and263 women. This compares with the 1996population of 1,077 male and 144 femalerestricted patients held in high securityh o s p i t a l s 2 7 , less than half of the total populationof 2,549 restricted patients detained in that year.The WISH research 28 provides detailed profiles ofhigh security patients in terms of their lifeexperiences, offending behaviour and mentalhealth needs, and identifies a number of keydifferences between male and female patients.R e s e a rch in relation to female patients detainedin Broadmoor in 1994 by Bland et al 2 9 a l s oreveals key diff e rences between male and femalepatients. The following diff e rences wereidentified in both studies. Women patients inhigh security hospitals are more likely than men:• to be admitted at a younger age• to be detained under a civil section of the MHA• to have a history of previous psychiatrictreatment• to be detained in high security for a longerperiod.Although women are more likely than men to bedetained under a civil section of the MHA anddespite the findings of Bland et al (1999) that23% of the female patients at Broadmoor hadnot been convicted of any offence, the authorsalso found that almost all of those who had notbeen convicted had been alleged to beunmanageable in their previous environmentbecause of assaultive, threatening or disturbedbehaviour. In other words, in almost all cases,they were accused of behaviour which couldhave been framed as criminal and could haveled to criminal proceedings. This raisesquestions of due process which are consideredin Chapter 3 when looking at women in thesecure system.At the beginning of this report, we pointed outthat female offenders generally share a numberof characteristics with female mentallydisturbed offenders. This view is supported bythe findings of Bland et al (1999) that women inspecial hospitals have similar backgrounds towomen in prison, especially in terms of socialdeprivation, childhood adversity, histories ofphysical and/or sexual abuse, and high levels ofself-harm and disturbed behaviour. These issuesare explored further in Chapter 3.26 Stafford P (1999) Defining Gender Issues … Redefining Women’sServices WISH27 Home Office (2001c) op cit28 Stafford P (1999) op cit29 Bland J, Mezey G and Dolan B (1999) ‘Special women, special needs: adescriptive study of female Special Hospital patients’ Journal ofForensic Psychiatry 10 (1): 34-45page 14

CHAPTER 3Women who challenge: women offenders and mental health issuesWhat are the mental health issues?Why should we be concerned about mentalhealth issues in the context of womenoffenders? As indicated above, there is ampleevidence which clearly establishes thatpsychiatric morbidity is a significant featurewithin the prison population. This raisesimportant questions about how offenders areresponded to once they come into contact withthe criminal justice system – from arrestthrough to conviction. It also raises a number ofquestions about the treatment of offenders withmental health problems, the availability ofservices for them, and how their mental healthproblems can be addressed with a view toreducing offending. As previously stated, it isour view – and not just our view but alsoexplicit Government policy – that mentallydisturbed offenders should be receiving careand treatment, not punishment. If thisfundamental principle is not observed, there arelikely to be adverse consequences, not just forthe individuals themselves but also for theirfamilies and wider society.We believe that there are a number of key issuesin the context of women offenders and mentalhealth. Failure to address them impacts not onlyon the women offenders themselves but also –because of the knock-on effects – on theirchildren and families, and society as a whole.These key issues are:• the difference in the way men and women aretreated by the criminal justice system• why mentally disturbed offenders end up inprison• mental health care for women prisoners• the impact of imprisonment on women andtheir families• the pattern of prescribing in women’s prisons• substance misuse• suicide and self-harm• women in the secure system.We explore these issues below.Are men and women treateddifferently by the criminal justicesystem?We have already seen in Chapter 2 that womencommit far fewer offences than men and thattheir patterns of offending are different, withwomen by and large committing less serious,non-violent offences. So one of the issues weneed to consider is whether men and women aretreated differently by the criminal justicesystem, both as offenders and in terms of theapproach to their mental disorder.If we look first at sentencing 1 , we see that, oncecaught up in the criminal justice system, thereare a number of variations in the likelyoutcomes for men and women. There are manyarguments about whether women are treatedmore harshly or more leniently than men butthere is no simple explanation to account forthe differences in treatment they experience.First, women are more likely than men to becautioned for an indictable offence. In 2000, therates were 47% for women and 29% for men.When it comes to summary non-motoringoffences, however, the rate of difference waspreviously inverted, with males more likely thanfemales to be cautioned. This gap diminished soas to become negligible in 1999 at 17% forwomen and 18% for men. In 2000, the rate forwomen fell significantly to 12%, as a result of arise in the number of convictions for TV licenceevasion, with a smaller decrease for men to 16%.A superficial glance at the sentencing outcomesfor indictable offences shows that women aremore likely than men to receive an absolute orconditional discharge or to be given acommunity sentence and less likely to be finedor sentenced to custody. On average, womenalso receive shorter custodial sentences thanmen for offences in the same category. However,it is unwise to jump to conclusions from whatstatistics show at face value. For example, therecan be considerable disparity in the seriousnessof offences within the same offence categoryand this can often account for differences insentencing.A study of sentencing in 1991 2 , which tookaccount of factors such as the seriousness ofthe offence, as well as any history of previousoffending, previous convictions and so on,looked at three particular categories of offence.These were chosen specifically to representcrimes seen as ‘typically female’ (shoplifting),1 Home Office (2001d) op cit2 Home Office (1997) Understanding the sentencing of women HomeOffice Research Study 170, London: Home Officepage 15

CHAPTER 3‘typically male’ (violence) and ‘gender-neutral’(drug offences). The main findings were asfollows:• female shoplifters were less likely thancomparable male counterparts to be sentencedto custody• there was a reluctance to fine femaleshoplifters, which meant that they might endup with either a more lenient sentence – anabsolute or conditional discharge – or atougher community penalty• men and women convicted of a first violentoffence were equally likely to be sentenced tocustody. In the case of repeat offenders,women were less likely than men to receive acustodial sentence• women convicted of a first drug offence wereless likely than their male counterparts to besentenced to custody, but repeat offenderswere equally likely to receive a custodialsentence• in the case of both violent and drug offences,women were more likely than men to bedischarged and men were more likely thanwomen to be fined.Although the sample was taken from 1991, theauthors undertook a comparison withsentencing in subsequent years, prior topublication of the study in 1997, which showeda degree of consistency in sentencing patternswhich made it unlikely that different resultswould have emerged from the analysis of amore recent sample.The reluctance to fine women can be a doubleedgedsword in that, though it can lead to amore lenient outcome in the form of adischarge, it can also result in the imposition ofa more severe community penalty. This is borneout by the data on community penalties 3 , whichshow that 35% of women who were commencinga community rehabilitation order (formerly aprobation order) had no previous convictions,compared to 23% of men. It was also less likelythat these women had previously beensentenced to custody, only 18% of the casescompared to 40% of the men. Of those womenstarting a community service order, 60% had noprevious conviction, whereas the comparablefigure for men was 45%, and only 7% hadpreviously been sentenced to custody comparedto 21% of the men. As the 1991 study pointsout 4 , the risk for those who embark prematurelyon the ladder of community penalties, in placeof being fined, is that they move up thesentencing tariff more swiftly and are liable toincur a more severe penalty at an earlier stagethan they otherwise would, if convicted of afurther offence.When analysing arguments about the disparitiesin the sentencing of men and women forcomparable offences, Lloyd (1995) 5 endorses theconclusions of a number of earliercommentators, notably Carlen (1983) 6 and Allen(1987), 7 that the sentencing of women isinfluenced by the extent to which they conformto the traditional stereotype of ‘good wife andmother’. Those who are judged not to have livedup to this stereotype run the risk of beingtreated more harshly than similar maleoffenders. They are considered to be doublydeviant because, in addition to having brokenthe criminal law, they are also deemed to haveoffended against the conventional view ofwomanhood. Those women who appear to fitthe ‘good wife and mother’ stereotype may wellreceive a more lenient penalty. This appears tobe borne out by the findings in the aboveresearch study, which show that, although thereare differences in the way women and men aretreated, there is no consistency in whetherwomen are sentenced either more harshly ormore leniently than men.We are especially interested in offenders withmental health problems and whether there isany difference of treatment in this context. Ithas long been government policy that prison isnot the place for mentally disturbed offendersand that, wherever possible, they should receivecare and support from the health and socialservices rather than being dealt with by thecriminal justice system. This policy wasreflected in Home Office Circular 66/90Provision for Mentally Disordered Offenders 8 at atime when there were few initiatives in place to3 Home Office (2001d) op cit4 Home Office (1997) op cit5 Lloyd A (1995) Doubly Deviant, Doubly Damned London: Penguin6 Carlen P (1983) Women’s Imprisonment London: Routledge & KeganPaul7 Allen H (1987) Justice Unbalanced: Gender Psychiatry and JudicialDecisions Open University Press8 Home Office (1990) Provision for Mentally Disordered Offenders.Circular 66/90 London: Home Officepage 16

Women who challenge: women offenders and mental health issueseffect diversion of mentally disturbed offendersfrom the criminal justice system.Since that time the situation has changedradically and there are now some 200 or socourt diversion schemes aimed at doing justthat. These are schemes in which mental healthassessments of defendants are undertaken inorder to provide the court with informationabout the defendants’ mental condition and anytreatment that may be appropriate. The purposeof this is to enable the courts to referdefendants to mental health services, wheretheir mental condition warrants this, rather thanto proceed automatically with a prosecution.The courts also have a number of psychiatricdisposals available to them, ranging from thehospital order, requiring detention in apsychiatric hospital, to the probation order witha condition requiring the offender to undergopsychiatric treatment. While these measuresmay be effective in many cases, the evidence ofpsychiatric morbidity in the prison population,referred to in Chapter 2, suggests that they arefar from providing a complete answer. In thissection, we also look at why, despitearrangements to prevent it, so many mentallydisturbed offenders – both male and female –seem to fall through the net and end up inprison.Maden (1996) 9 provides an analysis of how andwhy mentally disturbed men and women findthemselves behind bars. He examined evidenceof gender differences in the way men andwomen are treated by the courts and found thatthere did appear to be gender bias which madeit more likely that women would receive apsychiatric disposal than men. This appeared tobe not so much due to a tendency topsychiatrize women unnecessarily as due to afailure to respond appropriately to mentaldisorder in male offenders. Certainly the highlevels of psychiatric morbidity within both themale and female prison populations wouldappear to bear out this conclusion.Allen (1987) 1 0 e x p l o red sentencing decisions bythe courts in cases of male and femaleo ffenders where psychiatric evidence waslikely to be relevant. She found that womenw e re more likely than men to receive apsychiatric disposal. The reasons for thisseemed to be more to do with factors such asthe availability of appropriate tre a t m e n ts e rvices and questions of retribution than withthe level of psychiatric disorder manifested, sothat it was actually the less seriously disturbedwho were more likely to get a psychiatricdisposal. This was partly because they did notneed a hospital bed and could more easily beaccommodated within the community basedt reatment system. Conversely, the mostseriously disturbed were more likely to end upin prison because of a lack of available beds.Thus a psychiatric disposal could notnecessarily be taken to be indicative of a moreserious degree of disord e r.Evidence on the provision of mental healthservices given to the Select Committee onHealth 11 made it clear that problems arose inareas where there were no court diversionschemes. Furthermore, in his evidence to theCommittee, Dr Peter Snowden referred toresearch suggesting that such schemes onlyidentify one in five individuals with seriousmental illness. In a review of the work of courtdiversion schemes over a 10-year period,James 12 concluded that there was evidence thatcourt diversion schemes could be extremelyeffective at identifying mental disorder andachieving admission to appropriate psychiatricfacilities. However, he found that in the majorityof cases they were ineffective because ofinadequate planning, organisation andresources. The majority of research andevaluation into court diversion to date has beenconcerned with how the courts pick upindividuals with quite serious levels of disorder.It is quite likely that many such individualswould probably have been identified anyway,whether there was a diversion scheme in placeor not, either because of the seriousness of theirdisorder or because they are already known topsychiatric services. Much less certain iswhether people with less serious mental healthproblems are being identified and responded toadequately through these kinds ofarrangements.So we have cases where offenders with mental9 Maden A (1996) Women, Prisons and Psychiatry: Mental DisorderBehind Bars Oxford: Butterworth Heinemann10 Allen H (1987) op cit11 Health Committee (2000) Fourth Report (Provision of NHS MentalHealth Services)12 James D (1999) ‘Court diversion at 10 years: can it work, does it workand has it a future?’ Journal of Forensic Psychiatry 10: 507-524page 17

CHAPTER 3health problems have been identified during thecourse of criminal proceedings but are,nevertheless, sentenced to custody and othercases where an individual’s mental disturbancehas not become apparent prior to sentence andwill not have been taken into account indecisions about a custodial sentence. Thus, inaddition to any issues of gender bias, we havetwo major factors: the first, a major mismatchbetween the need for mental health services atvarying levels of security and the availability ofresources; and the second, a lack of informationabout individuals’ mental health problems;these obviously have repercussions in terms ofthe number of offenders with mental healthproblems who find their way into prison.Mental health care for womenprisonersAs we have seen, all the sources indicate thatthe prevalence of mental disturbance within theprison population is high, especially within thefemale prison population. So a particular issuefor women prisoners is what kind of care theyreceive in prison in terms of mental healthservices. We examine separately below the usein women’s prisons of prescribed medicationacting on the central nervous system. Here welook at the care available in more general terms.We consider the proposals for the futureprovision of health care for prisoners in Chapter4. At present, the bulk of prison health carecontinues to be provided by the Prison Servicewith some services contracted from NHS andindependent providers. Theoretically, healthcare in prisons is to be provided at anequivalent standard to that provided in the NHS,in accordance with health care standardsproduced by the Prison Service forimplementation by 1997 13 . In his 1997 ThematicReview 14 , the then Chief Inspector, Sir DavidRamsbotham, noted that the health carestandards, which apply to both men and women,contained very few specific references towomen, in spite of their very different needs inhealth terms. He recommended that a specificstandard for women’s health should be added tothe health care standards.This lack of care in relation to addressing thespecific needs of women was plainly revealed inan incident quoted by Devlin 15 , in which CaroleRigby of WISH showed conference delegates achart of a male body, which had been suppliedfor use in the preparation of medical reports onnew prisoners at Holloway. Such an ill-thoughtout act speaks volumes about the lack of astrategic approach to dealing with the needs ofwomen prisoners. Although some progress hadbeen made by the time of the Chief Inspector’sfollow-up report 16 , he still found it necessary torecommend the appointment of an OperationalHead of Women’s Health to have overallresponsibility for health care in women’sprisons.The overarching need for this becomes clearwhen the specific issue of mental health care isconsidered. In his 1997 Thematic Review, theChief Inspector recommended that the healthcare standards on mental health should beimplemented to improve services for prisonerswith a mental disorder. By the time of hisfollow-up report in 2001, this still had not beenachieved.The dearth of adequate mental health care inprisons is amply demonstrated by a re c e n ts u rvey by Reed and Ly n e 1 7 of 13 prisons within-patient beds, visited as part of HMInspectorate of Prisons’ programme ofinspection. Their findings showed that theprisons failed to meet the re q u i rements of thehealth care standards on mental health careand fell far short of standards in the NHS.S t a ffing levels in the health care centres wereinadequate both in terms of numbers and withre g a rd to staff training and qualifications. Thes u rvey revealed that, although the health cares t a n d a rds re q u i re that staff should re c e i v etraining in mental health care, most of thenursing staff in the prisons surveyed hadreceived no mental health training. Some of thedoctors with clinical responsibility for mentallyd i s o rd e red in-patients had some specialistpsychiatric training, but none was re g i s t e re d13 HM Prison Service (1999) Health care standards for prisons in Englandand Wales London: Prison Service14 HM Chief Inspector of Prisons (1997) op cit15 Devlin A (1998) op cit16 HM Chief Inspector of Prisons (2001) Follow-up to Women in PrisonLondon: Home Office17 Reed JL and Lyne M (2000) ‘Inpatient care of mentally ill people inprison: results of a year’s programme of semistructured inspections’British Medical Journal 320: 1031-34page 18

