Fitness for prison: it’s not as straightforward a decision as it seems In his latest in a series of articles on the criminal expert, Dr MARK BURGIN BM BCh (Oxon) MRCGP DCH CPE Dip Med Ethics explains how disability experts identify those who should be dealt with differently to achieve a better outcome.
[THE PRISON POPULATION is evolving: prisoners
are getting older, partly as a result of longer sentences, but there is a new group of pensioner prisoners. Prisons are having to provide residential and even nursing home care to prisoners suffering from a range of serious diseases. Dementia is top of the list of diseases on the criminal expert’s mind, but it is a challenging diagnosis to make even with the latest scans. Assessing people who are disabled by age using conventional means can involve up to five different specialists. Disability experts use a holistic approach, looking for psychological, physical and hidden disabilities. Their report provides all the answers to the court’s questions at low cost and using a model that is straightforward to understand. Early recognition of disabilities can ensure that the correct prison is chosen as well as appropriate treatment. As the number of deaths from natural causes continues to increase there is an interest in identifying those with restricted life expectancy. Disability analysis provides early warning of when rehabilitation is unlikely to be successful.
Childhood trauma
Those who have suffered childhood trauma end up in the criminal justice system, where they cause disruption. They often have personality disorders, PTSD and substance misuse, meaning that their prognosis is poor outside of prison. Surprisingly, a secure environment can reduce or even reverse their decline and early and lengthy prison sentences can be therapeutic. However, on the other hand short sentences without behaviour modification is highly damaging to those vulnerable prisoners. The psychiatrist may struggle to detect the markers of psychosocial disruption that characterise those in the earlier stages. A disability analyst may get a clear picture of what is happening and suggest alternatives, such as trauma therapy, which prevent deterioration. It is important to recognise if the accused has developed a personality disorder and is unlikely to respond to therapy. The change from victim to perpetrator is more obvious in changes to function than to symptoms.
Insight
Although it is assumed that most accused can follow a court case, understand their crime and instruct their legal team, a proportion are not able. Hidden disabilities can disrupt even those with normal intelligence, such as those with neurodifferent thinking. PTSD causes a problem with memory – for instance, dissociating when reminded of trauma. It is challenging for lawyers to identify those hidden disabilities even when their client appears distracted and describes similar problems at school and work. A simple test is to ask the accused – or prisoner – what their crime was and what were the components of that crime. A third make significant errors with the first, two thirds with the second. The importance to justice of prisoners not understanding their crime has
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been debated, with some believing that the purpose is to keep them out of society anyway. The problem with that approach is that if the prisoner is released they will continue to pose the same risks unless they are rehabilitated. Capacity assessments are useful to identify such problems.
Purposeful activity
Many of those who turn to crime have a lack of purposeful activity in their life: ‘The devil makes work for idle hands’. A central part of the prison rehab process is based around work and study, and there are carrots and sticks to encourage that. Fitness for work in prison is approached differently from outside. Outside, any person who has mild disability is given permission not to work if they do not want to: many mildly disabled people choose to work rather than take benefits. In prison it is essential that all those who are capable of work or study do so; it is part of their recovery. It is not unusual for a prisoner to argue that they are unable to work but then carry out similar activities such as sport or illegal drug supply. It is essential to determine the extent of any disabilities so that appropriate activities can be offered. There may need to be reasonable adjustments to ensure compliance, but both the prison and the prisoner benefit. At 65 years old the life expectancy is 20 years, and without a sense of purpose the risk of mental illness is high. The prison system is expensive and it could be argued that leaving disability decisions to prison staff is a false economy. I have shown how prisoners who are elderly, traumatised, lack insight or need purposeful activity could benefit. It is true that disability reports are cheap, easy to obtain and holistic, but should every prisoner have a disability report? It may be time for a local trial to see whether it assists the court to know what the prisoners need, so that they are safe to release. q • To contact Dr Mark Burgin call 0845 331 3304, email drmarkburgin@gmail.com or visit www.drmarkburgin.co.uk
