Trenčín statement on prisons and mental health

Trenčín statement on prisons and mental health WHO Collaborating Centre for Health and Prisons Trenčín statement on prisons and mental health Adopted in Trenčín, Slovakia on 18 October 2007 Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). © World Health Organization 2008 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. 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The Trenčín Statement on Prisons and Mental Health was adopted at the WHO International Meeting on Prisons and Health in Trenčín, Slovakia on 18 October 2007. The meeting was organized in close cooperation with the Ministry of Justice and the Ministry of Health of Slovakia and was co-sponsored by the WHO Collaborating Centre on Health in Prisons, Department of Health, United Kingdom and the Sainsbury Centre for Mental Health, United Kingdom. We thank the following group of experts, who drafted, discussed and commented on the background paper from which this Statement is extracted: Eileen Baldry University of New South Wales, Australia Jonathan Beynon International Committee of the Red Cross Sean Duggan Sainsbury Centre for Mental Health, United Kingdom Andrew Fraser Scottish Prison Service, United Kingdom Ladislav Getlík Trenčín Prison Hospital, Slovakia John Henderson Mental Health Europe, United Kingdom Karsten Kronholm Sanviken Hospital, Norway Hjalmar van Marle Erasmus University, Netherlands Lars Møller WHO Regional Office for Europe Colette Versporten Mental Health Europe, Belgium Brenda van den Bergh WHO Regional Office for Europe Frans Douw Prison Noord-Holland-Noord, Netherlands Aukje Ferket Erasmus University, Netherlands Alex Gatherer WHO Regional Office for Europe Paul Hayton WHO Collaborating Centre on Prison Health, United Kingdom Gerda van't Hoff Ministry of Justice, Netherlands (chair) Terry A Kupers Wright Institute, California, United States Matt Muijen WHO Regional Office for Europe Dick Raes Global Initiative on Psychiatry, Netherlands Robert van Voren Global Initiative on Psychiatry, Netherlands Trenčín statement on prisons and mental health 2 The guiding principles for this Statement are the following: The International Covenant on Economic, Social and Cultural Rights (Article 12): The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. United Nations Basic Principles for the Treatment of Prisoners, Principle 9: Prisoners shall have access to the health services available in the country without discrimination on the grounds of their legal situation. United Nations Principles of Medical Ethics relevant to the Role of Health Personnel, particularly Physicians, in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, Principle 1: Health personnel, particularly physicians, charged with the medical care of prisoners and detainees have a duty to provide them with protection of their physical and mental health and treatment of disease of the same quality and standard as is afforded to those who are not imprisoned or detained. United Nations Principles for the Protection of Persons with Mental Illnesses and the Improvement of Mental Health Care, G.A. res. 46/119 1991, Principle 1, paragraph 4: There shall be no discrimination on the grounds of mental illness. “Discrimination” means any distinction, exclusion or preference that has the effect of nullifying or impairing equal enjoyment of rights. Special measures solely to protect the rights, or secure the advancement, of persons with mental illness shall not be deemed to be discriminatory. Discrimination does not include any distinction, exclusion or preference undertaken in accordance with the provisions of these Principles and necessary to protect the human rights of a person with a mental illness or of other individuals. We recall the Mental Health Declaration for Europe, Facing the Challenges, Building Solutions, adopted at the WHO European Ministerial Conference in Helsinki, Finland, 12–15 January 2005 stated that policy and practice on mental health cover: the promotion of mental well-being; the tackling of stigma, discrimination and social exclusion; the prevention of mental health problems; care for people with mental health problems, providing comprehensive and effective services and interventions, offering service users and carers involvement and choice; and the recovery and inclusion into society of those who have experienced serious mental health problems. We recall our commitment to resolution EUR/RC51/R5 on the Athens Declaration on Mental Health and Man- made Disasters, Stigma and Community Care and to resolution EUR/RC53/R4 adopted by the WHO Regional Committee for Europe in September 2003, expressing concern that the disease burden from mental disorders in Europe is not diminishing and that many people with mental health problems do not receive the treatment and care they need, despite the development of effective interventions. We note resolutions that support an action programme on mental health. Resolution EB109.R8, adopted by the WHO Executive Board in January 2002, supported by World Health Assembly resolution WHA55.10 in May 