Women who challenge: women offenders and mental health issueson the relevant specialist register for thosewho are psychiatrically qualified.Reed and Lyne’s findings also showed that therewas a lack of therapeutic activity for patients,with most only spending 3.5 hours a dayunlocked as against the health care standardrequirement that those who are well enoughshould be unlocked for 12 hours a day, with atleast six hours of planned activity a day.Arrangements for the assessment of patients byvisiting psychiatrists, with a view to transfer tothe NHS or treatment in prison, were found towork reasonably well. However, prisonersassessed as suitable for transfer to hospitalwere waiting long periods before beds becameavailable.There is a dilemma about the level of mentalhealth care that should be provided in prisonsin the sense that we are saying that those whoare mentally disturbed should not be in prisonin the first place. The dismal picture revealed byReed and Lyne’s survey underlines the reasonswhy. Specialist services do not in our view havea place in prison and, indeed, as Reed and Lyneshow, it is in-patient care in prison that is themajor problem. It is, of course, whollyunacceptable that mentally disturbed offendersshould remain in prison for lengthy periodswithout specialist services. To match NHSstandards and ensure that prisoners are notdisadvantaged, prison health care should beable to provide much higher quality efficientand effective primary care, coupled withadequate arrangements for prompt referral andtransfer to secondary health care settings asrequired.Dr Reed has confirmed 18 that of the 13 prisonsincluded in the survey, two were women’sprisons and pointed out that, given the higherprevalence of mental disturbance found inwomen prisoners, it could be argued that thecriticisms made in the light of the survey applyeven more strongly in relation to the care ofwomen prisoners. With such poor standards ofcare in prison, there is no prospect of thosewith mental health problems coming out in abetter state than they went in. In fact, given theimpact of imprisonment itself, the reverse islikely, with all the implications that has forreoffending.The impact of imprisonment onwomen and their familiesThere is evidence to suggest that the experienceof imprisonment has a more detrimental effecton women than on men and a number ofreasons why this should be. First, the size of thefemale prison population itself has a bearing onthe matter. Since it is, compared with the maleprison population, so small, the female prisonestate is correspondingly small with only some18 female prison establishments currently (seeAppendix 1). This means that women prisoners,more often than men, are held far from theirhomes. To compound the problem, most ofthese establishments are in rural areas far fromurban centres, making it difficult and expensivefor families to visit and consequently makingthe maintenance of family ties even harder thanit is for most prisoners. The survey conductedat the end of 1996 for the Chief Inspector ofPrisons 19 found that for over 25% of womenprisoners, lack of contact with their childrenwas their greatest concern.The National Prison Survey 1991 20 found that47% of women prisoners had dependentchildren living with them prior to their beingimprisoned, compared to 32% of male prisoners.A survey conducted in 1994 21 , which definedmothers as women with children aged under 18and/or who were pregnant, found that 61% ofwomen prisoners were mothers. The ChiefInspector of Prisons’ survey found that twothirdsof women prisoners were mothers with anaverage of three children each and 55% had atleast one child under 16 years. More than onethirdof the mothers had one child or moreunder five years.However, whereas in the majority of cases thechildren of male prisoners are looked after bythe prisoner’s spouse or partner, this does notapply in the case of female prisoners. The 1991survey found that, in the case of 91% of themale prisoners with children, the children werebeing looked after by a current or formerspouse or partner. Only 7% said their childrenwere being looked after by other relatives and18 Personal communication with the author 15.08.0119 HM Chief Inspector of Prisons (1997) op cit20 Home Office (1992) The National Prison Survey 1991 London: HMSO21 Caddle D and Crisp D (1997) Mothers in Prison. Home Office ResearchFindings No. 38 London: Home Officepage 19

CHAPTER 32% had a child with foster parents or in care.The position for women prisoners is verydifferent. Only 23% with dependent children hadchildren being looked after by a current spouseor partner, while 52% had children being lookedafter by other relatives and 12% had a child withfoster parents or in care.Caddle and Crisp 22 found that 41% of mothersrelied on temporary carers, mostly grandparentsand female relatives. In their survey, childrenwere being cared for by their fathers in only 9%of cases and 8% of children were with fosterparents or in care. The survey for the ChiefInspector found 25% of the children were beingcared for by their father or the mother’s currentpartner. In the majority of cases, children werebeing cared for by friends or relatives (theprisoner’s own mother – 27%; other family orfriends – 29%). In most cases, women are stillthe primary carers of their children and carrythe major responsibility for running the familyhome. This makes their situation quite differentto that of men. As one prison governor, quotedby Angela Devlin 23 , put it: ‘It’s often said thatmen leave their home problems at the prisongate, do their bird, then go home. It’s never likethat for women.’Concerns about children are all the moreunderstandable in the light of the history ofabuse experienced by many women prisoners.The Chief Inspector’s survey found that nearlyhalf the women reported having been abused.This group was split evenly three ways intothose who had been both physically andsexually abused, those who had been sexuallyabused and those who had been physicallyabused. Forty per cent of those abused had beenunder 18 at the time and a further 22% had beenabused both as a child and as an adult. In mostcases, the perpetrator had been male and knownto the victim.Compared to the general population, of whom2% have spent time in care, the proportion ofwomen prisoners with a history of having beenin care is much higher. O’Brien et al 24 found that25% of the women prisoners surveyed had spenttime in care. It is of particular concern then thata significantly higher proportion of the childrenof women prisoners than those of maleprisoners end up in care. This suggests thatwomen’s imprisonment is leading to a cycle ofdeprivation being perpetuated. From 1997 to2000 the number of children being looked afterin local authority care rose by an average of4.4% per year 25 . We have to question whether therapid increase in the female prison populationmay have contributed to this year-on-yearincrease.Caddle and Crisp’s findings suggest thatchildren are also disadvantaged in other ways asa result of being separated from their mother.Forty-four per cent of the mothers reported thatthere were problems with their children’sbehaviour following their imprisonment and 30%said that their children had become withdrawn.Other research by Richards et al (1996) 26 , quotedby Caddle and Crisp, also found evidence ofquite serious emotional and behaviouralproblems in the children of women prisoners,whereas the problems of the children of maleprisoners were comparatively minor.It is not difficult to see why worries about whatis happening at home to children and familiesmay make prison a harder place to be forwomen than for men.The Prison Service’s preoccupation with securityfollowing escapes from male prisons hasunnecessarily impinged on the female estate.HM Chief Inspector made the point in 1997 27that women were being held with physicalsecurity restrictions which were unnecessarywhen the probability of their absconding wasnot high. In 2001, this position has not changedand he has reiterated the view that the securitymeasures for women should not be the same asthose for men 28 .One example of the repercussions ofunnecessary security measures on womenprisoners is the use of handcuffing where thiswould not have been considered necessary inthe past. Devlin 29 illustrates the damaging effectthis can have on women prisoners and theirfamilies with an example of mothers who willnot attend custody hearings in relation to their22 Caddle D and Crisp D (1997) op cit23 Devlin A (1998) Invisible Women Winchester: Waterside Press (page 54)24 O’Brien M et al (2001) op cit25 Department of Health (2001a) Children looked after in England;2000/2001 Statistical Bulletin 2001/26 London: Department of Health26 Richards M et al (1996) Imprisonment and family ties London: HomeOffice27 HM Chief Inspector of Prisons (1997) op cit28 HM Chief Inspector of Prisons (2001) op cit29 Devlin A (1998) op citpage 20

Women who challenge: women offenders and mental health issueschildren because they would have to behandcuffed to two officers. Not surprisinglythey are concerned that this would convey theimpression they were dangerous and wouldhave an adverse effect on their chances ofwinning or retaining custody. Use of handcuffscan also lead to wider problems in that somewomen will refuse to attend outsideappointments for medical treatment becausethey would have to be handcuffed.The experience of women in prison isqualitatively different to that of their malecounterparts. Carlen (1998) 30 described thatdifference as being attributable to three reasons:biological – because women’s physical needs aredifferent to those of men; social – because therole of women in the family is different to thatof men; and cultural – because women’sexperiences of prison differ from those of menand different meanings are attached to them.Many have concerns about children – which maybe exacerbated by their own experiences ofphysical or sexual abuse and/or time spent incare – which are largely not shared by maleprisoners. That such concerns are notunfounded is demonstrated by the evidencerespecting the effect on children of theirmother’s imprisonment. The inability to tackleproblems relating to the well-being of childrenand families leads to frustration and feelings ofpowerlessness, factors which may manifestthemselves in breaches of prison discipline,self-harm or suicide. Given that two-thirds ofwomen prisoners are mothers 31 , this is a majorissue.Prison disciplinePrison discipline may seem a strange subject toinclude in a paper on mental health issues. It isrelevant, however, because the proportion ofwomen prisoners (32% of sentenced women) 32who commit disciplinary infringements is highand this may be indicative – at least in part – ofthe detrimental effect of imprisonment on theirmental well-being.Individual prisons have a good deal ofautonomy which results in differences in localrules between one prison and another. One ofthe effects of this is that there are variations inregimes and privileges which can lead toinconsistency and disadvantage. In his 1997Thematic Review 33 , HM Chief Inspectorhighlighted the fact that there is no single list ofpossessions which women prisoners are allowedto retain so that items permitted in oneestablishment may be confiscated in another.Furthermore, as Devlin 34 points out, prisoners’possessions are controlled by volume butdifferent prisons use different sized propertyboxes – another unnecessary inconsistency. Aswell as being a source of frustration, this canlead prisoners inadvertently to fall foul of therules and causes worry that treasuredpossessions will be lost. This issue has not yetbeen resolved and the Chief Inspector thereforereiterated the recommendation that a consistentpolicy should be adopted across the femaleestate 35 .Although, outside prison, women commit fewercriminal offences than men, inside they offendagainst prison discipline at a far higher ratethan men. In 2000, the rates were 256 offencesper 100 female prisoners and 159 per 100 maleprisoners 36 . A range of options exists to punishbreaches of prison discipline. These includecautions, forfeiture of privileges, exclusion fromassociated work, stoppage of or deduction fromearnings, cellular confinement in a segregationunit (seclusion) and the addition of extra days tothe time a prisoner has to serve 37 . While themain punishment for both male and femaleprisoners is additional days, women prisonersare more likely than men to receive forfeiture ofprivileges, stoppage or reductions in earningsand cautions 38 . Maden et al (1994) 39 found thatwomen were less likely than men to be punishedby loss of remission and the fact that theaddition of days to be served is now the mainpunishment for both men and women suggeststhat an increasingly punitive approach towomen may have been adopted.There may be a number of explanations for thedifference in offending rates. One factor may be30 Carlen P (1998) Sledgehammer: Women’s Imprisonment at theMillennium London: Macmillan Press31 HM Chief Inspector of Prisons (1997) op cit32 O’Brien M et al (2001) op cit33 HM Chief Inspector of Prisons (1997) op cit34 Devlin A (1998) op cit35 HM Chief Inspector of Prisons (2001) op cit36 Home Office (2001d) op cit37 O’Brien et al (2001) op cit38 Home Office (2001d) op cit39 Maden A et al (1994) op citpage 21

CHAPTER 3the frustrations of female prisoners not beingable to deal with family problems. The issue ofproperty, highlighted above, is anotherunderstandable cause of frustration. Also,according to commentators, it is easier forwomen prisoners to breach prison rules because‘discipline in women’s prisons is more exactingand petty than in men’s’ (Carlen, 1998) 40 . Devlin(1998) 41 quotes examples which support this,such as punishments being given for eating tooslowly, swearing, smoking in non-smoking areasand breaching prison dress code (even thoughwomen prisoners are allowed to wear their ownclothes). She also indicates that most of thewomen she interviewed did not attempt toappeal against alleged unfairness because theyhad no faith in the statutory appeal proceduresand felt that prison staff would simply closeranks against them.There may be a link between mental healthproblems and disciplinary problems, althoughthe nature of that link remains unclear. O’Brienet al (2001) 42 looked, in relation to sentencedwomen prisoners, at the use of cellularconfinement and ‘stripped conditions’ (whereprisoners are held in an unfurnished room fromwhich all items which could potentially be usedfor self-harm have been removed) and at theimposition of additional days. The analysis wasrestricted to sentenced women because thesanction of adding additional days is notavailable for use with remand prisoners.In total, 32% of sentenced women prisonerswere found to have received punishment for adisciplinary offence in the form of one of thespecified sanctions. (Of the remainder who hadnot received either of these sanctions, somemight have been subject to one or more of thelesser forms of punishment but the research didnot identify this.) An association was foundbetween receipt of one of these punishmentsand mental disorder and also between mentaldisorder and the frequency with which thesepunishments were received. For example, 73% ofthose who had received additional days hadsignificant levels of neurotic symptoms, as did74% of those who had been subject to cellularconfinement, compared to 56% of those who hadnot received either punishment. Neuroticsymptoms, however, did not seem to beassociated with an increase in frequency ofpunishment.Of those who had been subject to cellularconfinement, 17% were thought to be psychotic,compared to 8% of those who had not receivedthis form of punishment. In this case, there wasan associated increase in frequency ofpunishment so that, of those who had beenpunished on three or more occasions, 19% werejudged to be psychotic, whereas only 9% ofthose who had been punished once or twicewere so judged.A higher incidence also applied to personalitydisorder, with 84% of those who had receivedeither of the sanctions showing evidence ofpersonality disorder, compared with 68% ofthose who had not. In the case of anti-socialpersonality disorder, the incidence was 63% ofthose who had received cellular confinementand 64% of those who had received added days,compared to 28% of those who had receivedneither. Given the nature of the condition, weshould not be surprised that the rate is high,nor that the incidence of anti-social personalitydisorder was also high (67%) in those whoreceived punishment three times or more and inthose punished once or twice (53%).It is also not unexpected to see an associationbetween receipt of disciplinary sanctions andprisoners dependent on drugs, since use and/orpossession of drugs in prison would clearly bebreaches of prison rules. Of those who weredependent on drugs in the year before enteringprison, only 17% had not received eitherpunishment. The survey does not indicatewhether their breaches of discipline weredirectly associated with drugs but 41% of theseprisoners had received added days and 35% hadbeen subject to cellular confinement. Frequencyof punishment was also linked to drugdependency with 64% of those punished threetimes or more being addicted, as well as 49% ofthose punished once or twice.Alcohol misuse prior to imprisonment was alsoconsidered as a factor and found in 27% ofwomen who had received additional days and23% subjected to cellular confinement. Only 15%of those who had received neither punishmentwere found to have been alcohol misusers.40 Carlen P (1998) op cit (page 86)41 Devlin A (1998) op cit42 O’Brien M et al (2001) op citpage 22

