Why are some mentally ill patients treated like criminals?

This article titled “Why are some mentally ill patients treated like criminals?” was written by Amelia Gentleman, for The Guardian on Wednesday 1st June 2011 19.30 UTC

By the time Joe Paraskeva started smashing his fist through the mirrors at his family home, saying he could no longer bear to look at his own face, his mother realised that he was having another serious mental health crisis and needed urgent medical help.

On 4 October last year, Linda Morgan accompanied her 20-year-old son to a secure unit within the adult psychiatric ward of a large London hospital where he was subsequently sectioned under the Mental Health Act. He had already spent seven months in an adolescent mental health unit when he was 17, where he was diagnosed and treated for bipolar affective disorder, but this was the first time he had been inside an adult unit and Morgan recalls that when she said goodbye, her son was very nervous at being left alone.

Two days later, frightened and disturbed, he tried to escape from the wing, attempting (unsuccessfully) to burn a hole in the doors by lighting his aerosol deodorant and firing the flame towards the lock. No one was hurt and only a couple of hundred pounds’ worth of damage was caused, Morgan says. Paraskeva pleaded guilty to arson and on 5 April he was given an indeterminate sentence of imprisonment for public protection (IPP), with a minimum requirement of two years in prison but no maximum limit – which means he could, depending on his behaviour, be detained for life.

His mother cannot understand how a patient sectioned within a mental health ward and apparently seriously ill has been given such a severe punishment. Her son, who had no previous criminal convictions, offered to pay for whatever damage was caused when he pleaded guilty. She is horrified that within two days of voluntarily admitting himself to hospital on grounds of mental ill health, he was transferred first to a police cell, and then subsequently to prison. Paraskeva is serving his sentence at Chelmsford Young Offenders Institute, and although he has spent some time on the medical wing there, he is currently with other prisoners in the general section of the institution.

“I don’t think that Joe should have been sent to prison at all after committing an offence under section in a psychiatric ward. He doesn’t need punishment; he needs help,” Morgan says. Confused and horrified by the speed with which her son was moved from being a patient to a prisoner, she has launched an online campaign, Justice for Joe.

The case is complex, but the questions raised by his apparently harsh treatment by the criminal justice system feed into an ongoing debate on how offenders with mental health problems should be dealt with. The Justice secretary, Ken Clarke, published a green paper, Breaking the Cycle: Effective Punishment, Rehabilitation and Sentencing of Offenders, last December, which aims to cut the exploding 85,000 prison population using more intelligent sentencing and introducing measures to address high reoffending rates. The paper includes proposals aimed at diverting the mentally ill away from prison and into treatment programmes, initiatives that have been broadly welcomed by mental health charities.

The judge’s decision rests on an assessment by the psychiatrist at the Homerton hospital that Joe was not suffering from a mental illness at the time of the arson attack. His mother is bemused by that assessment, given that he had so recently been sectioned for a 28-day assessment period, and she remains unclear about how doctors came to this conclusion. Although the doctor concluded that Paraskeva was not unwell, he also concluded that he was not dangerous. The judge’s decision that he did pose a risk to the public, warranting an IPP, was based on a risk assessment compiled by a probation officer who had not met Paraskeva. The probation officer’s analysis was formed by inputting facts about the case and Paraskeva’s background into a computerised risk-analysis system, which crunched the data through complex algorithms and categorised him as dangerous. The case has triggered unease among mental health campaigners.

Marjorie Wallace, chief executive of Sane, says: “In our view this case is cruel and inhumane, yet sadly this happens all too often. There are 70% of prisoners who have two or more psychiatric conditions. Sane questions why a young man who is known to suffer from a serious mental illness should be taken to prison where, because of the IPP, he could be detained for many years.

“He is being given a double penalty – a deeply debilitating illness and being treated as a criminal and not receiving the treatment he desperately needs. Had he been judged under the Mental Health Act he could receive medication and therapies, and be able to appeal to a tribunal when the symptoms of his illness were controlled.”

Wallace argues there is a need for urgent reform so that prisoners such as Paraskeva do not end up in prison. “We believe that prisons are now the ‘dumping grounds’ replacing psychiatric institutions – which have been closing by the day. Many of the old ‘asylums’ were replaced by prisons,” she adds.

Although unable to comment on the details of this case, Jane Harris from the charity Rethink Mental Illness says: “Much more money needs to be invested in the system so that people aren’t just locked away and left to deteriorate. This does not serve the interests of those who are ill, or wider society, as it does nothing to help people recover, which would reduce reoffending in the longterm. We need to make sure that people with illnesses such as bipolar get help to improve their mental health. Sadly, too often people in prisons and young offender institutions do not get the help they need.”

Juliet Lyon, director of the Prison Reform Trust, is very uneasy at the ongoing use of IPPs to punish people with mental problems. “Despite some efforts to curb its ambit, far too often this Kafkaesque indeterminate sentence is handed down to people with mental health problems or learning disabilities,” she says. “This effectively condemns them to years of uncertainty during which time they must somehow prove, from the confines of a bleak prison, that they no longer present a risk to the public. The means to do this – attendance at scarce offending behaviour programmes – is barred to people with a diagnosable mental disorder, those on medication and anyone with a low IQ score, trapping the most vulnerable in a maze with no exit.”