2002, calls on WHO Member States to: adopt the recommendations contained in The World Health Report 2001; to establish mental health policies, programmes and legislation based on current knowledge and considerations regarding human rights, in consultation with all stakeholders in mental health; and to increase investment in mental health, both within countries and in bilateral and multilateral cooperation, as an integral component of the well-being of populations. Resolutions of the Council of the European Union, recommendations of the Council of Europe and WHO resolutions dating back to 1975 recognize the important role of mental health promotion and the damaging association between mental health problems and social marginalization, unemployment, homelessness and alcohol and other substance use disorders. We accept the importance of the provisions of the Convention for the Protection of Human Rights and Fundamental Freedoms, of the Convention on the Rights of the Child, of the European Convention for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment and of the European Social Charter, as well as the Council of Europe’s commitment to the protection and promotion of mental health that has been developed through the Declaration of its Ministerial Conference on Mental Health in 3 Trenčín statement on prisons and mental health the Future (Stockholm, 1985) and through its other recommendations adopted in this field, in particular Recommendation R(90)22 on protection of the mental health of certain vulnerable groups in society and Recommendation Rec(2004)10 concerning the protection of the human rights and dignity of persons with mental disorder. Statement Delegates at the International Meeting on Prisons and Health in Trenčín, Slovakia on 18 October 2007, representing senior staff from prison and public health services across Europe, wish to draw the attention of all countries in Europe to the essential need for greater focus on mental health problems among people in custodial settings. Delegates underline the fact that these problems are highly relevant not only for penitentiary systems in European countries but also for the whole global community. Delegates also note previous statements made and instruments adopted by the United Nations and the Council of Europe on the rights of prisoners. Without urgent and comprehensive action, prisons will move closer to becoming twenty-first Century asylums for the mentally ill, full of those who most require treatment and care but who are held in unsuitable places with limited help and treatment available. The mental health of prisoners cannot be left as an issue only for prison authorities; it impacts on all of society. As a great majority of prisoners will at some point return to the community, it is in the best interest of society that a prisoner’s health needs are met, that the prisoner is adequately prepared for resettlement and that the causes of re-offending are addressed. International research consistently shows that prisons in Europe hold a very high proportion of prisoners with mental disorders. Reasons for this are: • number of prisoners already have mental health problems before entering prison; • prison environments are, by their nature, normally detrimental to protecting or maintaining the mental health of those admitted and held there; • many vulnerable prisoners have a drug problem prior to entering prisons, but a large proportion have their first drug experience in a prison; • diversion schemes prior to and at the point of sentencing are often poorly developed, under-resourced and badly managed; and • prisons have too often become the place used to hold individuals who have a wide range of mental and emotional disorders. The global facts are clear and startling: of the 9 million prisoners world-wide, at least 1 million suffer from a significant mental disorder, and even more suffer from common mental health problems such as depression and anxiety. There is often co-morbidity (dual diagnosis) with conditions such as personality disorder, alcoholism and drug dependence. Prisons perform a service required by society, and must therefore be seen as an integral part of that society. In the same way, prison health services should be viewed as an integrated part of the society’s national health system, but this is rarely the case. It requires the combined efforts of society and its health system to tackle this lack of cohesion. Society, through its political, judicial and social systems, has to address with urgency issues such as overcrowding, marginalization of, and discrimination against prisoners, and the lack of community care facilities or alternatives to prison. Otherwise, attempts to provide good health care in prisons, and especially good mental health care, will almost certainly fail. There are key criteria that can transform the current unsatisfactory level of mental health care in prisons, with their high prevalence of mental illness. These steps require a coordinated effort by all those working in justice and health systems, and not just the prison health care staff. They will also require a concerted effort from policy-makers, the wider public and the media. Key criteria for success 1. There must be a clear acceptance that penal institutions are seldom, if ever, able to treat and care for seriously and acutely mentally ill prisoners. Such prisoners should be diverted whenever possible to appropriate mental health services before reaching the prison gate. Those already in prison should be transferred to specialist psychiatric care as soon as possible. For those awaiting transfer, those where diversion is not possible or those with minor mental health problems, adequate psychiatric facilities and support should be made available to address their immediate needs. 