During the 1960s and 1970s in the USSR, the Communist Party categorized and dealt with ideologi- cal deviance by diagnosing and institutionalizing so-called ‘counter-revolutionaries’ with mental illness. Citizens could be deemed psychotic, simply on account of their political views. Dissenters, who were often seen as both a burden and a threat to the system, could be easily discredited and detained. To accommodate to this extreme form of psychiatrization, Soviet definitions of men- tal disease were expanded to include political disobedience. This crude form of psychiatrization amounted to little more than political abuse and repression.
However, while the extremes of criminalization versus psychiatrization are not always as stark as the Soviet example, we noted earlier that there is an inevitable ambiguity when the State detains people who are deemed to be mentally disordered. The competing logics of care and punishment discussed above still recur and are ubiquitous. The navigation and construction of statuses in the criminal justice system are blurred. Fernandez and Lézé (2011) suggest that prisoners are selected and converted into ‘patients’ as a result of earning attention by their honesty, sincerity and role compliance. In other words, the non-disordered offender is treated with caution and suspicion because of their knowingly resistive, deceitful and manipulative ways, whereas those warranting patient-hood do not present in this manner to staff but are accepted as being less self-serving.
Treatment thereafter is orientated to the therapeutic and moral expectations of responsibility, recognition of guilt and self-esteem.
However, this separation in the prison population does not mean that those with mental health problems are less criminalized at the outset. Those with mental health problems are more likely to be criminalized than those who have not been considered to have a mental health problem. For similar offences those with a label of mental illness have a greater chance of being arrested than non-mentally-disordered people (Teplin 1984). However, the criminalization versus psychiatriza- tion paths are evident in discussing the dilemmas of the apparently psychopathic or psychotic
150 A SocIologY oF meNTAl heAlTh ANd IllNeSS
patient who acts dangerously. These patient groups emerged in the UK with institutions like Broad- moor and subsequent asylums for the ‘criminally insane’. (As another indication of the blurring of different forms of the State apparatus of coercive control, the Prison Officers’ Association (POA) in the UK was established at Broadmoor after it was built in 1863. Broadmoor was and is still not a prison but the POA remains there and in other high-security hospitals.)
By definition, the mentally disordered offender qualifies for entry into both the crimi- nal justice and mental health systems. This raises particular dilemmas and questions, which arise out of the conceptual merging of two types of deviance: criminality and mental disorder.
Explicitly stated, should individuals be dealt with in the system designed to deal with the crimi- nal aspects of their behaviour (i.e. in prison) or should they be treated for their mental disorder in hospital?
The arguments for psychiatrization are made on the grounds that hospitalization of mentally disordered offenders is less stigmatizing and hospital treatment benefits patients more than do prisons. Prisons, the argument goes, are unable to provide the environment or range of treatments that a health care regime can (Abramson 1972). A policy initiative stemming from this reasoning was the diversion of mentally disordered offenders from custody projects which were informed by the prevailing ethos of community care in the 1980s.
However, others (Monahan 1973; Fennell 1991) see psychiatrization as resting on dubious logi- cal and empirical grounds. They point out that mental hospitals are far from stigma free. Arguably, in Britain the association of the high-security hospitals, like Ashworth and Broadmoor, with notori- ous serial killers and gangsters means that they are far more stigmatizing than prisons. For exam- ple, when poor care has been exposed in these places, staff defending their traditional role have been keen to emphasize the notoriety of their residents (Pilgrim 2007b). This both confirms stig- matization of these patients and offers a basis to rationalize their mistreatment by staff accused of wrongdoing (see later).
Even though many official bodies overseeing mental health care in prison settings argue for more transfers to medical settings (e.g. Mental Health Act Commission 2008), there remain sub- stantial doubts over whether medical treatment regimens are superior, as was noted earlier. Those labelled as ‘personality disordered’ make up a significant proportion of those in high-security hospitals, yet there is little evidence to suggest that there is an effective treatment for antisocial behaviour in every case.
There is evidence that the ‘recidivism’ rate is lower for those coming out of hospital; in other words, discharged forensic patients are less likely to re-offend than mentally disordered offenders discharged from prison (Fennell 1991). But this may be attributed to the conservative discharge policies of hospitals, noted earlier, which are driven as much by ‘security’ considerations, as it is to changes in the mental state of patients. ‘Psychopaths’ in high-security hospitals receive longer peri- ods of detention, on average, than their counterparts in mainstream prison provision, as judged by equivalent index offences (Peay 1989). Logically this leads then to false positive biases being possible in hospitals (patients continue to be detained in case they are dangerous, when actually they would not go on to re-offend). By contrast, prisons are more likely to have a false negative bias: prisoners are released at the end of their defined sentence and might and often do re-offend.
