What happens to mentally ill ex-offenders when they are released back into a community that often views them with suspicion and fear? Community psychiatric nurse Ruth White talks about keeping patients on the straight and narrow and the importance of understanding their view of reality.
Mental illness makes many of us feel uncomfortable and the resulting discrimination runs deep, despite the plethora of laws and right-on noise to the contrary. This reaction can be extreme when mentally ill offenders are released and it’s hardly surprising, given the media attention that often accompanies high-profile murder cases involving mental illness and their cumulative influence on the public psyche.
It is also highlighting misleading; reoffending rates amongst those suffering from a mental illness are low compared to ex-prisoners and the prospect of becoming a victim is highly unlikely.
It is hard to gauge what effect this backdrop of prejudice has on patients re-entering society on top of their daily struggle to manage conditions, such as bi-polar disorder and schizophrenia. Freedom brings its own challenges and offenders spend an average of five years in a medium security unit before being released. They often face an uphill struggle, including the day-to-day challenge of managing their condition, resisting the temptations of returning to their old life, public stigma, isolation and finding employment.
At present, I have a caseload of 15 patients who I see on a regular basis, including ex-murderers, rapists and armed robbers. Caseloads are kept manageable so that we can provide intensive support and close monitoring. My clients would have all originally received a hospital order (Section 37/41) rather than a prison sentence because of mental illness. They remain subject to strict conditions set out prior to their release. This includes where they live and an obligation to remain in regular contact with a community support team that includes a psychiatrist, mental health nurse, social worker and sometimes a psychologist.
A conditionally discharged patient lives in a hostel for between 18 months and two years, before being supported to move on to independent accommodation. My role is to monitor and assess an individual’s progress, as well as ensure they meet the conditions of their release.
The advantage of a hospital order is that someone can be immediately recalled to a secure unit if deemed a risk to themselves or others. It negates the need for a mental health act assessment, which can take several days to arrange, and ensures the patient remains in the unit until a panel of experts or the Justice Minister decide otherwise.
This is a very much a last resort and our efforts remain focused on helping ex-offenders manage their condition on a day-to-day basis and hopefully move towards finding employment. The price of freedom can be a tough pill to swallow with ex-offenders surviving on benefits in often low-quality accommodation. The odds of finding employment are stacked against them through a combination of prejudice, previous convictions and lack of employable skills.
The practicalities of my job includes home visits, so as to to keep an eye on patient’s condition, ensuring they take their medication, screening them for alcohol and drug use and helping out with issues such as housing and benefit payments.
I also conduct random drug tests if I suspect that someone is using. This is especially true for drugs like crack cocaine which only stay in the system for 24 hours. Cannabis is another popular drug and can lead to psychosis. We also have an on-going problem with ‘legal highs’, many of which don’t show up in conventional testing.
The insights gained by a home visit - compared to meeting in a clinical setting like a surgery - are invaluable and often present tell-tale signs if something is wrong. An untidy living space, curtains drawn during daylight hours, a lack of foodstuffs and poor personal hygiene are all physical indications that something might be amiss.
A patient’s mental state can change for a number of reasons - some more obvious than others. I’ve walked into flats littered with bottles after drink binges, drug paraphernalia including crack pipes and foil; I have patients who miss appointments, go A.W.O.L or don’t take the medication which helps to stabilise their condition.
These are extremes but adapting to the outside world as well as managing a mental illness can be testing and patients can readily contact me through my work mobile. A recent example was someone worried about the increased frequency of voices inside her head. I was round there the same day to provide support and assess her mental state.
I think it’s important to treat people as you’d expect to be treated yourself, irrespective of their mental health. A large part of that is listening to what people have to say and not labelling their experience because of their condition. It’s easier said then done because we make presuppositions and assumptions about situations and individuals we are familiar with. It’s important to recognise that none of us experience events in exactly the same way because we all view the world through our personal lens of experiences and beliefs. Our perception of reality isn’t reality itself - it’s just our take on it and that understanding has to be extended to people with mental illness.
It certainly highlights the need to look beyond a patient’s immediate condition and see how their social and economic environment has shaped - and possibly contributed, to their condition. If we don’t do this then we are simply treating the effect without looking for the cause, and that just putting a band-aid on the problem. A patient living with schizophrenia, paranoid about being picked on by the police would have been easy to dismiss claims from, purely because of his illness. However, this patient’s fear was not without reason when you understood that as a young black man growing up in a certain area of London during the height of the controversial SUS law, he most probably was regularly stopped and searched for no apparent reason.
It’s too easy to label and fit people into a box because of their illness and discount their opinion and experience of what’s happening to them. You have to be a people person to get on in this job and I’m genuinely interested in what makes people tick.
There are an increasing number of mentally ill offenders filling up secure wards and that, in turn, is putting pressure on forensic services to effectively rehabilitate and release them. We’re an important part of that care pathway because there is a lot of public and political fragility around the subject, and successful reintegration is crucial - both for patients and mental health services.
It’s worth pointing out that patients often respond well to the intensive community support we provide and are eventually granted absolute discharges, but it is a time-consuming and expensive process, one which often, invariably sees some patients move two steps forward and one step back. However, effective rehabilitation takes time and that requires commitment, patience and resources.
Ruth White is a community psychiatric nurse who works for Barnet, Enfield and Haringey Mental Health NHS Trust in North London.