Women who challenge: women offenders and mental health issuesHowever, no link was identified betweenprevious alcohol misuse and frequency ofpunishment.The profile, in terms of social characteristics, ofthose women who received punishment was alsorevealed by the research and can be distilled toidentify those who were more likely to havereceived added days or to have been subject tocellular confinement and those less likely tohave received one of these punishments.Characteristics of women likely to receivedisciplinary punishmentMore likelyAged 21 to 29Single or cohabitingLow educationalattainmentLikely to have beenliving off crime beforeimprisonmentLess likelyAged 40 or overMarriedHigher educationalattainmentUnsurprisingly, given that ‘stripped conditions’are used as a means of avoiding the possibilityof self-harm, there did appear to be anassociation between being held in ‘strippedconditions’ and the presence of mental disorder,as the following figures show.Table 5 Percentage of women prisoners heldin ‘stripped conditions’ exhibitingsigns of mental disorderType of mental disorder % of those % of thoseheld in not held in‘stripped’ ‘stripped’conditions conditionsSignificant neuroticsymptoms 27 13Psychotic illness 31 7Probable personalitydisorder 49 28Attempted suicide inprevious 12 months 26 13Source: Office for National Statistics (2001) Psychiatric MorbidityAmong Women Prisoners in England and Wales London: Office forNational StatisticsLooking at the two punishments separately, theresearch also identified the key factors whichincreased the likelihood of receivingpunishment when other factors had been takeninto account. In the case of receipt of additionaldays, the three key factors were:• probable personality disorder• drug dependence• marital status (being single or cohabiting).In the case of cellular confinement, the keyfactors were:• probable personality disorder• marital status (being single or cohabiting)• having attempted suicide in the past year.As indicated above, the research also looked atthe use of holding prisoners in ‘strippedconditions’. This might be, but was notnecessarily, associated with breaches ofdiscipline. It was found that 12% of women hadbeen held in ‘stripped conditions’, of whom 46%had been held in the hospital wing and 54% hadbeen held elsewhere in the prison.As a postscript to this, it is worth noting that inMarch 2000, the Prison Service issued aninstruction directing the elimination of the useof strip cells in the management of prisonersidentified as at risk of suicide or self-harm 43 .Social characteristics were also considered inrelation to this group, but did not appear tohave any particular significance. After analysis,the key factors found likely to increase theprobability of being held in ‘strippedconditions’ were having a psychotic disorderand having attempted suicide in the previous12 months.What is particularly interesting in the contextof the apparent association betweendisciplinary offences and mental disorder isthat, as Devlin 44 points out, it is contrary toprison rules for prisoners to be sent foradjudication (a disciplinary hearing) if they arenot capable of fully understanding the rules.Given the proportion of mentally disturbed43 HM Prison Service (2000) Caring for the Suicidal in Custody:Eliminating Strip Cells Prison Service Instruction 27/2000 London:HM Prison Service44 Devlin A (1998) op citpage 23

CHAPTER 3women shown by the statistics to have beensubject to disciplinary sanctions, it appearslikely that, in at least some cases, this rule wasnot adhered to. Women prisoners’ reported lackof confidence in the prison justice systemseems understandable in this light.Patterns of prescribing in women’prisonsThere is plenty of anecdotal evidence to suggestthat there are high levels of prescribing ofpsychotropic medication within women’sprisons. Devlin (1998) 45 , for example, quotesnumerous reports from prisoners about theprescribing of anti-psychotic drugs, such asMelleril and Largactil, to an extent where sideeffects become visibly apparent.Concerns about the level of prescribing,especially of combining anti-depressants, majortranquillisers and night sedation, wereexpressed by the Chief Inspector in his ThematicReview 46 . He recommended that:‘Clinicians should agree a sensible protocol inconjunction with an independent specialist forprescribing drugs. This should be co-ordinatedcentrally through the professional Head ofWomen’s Health who should regularly audit theresults.’Disappointingly, there is no reference in hisfollow-up report 47 to indicate the extent towhich, if at all, this recommendation has beenimplemented. His concerns were, however,shared by the Prison Reform Trust (PRT)Committee on Women’s Imprisonment 48 , whichrecommended the undertaking of:‘… an audit of drug prescribing in prison andthe development, in collaboration with the NHS,of a protocol for prescribing for womenprisoners which should be monitored by NHSpersonnel.’In both cases, doubt was expressed aboutwhether unacceptable prescribing patternswithin prisons were wholly attributable to thestaff within the prisons themselves or whetherpoor prescribing by GPs in the community mighthave had a part to play in establishing patternswhich were then simply perpetuated in prison.For example, one prison medical officer hassfound 17 year olds coming into prison withlegitimate prescriptions for drugs such asdiazepam, temazepam, methadone anddihydrocodeine 49 . She found many of those whowere being detoxified from benzodiazepines andheroin while in prison were returning to theirGPs on release and being put straight back on tothe prescribed drugs. A different light is shedon this issue by the survey carried out by theOffice of National Statistics 50 . This found that asubstantially higher proportion of women inprison (50%) were being prescribed drugs actingon the central nervous system (CNS drugs) thanhad already been receiving prescriptions forsuch drugs before entering prison (17%). Thefigure for women prisoners was alsoconsiderably higher than that for maleprisoners, of whom only about 20% werereceiving such prescriptions.In their survey, Maden et al (1994) 51 found lowerlevels of prescribing of psychotropic medicationin prison – at 26% for women and 8% for men –though the much higher prescribing level forwomen prisoners is still apparent. Thisinformation is reported under the sub-heading‘Psychiatric treatment within prison’, thoughthere is no mention of any other forms oftreatment other than medication. They state thatnone of the prisoners reported being givenmedication against their will – which is perhapsto miss part of the point. In order to be able togive informed consent to treatment, patientsmust be provided with sufficient informationabout what is involved, such as the details oftheir diagnosis and its prognosis, uncertaintiesabout diagnosis, the likely benefits of theproposed treatment and the probabilities of itssuccess or otherwise. Prisoners should be nodifferent to other patients in this respect. Thisis particularly important since, as the HealthSelect Committee 52 points out, treatment inprison is not covered by the terms of the MentalHealth Act 1983, which means that patientstreated without consent are also not covered by45 Devlin A (1998) op cit46 HM Chief Inspector of Prisons (1997) op cit (page 106)47 HM Chief Inspector of Prisons (2001) op cit48 Committee on Women’s Imprisonment (2000) Justice for Women: theNeed for Reform London: Prison Reform Trust (page 21)49 Nelson-Owen M (1997) ‘A doctor’s dilemma’ British Medical Journal315: 553-55450 O’Brien M et al (2001) op cit51 Maden A et al (1994) op cit52 Health Committee (2000) op citpage 24

Women who challenge: women offenders and mental health issuesthe safeguards which the Act provides.Treatment in prison health care centres iscovered only by common law and, as such,when it comes to prescribing psychotropicmedication and to the possibility of pressure orincentives to accept it being applied, it lackstransparency. A survey establishing the extentto which prisoners have given informed consentto medication with CNS drugs might prove afruitful area for research.The PRT Committee on Women’s Imprisonment 53expressed understandable concern that theapproach to prescribing in women’s prisons wasliable to perpetuate or even increase addictionamong women prisoners. This is not to say thatthere is never a case for prescribingpsychotropic medication to women prisoners.The concern is to get away from the mindsetwhich automatically reaches for the prescriptionpad as a response to a cry for help and insteadto promote adherence to the principle ofprescribing according to therapeutic need.It is interesting to compare the approach toprescribing in women’s prisons with that inspecial hospitals. For example, at Broadmoor,Bland et al (1999) 54 found that anti-psychoticmedication was prescribed to 96% of women,even though only 72% were diagnosed as havinga mental illness, which suggested that antipsychoticmedication was being prescribed tosome women who had no diagnosable mentalillness. Even in this environment, which should,after all, be therapeutic, only 32% of the womenhad received or were receiving psychotherapy.While recognising that psychotherapy may beprecluded in some extreme cases, Bland et almake the point that, given the background oftrauma, abuse and deprivation experienced bymany of these women, psychotherapy could bea vital element of their treatment.Substance misuseViews differ about whether drug or alcoholdependency should be regarded as a psychiatricdisorder. In effect, whether it is or not matterslittle, since there is no dispute about the impactit has on the physical and mental health andwell-being of women prisoners. The figuresincluded in Chapter 2 give an indication of thescale of the problem and a comparison betweenthe findings of Maden et al’s survey 55 , conductedat the end of the 1980s,and the findings of theONS survey, conducted in 1997, show that it isgrowing. The concerns of the Committee onWomen’s Imprisonment 56 , referred to above, inrelation to the possible impact on addictivebehaviour of prescribing patterns in prison caneasily be understood in this context.In his Thematic Review 57 , the Chief Inspector ofPrisons referred to research suggesting thatwomen prisoners’ use of drugs and alcohol ismore likely to be for the purposes of ‘numbingout’ or as a coping mechanism than forpleasure. He made the point that womenoffenders with substance misuse problems havedifferent needs to those of their malecounterparts and suggested that the PrisonService should have a separate strategy for maleand female offenders. He highlighted concernsthat there was no central strategy for womensubstance misusers and no consistentdetoxification strategy across the female estate,which led to very different levels of provisionwithin different establishments. Herecommended that there should be greater coordinationin a drugs treatment policy forwomen so that counselling and treatment needscould be properly met across all establishments.There have been considerable changes since theThematic Review, with the introduction ofCounselling, Assessment, Referral, Advice andTreatment Services (CARATS), which are aimed atachieving follow-up care in the community postrelease,and which are now available in most,though not all, female establishments. In hisfollow-up report 58 , the Chief Inspector foundthat these, together with services provided byeducation departments and outside drugagencies, had helped to ensure the availabilityof drug education programmes focusing onmultiple high-risk behaviour and the risks forthe women themselves and their unbornchildren.There is, however, clearly still a long way to go.The ONS survey 59 found that 54% of female53 The Committee on Women’s Imprisonment (2000) op cit54 Bland J et al (1999) op cit55 Maden A et al (1994) op cit56 Committee on Women’s Imprisonment (2000) op cit57 HM Chief Inspector of Prisons (1997) op cit58 HM Chief Inspector of Prisons (2001) op cit59 Singleton N et al (1998) op citpage 25

CHAPTER 3remand and 41% of female sentenced prisonersreported a degree of dependency in the yearbefore entering prison. Women were more likelythan male prisoners to report dependence onopiates (ie heroin and non-prescribedmethadone) at rates of 41% of female remandand 23% of female sentenced compared to 26%of male remand and 18% of male sentencedprisoners. There was a clear relationshipbetween substance misuse and age, with bothhazardous drinking and drug use being moreprevalent in the young. Hazardous drinking wasreported by 50% of 16-20 year olds but haddeclined to 18% for those aged 45 or over.Similarly, drug dependence was reported by 57%of 16-20 year olds but only 3% of those aged 45or over. The largest proportions of those whoreported hazardous drinking were found amongthose held for robbery or violent offences at60% and 52%, respectively.An association between drug dependency andparticular offences was also found. In the caseof both male and female prisoners, those heldfor offences of burglary, robbery and theft weremost likely to report drug dependency beforeentering prison. Of the women prisoners, 60%reported some dependence on drugs and 50%reported dependence on drugs other thancannabis. This fits with the widely held viewthat a large amount of property crime is linkedto the need to feed a drug habit, though the linkis by no means clear cut and it is not suggestedthat drug dependency automatically leads tocrime. Interestingly, those held for violentcrimes reported a lower level of drugdependence prior to imprisonment (31%),compared to that for the sample as a whole(44%). Those held for drugs offences were alsoless likely than the average to have beendependent on drugs before being imprisoned.What is of particular concern is the prevalenceof drug use within prisons. The ONS survey alsofound that a quarter of female remand prisonersand one-third of female sentenced prisonersreported using drugs during their current prisonterm. These figures were not as high as thosefor male prisoners, which amounted to morethan one-third for remand and nearly half forsentenced prisoners. Of further concern is that8% of female remand and 14% of femalesentenced prisoners reported that at least oneof the drugs they had used had first been usedin prison. The drug most likely to have beenused in this way was heroin. This may bebecause heroin is the most frequently used drugin prison but it is especially significant becausewe know that female prisoners are more likelythan men to be dependent on opiates andbecause heroin is less easily detected thancannabis in the drug tests used under themandatory drug testing (MDT) arrangements.MDT in prisons was initially introduced as apilot scheme in 1995 and is now used in allprison establishments. Each prison must test10% of its population each month and prisonersare selected for testing on a random basis.Lower levels of current drug use are suggestedby the results of the MDTs carried out by thePrison Service during 2000/01, which werepositive in 9.9% of cases in female prisons and12.8% in adult male prisons 60 . This may bepartly because MDT is failing to detect heroinuse and thus not giving an accurate picture ofthe level of drug use. The Chief Inspector 61pointed out that the number of positive resultsvaried considerably from one establishment toanother according to the size and nature of theunit and also that, because of the high turnoverof women prisoners, the system did not ensurethat 10% of the female population as a wholewas tested on a regular basis. Anecdotalevidence gathered by Devlin (1998) 62 , fromprisoners throughout the female estate,suggests that the MDT regime is not properlyrandom, with selections being made by stafffrom the random sample, so that the number ofpositive results would not be too high and thusreflect badly on the prison. Similar anecdotalevidence suggests this is the case in relation tothe MDT arrangements generally. It is notpossible to substantiate these claims one way orthe other. However, this may also provide partof the explanation for the lower levels of druguse suggested by MDT.A major concern arising from drug use inprisons is bullying. Attacks by prisoners onother prisoners believed to have a supply ofdrugs have become commonplace. Devlin alsoquotes a senior prison officer as saying: ‘Drugsare causing terrible intimidation and brutality in60 Home Office (2001d) op cit61 HM Chief Inspector of Prisons (1997) op cit62 Devlin A (1998) op citpage 26

Women who challenge: women offenders and mental health issueswomen’s prisons as well as in men’s. But … malegovernors won’t admit this is happening in thewomen’s prisons they run. They can’t face thefact that women will do such things to eachother. But until they admit it, these terribleincidents will continue.’ 63 Allegations of bullyingin relation to drugs were made in every prisonvisited by Devlin in the course of her research.This is yet another reason why tackling drug usein prison is so important.According to the Chief Inspector 64 , the PrisonService’s drug misuse strategy has three mainstrands: reducing supply; reducing demand; andrehabilitating drug misusers. The final strand iscrucial if long-term reductions in drug use areto be achieved. Nevertheless, the recorddemonstrated by the ONS survey 65 wasdisturbing. Of those women prisoners who hadbeen assessed as being drug dependent, 54%had received some form of treatment or advicein relation to their drug problem in the yearbefore entering prison. However, this figure fellto 33% of prisoners who had received helpduring their current prison term. It is likely thatthis situation is now improving as a result ofthe introduction of the CARATS system andother drug treatment programmes but there willclearly be a lot of work to do if help is to beextended to most of the prisoners who need it.At the beginning of this report, we said that itwas important to address issues relating towomen offenders because of the ramificationsof failing to do so. Perhaps there can be nomore poignant illustration of this – and no moredamning indictment – than that provided by theprison officer at Risley, quoted by Devlin(1998) 66 , who said:‘Back in the seventies we had very few drugusers – it was mainly alcoholics. Now we aregetting the children of addicts. The other day Icounted five girls in here who were born toaddicts in Styal prison.’We share the view of the Committee on Women’sImprisonment 67 that drug treatment regimes inprison are far from adequate.Suicide and self-harmharming behaviours are necessarily sufferingfrom a diagnosable mental disorder. It isunlikely, however, that anyone would disputethat they are distressed and in need of help. Wefeel that, in a review of mental health issues,these behaviours should not be overlooked.Maden et al (1994) 68 found that the prevalence ofself-harming behaviour was a lot higher inwomen prisoners (32%) than in men (17%),though the proportions who displayed thisbehaviour while in custody were the same at 5%.The most common forms of self-harmingbehaviour were overdosing and cutting, theformer being more common outside prison. The1996 survey for the Thematic Review found over40% of women prisoners had intentionallyharmed themselves and/or attempted suicide.Approximately one-third had attempted suicideand 11% reported self-harming. Higher rates ofself-harming while in custody were found by theONS survey 69 , where the rates were still 5% formale remand prisoners but rose to 7% for malesentenced, 9% for female remand and 10% forfemale sentenced prisoners. Suicidal thoughtswere also reported by a significant proportion,ranging from 4% of sentenced men to 23% offemale remand prisoners, who had had suchthoughts during the previous week.Evidence given to the Health Select Committee 70by the organisation INQUEST drew attention tothe tendency for self-harm by prisoners to betreated as a disciplinary rather than a healthproblem. As indicated above in the section onprison discipline, the ONS survey 71 did find thatthere was a link between being held in ‘strippedconditions’ and having a psychotic disorder andalso that over one-third of those assessed ashaving a psychotic disorder reported selfharmingbehaviour compared to less than 10%of those who were not assessed as psychotic. Intheir survey, Reed and Lyne 72 found that the useof seclusion in prison related to the risk ofself-harm in nearly all cases, whereas in the NHS63 Devlin A (1998) op cit (page 189)64 HM Chief Inspector of Prisons (1997) op cit65 O’Brien M et al (2001) op cit66 Devlin A (1998) op cit (page 198)67 Committee on Women’s Imprisonment (2000) op cit68 Maden A et al (1994) op cit69 Singleton N et al (1998) op cit70 Health Select Committee (2000) op cit71 O’Brien M et al (2001) op cit72 Reed JL and Lyne M (2000) op citNacro’s Mental Health Advisory Committee isnot attempting to suggest that all those whocommit or attempt suicide, or who practise selfpage27