In the kitchen of her house in Dalston, east London, Morgan, a landscape gardener, describes how her son began first to get ill in 2007 when he was due to take his GCSEs and was diagnosed with bipolar affective disorder when he was 17, during a seven-month stay in a specialist adolescent mental health unit. His father has suffered form the same condition all his life and Morgan was led to understand when her son was diagnosed that this would be a permanent condition. Medication helped to manage the disorder for a while, but when he turned 18, Paraskeva was transferred to an adult mental health team.

Morgan feels the new service offered less instensive medical support than what had been on offer previously. In July 2009, fed up with the side-effects, Paraskeva stopped taking his pills, to the dismay both of his mother and his doctor. “He didn’t like the side-effects; he thought he was not really feeling reality,” Morgan says. “There was also huge weight gain because the pills make you feel hungry when you are not.” Her son tried attending several college courses, but felt unable to motivate himself. By last summer she was very concerned by his deteriorating condition.

“He started becoming more paranoid. I knew he was becoming more ill all summer. He stopped looking after himself,” she says. “He would go missing and I would have to report him to the police as a vulnerable person.” At the end of August, he hit his sister during an argument.

“It was the first time he had done this and his behaviour frightened him. He sought psychiatric help in the community but support did not come soon enough. Within weeks of this incident, he had admitted himself to the psychiatric unit of the local hospital, as he had been advised to do,” Morgan says.

On 29 September 2010, Paraskeva called 999 and asked the police to take him into hospital, saying he could no longer control his behaviour. “He was obviously very desperate. I don’t think many young people would call the police and ask to be taken to hospital. He was punching walls and doors and hurting himself. He was becoming very ill. He refused to write down his name in the dentist’s surgery because he was so paranoid,” Morgan says. The police were very sympathetic, and took him to hospital, but the A&E ward was crowded and after a few hours of waiting, he returned home.

“That Sunday evening, he packed his bag again and said he wanted me to go with him to hospital. He had damaged his hand breaking a mirror. He was fearful about himself. I was very pleased that he had decided to go into hospital again,” Morgan says.

They had another long wait in A&E, before being admitted to the secure, acute ward of the adult psychiatric unit at around 2.30am on 4 October. The next day he was formally sectioned. “He was definitely paranoid; he couldn’t control his behaviour. The doctors agreed to assess his mental state and he was detained so he couldn’t leave,” Morgan says.

Although he seemed calm initially, less than 48 hours later Paraskeva was very distressed, wanted to go home and decided he would try to escape, Morgan says. “It is a very common occurrence to try to escape from a psychiatric ward, I gather. He set fire to some newspapers on the floor of his ward and he also burned the doors using a lighter and an aerosol deodorant. He jumped on a table and threw a fire extinguisher – when he is in that kind of mood, he thinks he is in a cartoon,” Morgan says. “Apparently he kept saying: ‘I want to get out.'” He was arrested and transferred to a police station in the early hours of 6 October.

“I think that was an odd thing to do. Personally I don’t think he was responsible for his actions. He had never been in prison before. Over the course of a few days he had been in an adult psychiatric ward for the first time, and then in prison, charged with arson. The prison asked for a hospital transfer but the hospital did not want him back,” Morgan says.

The severity of the sentence rests on the assessment by the hospital doctor that Paraskeva was not mentally ill when the attack occurred. Medical staff have also questioned the original diagnosis of bipolar disorder, according to Paraskeva’s lawyer, Graeme Hydari. He is in the process of lodging an appeal.

Morgan is not clear why the diagnosis was under question, nor does she understand why her son has been classified as a danger to the public, and points out that he was charged with the lesser offence of simple arson, rather than the more serious crime of arson with recklessness or intent to endanger life. The hospital was unable to comment because of rules on patient confidentiality. Staff at the young offenders institute have been very understanding, Morgan says, and have told her that they believe her son is unwell. But while the prison psychiatrist recommended a transfer to a hospital, the doctor from the hospital in Hackney did not support this application for a transfer, Hydari says.

“It was surprising that the judge felt able to conclude that Joe was ‘dangerous’ based on a probation report prepared by a probation officer whom Joe had refused to meet and in circumstances where a consultant psychiatrist who had interviewed him had stated that he was not ‘dangerous’. This had resulted in a sentence of indefinite imprisonment based primarily on a report by someone who had never met Joe,” Hydari adds.

“We have lodged an application for leave to appeal against sentence based on the fact that the sentence is manifestly excessive, taking into account Joe’s previous good character and guilty plea. We do not believe that the judge had taken sufficient regard of Joe’s previous psychiatric history, including a previous compulsory hospitalisation or the fact that he was a compulsory inpatient in hospital for a psychiatric assessment at the time of the commission of the offence.”

Paraskeva’s mother says she feels amazed at how the criminal justice system has sucked her son into a Kafkaesque trap. “The sentence is unbelievably harsh. It is an extremely serious conviction that will ruin Joe’s life. A young man with serious and enduring mental health problems who tried to escape from a psychiatric ward is being treated as a criminal. We are shocked and dismayed that his diagnosis and previous psychiatric history have been disputed and ignored,” she says.

“Is this how we treat ill young adults? He got immediate, responsive care when he was an adolsecent and he has not received this as an adult. I have very little faith left in the mental health system. Why was he told to go to A&E? He thought he was in a safe place where he would be looked after, but he ended up in prison, facing the rest of his natural life in jail. They suggest he is a danger to himself and others but he should be in a hospital under section, encouraged to take his medication and have some therapy.”

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