2. The vulnerability of newly admitted prisoners must be understood and assessed. The need to plan and provide reception policies which will prepare prisoners for their life inside prisons is essential. Health and other needs assessments should be conducted by trained staff, working with a caring attitude, and this should be laid down by the governor or director of the prison. In this regard, leadership is essential in ensuring that daily prison life is as little harmful as possible to the (mental) health of those inside. An understanding of the particular needs of vulnerable prisoners, such as those with mental illnesses, learning disabilities/difficulties, women, young prisoners, elderly prisoners and those from ethnic minorities, is crucial. 3. A personal sentence and care plan should be prepared for each individual prisoner, based on both initial and later assessments of needs. Similarly, the needs of those prisoners who are awaiting trial or not yet sentenced need to be met in a care plan. In many cases, this can be simple and straightforward but, if there are mental health problems, the plan should include specific means of help and support. Psychopharmacology offers great potential but medications must be adjuncts to comprehensive psychiatric treatment. Special steps will be needed where there is risk of self-harm or suicide. In addition, screening and enhanced programming are essential to identify and care for those undertreated prisoners who run foul of the disciplinary system and end up in segregation, where isolation and idleness cause their condition to worsen. 4. Promoting mental health and well-being should be central to a prison’s health care policy. This will address such matters as the general prison environment, prison routines and levels of prisoner activity, education and work opportunities, and staff-prisoner relationships. 5. Prisons should be resourced to take the necessary steps briefly summarized above. Two essentials are effective leadership by the governor or director and adequate resources to provide a sufficient level of staff with proper initial and continuing training. 6. Health care is very important for the general rehabilitation of prisoners: mental health treatment for those with mental illness and mental health promotion for all prisoners are crucial parts of health care in prisons. The level of health care should be based upon assessed need and be as equivalent as possible to that available in the community. Contact between inmates and staff, and with the outside world, should be supported whenever possible. These criteria will require the interest, support and understanding of those in political control of the justice, health and prison systems, but also understanding on the part of the wider society. The current situation related to mental illness and prisons is often very unsatisfactory. Prison services frequently fail to meet the standards of humane care called for by internationally agreed conditions of human rights, and therefore may fail to make their proper contribution to the emerging mental health plans of the World Health Organization and the European Union. However, much can be done, even in countries with the most limited resources, to make substantial and long- lasting improvements to the treatment and care of those people in prisons with mental disorders, and to the diversion of many such individuals away from the criminal justice system at the earliest stage possible. The evidence for action is strong and justifies giving priority to this important area. The steps outlined above would contribute significantly to the mental health and well-being of all prisoners and to the well-being of the community as a whole. 4 Trenčín statement on prisons and mental health The Trenčín Statement on Prisons and Mental Health was adopted at the WHO International Meeting on Prisons and Health in Trenčín, Slovakia on 18 October 2007. The meeting was organized in close cooperation with the Ministry of Justice and the Ministry of Health of Slovakia and was co-sponsored by the WHO Collaborating Centre on Health in Prisons, Department of Health, United Kingdom and the Sainsbury Centre for Mental Health, United Kingdom. World Health Organization Regional Office for Europe Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark Tel.: +45 39 17 17 17 Fax: +45 39 17 18 18 E-mail: postmaster@euro.who.int Website: www.euro.who.int