Prison inmates with major mental illness, a Norwegian challenge, also a Nordic?

1. Prison inmates with major mental illness, a Norwegian challenge, also a Nordic? Pål Hartvig paal.hartvig@kompetanse-senteret.no Centre for Forensic Psychiatry, Oslo University Hospital, Oslo, Norway www.forensic-psychiatry.no

2. Meta-perspective 1 (of 2):Size of prison vs. mental hospital sector • ”Penroses law” (Penrose 1939) ”Inverse relationship between hospital and prison beds in all studied European nations, including Nordic” • ”The law” proven robust also in longitudinal studies up to now (Hartvig&Kjelsberg 2009), though mental deinstitutionalisation e.g. not found guilty of the increase in homicides, same in other countries (e.g.Gunn 2000, Wallace et al. 2004) • Still probably causing increase in psychotic prisoners www.forensic-psychiatry.no

3. Prevalence in prisons of MMI • Trans-nationally: 4 % psychotic, (including psychotic depression) (Fazel&Danesh 2002) • In Norway seemingly corresponding occurrence (Kjelsberg, Hartvig,Østberg 2004, 2005). • In Denmark (Andersen et al. 1996, 2004) • But: Tells little about the real percentage of insane prisoners in a nation’s total population, example: USA ten times higher incarceration rate than Norway; if(?) same prison prevalence, ten times higher national percentage • ”America’s new mental hospitals” (Torrey 1995) www.forensic-psychiatry.no

4. The ”Import model” of Norwegian prison health service, since 1988 • Health services not ”owned” or administered by prison authorities • Consttutes a well functioning general health care for all prisoners • All prisons have attached psychiatric teams responsible for service, in the larger on a daily present basis • A much higher portion of prisoners than in general society are offered psychotherapeutical sessions. Still; increase and enhancement desirable www.forensic-psychiatry.no

5. Norwegian status; psychotic prisoners • 4 % means circa 90 actively psychotic detainees;humanitarian disgrace or just a problem? • Crim Proc Code: ”Psychotics unfit for serving”, ”Standard international doctrine” • De-dramatizing factors: Short stay, take medication • Still too many, creating unease and partly conflict • Main problem: Those psychotic, unconsenting to medication; coerced tratment is unlawful and unworthy outside mental health system • Such patients often admitted, but quite many primarily rejected or too quickly returned www.forensic-psychiatry.no

6. Norwegian status • Easy to understand both sides in the ”conflicts” • ”Psychiatry”: a)too small bed capacity in a system 75 % reduced in 30 years, b) difficulties with custodial demands for prisoners, c) easier to discharge to prison control than to society • Prison: ”Don’t belong here, great strain for prison officers, unjust and a social disgrace” • Possible solutions: a) Definite growth in general psychiatric bed institutions; impossible! b) return to very limited establishment of ear-marked ”asylum wards” in Crim Just System; more possible www.forensic-psychiatry.no

7. Meta-perspective 2: What about prisoners with serious mental, but not psychotic(or gravely mentally retarded) disorders? PD’s serve in hospitals? • Most countries practise a clear demarcation line; psychotic or not?, related to the ”insanity excuse”, both to sentencing to and serving in prison • In last decade emerging discussion about ”free will” and its opposite ”determinism”; in Philosophy, Law, Psychology, Psychiatry and Neuroscience • New field: Neuroethics. • Determinists claim; not only psychotics be excused, but also serious personality disordered including psychopaths, because of very limited free will www.forensic-psychiatry.no

8. Neuroethics, implications • Basis: Biochemical findings and especially brain scanning (PET,MRI) showing strucural and functional defects, especially ventromedial prefrontal cortex and amygdala • Giving strong, at times uncontrollable drives and urges, approaching the free will to almost zero • Some determinists propose the ”insanity excuse” to be strongly expanded to comprise such disordered persons • Where could these be controlled/treated? www.forensic-psychiatry.no

9. Neuroethics, implications • Convert a large portion of prisons to psychiatric institutions? • Not in accordance with ”folk psychology” and be rejected by a strong societal majority. • Likewise by the psychiatric profession, because of very low treatability of ”psychopathy-near PD” (e.g. Kernberg 2007) and custodial problems • Pragmatically, the ”insanity excuse” will prevail regarding diversion from prison to mental institution www.forensic-psychiatry.no

10. Neuroethics, implications • Still, the ”free will vs. determinism” discussion should lead to: Reduction of a moral and retributional condemnation in our dealing with mentally disordered, not psychotic criminal perpetrators www.forensic-psychiatry.no

11. Thanks for the attention Pål Hartvig paal.hartvig@kompetanse-senteret.no Centre for Forensic Psychiatry, Oslo University Hospital, Oslo, Norway www.forensic-psychiatry.no