CHAPTER 3seclusion was used primarily because of risks toother patients or staff. Indeed, the MHA Code ofPractice 73 specifically prohibits the use ofseclusion in relation to patients liable to selfharmor at risk of suicide and instead advocatesthat, in such cases, individual care plans shouldspecify the measures required to manage therisk safely.A c c o rding to the Chief Inspector in his follow-upre p o rt 7 4 , some pro g ress has been made in dealingwith self-harm and the health care standard onthe management of those who self-harm hasmostly been implemented, except in Holloway.As we saw above (page 23), one of the positivesteps has been the Prison Service Instru c t i o nd i recting the elimination of the use of strip cellsfor prisoners at risk of suicide or self-harm 7 5 H ealso found that the Wo m e n ’s Policy Group wasworking with the Prison Service SuicideAw a reness and Support Unit to provide guidancespecifically in relation to women prisoners. Heremains concerned that self-harm and suicidep revention should be seen as responsibilities forall staff, not just health care staff, and we sharethat concern. At the same time, we also take theview that all prisoners who self-harm or attemptsuicide should receive a proper mental healtha s s e s s m e n t .Women in the secure systemChapter 2 noted that the population of mentallydisturbed offender/patients detained in secureprovision under Part III of the MHA (that is thosewho have been subject to criminal proceedings)is very small. This is partly because, as Maden(1996) 76 points out, except in the most seriouscases, there is a considerable degree of chanceinvolved in whether the behaviour of mentallydisturbed individuals results in criminalproceedings leading to admission to hospital onthe basis of a court order, or in compulsoryadmission to hospital under a civil section ofthe MHA. In the latter case, the individual willnot be included in the statistics of thoselabelled ‘mentally disordered offenders’ eventhough the behaviour which prompted theadmission may often have been quite similar tothat which in other cases has resulted incriminal proceedings. Once detained within thesecure services under the MHA, individuals maybe transferred from one level of security to ahigher level, because of difficulties in theirmanagement, without the involvement ofcriminal proceedings.Stafford’s research for WISH 77 shows that theproportion of female patients detained in highsecure hospitals under the civil provisions ofthe MHA is far higher (26%) than that of malepatients similarly detained (9%). A similarproportion of the female patients at Broadmoor(23%) were found by Bland et al 78 not to havebeen convicted of any offence.The Health Select Committee 79 expressedconsiderable concern about the position ofwomen detained within the secure system. Inevidence to the Committee, the Secretary ofState revealed that there were approximately110 women in special hospitals who did notneed to be detained at that level of security. Weknow from Chapter 2 that women tend to bedetained in high security hospitals for longerperiods than men. As the evidence to the SelectCommittee confirms, there are two main reasonswhy women are being detained in conditions ofhigh security when, arguably, this is notwarranted by the threat they pose to the public.The first concerns the management of patientsdeemed to be difficult. Stafford points out thatpatients detained under civil provisions may betransferred to high security hospital following a‘violent’ incident but where no criminalproceedings have been initiated and there hasbeen no independent inquiry to determine thefacts of the alleged offence. There has, thus,been no independent scrutiny to assess whetherdetention under provisions of high security isjustified by the risk the patient poses to thepublic. Arguably, they are being detained at alevel of high security without due processhaving established the need for this and, onceplaced in high security, it becomes much harderfor them to obtain transfer back to a lower levelof security.The second reason relates to the inadequacy of73 Department of Health and Welsh Office (1999) Mental Health Act 1983Code of Practice London: The Stationery Office74 HM Chief Inspector of Prisons (2001) op cit75 HM Prison Service (2000) op cit76 Maden A (1996) op cit77 Stafford P (1999) op cit78 Bland J et al (1999) op cit79 Health Committee (2000) op citpage 28

Women who challenge: women offenders and mental health issuesservice provision at a medium-secure level,where female patients have frequently foundthemselves in an extremely vulnerable positionon their own, or as one of a very small numberof women, in units populated predominantly bymen. The men held in medium secure units haveoften been perpetrators of violent or sexualoffences, while the women have frequently beenvictims of physical or sexual abuse and this hasmade for a wholly unsatisfactory environment.The limited resources available at this level ofsecurity also have a bearing on the size of thepopulation in the secure system in that, if nosuitable beds are available, offenders may wellend up with a custodial sentence rather than ahospital disposal, as shown above by Allen’sresearch 80 . It can also be the case – and this mayapply particularly to women – that offenders aresometimes excluded from low secure places,which would be appropriate to their condition,because they are offenders and clinicians areconcerned that they may have a disruptiveinfluence.The Government is now committed to theelimination of mixed sex accommodation and isworking towards three main objectives in thiscontext 81 :• ensuring that appropriate organisationalarrangements are in place to secure goodstandards of privacy and dignity for hospitalpatients• achieving fully the Patient’s Charter standardfor segregated sleeping, washing and toiletfacilities across the NHS• providing safe facilities for patients inhospital who are mentally ill, which safeguardtheir privacy and dignity.This is a welcome step towards providingvulnerable women with an environment inwhich they can feel safe. It does not, however,resolve the issue of providing adequate accessto services at a medium secure level. Thedevelopment of women-only units may notnecessarily be the complete solution it seemsand there are consequences of such a move,both foreseen and unforeseen, that need to bemonitored and reviewed. Because of the smallnumbers of women involved, the number ofwomen-only units required would still be small,even if limited in size. This could have thedrawback that women would end up beingdetained even further away from home thanmight otherwise be the case. Also, while thearguments for segregated sleeping, washing andtoilet facilities are now undisputed, the positionin relation to separate social, educational andother facilities is less clear-cut. While somefemale patients would undoubtedly prefer awholly separate living environment, this doesnot apply to all. Some prefer to haveopportunities to mix and this may also betherapeutically advisable given that whenpatients leave hospital they won’t be insegregated environments. The solution may bethe further development of sites containingseparate single sex units, as well as facilitieswhich allow opportunities for mixed social andother activities.80 Allen H (1987) op cit81 Department of Health (1997) The Patient’s Charter: Privacy and dignityand the provision of single sex hospital accommodation NHS CircularEL(97)3 London: Department of Healthpage 29

CHAPTER 4What are Government strategies doing to help?We have looked at the major factors whichimpact on women offenders with mental healthproblems.:• gender bias in the criminal justice system• why mentally disordered offenders end up inprison• mental health care for women prisoners• impact of imprisonment• pattern of prescribing psychotropicmedication• substance misuse• suicide and self-harm• women in secure care.So what is the Government doing to addressthese issues? In this chapter we considercurrent Government initiatives in these areasand the extent to which they are addressing theneeds of women offenders. We set out theresponses of Nacro’s Mental Health AdvisoryCommittee to these issues.Women and Equality UnitThe Women and Equality Unit – formerly theWomen’s Unit – is charged with helping theGovernment to deliver on the key issues thatmatter to women. According to the Unit’swebsite 1 , its top priorities are:• developing policies which support flexibleworking and enable women to juggle theirbusy lives• delivering high quality services in health,education and that respond to women’s needs• enabling women to play a greater part inpublic life• working to close the pay gap between men andwomen.The Unit is based in the Cabinet Office and isresponsible for co-ordinating policy on womenand gender equality issues. There are twoMinisters for Women, one who sits in theCabinet and another who has day-to-dayresponsibility for the Unit’s work.Claims for success by the former Women’s Unithave so far included:• a Budget for Women in 2001 (aimed atdelivering: better maternity pay for longer;paid paternity leave for fathers; help infinding high quality childcare to enablemothers to return to work)• holding a business fair and setting up awebsite (www.womens-unit.gov.uk/unlimited)to promote employment opportunities forwomen• running ‘taster days’ to give young women theopportunity to obtain work experience intraditionally male-dominated areas such asconstruction, property, architecture, IT andengineering.The Committee believes that the Unit should bethe cornerstone of strategies aimed at womenoffenders with mental health problems andregards it as a positive sign that there is aresponsibility for co-ordinating policy on womenand gender equality at Cabinet level.The Committee welcomes the initiatives that havebeen undertaken so far, but does not believe theyreach to the heart of the fundamental problemsfacing the women with whom we are concernedin this report. The Committee believes that muchmore needs to be done to co-ordinate and pulltogether the various strands of policy whichaffect women in general and women offenders inparticular.The Government’s strategy forwomen offendersTowards the end of 2000, the Governmentpublished a document setting out its strategyfor protecting the public and preventingreoffending by women offenders 2 . In thisdocument, the Home Secretary acknowledgedthat, owing to the small numbers of womenoffenders, the factors leading women to offendor reoffend had in the past been overlooked. Hepresented his vision for the future as one inwhich prison and probation services would worktogether effectively to stop women reoffendingand a supportive network would be available inthe community to help vulnerable women by1 www.womens-unit.gov.uk2 Home Office (2000) The Government’s strategy for women offendersLondon: Home Officepage 30

Women who challenge: women offenders and mental health issuespreventing them from offending in the firstplace and supporting the resettlement ofex-offenders.The Women and Equality Unit is to play acentral role in this strategy by co-ord i n a t i n gthese and other initiatives to tackle socialexclusion – such as raising family incomes,i m p roving care in childre n ’s homes and tacklingd rug abuse – so as to ensure that they make ad i ff e rence to women.The Committee wholeheartedly supports these aslaudable aims and liable to impact directly onthe circumstances which result in femaleoffending, if they can be achieved. However, theCommittee considers it will take fundamentaland comprehensive changes if these goals are tobe met.The strategy document says that 50% of theincrease in the female prison population in thelast five years is attributable to more womenbeing convicted of drugs offences, though as wehave seen (Chapter 2), it is not these womenwho are the ones most likely to have beendependent on drugs before coming into prison.It also recognises that there are high levels ofpsychiatric morbidity and drug dependencywithin the female prison population but howdoes it propose to tackle these issues?The strategy outlines the work being carried outacross Government departments to tacklepoverty and social exclusion.The Committee commends the initiatives put inplace during the period since the Governmentwas first elected in 1997 but is, nevertheless,concerned about their efficacy in practice,especially where women offenders are concernedwhen we see that the female prison populationhas continued to rise, reaching an all-time highin 2001 (see Chapter 2).The strategy document states that moreresearch will be undertaken to identify moreclearly which of the characteristics of femaleoffenders are likely to lead them to reoffend sothat offending behaviour programmes can bedeveloped and targeted more effectively.The Committee does not dispute the benefits offurther research but believes the results of thatresearch should be directed towards thedevelopment of provision for women in thecommunity so that they are better supportedbefore they resort to crime and they are lesslikely to drift into a pattern of offending.Furthermore, the Committee believes there isalready sufficient evidence available of what isneeded to support women in the community tobegin to put a programme of provision in placewithout awaiting the outcome of new research.The Committee is concerned that the emphasison offending behaviour programmes suggests anoverly narrow approach which fails to recognisethat more generalised support for women indealing with their basic social and health needsand their responsibilities as primary carers isalso likely to have an impact on offendingbehaviour. Unless investment in offendingbehaviour programmes is matched by acomprehensive strategy to meet these practicalneeds, they will have only a very limited impacton reoffending rates.The document recognises that women are lesslikely than men to use drugs treatment serv i c e sand that the reasons for this are most likely to befears that their children will be taken into careand/or the fact that the services are not geared towomen. A study has been commissioned to lookat the specialist and mainstream serv i c e sc u rrently available and to identify the barriers toaccessing them with a view to setting up pilotp rojects to plug gaps in pro v i s i o n .The Committee considers that this work is longoverdue. The seriousness of drug misuse as anissue in the context of offending generally, andwomen offenders in particular, has long beenwell known.The Committee urges that resources be madeavailable to ensure that services, tailored to theneeds of women, are put in place as a matter ofurgency and that use of those services issupported and encouraged, alongside anaccountable process to monitor and evaluatetheir efficacy. There is likely to be demand forsuch services from offenders and non-offendersalike and this needs to be recognised to securethe sensitive and flexible services that arerequired.The Government strategy refers to twoinitiatives within the criminal justice settingwhich may prove beneficial to women offenderswho are drug dependent, but more research isneeded to ensure that women are able to benefitfully from them. The first – arrest referralpage 31