For example, re-offending in sex offenders is a case in point here.
There are two main arguments underlying a criminalization position. The first relates to a moral and philosophical argument that both those who are designated mentally ill and those who are not should be treated as humanely as possible. That is, poor and ‘brutalizing’ conditions should not exist in either the prison or the mental health systems (Monahan 1973). Reforming the prison system has also been argued for on pragmatic grounds. Fennell (1991) suggests that there will always be situations which do not permit the rapid transfer of mentally disordered offenders out of the prison system.
PRISoNS, cRImINAl juSTIce ANd meNTAl heAlTh 151
Prisoners may not meet the legal criteria for transfer or transfer cannot be arranged quickly enough. Additionally, transfer may not always be the fairest option for prisoners. Sentences are often suspended for prisoners who spend time in hospital and recommenced if a person is trans- ferred back to prison. (That is, there is no remission for the period that they have been treated as patients, and so their detention is actually extended beyond their sentence.) Moreover, increased diversion into psychiatric facilities is unrealistic, given the burden on existing facilities and the failure to rapidly develop more regional secure facilities.
Fennell argued for a proper legal framework for psychiatric treatment in prisons to be estab- lished as a means of improving the standard of care that is currently provided. One policy option, which tried to bridge the gap in the UK between these two positions, was proposed by the Tumin Report (Woolfe and Tumin 1990). This suggested that adequately staffed psychiatric intensive care wards from the NHS be provided inside prisons.
Finally, we can note here that a focus on the challenges of humane mental health provision in the prison services would not disappear if suddenly all mentally abnormal offenders were dealt with under mental health law in hospital settings instead. For example, the high security hospitals in England (Broadmoor, Ashworth and Rampton) have experienced recurrent scandals related to patient abuse, which has sometimes been linked to iatrogenic deaths (Boynton 1980; NHS Hospital Advisory Service 1988; SHSA 1990, 1993; Blom-Cooper et al. 1992).
Moreover, as we noted earlier, prisoners know their time of release, whereas patients in secure psychiatric provision do not. Being detained indefinitely can be considered as a human rights violation, and even a claim of torture can be claimed (Levin 1986). For example, the indefinite detention of asylum seekers and terrorist suspects has been discussed by ethicists in terms of both human rights violations and its negative impact on mental health (Silove et al. 2007; Freckleton and Keyzer 2010). With these considerations in mind, a patient detained indefinitely in secure psy- chiatric conditions is being subjected inherently to the same risks.
The convergence of an actuarial approach to risk
The debates about the comparative merits of criminalization and psychiatrization are mainly in relation to different ways of controlling and containing offender patients. Alongside these argu- ments about which institutional structures (penal or health care?) should take precedence is evi- dence of a convergence of organizational philosophy. There has been a shift in both mental health and criminal justice facilities towards an actuarial policy (Armstrong 2002; Gray et al. 2004). The latter refers to the emphasis on risk calculation as the main procedural guide to professional action in both systems.
While the penal system traditionally aimed to rehabilitate offenders, and the psychiatric sys- tem aimed to treat patients, in recent years both aspirations have been displaced by an emphasis on risk assessment and minimization. Treatment and rehabilitation in different ways are orien- tated towards the reform of the deviant individual. Treatment ideologies, prior to the emergence of ‘actuarialism’ had, to some extent, influenced rehabilitation interventions for some prisoners.
For example, prisons have contained therapeutic communities as part of their rehabilitative strat- egy. By contrast, actuarial management is more about using observational and psychometric methods to efficiently deal with the social threat of groups of deviant people, wherever they are contained.
Both actuarial and treatment approaches are examples of how mental health assessments and interventions have permeated the criminal justice system. For example, in prisons we find con- cerns about prisoners at risk of self-harm and suicide, which might require the input of complex psycho-social interventions. These require risk assessments at the outset. Similarly, we find the link of risk assessment to the warranting of treatment provision in relation to abused and bereaved women, as well as initiatives to improve staff–prisoner relationships and reduce the bullying
152 A SocIologY oF meNTAl heAlTh ANd IllNeSS
arising from institutional norms (Marzano et al. 2011). In other words, proving risk at the aggre- gate level can be a rationale for resource requests and with it forms of changes in institutional practice, which can then be audited to ascertain whether interventions have led to risk reduc- tion, as intended. However, the aggregate argument is also one to cast doubt at the individual level. Aggregate data does not help to answer the question, ‘will this particular patient/prisoner re-offend if discharged/released?’