CHAPTER 4schemes – uses drug workers, whose function isto identify drug misusers at police stations atthe point of arrest and to refer them forappropriate treatment. The strategy documentclaims that pilot schemes have achieved an 80%reduction in offending by those successfullyreferred for treatment but, as with other drugservices, it appears that women may be lesslikely than men to access help through theschemes. Research into barriers to access bywomen has apparently been initiated.The second – the Drug Treatment and TestingOrder (DTTO) – was introduced by the Crimeand Disorder Act 1998. It provides courts withthe option to sentence an offender to drugtreatment, provided the person consents, and isaimed specifically at those who commitproperty crimes in order to fund a drug habit.The sentencing court is able to monitor theoffender’s progress and response to treatmentby means of regular testing. In its strategydocument, the Government indicates that usageof the order in terms of gender breakdown willbe monitored. The Howard League for PenalReform 3 has assessed the effectiveness of pilotschemes in terms of their impact in meeting theneeds of women offenders. It believes the DTTOhas considerable potential for reducing thenumbers of women in prison, if the specificneeds of women are addressed in itsdevelopment.The Committee considers that a key element ofany strategy aimed at women offenders must bethe policy for tackling drug dependency andmisuse and wholeheartedly supports initiativeswhich work with offenders in the community soas to avoid sentencing offenders to custody.The Committee urges that all such new initiativeswithin the criminal justice system should beapproached with gender sensitivity and that theassessment of any gender bias or barriers toaccess should automatically be an integral partof any evaluation process.A major problem so far as women prisoners areconcerned is that the vast majority are servingshort sentences (75% of women prisoners areserving sentences of 12 months or less,according to the strategy document), whichgives very little opportunity for them to getaccess to drug rehabilitation programmes whilein prison or to benefit from them.The Committee recommends that there should bea major initiative to ensure that every prisonerwith a drug problem is identified – no matterhow short their sentence – and arrangementsmade for them to receive post-release help in thecommunity. For this to be achieved, there will bea need, above all, for a genuinely joined-upapproach to work with women offenders,involving a wide range of agencies from thePrison Service through CARATS initiatives toProbation; Drug Action Teams (DATs); local drug,health and mental health services; and thevoluntary sector.When it comes to mental health, the strategydocument refers to the Government’scommitment to modernising health and socialservices, as set out in the Mental HealthNational Service Framework, published by theDepartment of Health 4 , which is consideredseparately below (see page 34), and to theexistence of court assessment schemes atmagistrates’ courts, which, it says, theGovernment encourages.The Committee is very disappointed that thestrategy for women offenders proposes nothingnew to tackle mental health issues.As we have seen, court assessment or diversionschemes provide courts with advice ondefendants’ mental condition and any necessarytreatment, enabling the courts to make referralsto mental health services where appropriate,instead of automatically pursuing a prosecutionwith the prospect of mentally disturbedoffenders ending up in prison.There are 200 or so such schemes throughoutEngland and Wales and Nacro’s Mental HealthAdvisory Committee has worked hard topromote their use as part of effective interagencyworking in dealing with mentallydisturbed offenders. However, as we said inChapter 3 – and the report of the Health SelectCommittee 5 makes clear – current arrangementsare far from adequate. In his review of diversionwork, James (1999) 6 concluded that, if court3 The Howard League for Penal Reform (2000) A Chance to Break theCycle: Women and the Drug Treatment and Testing Order London:Howard League for Penal Reform4 Department of Health (1999) National Service Framework for MentalHealth: Modern Standards and Service Models London: Department ofHealth5 Health Select Committee (2000) op cit6 James D (1999) op citpage 32

Women who challenge: women offenders and mental health issuesdiversion was to be successfully developed as auseful tool, there needed to be central planningfor a comprehensive strategy based on joinedupthinking at government level, which wouldfacilitate inter-agency working at a local level.He expressed the view that diversion servicesneed to become an integral part of mainstreampsychiatric provision if they are to becontinued. This is also the view of Nacro’sMental Health Unit which is working on behalfof the Home Office to achieve this.The Health Select Committee recommended thatit should be a requirement for courts and localmental health providers to liaise so that allcourts had access to a court diversion scheme.Although the Government’s stated aim is toencourage such schemes, so far nothing hasbeen done to implement the Health Committee’srecommendation and there is nothing in thestrategy on women offenders to suggest that itintends to do so. The Mental Health NationalService Framework includes several referencesto the existence of court diversion schemes andsays that they should be linked into local mentalhealth services. It also says that effective out-ofhoursservices should be accessible to thecriminal justice system. However, there isnothing to stipulate that all courts should haveaccess to a court diversion scheme.Notwithstanding the Government’s claims tosupport court diversion schemes, far frompromoting the establishment of furtherschemes, central funding for existing schemes isbeing withdrawn with effect from April 2002and schemes will in future have to be supportedentirely through local resources.The Committee does not object in principle toschemes being funded at a local level butquestions whether this move gives the rightmessage at a time when the establishment offurther schemes needs to be encouraged and thecentral planning and comprehensive strategyrecommended by James, which we endorse, havenot yet been put in place.The Health Select Committee also recommendedthat research should be commissioned toimprove the efficacy of court diversionschemes. Research to date has been limited,especially in relation to their efficacy for womenoffenders.The Committee believes further research isneeded:• to establish whether there is any gender bias inthe use or efficacy of diversion schemes• to determine the effectiveness of such schemesin identifying the particular problems ofwomen offenders• to establish what constitutes best practice forthe purpose of identifying mentally disturbedoffenders.The evidence in Chapter 2 above indicatesclearly that, as with male offenders, the peakperiod for female offending is the teenage years.The strategy document states that research isbeing carried out into two crime reductionprojects aimed at young people, to ensure thatspecific lessons can be learned about the riskfactors predictive of offending in young women.The Committee believes that research is alsoneeded into the identification of that proportionof young offenders who will not grow out ofoffending but will go on to commit a catalogue ofoffences. Gender differences in this group needto be analysed so that the specific problems oftackling their reoffending can be considered.A key omission from the strategy – no doubtdue to the fact that so little attention is paid tomental health issues – is recognition thatdeviant behaviour may be seen as criminal,when in fact it represents the first stages of adeveloping mental disorder, and proposals forhow this issue should be addressed. This isparticularly important in relation to disorders,such as the schizophrenias, which have definedperiods of onset.The Committee recommends that the importanceof this issue should not be overlooked in theformulation of an offending strategy.At the end of September 2001, the Governmentannounced that a major cross-governmentalstrategy – the Women’s Offending ReductionProgramme 2002-2005 – was being launched inthe light of the feedback received in response tothe strategy document published the previousyear. That feedback has been published in afurther report 7 , from which five key messageshave been identified:7 Home Office (2001a) The Government’s Strategy for Women Offenders:Consultation Report September 2001 London: Home Officepage 33

CHAPTER 4• alternatives to custodial sentences for womenmust be pursued• prison and probation regimes need to respondbetter to women of diverse ethnic groups andages, those with special needs and thosesentenced for different types of offence• throughcare for women offenders releasedfrom custody needs to be improved• efforts need to be co-ordinated acrossgovernment to address the factors that lead tooffending, such as those relating to family,health, employment, housing and training• the evidence base on ‘what works’ in reducingoffending should be broadened and includelistening to the views of women offenders.The Committee wholeheartedly endorses these asbeing key aims in the strategy to reduce women’soffending. The Committee also stresses theimportance, also recognised by others whoparticipated in the consultation process, ofaddressing mental health needs, alongside otherkey factors such as childcare, poverty andhousing issues.Mental Health National ServiceFrameworkAs we have seen, in its strategy for womenoffenders 8 , the Government relies upon theNational Service Framework for Mental Health(MHNSF) 9 when it comes to the mental healthneeds of women offenders. It makes no separaterecommendations to address the specific issuesthat arise in relation to this particular group. Itis our intention here to review the MHNSF fromthe perspective of whether it caters for themental health needs of women offenders andthose at risk of offending.The National Service Frameworks as a whole aimto ‘lay down models of treatment and carewhich people will be entitled to expect in everypart of the country’ 10 . What becomes apparent,however, from a careful scrutiny of the MHNSFis that, in spite of its intentions to ‘help raisestandards, tackle inequalities and meet thespecial needs of women (our italics), men, anddifferent ethnic groups’ 11 , too little attention hasbeen paid to meeting the separate, disparateneeds of groups, such as mentally disturbedoffenders, whose needs don’t correspond withthose of the population as a whole.The MHNSF does make re f e rence to mentalhealth care for prisoners and there is a specificcommitment in the NHS Plan to improve serv i c e sfor prisoners. The role of the National Dire c t o rfor Mental Health is to spearhead theimplementation of the standards set out in theMHNSF and the commitments relating to mentalhealth services, which are contained in the NHSPlan. This remit includes responsibility foroverseeing the implementation of those aspectsof the NHS Plan which relate to the impro v e m e n tof mental health services for prisoners. Weconsider the current plans for the re o rg a n i s a t i o nof health care for prisoners below.The Government’s strategy for women offendersrelies upon the MHNSF when it comes to dealingwith the mental health needs of womenoffenders and the MHNSF states, in relation toservices generally, that agencies must worktogether to identify gaps in service provisionand to plan and develop the range ofaccommodation and services that are required.The need for criminal justice agencies to beincluded in this process is stressed.The Committee welcomes the recognition thatcriminal justice agencies must be included in theplanning process but is dismayed that the MHNSFhas no special measures aimed at the needs ofwomen offenders or of mentally disturbedoffenders generally. The Committee sees this as amajor flaw in the strategy for women offenders.The MHNSF contains seven standards relating tothe provision of mental health services. Thefirst one, which is concerned with mental healthpromotion, recognises that mental healthproblems may arise from the adverse factors(such as poverty, unemployment, being a victimof abuse or domestic violence, homelessness,being drug or alcohol dependent), which areparticularly associated with social exclusion. Aswe have already seen, women offenders are verylikely to score highly on the scale of adverse lifeexperiences. Individuals in prison arerecognised as one of a number of vulnerablegroups, for whom specific programmes should8 Home Office (2000) op cit9 Department of Health (1999) op cit10 Department of Health (1999) op cit page 111 Department of Health (1999) op cit page 1page 34

Women who challenge: women offenders and mental health issuesbe available. What the standard fails to pick upon is that there are certain groups, of whomwomen offenders are one, who suffer from amultiplicity of adverse factors. In the absence ofprogrammes geared to recognise this, theywould effectively need to access a whole host ofprogrammes for individuals at risk andvulnerable groups to gain help and support withtheir wide-ranging problems. Furthermore, weknow already that it is usually those most inneed of services who are least likely to accessthem. This applies particularly to womenoffenders who, as the Government’s strategydocument recognised, often fail to accessservices.The Committee urges that, in addition tomaking a wide range of mental health serv i c e savailable, there must be an emphasis onidentifying and removing barriers to access andon establishing the type of outreach serv i c e swhich will ensure services are accessed by thosewho need them.Standards two and three, which relate toprimary care and access to services, are keywith their recognition that access to specialistmental health services should be available 24hours a day and that this is especially importantfor local agencies, such as the police, who dealboth with disturbed persons in public places, aswell as with mentally disturbed offenders. Thestandards specify that these specialist servicesshould include a duty doctor, approved undersection 12 of the Mental Health Act 1983, as wellas an approved social worker and securepsychiatric services. This should ensure theavailability of appropriate mental healthassessment, where issues of detention under theMental Health Act arise. The standards alsorecognise the value of mental health assessmentschemes at courts and police stations, whichfacilitate the process of diversion from thecriminal justice system, where appropriate, byproviding assessments enabling courts to decideon the most suitable action in individual cases.The Committee is very disappointed that theMHNSF does not include any stipulation thateffective police station and court assessmentschemes should be established in every area.The Committee also stresses that, because only asmall proportion of mentally disturbed offendersare treated by forensic services, the majorityneed to be able to access mainstream servicesand planning for mainstream services needs totake account of this.The Committee is most concerned that theMHNSF contains no mention, and no milestonefor monitoring purposes, to ensure that servicescater for, and are genuinely accessible to, womenand mentally disturbed offenders generally.Effective services for people with severe mentalillness are covered by standards four and five,though there is no definition of what constitutes‘severe mental illness’. These standards areconcerned with the implementation of the CareProgramme Approach (CPA) and the provision ofin-patient services. Effective arrangements inrespect of these services are crucial to preventthe kinds of problems which occur when thosewith mental illness suffer relapses or crises orlose touch with services; circumstances whichcan easily result in behaviour which leadsindividuals to become embroiled in the criminaljustice system. However, the effectiveness ofsuch services is undermined by the lack of abasic infrastructure for providing adequatesupport to the mentally ill in the community. Asone psychiatrist put it:‘It’s all very well setting up new teams andinitiatives, but when you have not got the basicinfrastructure to house people outside hospitalit’s difficult to see how it will work. There is atotal lack of supportive accommodation formental health patients.’ 12The MHNSF makes reference to specialistservices to be provided by community mentalhealth teams, such as assertive outreachinvolving the provision of help to find housing,to secure an adequate income and to sustainbasic daily living. However, it recognises thatthere are shortfalls around the country in theprovision of suitable accommodation and it isdifficult to see how these services can beexpected to work if there is a lack ofappropriate supported housing.The Committee stresses that the availability ofadequate suitable supported accommodation inthe community is essential and urges that thestatutory agencies, working with the voluntarysector, must make this a priority.12 Dr Martin Deahl quoted in ‘Madness is a release from all this’ TheTimes 7 September 2001page 35

CHAPTER 4In the case of women especially, many of whomhave a history of abuse, there is additionally theneed for single sex accommodation to providethem with an environment where they can feelsafe. We have already noted that this need hasbeen recognised in respect of the provision ofin-patient facilities and the MHNSF reiterates theGovernment’s commitment to the elimination ofmixed sex accommodation in that context.The Committee considers that it is equallyimportant for a safe environment to be providedfor those who are housed in the community,while recognising that this adds a furtherdimension to the already major challenge ofensuring an adequate supply of accommodation.As we saw in the previous chapter, the issue ofproviding single sex accommodation is alsolinked to the provision of secure services. Inthis context, the MHNSF states that servicesshould include a range of secure provision, withlocal intensive care or high-dependency units,as well as medium and high secure places, withespecial consideration to be given to the needsof women, among others. Regional specialistcommissioning groups are to commission arange of secure provision to meet service needs.One measure of performance is to be the accessto single sex accommodation in hospital andone of the milestones for monitoring progress isthe review of the use of high and mediumsecure beds.The Committee urges that the increasedprovision for women needed at a medium securelevel will be in place at an early date.In March 2001, the Minister for Healthannounced the development of a nationalstrategy for women’s mental health, the aim ofwhich is to produce a framework for thedelivery of comprehensive, high quality, mentalhealth services that meet the needs ofindividual women. This is a positive sign and weunderstand that the final strategy document isto be published in July 2002. It remains to beseen whether it will contain any specific plansto tackle the needs of women offenders.The feedback report to the strategy documenton women offenders 13 shows that we are notalone in regarding mental health as one of the13 Home Office (2001a) op citfundamental issues to be addressed in thecontext of women’s offending. Yet theannouncement of the new Women’s OffendingReduction Programme neither mentions thenational strategy for women’s mental healthcurrently being developed nor any other newinitiative specifically aimed at tackling this.That is not to say that the MHNSF fails torecognise the potential for a link betweenoffending behaviour and mental healthproblems and there are numerous referencesthroughout the MHNSF to the need to involve,and work with, the criminal justice agencies.However, this seems to be another examplewhere the needs of women offenders are notbeing addressed directly but simply as part andparcel of a strategy aimed at a largerpopulation.The Committee believes this is a short-sightedapproach and deplores the lack of joined-upthinking at the centre demonstrated by thefailure to link the Women’s Offending ReductionProgramme with the forthcoming nationalstrategy for women’s mental health. TheCommittee hopes that, when the nationalstrategy is finally published, these misgivings willprove to be unfounded.The Committee believes that comprehensiveimplementation of the MHNSF would probablyhave some beneficial effect for women offendersthrough improvements in the provision of, andaccess to, mental health services generally andrecommends that, for maximum benefit to beachieved:• specific steps must be taken as part of theimplementation process to ensure that theMHNSF is applied to the needs of mentallydisturbed offenders and that their needs areplaced firmly on the agenda of change• local strategy groups or networks dealing withmentally disturbed offenders should be linkedto, and represented on, the LocalImplementation Teams (LITs) charged with theimplementation process• the work also needs to be tied in with that ofthe Crime and Disorder and Community SafetyPartnerships created under the Crime andDisorder Act 1998 to provide liaison betweenthese various strategic groups.page 36

Women who challenge: women offenders and mental health issuesReorganisation of prison health carThe issue of prison health care, given the highlevels of psychiatric morbidity within the prisonpopulation, is fundamental to any considerationof women offenders and mental health issues.We know from the evidence set out in Chapter 3that improvements in the provision of mentalhealth services for prisoners are long overdue.In this section, we look at what is being done toimprove the situation.The Future Organisation of Prison Health Care 14 ,published in March 1999, was the work of ajoint group from the Prison Service and the NHSExecutive, established to consider ways ofimproving the organisation and delivery ofprisoners’ health care. The Working Group hadconsidered, in particular, HM Chief Inspector ofPrisons’ recommendation 15 that responsibilityfor providing prison health care should betransferred from the Prison Service to the NHS.The Working Group found many shortcomings inthe provision of prison health care, with a widevariation between different establishments inthe quality and standards of care beingprovided. It recommended a five-yearprogramme of change intended to bring aboutimprovements in order to achieve the previouslyexisting aim that prisoners should have accessto an equivalent standard of care to thatprovided in the NHS. To facilitate this, jointPrison Service/NHS Task Force and Prison HealthPolicy Units were set up: the first to providesupport and assistance to prisons and healthauthorities charged with working together todevelop Prison Health Improvement Programmesas part of the wider NHS reforms; the second toreplace the Prison Service Directorate of HealthCare and to be responsible for the developmentof prison health policy.The Working Group recommended that adecision on whether total responsibility forprison health care should be transferred to theNHS should be deferred until it had beenpossible to assess the outcome of itsrecommended programme of change. In themeantime, the Prison Service would continue, asbefore, to be responsible for the provision ofprimary care within prisons, while the NHSwould continue in its current role of provider ofsecondary care.eOf particular interest, in the context of thisreport, are the Working Group’s proposals inrelation to the provision of mental healthservices for prisoners. These are reproduced infull below:• the care of mentally ill prisoners shoulddevelop in line with NHS mental health policyand national service frameworks includingnew arrangements for referral and admissionto high and medium secure psychiatricservices• special attention should be paid to betteridentification of mental health needs atreception screening• mechanisms should be put in place to ensurethe satisfactory functioning of a CareProgramme Approach within prisons and todeveloping mental health outreach work onprison wings• prisoners should receive the same level ofcommunity care within prison as they wouldreceive in the wider community and policiesshould be put in place to ensure adequate andeffective communication and joint workingbetween NHS mental health services andprisons. Health authorities should ensure thatservice agreements with NHS Trusts includeappropriate mental health services for theirlocal prisoner population (page 29).In its role as provider of secondary care, theNHS was charged with ensuring that communitymental health services should be extended intoprisons and that, in accordance with the needsidentified by the prison health needsassessments (required to facilitate developmentof the health improvement programmes),sufficient capacity should be provided for thosementally disturbed offenders who requirehospital care. It was expected that it would takethree years for the work on health needsassessments (beginning end of 1999) and healthimprovement programmes (beginning early in2000) to be completed. This is a harder task insome areas than others because prisons – andthus the workloads involved – are not evenly14 HM Prison Service and NHS Executive (1999) The Future Organisationof Prison Health Care London: Department of Health15 HM Chief Inspector of Prisons (1996) Patient or Prisoner?: A NewStrategy for Health Care in Prisons London: Department of Healthpage 37

CHAPTER 4distributed throughout health authority areas. Itremains to be seen whether these essential keysto service development will be completed withinthe timescale envisaged.The Government’s commitments to developingmental health services 16 include the longer termplans to provide 300 additional mental healthstaff by 2004, with the aim of ensuring that, bythat date, all prisoners with severe mentalillness will be receiving treatment and no suchprisoners will leave prison without a care planand care co-ordinator.In the shorter term, a mental health strategy forimproving mental health services for prisonerswas to have been produced by Spring 2001.That strategy has now, at last, been published inDecember 2001 17 . The strategy identifies womenprisoners as one of a number of groups withspecific needs and recognises that they mayneed some services that might not be requiredin male prisons and also that staff will needspecific training and skills to meet the needs ofwomen. The strategy also refers to the nationalmental health strategy for women which iscurrently being developed (see page 36) andstates that it will be relevant to services forwomen prisoners. There is no further mentionin the prison mental health strategy specificallyin relation to requirements for women.The purpose of the strategy is identified asbeing to point the direction in which the NHSand Prison Service should be moving, to showhow both the National Service Framework forMental Health and the NHS Plan apply toprisoners, and to identify issues that will needto be considered in the development of services.It specifically states that it does not set out tobe a blueprint of what to do and points out thatactions required by different prisons will varybecause of the varying natures of theirpopulations, regimes and so on.The strategy sets out how the MHNSF applies ina prison context and what the components ofmental health services in prisons should be toensure that prisoners have access to the samerange and quality of services that are available16 Department of Health website (www.doh.gov.uk/prisonhealth/devservices.htm)17 Department of Health, HM Prison Service and National Assembly forWales (2001) Changing the Outlook: A Strategy for Developing andModernising Mental Health Services in Prisons London: Department ofHealthto the general population. These include:• mental health promotion• primary care services• wing-based services• day care• in-patient services• transfer to NHS facilities• throughcare.The Committee warmly welcomes the strategyand the proposals it makes for improvements inprimary mental health care provision in prisons.The Committee is nevertheless concerned aboutthe proposal for psychiatric in-patient services inprisons aimed at those with severe mental healthproblems. The Committee believes such servicesgo beyond the level of primary care, whichshould be the function of prison health care, andrepresent secondary care which should beprovided by the NHS outside a prisonenvironment.In April 2001, the Prisons Minister announced ajoint investment package to improve healthservices in prisons across England and Wales,aimed at achieving the longer termcommitments outlined above. Theannouncement heralded the start of aprogramme for new NHS mental health in-reachteams to be piloted, initially in 12 prisons. Thefirst phase included Eastwood Park, Hollowayand Winchester, and the second phase(beginning in November 2001) includesBullwood Hall and Durham, so there is thepotential for women prisoners to benefit fromthe pilot.The Committee welcomes this major programmeof change aimed at improving the delivery ofhealth services, and mental health services inparticular, to prisoners.The Committee has noted the commitments inthe programme for the development of servicesto prisoners with what has been designated as‘severe mental illness’. It is concerned that thestrategy should be one of promptly transferringsuch prisoners to suitable secondary care settingsrather than developing such services in theunsuitable environment of prison. ‘Severe mentalillness’ has not been defined but those with apage 38

Women who challenge: women offenders and mental health issuessevere level of disorder should in any case betransferred to hospital.The Committee commends the eff o rts being madeto improve prison health care but warns thatthey must not be seen as a substitute for workingto prevent those who are mentally disturbed fro mentering prison in the first place.Reform of the Mental Health ActThe section on female mentally disturbedoffenders in Chapter 2 sets out the basis onwhich offenders/patients can currently bedetained in hospital under the terms of theMental Health Act 1983. That Act is at presentunder review and proposals to amend the Actwere published in December 2000 in a WhitePaper entitled Reforming the Mental Health Act.This is not the place for a detailed review ofthose proposals but some reference to them isnecessary in considering the overall frameworkfor dealing with mentally disturbed offenders.The White Paper consists of two parts,stemming from consultation papers concerningreform of the existing Mental Health Act andnew proposals for managing dangerous peoplewith severe personality disorder. The first partwould replace the 1983 Act and containsproposals for the compulsory care andtreatment of mentally disordered offenders, inplace of the measures contained in Part III of theexisting Act. The second part is concerned withhigh-risk patients and proposes a completelynew set of arrangements for dealing with thesmall minority of people who pose a significantrisk of serious harm to others as a result oftheir mental disorder.The proposals include a new, broader definitionof mental disorder which does not specifyparticular categories. New measures, whichwould be introduced by the first set ofproposals, include powers for courts to orderassessment of mental disorder in thecommunity and compulsory care and treatmentin the community, in addition to the powers toorder assessment or detention in hospital. Itwould also be possible to direct a prisoner toundergo specialist assessment for mentaldisorder and for such an assessment to takeplace in prison.The Committee argues that such a specialistassessment would go beyond the level of primarycare which should be the limit of health care inprison and recommends that prison should notbe considered a suitable environment for such anassessment.The second set of proposals would introducestatutory powers for the assessment andtreatment of dangerous people with a severepersonality disorder. Specific reference is madeto the needs of women who are identified asfalling into this category. The proposalsexplicitly recognise that the development ofservices for the assessment and treatment ofthis group should be gender sensitive, since, forexample, treatment programmes suitable forwomen may differ from those which are suitablefor men. The issue of gender sensitivity inassessment is more problematic because of theneed to ensure that the same criteria are appliedto men and women for the purposes ofidentification of dangerous severe personalitydisorder.The Committee considers that it would be quitewrong if there was a difference between menand women in the threshold of risk applied andurges that pilot testing of assessment tools mustbe vigilant to avoid such a possibility.It is not known when, or if, the proposals asthey currently stand will be taken forw a rd asthey are not contained in the curre n tlegislative programme. It is understood thatthe earliest point at which they could now bei n t roduced into legislation would be in thep a r l i a m e n t a ry session beginning in the autumnof 2002. There would no doubt be some furt h e rlapse of time thereafter before implementationof the proposals could be effected. Ap rogramme of pilot projects is underway toestablish what works in terms of assessmentand tre a t m e n t .The Committee urges that the lapse of timeshould be used to advantage to learn from theevaluation of the pilots to inform the final shapeof the proposed legislation.page 39

CHAPTER 5Where do we go from here?In this report so far, we have identified what wethink are the major issues in relation to womenoffenders with mental health problems. We havehighlighted areas of concern and gaps in serviceprovision and we have indicated what theGovernment is doing in terms of currentstrategies to tackle these issues.So where does this leave us? We think there arekey themes to draw out from this process andwe propose to say in conclusion what Nacro’sMental Health Advisory Committee believesshould be in place to provide a system thatworks to address the needs of women offenderswith mental health problems in a constructiveand effective manner. We set out our stall ofrequirements in general terms. Specificexamples of service models and relevant contactpoints are included in Appendix 2 for reference.It is our intention here to propose a strategicframework, not a prescriptive model.Community alternatives to custodyOne of the major and fundamental factors whichemerges in Chapter 1 is that the female prisonpopulation has been growing at a massive anddisproportionate rate. This is an area ofimmense concern, as identified in Chapter 3,because of the detrimental effects of women’simprisonment both on the women themselvesand on society as a whole. This has now beenrecognised by Government, with Home OfficeMinister, Beverley Hughes, observing inSeptember 2001 1 at the launch of the Women’sOffending Reduction Programme that:‘The separation of children from women servingcustodial sentences, in particular, may be aprime cause of transmitted disadvantage.’As we indicated in Chapter 2, the majority ofwomen prisoners have not committed a violentoffence and do not pose a danger to the public.We have also seen (Chapter 4) that 75% ofwomen prisoners are serving sentences of 12months or less, which means that little by wayof constructive work is being done with themwhile they are in prison and they do not benefitfrom statutory supervision on their release. Ithas been policy throughout the 1990s thatmentally disturbed offenders – and this shouldinclude female offenders suffering from mentaldisorder – should normally be diverted from thecriminal justice system to receive care andsupport from health and social care services.The Committee considers that the key issue hereis that more needs to be done to reduce thenumber of women being sent to prison.Sentencing to custody should be a measure oflast resort and there is no obvious justificationfor not imposing community penalties in its placein the majority of cases of women offenders.The Committee recommends that communityalternatives should become the sentencing normfor women, in place of custodial sentences.The Committee recommends that more needs tobe done to ensure that community penalties areregarded as viable alternatives to custodialsentences:• they must be developed with gender sensitivity,ensuring that options are available which aredesigned for use with women• they must take account of women’sresponsibilities as carers, which means thatchildcare facilities must be developed alongsidethem.The Committee recommends that court diversionschemes be enabled to play a major part inrelation to women offenders with mental healthproblems and reiterates the view expressed inChapter 4 that further research is needed to:• establish whether there is any gender bias inthe use or efficacy of diversion schemes• determine the effectiveness of such schemes inidentifying the particular problems of womenoffenders• establish what constitutes best practice for thepurpose of the identification of mentallydisturbed offenders.The Halliday Report 2 recommends that the useof short prison sentences should be reviewed.We would go further than this. We believe thereis plenty of evidence that the imprisonment ofwomen – in the majority of cases – isdestructive and serves no useful purpose.1 The Minister was addressing the QMW Public Policy Seminar ‘TakingForward the Government’s Strategy for Women Offenders’ at the RoyalOverseas League, London on 25 September 20012 Halliday J (2001) Report of a Review of the Sentencing Framework forEngland and Wales London: Home Officepage 40

Women who challenge: women offenders and mental health issuesThe Committee recommends that active stepsshould be taken to promote the use of communitypenalties in place of custodial sentences by:• delivering community alternatives designedspecifically with women in mind• promoting and disseminating informationabout those alternatives to criminal justiceprofessionals and sentencers• training sentencers to ensure they are aware ofthe options open to them when sentencing• creating an environment in which communitypenalties are accepted as a constructive andappropriate response to crime.Community supporWe know that women offenders are prey tomany factors tending to social exclusion. Thosewho are also suffering from mental healthproblems, to whatever degree, are especiallyvulnerable. It is often difficult to identifywhether it is adverse living conditions whichhave precipitated mental disturbance or whetherfactors pertaining to social exclusion have comeabout as a result of pre-existing mental healthproblems.Either way, we believe support in thecommunity is a key factor in helping individualsto cope by providing positive strategies andreducing isolation. Community support can takea number of forms, ranging from mentoring onan individual or family basis, to community,support and self-help groups. Differentindividuals will need help with differentproblems, such as:• domestic violence• coping with children• coping while a partner is in prison• financial difficulties.Putting women in touch with others who canoffer practical advice and guidance in a nonjudgmentalway, assisting them to developcoping strategies of their own, can provide anessential lifeline to halt a downward spiral ofdecline. Ensuring that these types of support arein place and can be easily accessed is crucial interms of preventing the type of deterioration incircumstances which can precipitate offending.tThe Committee recommends that the researchcommissioned to identify factors likely to lead toreoffending (referred to in Chapter 4) should bedirected towards the development of provisionfor women in the community so that they arebetter supported before they resort to crime andthe likelihood of them developing a pattern ofoffending is reduced.The Committee urges that concerted action betaken to promote the development now ofsupportive community programmes, the benefitsof which have already been demonstrated.ResettlementResettlement issues are crucially important forwomen offenders because of the destructivenature of women’s imprisonment. While shortprison sentences are usually too short forconstructive work with women while they are inprison, they are frequently long enough to leadto tragic consequences, such as the placing oftheir children in care, the loss ofaccommodation and the loss of employment.The net effect is that women prisoners come outof prison with none of the problems solved thatgot them there in the first place, but with majoradditional difficulties to overcome, such astrying to obtain accommodation to recreate ahome for their children, and with no statutorysupport or supervision to help them.The Committee recommends that it should be arequirement to provide assistance withresettlement, regardless of the length ofsentence, since the adverse consequences ofshort-term imprisonment can be just as seriousas those of long-term imprisonment.For resettlement of women offenders to beimproved, work must begin in prison. In thecase of short-term prisoners, for example,prompt liaison with appropriate agencies maysuffice to ensure that tenancies can bemaintained pending a prisoner’s release, so thataccommodation is not lost. Access to adequateand appropriate housing is an essential andfundamental requirement. Ensuring that womenprisoners have a home to go to on release andcan access appropriate benefits without delay islikely to have a major impact on their ability tomaintain family ties and to provide for theirchildren.page 41

CHAPTER 5Accessing a job and/or training on release isimportant, and increasing the proportion ofprisoners who obtain a job on release is aresettlement target for the Prison Service.Arranging accommodation is not currently atarget for the Prison Service, though wherewomen are concerned this should actually be ahigher priority.The Committee recommends that there should bea separate resettlement strategy for male andfemale offenders since the priorities for eachgroup are not necessarily the same.The Committee argues that constructive action totackle resettlement issues from the outset in eachprisoner’s sentence is the single most likely factorto impact significantly on reoffending. Thisshould include:• taking account of throughcare issues inrelation to mental health and substance misuseproblems• identifying the key priorities for the individualprisoner• adopting a co-ordinated approach whichensures liaison and joint-working with all therelevant agencies.Comprehensive mental healthservicesThe level of psychiatric morbidity in the femaleprison population makes it clear that addressingthe mental health needs of women offendersshould be a top priority. This involves lookingat the availability and provision of mentalhealth care for women in prison, in thecommunity, and in the secure care system.First and foremost, the Committee repeats itsrecommendation that more should be done toreduce the number of women being sent to prison.For those who are held in prison, the Committeemakes the following recommendations about theprovision of mental health care:• the function of prison mental health care shouldbe to provide efficient and effective primaryc a re with proper arrangements in place for thep rompt re f e rral and transfer of prisoners tos e c o n d a ry health care settings, if re q u i re d• prisoners diagnosed as suffering from severemental illness should be transferred to hospital• where psychotropic medication is prescribed,this should be in accordance with an agreedprotocol and monitored by NHS staff – asrecommended by HM Chief Inspector of Prisonsand the Prison Reform Trust’s Committee onWomen’s Imprisonment• primary mental health care for prisonersshould include a range of options for day care,group work and psychotherapy, such as wouldbe available in the community, and should notbe limited to the prescription of psychotropicmedication.Mental health assessment schemes enable thecourts to make better informed decisions incases where mental health is an issue, so as toavoid inappropriate custodial remands andsentences.The Committee recommends that effective mentalhealth assessment schemes, building on re s e a rc hidentifying best practice, should be developed inall areas as an integral part of mainstre a mpsychiatric services in the community, so thatthey are accessible to all court s.With regard to mainstream community mentalhealth services, the Committee recommends that:• a comprehensive range of treatments andpsychotherapeutic approaches, which areaccessible to women offenders, should beprovided• barriers to access, such as lack of childcare,should be addressed in the course of servicedevelopment• proper throughcare arrangements involvingclose liaison between criminal justice agenciesand health and social care services, must bemade for patients who offend and aresubsequently imprisoned, for prisoners withmental health problems released into thecommunity, and for offender/patients whomove in and out of the secure system• throughcare arrangements must be regardedas an integral part of mainstream communitymental health provision.There will always be a need for securepsychiatric services for those women offenderswho, by reason of the nature and degree of theirmental disorder, pose a threat to themselvesand/or the public.page 42

Women who challenge: women offenders and mental health issuesThe Committee recommends that the securesystem for women should incorporate thefollowing key features:• an environment in which womenoffender/patients can feel safe• different levels of security so that patients canbe transferred to less secure provision as theircondition improves• a comprehensive range of treatments• a constructive regime of educational and otheractivities.Tackling substance misuseThe profile of women prisoners in Chapter 2demonstrates clearly that substance misuseamong women offenders is a major issue whichcannot be ignored, with up to 54% of femaleremand prisoners reporting dependence ondrugs and 38% of women prisoners reportingdrinking at hazardous levels prior toimprisonment. Substance misuse among womenoffenders must be tackled for a number ofreasons, including the following:• it is detrimental to offenders’ general healthand well-being• it can exacerbate mental health problems• it contributes to offending and reoffending,especially property crime• addiction in an offender can adversely affectthe well-being of the offender’s children• drug addiction is a major cause of bullying inprison.Resources used in the community are wasted ifan offender who has been receiving treatment oradvice is then imprisoned and treatment ceases– which happens not infrequently, as we sawfrom the ONS figures which found 54% of drugdependent women prisoners were receiving helpprior to imprisonment but this dropped to 33%who were receiving help during their currentprison term (Chapter 3).The Committee recommends that there must be aco-ordinated and strategic approach to tacklingsubstance misuse, which:• should address the issue both inside andoutside prison• does not overlook the problem of alcoholmisuse in its concentration on drug misuse• involves liaison at all stages of the criminaljustice process, as well as with communityservices.The prison population provides – literally – acaptive population and the ideal opportunity tocapitalise on this to promote health educationand provide treatment programmes to anaudience which is typically hard to engage inservices in the community. Short-term prisoners– and, as we know, that means three-quarters ofthe female prison population – potentially havethe most to lose if nothing is done to help themwhile they are in prison, if any treatment theymight have been receiving is disrupted and theyare returned to the community worse off thanbefore they were imprisoned.The Committee recommends that thisopportunity should not be missed and considersit essential that treatment options should bemade available to all prisoners, not just thoseserving longer sentences.The Committee believes a lot more needs to bedone to improve the impact and effectiveness ofthe existing substance misuse strategy andsuggests the following elements should be put inplace at the prison end of the process:• reception screening should be used to identifyprisoners with drug or alcohol problems• throughcare should be implemented fromcommunity services to prison to achievecontinuity of care• treatment/advice programmes should routinelybe offered to prisoners during the receptionprocess• the emphasis should be on providingadvice/treatment, rather than on thedisciplinary process• drug testing should be used as a mechanism toidentify prisoners who need help, not simply asa basis for the imposition of disciplinarysanctions• throughcare arrangements should routinely bemade for post-release support to take effect ondischarge.page 43

CHAPTER 5Evidence from the CARAT programme 3 indicatesa lack of adequate support is being provided ondischarge to clients who have participated in theprogramme while in custody, which again meansthat resources are being wasted. We also know(Chapter 4) that women are less likely than mento use drugs treatment services.The Committee recommends that, for thestrategy to work more effectively, the followingimprovements in community drug and alcoholservices are needed:• services tailored to the needs of women foroffenders and non-offenders alike• a programme of support and encouragementto access services, with arrangements in placeto monitor and evaluate their efficacy• active promotion of measures, such as arrestreferral schemes and the Drug Treatment andTesting Order, aimed at providing treatment asa means of tackling crime, rather thanimposing custody, together with training ofsentencers• increased resources to ensure support andthroughcare is provided to prisoners onrelease.Gender-specific servicesA key theme running through this report hasbeen the importance of ensuring that servicesmeet the needs of women.One of the areas where this is most crucial is inregard to the provision of secure psychiatricservices. It is also vital in the context ofcommunity mental health services, so as toensure that they are both accessible andeffective. It is also important not to overlook theissue of accommodation for women offendersliving in the community and to ensure that theirneeds are taken into account in the provision ofsupported housing and hostel accommodationintended to meet bail or probationrequirements. In relation to mixed hostels, thesame arguments apply as those which havealready been aired in the context of securepsychiatric units (Chapter 3).3 Nacro and the Prison Reform Trust quoted in The Government’s Strategyfor Women Offenders: Consultation Report September 2001 Home OfficeThe Committee recommends that the followingprinciples should underpin the provision ofservices for women offenders with mental healthproblems:• initiatives within the criminal justice systemand the provision of mental health servicesshould be planned with gender sensitivity inmind• the assessment of gender bias or barriers toaccess should be an integral part of theevaluation of services• a safe environment should be provided in thecommunity, as well as in in-patient services.A joined-up approachWe stated at the outset that women offenderswith mental health problems present anextremely complex array of challenges to themany agencies and organisations involved inworking with them. It is the very range anddiversity of issues which come into play whendealing with those challenges which make agenuinely joined-up approach to policydevelopment at once indispensable and yethighly difficult to achieve.There is evidence, however, that theGovernment is failing to deliver its muchvaunted joined-up approach from the centre.There have been a plethora of initiatives,especially in the fields of health and criminaljustice, some aimed specifically at women andsome not, but co-ordination and management ofthese appears to be lacking. For example,neither the original document on theGovernment’s strategy for women offenders northe feedback report published in September2001 make any reference to the forthcomingnational strategy for women’s mental health,even though mental health is acknowledged tobe an important issue in the context of women’soffending.There is no clearly identifiable list of initiatives,activities or milestones relating to womenoffenders generally, or female mentallydisturbed offenders in particular, which allowsindependent scrutiny of targets and timescaleswith a view to ensuring that promisedimprovements are being delivered and thatessential co-ordination is happening. We havepage 44

Women who challenge: women offenders and mental health issuesattempted below to compile a list of currentinitiatives, reviews and activities – which, by nomeans, claims to be definitive – to illustrate theproblem:• a national strategy for women’s mental health• elimination of mixed sex accommodation fromthe NHS• implementation of MHNSF targets• plans for modernising mental health servicesin prisons• plans for delivering a full range of secureprovision• Women’s Services Project aimed at identifyingthe needs of women with dangerous severepersonality disorder and developing specialistservices for them• development of the Women’s OffendingReduction Programme• research into a variety of issues, including:– characteristics which lead to reoffending– barriers to accessing services• extending the availability of arrest referralschemes• analysis of resettlement pathfinderevaluations• responding to recommendations of theHalliday Report• social exclusion initiatives.It is encouraging to see so much work going onbut there is a danger – highlighted by theexamples referred to in the context of substancemisuse (page 25) – of resources being wastedbecause of a lack of co-ordination of what isrequired at different stages of a process. Also,what mechanism is there for ensuring thatheralded improvements have been implementedor achieved? With so much going on, it isextremely difficult to keep track.The Committee recommends that for currentinitiatives to be productive and to be made towork effectively, there must be joined-upthinking and working at two levels: at a nationallevel in terms of Government thinking and policymaking, with cross-departmental initiatives andco-ordination, and at a local level in terms ofinter-agency working and agreements. It is nogood having one without the other. TheGovernment must take the lead and set theexample by pursuing a genuinely joined-upapproach at a policy level, which will translateon implementation into good practice on theground.The Committee recommends that, as a first step,what is needed is a fully comprehensive list of allactivities and initiatives relevant to womenoffenders, complete with target andimplementation dates, which is regularlyupdated so that the current state of play isapparent where targets have been missed ortimescales have been revised. This needs to bereadily accessible to practitioners and policymakers alike to facilitate the co-ordination ofactivities and liaison with relevant parties toachieve joined-up working.The Committee recommends this should be set upand maintained on the Women and EqualityUnit’s website.However, above all, the Committee believes thatthere is an overarching need for an overallstrategy aimed at co-ordinating the variouspieces of work relating to women offenders ingeneral, and those with mental health problemsin particular. The Committee hopes this paperhas demonstrated that it is in everyone’s intereststo give a high priority to the development andimplementation of such a strategy: bysuccessfully tackling these issues, society as awhole would be likely to benefit from theresulting reduction in offending behaviour andsocial exclusion and the improvements to familyunity.page 45

BibliographyAllen H (1987) Justice Unbalanced: Gender Psychiatry andJudicial Decisions Open University PressBland J, Mezey G and Dolan B (1999) ‘Special women,special needs: a descriptive study of female specialhospital patients’ Journal of Forensic Psychiatry 10 (1):34-45Caddle D and Crisp D (1997) Mothers in Prison. HomeOffice Research Findings No. 38 London: Home OfficeCampbell S and Harrington V (2000) Youth Crime:Findings from the 1998/99 Youth Lifestyles Survey HomeOffice Research Findings No.126 London: Home OfficeCarlen P (1983) Women’s Imprisonment London: Routledge& Kegan Paul– (1998) Sledgehammer: Women’s Imprisonment at theMillennium London: Macmillan PressCoid J (1988) ‘Mentally abnormal prisoners on remand:rejected or accepted by the NHS’ British MedicalJournal 296: 1779-82Committee on Women’s Imprisonment (2000) Justice forWomen: the Need for Reform London: Prison ReformTrustDell S, Robertson G, James K and Grounds A (1993)‘Remands and psychiatric assessments in HollowayPrison I: the psychotic population; II: the non-psychoticpopulation’ British Journal of Psychiatry 163: 634-44Department of Health (1997) The Patient’s Charter:Privacy and dignity and the provision of single sexhospital accommodation NHS Circular EL 97(3) London:Department of Health– (1999) National Service Framework for Mental Health:M o d e rn Standards & Service Models London: Depart m e n tof Health– (2001a) Children looked after in England; 2000/2001.Statistical Bulletin 2001/26 London: Department ofHealth– (2001b) In-patients formally detained in hospitalsunder the Mental Health Act 1983 and other legislation,England: 1990-1991 to 2000-2001. Statistical Bulletin2001/28 London: Department of HealthDepartment of Health, HM Prison Service and NationalAssembly for Wales (2001) Changing the Outlook: AStrategy for Developing and Modernising Mental HealthServices in Prisons London: Department of HealthDepartment of Health and Welsh Office (1999) MentalHealth Act 1983 Code of Practice London: TheStationery OfficeDevlin A (1998) Invisible Women Winchester: WatersidePressHalliday J (2001) Report of a Review of the SentencingFramework for England and Wales London: Home OfficeHealth Committee (2000) Fourth Report (Provision of NHSMental Health Services)Heidensohn F (1994) ‘Gender and crime’ in Maguire M,Morgan R and Reiner R (eds) The Oxford Handbook ofCriminology Oxford: Clarendon PressHM Chief Inspector of Prisons (1996) Patient or Prisoner?:A New Strategy for Health Care in Prisons London:Department of Health– (1997) Women in Prison: A Thematic Review London:Home Office– (2001) Follow-up to Women in Prison London: HomeOfficeHM Prison Service (1999) Health Care Standards forPrisons in England and Wales London: HM Prison Service– (2000) Caring for the Suicidal in Custody: EliminatingStrip Cells Prison Service Instruction 27/2000 London:HM Prison ServiceHM Prison Service and NHS Executive (1999) The FutureOrganisation of Prison Health Care London: Departmentof HealthHome Office (1990) Circular 66/90 Provision for MentallyDisordered Offenders London: Home Office– (1992) The National Prison Survey 1991 London:HMSO– (1997) Understanding the sentencing of women HomeOffice Research Study 170 London: Home Office– (2000) The Government’s strategy for women offendersLondon: Home Office– (2001a) The Government’s Strategy for WomenOffenders: Consultation Report September 2001 London:Home Office– (2001b) Prison Population Brief, England and Wales:October 2001 London: Home Office– (2001c) Statistics of mentally disordered offenders2000 Home Office Statistical Bulletin 22/01 London:Home Office– (2001d) Statistics on Women and the Criminal JusticeSystem London: Home OfficeHoward League for Penal Reform (2000) A Chance toBreak the Cycle: Women and the Drug Treatment andTesting Order London: Howard League for Penal ReformJames D (1999) ‘Court diversion at 10 years: can it work,does it work and has it a future?’ Journal of ForensicPsychiatry 10: 507-524Lloyd A (1995) Doubly Deviant, Doubly Damned London:PenguinMaden A (1996) Women, Prisons and Psychiatry: MentalDisorder Behind Bars Oxford: Butterworth HeinemannMaden A, Swinton M and Gunn J (1994) ‘A criminologicaland psychiatric survey of women serving a prisonsentence’ British Journal of Criminology 34 (2): 172-191May T, Edmunds M and Hough M (1999) Street Business:The Links Between Sex and Drugs Markets. PoliceResearch Series Paper 118 London: Home OfficeMeltzer H, Gill B, Petticrew M and Hinds K (1995) OPCSSurveys of Psychiatric Morbidity in Great Britain Report1: the prevalence of psychiatric morbidity among adultsliving in private households London: HMSONacro (2001) Women Beyond Bars London: NacroNelson-Owen M (1997) ‘A doctor’s dilemma’ BritishMedical Journal 315: 553-554O’Brien M, Mortimer L, Singleton N & Meltzer H (2001)Psychiatric morbidity among women prisoners inEngland and Wales London: Office for NationalStatisticsReed JL and Lyne M (2000) ‘Inpatient care of mentally illpeople in prison: results of a year’s programme ofsemistructured inspections’ British Medical Journal 320:1031-1034Richards M et al (1996) Imprisonment and family tiesLondon: Home OfficeSingleton N, Meltzer H, Gatward R, Coid J and Deasy D(1998) Psychiatric morbidity among prisoners inEngland and Wales London: The Stationery OfficeStafford P (1999) Defining gender issues … redefiningwomen’s services WISHWark P (2001) ‘Madness is a release from all this’ TheTimes 7 September 2001page 46

APPENDIX 1Women who challenge: women offenders and mental health issuesThe female prison estateSource: The Government’s Strategy for Women Offenders: Consultation Report, Home Office, September 2001*Askham GrangeYorkFemale prison and young offender institutionCategory: openBrockhillRedditch, WorcsFemale prison and young offender institutionCategory: localBullwood HallHockley, EssexFemale prison and young offender institutionCategory: closedCookham WoodRochester, KentFemale prison and young offender institutionCategory: closedDownviewSutton, SurreyFemale prisonCategory: closedDrake HallEccleshall, StaffsFemale prison and young offender institutionCategory: semi-openDurhamDurhamPrison and close supervision centre (shared site)Category: B, local male and femaleEast Sutton parkMaidstone, KentFemale prison and young offender institutionCategory: openEastwood ParkWotton-under-Edge, GloucestershireFemale prison and young offender institutionCategory: closed female remand, local trainingFoston HallFoston, DerbyshireFemale prison and young offender institutionCategory: closedHighpointNewmarket, SuffolkPrisonCategory: closed female, C maleHollowayLondonFemale prison and young offender institutionCategory: localLow NewtonBrasside, DurhamFemale prison and young offender institutionCategory: local and closedMorton HallSwinderby, LincolnFemale prisonCategory: semi-openNew HallWakefield, West YorkshireFemale prisonCategory: closedSendSend, SurreyFemale prisonCategory: closedStyalWilmslow, CheshireFemale prisonCategory: local and closedWinchesterWinchesterPrisonCategory: Male local and female annex closed* It was announced in November 2001 that HMP Buckley Hall, Rochdale, was to be converted to house women in an attempt to copewith the dramatic rise in the female prison population.page 47

APPENDIX 2Service modelsForensic mental health servicesCalderdale &Kirklees ForensicMental HealthServicesA service for individuals with mentalhealth problems or challenging behaviourswhich is delivered through inter-agencycollaboration. It promotes a balancebetween individual autonomy and socialresponsibility through a risk managementframework.Contact:Calderdale & Kirklees Forensic Mental HealthServices, St Luke’s Hospital, BlackmoorfootRoad, Huddersfield, West Yorkshire HD4 5RQTel: 01484 343010Fax: 01484 343575Email: ru t h . h e a t o n @ c h t . n h s . u kThe Hutton Centr eTees and North EastYorkshire NHS TrustForensic ServicesA multi-disciplinary mental health teamproviding health care within prisonsettings. The centre aims to provideprisoners with a service equitable to thatwithin mainstream NHS psychiatricservices. Includes female prisoners withinthe Durham cluster of prisons.Contact:The Hutton CentreTees & North East Yorkshire NHS TrustForensic ServicesSt Luke’s Hospital, Marton Road,Middlesbrough, Cleveland TS4 3AFTel: 01642 283340Fax: 01642 283345Email: s.collman@ntlworld.comMid-Cheshir eHospitals NHS T rustForensic Liaison SchemeThe scheme provides:• psychosocial assessments for court,custody, probation and bail• a comprehensive rapid response servicefor people who come into contact withthe criminal justice system, who aresuspected of having mental healthproblems• an outreach service for probation, bailand prison• the care programme approach withinlocal prisons (including HMP Styal)Contact:Forensic Liaison TeamMental Health Unit, Leighton Hospital, CreweCheshire CW1 4QJTel: 01270 612299Fax: 01270 612104Email: admin@mchmh.1to1.orgNorfolk MentalHealth Care NHSTr ustForensic DirectorateA service which provides specialistassessment, treatment and rehabilitationfor mentally disordered patients whocreate major psychiatric managementproblems and who have usually offended.Contact:Norfolk Mental Health Care NHS Trust,Forensic Directorate, Norvic Clinic, StAndrew’s Business Park, Thorpe St Andrew,Norwich, Norfolk NR7 0HTTel: 01603 421045Fax: 01603 701954Email: Chris.chambers@norfmhctr.anglox.nhs.ukNorth West AngliaHealthcare T rustMental HealthAssessment TeamThe Mental Health Assessment Teamprovides urgent psychosocial assessmentfor those in crisis presenting with issuessuch as self-harm. Referrals come from avariety of sources, including the voluntarysector and the police. The aim is toidentify what care and support is neededand to refer clients to relevant agencies.Contact:North West Anglia Healthcare Trust, LucilleVan Geest Unit, Peterborough DistrictHospital, Thorpe Road, PeterboroughCambridgeshire PE3 6DATel: 01733 318152Fax: 01733 318140Email: jhudson@nwahc-tr.anglox.nhs.ukpage 48

Women who challenge: women offenders and mental health issuesNottinghamHealthcare NHS TForensic CommunityTeamrustThis is a multi-disciplinary team, whichworks with criminal justice agencies toprovide a screening, assessment andliaison service for individuals in custody,and has access to a low secure unit, aforensic ward and rehabilitation services.Contact:Nottingham Healthcare NHS TrustThe Wells CentreThe Wells RoadNottingham NG3 3AATel: 0115 969 1300 (x 49585)Fax: 0115 952 9420Email: carronm@nadt.org.ukPersonality disorder servicesHaringey Healthcar eNHS T rustPsychological TherapiesServiceDorset Healthcar eNHS T rustIntensive PsychologicalTherapies ServiceThis service provides psychotherapeutictreatment of personality disorder throughan evidence-based integrated approach,using group and individual therapy withmedication. It is tailored to the specificneeds of patients with severe personalitydisorder.An outpatient service for patients withpersonality disorders, many of whom areparasuicidal. Aims to provide evidencebasedpsychological interventions and todevelop awareness and clinical expertisein this area.Contact:Halliwick Psychotherapy Day Unit, St Ann’sHospital, St Ann’s Road, London N15 3THTel: 020 8442 6544Fax: 020 8442 6545Email: halliwick.therapy@hhct.thenhs.orgContact:Intensive Psychological Therapies Service,Dorset Healthcare NHS trust, BranksomeClinic, 51A Layton Road, Parkstone, DorsetBH12 2BJTel: 01202 735300Fax: 01202 734092Email: susan.clarke@dorsethc-tr.swest.nhs.ukRampton HospitalPersonality DisorderServiceThis service uses evidence-basedinterventions in a structured therapeuticenvironment to address patients withdysfunctional personalities and to reducethe risks posed by offending behaviour.Contact:Personality Disorder ServiceRampton Hospital, Retford, Notts DN22 0PDTel: 01777 247220Fax: 01777 247303Email: chris.anderton@ramptonhosp.trent.nhs.ukPrison-based servicesThe Bourne T rustFirst Night in Custody inHolloway ProjectThe project aims to make contact withdistressed women entering HMP Hollowayfor the first time in order to assess theirmental health needs and reduce theiranxiety by finding out what help theyneed with immediate practical issues.Contact:The Bourne Trust, Lincoln House, 1-3 BrixtonRoad, London SW9 6DETel: 020 7607 6747 (x 2656)Fax: 020 7735 6077Website: www.imprisonment.org.ukHMP Eastwood ParkCounselling and SupportServiceProvides induction and assessmentprocedures for early identification ofwomen prisoners with mental healthproblems. Also provides counselling andan information on the successful aftercareof women when they return to thecommunity.Contact:Keith Boulton, HMP Eastwood Park, Falfield,Wotton-under-Edge, Gloucestershire GL128DBTel: 01454 262115page 49

APPENDIX 2Community-based servicesBlack Women’ sMental HealthProjectCommunity basedservicesIncludes a drop-in and advice service, aswell as mental health workshops andseminars.Contact:Black Women’s Mental Health Project, 12Donovan Court, Exton Crescent, Stonebridge,London NW10 8DATel: 020 8961 6324Elizabeth Fry FamilyCentr eA local voluntary agency working inpartnership with health and socialservices to provide family centre supportfor families with young children at a timewhen they are experiencing difficulties intheir family life.Contact:Elizabeth Fry Family Centre, All SoulsCommunity Centre, Ilkeston Road, Radford,Nottingham NG7 3HFTel: 0115 970 6221Home-Start UKA voluntary organisation in whichvolunteers offer regular support,friendship and practical help to youngfamilies under stress in their own homes.The service aims to help prevent familycrisis and breakdown and emphasise thepleasures of family life.Contact:2 Salisbury Road, Leicester LE1 7QRTel: 0116 233 9955Fax: 0116 233 0232Email: info@home-start.org.ukWebsite: www.home-start.org.ukNewham AsianWomen’s ProjectThis service includes a mental health andclient support project to provide clientswho experience mental or emotionaldistress with complete packages of care.Contact:661 Barking Road, Plaistow, London E13 9EXTel: 020 8472 0528Fax: 020 8503 5673Domestic violence helpline: 020 8552 5524Website: www.nawp.orgRevolving DoorsAgencyLink Worker SchemeThis service aims to improve access tosupport in the community for people withmental health and multiple needs whocome into contact with the criminal justicesystem. Experimental teams operate inEaling, Tower Hamlets, Islington andSouth Buckinghamshire.Contact:45-49 Leather Lane, London EC1N 7TJTel: 020 7242 9222Fax: 020 7831 5140Email: admin@revolving-doors.co.ukWebsite: www.revolving-doors.co.ukSure-Star tThis service aims to improve the wellbeingof families and children. It doesthis by setting up local Sure-Startprogrammes to improve services forfamilies with children under four yearsand by spreading good practice fromlocal programmes to all involved inproviding services for young children.Contact:Sure Start Unit, Level 2, Caxton House, TothillStreet, London SW1H 9NATel: 020 7273 4830Fax: 020 7273 5182Email: sure.start@dfes.gov.ukWebsite: www.surestart.gov.ukThreshold Women’Mental HealthInitiativesRun by women for women, the schemeprovides mental health services forwomen on low incomes in East Sussex. Itincludes community drop-in sessions,counselling, group therapy and supportgroups.Contact:14 St George’s Place, Brighton BN1 4GBFax: 01273 626444National Women and Mental HealthInformation Line: 0845 300 0911Email: thrwomen@globalnet.co.ukWebsite:www.users.globalnet.co.uk/~thrwomen/page 50

Women who challenge: women offenders and mental health issuesOrganisations, self-help and support groupsAlcoholicsAnonymousPO Box 1, Stonebow House,Stonebow, York YO1 7NJTel: 01904 644026National Helpline: 0845 7697555Website: www.alcoholicsanonymous.org.ukMental HealthFoundation20/21 Cornwall Terrace,London NW1 4QLTel: 020 7535 7400Fax: 020 7535 7474Email: mhf@mhf.org.ukWebsite:www.mentalhealth.org.ukAlcohol Concer n Waterbridge House, 32-36Loman Street, London SE1 0EEConsumer CreditCounsellingService (CCCS)CRUSEBereavement CareTel: 020 7928 7377Helpline: 0800 917 8282Fax: 020 7928 4644Email:contact@alcoholconcern.org.ukWebsite:www.alcoholconcern.org.ukWade House, Merrion Centre,Leeds LS2 8NGTel: 0113 297 0121Helpline for free debt advice:0800 138 1111Email: info@cccs.co.ukWebsite: www.cccs.co.ukCruse House, 126 Sheen Road,Richmond, Surrey TW9 1URTel: 020 8939 9530Helpline: 0870 167 1677Fax: 020 8940 7638Email:info@crusebereavementcare.org.ukWebsite:www.crusebereavementcare.org.ukMindNarcoticsAnonymousGranta House, 15-19 Broadway,London E15 4BQTel: 020 8519 2122Fax: 020 8522 1725Email: contact@mind.org.ukWebsite: www.mind.org.ukUK Service Office, 202 CityRoad, London EC1V 2PHTel: 020 7251 4007UK Helpline: 020 7730 0009Fax: 020 7251 4006Email: helpline@ukna.orgWebsite: www.ukna.orgNHS Direct Helpline: 0845 4647Website: www.nhsdirect.nhs.ukNationalSchizophreniaFellowshipHead Office, 30 TabernacleStreet, London EC2A 4DDTel: 020 7330 9100National Advice Line: 020 89746814Fax: 020 7330 9102Email: info@nsf.org.ukWebsite: www.nsf.org.ukDepressionAllianceDrugScope35 Westminster Bridge Road,London SE1 7JBTel: 020 7633 0557Fax: 020 7633 0559Email:information@depressionalliance.orgWebsite:www.depressionalliance.org32-36 Loman Street, LondonSE1 0EETel: 020 7928 1211National Drugs Helpline: 0800776600Fax: 020 7928 1771Email:services@drugscope.org.ukWebsite:www.drugscope.org.ukRefugeRelateRoyal College ofPsychiatrists2-8 Maltravers Street, LondonWC2R 3EETel: 020 7395 7700Helpline: 0870 599 5443Fax: 020 7395 7721Email: info@refuge.org.ukCentral Office, Herbert GrayCollege, Little Church Street,Rugby, Warwickshire CV21 3APTel: 01788 573241Helpline: 0845 130 4010Fax: 01788 535007Email:enquiries@national.relate.org.ukWebsite: www.relate.org.uk17 Belgrave Square, LondonSW1X 8PGTel: 020 7235 2351Fax: 020 7245 1231Email: rcpsych@rcpsych.ac.ukWebsite: www.rcpsych.ac.ukpage 51

APPENDIX 2The SamaritansThe Upper Mill, Kingston Road,Ewell, Surrey KT17 2AFNational Helpline: 0845 7909090Website:www.samaritans.org.ukFor information aboutvolunteers visiting local prisonsand prisoner listener schemes,email: admin@samaritans.orgSANE 1st Floor, Cityside House, 40Adler Street, London E1 1EETel: 020 7375 1002Helpline: 0845 767 8000Fax: 020 7375 2162Email: london@sane.org.ukWebsite: www.sane.org.ukWomen’s AidFederationWomen in PrisonWomen in SpecialHospitals (WISH)PO Box 391, Bristol BS99 7WSTel: 0117 944 4411National domestic violencehelpline: 0845 702 3468Fax: 0117 924 1703Email: web@womensaid.org.ukWebsite:www.womensaid.org.uk22 Highbury Grove, London N52EATel: 020 7226 5879Email:admin@womeninprison.org.ukWebsite:www.womeninprison.org.uk15 Great St Thomas Apostle,London EC4V 2BBTel: 020 7329 2415Fax: 020 7329 2416Email:wishlondon@compuserve.compage 52

Women who challengeWomen offenders and mental health issuesMental health problems can contribute to women’soffending and may be exacerbated rather thanaddressed in prison. This can be extremelydamaging both to the women themselves and totheir families and children. The aim of Women whochallenge is to provide a comprehensive overviewof the problems faced by female prisoners withmental health problems. The report argues thatthere are a number of key issues which need to beaddressed, including the impact of imprisonmenton women and their families; mental health care ofwomen prisoners; substance misuse; provision forwomen in the secure mental health services; anddifferences in the way men and women are treatedby the criminal justice system. Women whochallenge examines the emerging and existingstrategies to tackle the challenges presented bywomen offenders with mental health problems andmakes recommendations about what more shouldbe done to address their needs.£12.50